Bundle Finance & Performance Committee 19 December 2019

1 15:30 - FP19/291 Apologies for absence 2 FP19/292 Declaration of Interests 3 15:30 - FP19/293 Draft minutes of the previous meeting held on 4.12.19 and summary action plan FP19.293a Minutes FPC 4.12.19 Public v.03.docx FP19.293b Summary Action Log v2.doc 4 15:35 - FP19/294 Finance Report Month 8 Ms Sue Hill Recommendation: It is asked that the report is noted, with particular reference to the forecast deficit of £35m and the specific actions in progress to achieve plan. FP19.294 Finance report Month 8.docx 5 15:55 - FP19/296 2019/20 Annual Plan Progress Monitoring Report Mr Mark Wilkinson Recommendation: The Finance & Performance Committee is asked to note the report. FP19.296a APPMR.docx FP19.296b Annual Plan Progress Monitoring Report - November 2019 v0.8.pptx 6 16:05 - FP19/297 Integrated Quality and Performance report Month 8 Mr Mark Wilkinson Recommendation: Finance & Performance Committee is asked to scrutinise the report and to consider whether any area needs further escalation to be considered by the Board. FP19.297a IQPR cover November 2019 FINAL.docx FP19.297b IQPR November 2019 FINAL v1.0.pdf 7 Business cases for approval prior to Board ratification 7.1 16:35 - FP19/298 Bryn Beryl Integrated Dementia & Adult Mental Health Centre Capital Business Case Mr Mark Wilkinson Recommendation: The Committee is asked to approve the capital business case for the Bryn Beryl Integrated Dementia & Adult Mental Health Centre FP19.298a Bryn Beryl business case december 2019 (2).docx FP19.298b FINAL BB Integrated Dementia AMH Centre buisess case 18 Nov 19 (V9 Updated Costs).docx FP19.298c EqIA screening form BB Dementia AMH Centre (003).doc 8 16:45 - FP19/299 Summary of Private business to be reported in public Recommendation:

The Committee is asked to note the report

FP19.299 Private session items reported in public v1.0.docx 9 16:47 - FP19/300 Issues of significance to inform the Chair's assurance report 10 16:49 - FP19/301 Date of next meeting 23.1.20 9.30- 13.00 Bangor University 11 16:49 - FP19/302 Exclusion of the Press and Public Resolution to Exclude the Press and Public “That representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest in accordance with Section 1(2) Public Bodies (Admission to Meetings) Act 1960.”

3 FP19/293 Draft minutes of the previous meeting held on 4.12.19 and summary action plan 1 FP19.293a Minutes FPC 4.12.19 Public v.03.docx

Minutes F&P 4.12.19 Public session v.03 1

Finance & Performance Committee Draft minutes of the meeting held In-Committee on 4.12.19 in Carlton Court, St Asaph

Present:

Mr Mark Polin BCUHB Chairman Mr John Cunliffe Independent Member / Committee Vice Chair Mrs Jackie Hughes Independent Member (co-opted for meeting)

In Attendance: Mr Phillip Burns Interim Recovery Director Mr Gary Doherty Chief Executive Mrs Sue Green Executive Director Workforce and Organisational Development (OD) Mr Michael Hearty Financial Advisor Ms Sue Hill Acting Executive Director of Finance Mr Trevor Hubbard Deputy Director Nursing and Midwifery (part meeting) Mr Andrew Kent Interim Head of Planned Care (part meeting) Mr Rob Nolan Finance Director ~ Commissioning and Strategy (part meeting) Mrs Jill Newman Performance Director Mrs Llinos Roberts Executive Business Manager Mr Andrew Sallows Delivery Programme Director, Welsh Government (WG) Mrs Katie Sargent Assistant Director ~ Communications (observer) Ms Emma Wilkins Deputy Director, Financial Delivery Unit (FDU) Mr Mark Wilkinson Executive Director Planning and Performance (part meeting) Ms Diane Davies Corporate Governance Manager (Committee Secretariat)

Agenda Item Discussed Action By FP19/267 Apologies for absence

It was noted that the meeting date had been postponed from 28.11.19 to 4.12.19 due to operational needs, subsequently apologies were received from Mr Eifion Jones, Mrs Helen Wilkinson, Mrs Gill Harris and Mrs Deborah Carter.

FP19/268 Declarations of Interest

A declaration of interest regarding the CT Scanner, Ysbyty Glan Clwyd (YGC) business case was received from Mrs Jackie Hughes, Independent Member in respect of her substantive post within radiology services.

FP19/269 Draft minutes of the previous meeting held on 24.10.19 and summary action plan Minutes F&P 4.12.19 Public session v.03 2

The minutes were agreed as an accurate record, subject to a typographical error, and updates were provided to the summary action log.

FP19/270 Review of Corporate Risk Assurance Framework - risks assigned to Finance and Performance Committee

FP19/270.1 The risks assigned to the Committee were discussed. It was noted that the framework would be evolving into a new format with effect from March 2020 which could address concerns raised by some members in relation to the correct utilisation of the terms ‘controls’ and ‘actions’ within the documentation provided. The Chief Executive reminded that during the changeover period it remained important to ensure all risks were adequately reflected until 31.3.20.

FP19/270.2 In respect of CRR06 Financial stability, the RTT funding issue risk was highlighted by the Executive Director of Finance. The efficacy of the controls introduced / initial risk rating assignment were also questioned given that the current risk rating had increased from 12 to 16. The Chairman also questioned whether a risk needed to be raised on the overall financial sustainability of the Health Board.

FP19/270.3 In respect of CRR11a Unscheduled care, the Committee also queried the efficacy of the control, however the Chief Executive advised that whilst there had been an increased demand there had also been significant areas of improvement made.

FP19/270.4 In respect of CRR11b Planned Care, the Committee questioned whether the risk effectively addressed safety and potential areas of harm.

FP19/270.5 The Chief Executive undertook to feedback discussion to the GD Deputy Chief Executive regarding addressing risks of:  Overall financial sustainability of the Health Board  Reputational risk  Overarching delivery of the overall plan

FP19/270.6 The Chief Executive also agreed to provide a briefing note to GD members to address:  What is the ‘in year’ reporting plan?  How this would fit for next year?  The robustness of plan  Consideration of whether planned care ‘Harm’ risks were adequately identified within the corporate register especially in areas of Urology and Endoscopy.

It was resolved that the Committee agreed that the risk ratings CRR06, 11a, 11b and 12 remain as stated

FP19/271 Three Year Outlook and 2019/20 Annual Plan Update

FP19/271.1 The Executive Director of Planning and Performance presented this item, highlighting the 8 proposed changes and provided assurance that these Minutes F&P 4.12.19 Public session v.03 3 had not been reset due to non-delivery but for pratical operational reasons set out in the report. In the discussion which followed the Committee stated that it was difficult to ascertain differences in comparison to the previous position reported within the format provided and questioned whether more narrative could be included to address this.

FP19/271.2 The Committee asked that health records storage at YGC be MW reviewed in order to ensure that they continued to be addressed in respect of capital changes. In discussion of delays with the WCCIS programme, the Executive Medical Director agreed to follow up potential domiciliary care DF software in use within a South Wales Health Board as a potential interim solution ahead of WCCIS implementation. The Interim Recovery Director advised a degree of caution given the Board’s experience in relation to the potential delays with software implementation (Microsoft).

It was resolved that the Committee noted the report and approved the proposed changes to the plan as set out

The Interim Head of Planned Care joined the meeting FP19/272 Integrated Quality and Performa7nce report

FP19/272.1 The Executive Director of Planning and Performance presented this item drawing attention to the content of the executive summary provided within the report. He particularly highlighted stabilisation of the 36 waiters and sustained improvement within unscheduled care at Wrexham Maelor although performance overall was challenging. The Committee observed that there was insufficient narrative to explain the declining performance in respect of RTT within the report.

FP19/272.2 The Financial Advisor questioned at what point the 70% of performance reporting at RED overall would improve, following discussion in which the Executive Director of Planning and Performance pointed out that MW these were not all of equal weighting, it was agreed that the January report would present a longitudinal view on the profile of targets and performance.

FP19/272.3 The Committee questioned deterioration in a number of areas including diagnostics and cancer, and whether these were significant trends or short term issues. The Interim Lead for Planned Care undertook to respond to AK IM Lucy Reid’s question regarding follow up waits following the meeting. Significant concern was raised regarding Eye Care services, especially in respect of the interface between primary and secondary care which were being addressed. The Executive Director of Planning and Performance undertook to consider a more effective presentational format to reflect the profile of activity MW regarding External Contracts performance.

FP19/272.4 In relation to the Financial Advisor’s observations regarding a discrepancy of figures between the RTT and IQPR report, the Interim Lead for AK Planned Care undertook to review the IQPR each month to ensure correlation with his report. He also agreed to include further process control context AK highlighted by WG’s Delivery Programme Director to ensure RTT reporting Minutes F&P 4.12.19 Public session v.03 4 addressed WG requirements and concerns within the report to be presented on 23.1.20. WG’s Delivery Programme Director undertook to share RTT reporting AS formats by other Health Boards, which could be helpful to BCUHB, with members and the Interim Lead for Planned Care. He emphasised the need to demonstrate transparency in closing gaps that he had highlighted in respect of cohort numbers and planned delivery.

FP19/272.3 Agency expenditure increase was discussed including the non- delivery of expected improvements following the increased recruitment to substantive appointments which had been taking place. The increase in workforce sickness was discussed in which the Executive Director of Workforce & OD explained various initiatives which were taking place to address the issue, noting that BCU was not an outlier in Wales.

FP19/272.4 It was noted that the Chairman had raised a number of issues with the Executive Director of Primary and Community Care services outside the meeting in relation to primary care and dental services performance.

It was resolved that the Committee noted the report

FP19/273 Update on Referral to Treatment (RTT) improvement programme and year-end forecast

FP19/273.1 The Interim Lead for Planned Care presented this item, he advised that of the 15 actions being progressed within the action plan, work was on schedule with the exception of two, due to delays within the external text messaging service and demand & capacity work. Discussion ensued on these issues including levels of confidence, the need for process robustness, and the Financial Advisor questioned how financial planning might be ensured.

FP19/273.2 The Chairman questioned when endoscopy performance trajectory would be understood. The Interim Lead for Planned Care advised that clarity on demand and capacity would be provided within 8 weeks on 4/5 key specialties noting particular issues with capacity and variance across the organisation. The Financial Advisor emphasised the difficulties involved in planning around a forecast performance in the range of 9 - 12k.

FP19/273.3 The Committee questioned why the ‘treat in turn’ initiative had not realised the improvements envisaged which the Interim Lead for Planned Care explained, including the complexity and difficulties around organisational culture across various workforce groups. It was noted that substantive capacity and adjustment to organisational process was being discussed with the Deputy Chief Executive.

FP19/273.4 A discussion ensued on the effect of HMRC changes on activity, in which WG’s Delivery Programme Director advised that other Health Boards had noted an increase, but this was much more significant at BCUHB. In response to the Chairman’s question on whether RTT funding had been spent on core activity, the Interim Lead for Planned Care explained how some funding had Minutes F&P 4.12.19 Public session v.03 5 been utilised eg Urology West. The Interim Recovery Director advised that this was an area in which he and the Executive Director Workforce & OD needed to ensure increased understanding in order to improve financial grip in this significant area of expenditure, whilst noting work undertaken in supporting core specialty activity by the Workforce & OD Division. It was also noted that discussion was taking place in relation to financial support for endoscopy services in order to address patient risk.

FP19/273.5 It was agreed that the Interim Lead for Planned Care would ensure AK that Demand and Capacity was addressed in the January report including resources, waiting list additions and improved understanding re HMRC implications.

FP19/273.6 The Committee sought further clarification on the revised forecast. The challenges of meeting 11,799 were outlined, however it was noted that, should more funding be secured to address capacity, there was a possibility of attaining in the region of 9,000. The Financial Advisor was informed that figures reported within the finance report had been superseded by the updated RTT report.

FP19/273.7 Considerable debate ensued on the spending required, in which the FDU Deputy Director sought clarification on the amount being committed. The Chief Executive assured that BCU would not expend more than allocated on RTT.

FP19/273.8 It was agreed that the Interim Planned Care Lead, Acting Executive AK/ SH/ Director of Finance, WG’s Delivery Programme Director and the FDU Deputy AS/ EW Director would arrange to discuss  Clarification on definitive RTT number  Investment – per key decision slide  Diary / Timeline confirmation re financial planning before the 5.12.19 Board workshop meeting  Clinical risk and cost issues (Risk v Finance / Performance v Deficit)  Provide clarity on what will be delivered (activity forecast) based on £13.8m as committed by WG.

It was resolved that the Committee noted the report and revised forecast position

The Interim Head of Planned Care left the meeting. FP19/274 Unscheduled Care and Building Better Care update

FP19/274.1 The Deputy Director Nursing and Midwifery joined the meeting to present this item which provided an update against both the unscheduled care performance of each acute site and the fourth 90 day cycle of the unscheduled care Building Better Care programme for the period of October 2019. The improvements within Wrexham Maelor ED were highlighted, albeit with the aid of additional senior resource and it was noted that targeted work was also being undertaken at Ysbyty Glan Clwyd (YGC) and Ysbyty Gwynedd (YG). Minutes F&P 4.12.19 Public session v.03 6

Performance within West, Central and East Health Economies were provided within the report.

FP19/274.2 Debate ensued on the improvements introduced. WG’s Delivery Programme Director commended the improvement made, especially at Wrexham Maelor however, he questioned sustainability and cultural change. The Chief Executive supported the permanent transformation work being undertaken, citing examples of good practice and positive staff experience as well as highlighting the positive effect on the ‘front door’ of YGC and YG.

FP19/274.3 The Chairman questioned ambulance handover performance and actions necessary to address long waiters within ED which had been highlighted to him on a recent visit. Discussion ensued in which DTOC, bed day improvement, ED pathway, YGC establishment and new modelling was raised as well as whether cost pressures were being factored into planning for the following year. The Interim Recovery Director highlighted ‘noise in the system’ in respect of a perception of inequality between sites which were under performing in managing funding.

It was resolved that the Committee noted the unscheduled care performance for October across BCUHB and for each health economy noted the update from the Building Better Care programme and ongoing work within phase 4

FP19/275 Item deferred

FP19/276 Capital Programme report Month 7

It was resolved that the Committee noted the report and revised programme

FP19/277 Finance Report Month 7

FP19/277.1 The Acting Executive Director of Finance presented the report. The Chairman questioned why expenditure was not perceived to be under control, especially in respect of continued overspending at the YGC site, and whether this was repeat pattern behaviour of the previous year.

FP19/277.2 The Interim Recovery Director advised that YGC was a specific area of concern given that there was reporting instability. He advised that a £2.9m cost pressure was being absorbed by other areas of the organisation and reported on work being undertaken with Improvement Groups.

FP19/277.3 In response to the Chairman’s question regarding the level of confidence in attaining the year end forecast, the Chief Executive affirmed that he expected BCU would achieve this. The Financial Advisor raised his concern regarding the year to date overspend and inability to manage cost pressures. He was cautious regarding the rate of savings generation required to deliver by year Minutes F&P 4.12.19 Public session v.03 7 end, which included 50% of ‘red’ schemes . He also questioned when prioritisation would be addressed in respect of the allocative approach being taken. FP19/277.4 The Chairman emphasised the need to understand the drivers of the deficit. In the discussion which followed regarding the cost pressures faced and achievement of planned savings, the Acting Executive Director of Finance advised that decisions were being made with some urgency. The Interim Recovery Director advised confidence in delivery of £40m savings by year end in order to achieve the £25m target. He also stated that discussion had commenced with the Health Economies and questioned whether funding for the interim Managing Directors had been factored into next year’s planning.

FP19/277.5 The Chief Executive stated that BCU would need to meet the £35m deficit forecast, excluding the Welsh Risk Pool cost pressure highlighted and explore scope for other savings. He assured that BCU’s ambition had always been to deliver on the control target.

It was resolved that the Committee noted the report with particular reference to the forecast deficit of £35m and the specific actions in progress to achieve plan.

FP19/278 Financial Recovery Group report 7

FP19/278.1 The Interim Recovery Director reported positively on the forecast position and delivery of the cost improvement programme at month 8. He advised that the programme contained £46m savings with scope for more.

FP19/278.2 The Interim Recovery Director informed that prospective savings plans for the next financial year were being identified, highlighting the tightened grip and control processes introduced and transformation required which would be discussed further at the Board Workshop scheduled to be held on 5.12.19 including challenges within Estates, Facilities and Digital. The Chairman requested that these would need to be presented no later than January 2020.

FP19/278.3 The Interim Recovery Director advised that PWC actions had been completed with the exception of 12 which were expected to be delivered by the end of December and going forward the actions would be managed within executive portfolios. In response to the Committee’s question regarding whether there was sufficient capacity to deliver in respect of Continuing Health Care, he advised that ongoing oversight was required along with addressing the CHC structure and longer term budgeting.

It was resolved that the Committee noted the report

FP19/279 Presentation: Financial Planning

FP19/279.1 The Finance Director ~ Commissioning and Strategy joined the meeting to provide the presentation which set out BCU’s ambition to exit Special Measures, improve Key Metrics, achieve service Redesign / Transformation and Minutes F&P 4.12.19 Public session v.03 8 establish a Digitally Enabled Clinical Strategy. The paper also referenced the outline timetable, the resource allocation and BCUHB’s planning assumptions.

The Financial Gap Assessment also addressed Health Board’s statutory duties, cost pressure assessment and savings opportunities.

Key decisions to be discussed are: • What is the ask for 20/21? • How will the underlying deficit assessment will be considered as part of budget setting? • What growth / cost containment will be supported / presented? • How the savings target will be set • Profile of savings • Prioritisation of funding • Source of funding for any developments to be identified as part of IMTP

FP19/279.2 In response to the Committee the Finance Director – Commissioning & Strategy clarified that transformation funding was non- recurrent, not required to be reimbursed and had not been factored into the figures provided. Discussion ensued on potential reputational risk should BCU withdraw from activities provided via transformation funding which was understood to be the subject of evaluation and investment decisions. The Interim PB Recovery Director agreed to include investment sums required within key decisions to be discussed at the Board workshop. The Committee discussed the difficulty in moving forward the planning process before WG’s allocation letter was received which would necessitate consideration based on assumptions.

It was resolved that the Committee received the presentation

FP19/280 Value Based Healthcare

FP19/280.1 The Acting Executive Director of Finance provided the presentation which was seen to be driving huge benefits for patients as well as cost across the healthcare sector, particularly the NHS in Wales. It was noted that the approach was successful within other Health Boards and a necessary part of the transformation agenda to move forward.

It was resolved that the Committee • approved the Executive Leadership of the programme through the Executive Medical Director and Acting Executive Finance Director • approved the structure for progressing this programme and the central role of the Clinical Effectiveness Group • endorsed the request for the Clinical Effectiveness Group to develop the VBHC programme • approved the Heart Failure Service as the development programme for VBHC in the Health Board • note that programme documentation for Heart Failure Services would be provided to a future meeting along with an assessment of capacity required to deliver the programme Minutes F&P 4.12.19 Public session v.03 9

FP19/281 External Contracts Update

FP19/281.1 The Acting Executive Director of Finance presented this report. She highlighted that there had been some quality issues raised in relation to the Countess of Chester contract. The Committee discussed how BCU might be more innovative in the utilisation of care homes, noting that the Executive Director of Primary and Community Services was exploring developments within Hywel Dda Health Board.

It was resolved that the Committee  noted the financial position on the main external contracts at September 2019 and anticipated pressures  noted the work underway in respect of stabilising wider health / patient care contracts and key risks / related activity  noted the work underway in relation to RTT

FP19/282 Workforce Quarter 2 2019/20 Performance Report

FP19/282.1 The Chairman questioned whether there was any area of concern in respect of objectives reporting red status. It was noted that in respect of Mental Health and Learning Disability vacancy levels that an establishment review would address this area which was currently being supported by the W&OD Division.

It was resolved that the Committee noted the report

FP19/283 Estates / Capital Business Cases for approval prior to Board ratification

The Executive Director of Planning and Performance advised that the following business cases had been progressed via the newly introduced process agreed at a recent F&P Committee meeting.

FP19/283.1 Replacement of a CT scanner at Ysbyty Glan Clwyd business case

It was resolved that the Committee supported the business case for the replacement of a CT scanner at Ysbyty Glan Clwyd.

FP19/283.2 Critical Care Business Case

The Committee were assured that the business case was supported via discretionary funding. In respect of a question raised by the Committee the Executive Director of Planning and Performance agreed to review the accuracy MW of a salary quoted within the business case.

It was resolved that the Committee supported the business case Minutes F&P 4.12.19 Public session v.03 10

FP19/284 2019/20 Monthly monitoring report

It was resolved that the Committee noted the report made to Welsh Government about the Health Board’s financial position for the seventh month of 2019-20

FP19/285 NHS Wales Shared Service Partnership Committee Summary Performance Report

It was resolved that the Committee noted the report

FP19/286 Summary of inCommittee business to be reported in public

It was resolved that the Committee noted the report

FP19/287 Issues of significance to inform the Chair's assurance report

To be agreed outside the meeting

FP19/288 Date of next meeting

19.12.19 3.30pm Optic Centre

(Post meeting amendment to time and venue)

Exclusion of the Press and Public Resolution to Exclude the Press and Public “That representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest in accordance with Section 1(2) Public Bodies (Admission to Meetings) Act 1960.” 1 FP19.293b Summary Action Log v2.doc

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BCUHB FINANCE & PERFORMANCE COMMITTEE Summary Action Log – arising from meetings held in public Officer Minute Reference and Action Original Latest Update Position Revised Agreed Timescale Timescale Actions from 22.8.19 meeting: Phillip FP19/191 Financial Recovery 20.9.19 A BCU wide review of programme management capacity has been Burns / Group (FRG) report Month 4 completed that suggests we may have a group of staff currently Sue Hill 2019/20 not aligned to the recovery programme. This group are now being FP19/191.2 In relation to the exit assessed to establish what capacity could be released and re- transition from PWC and remaining aligned to the recovery programme, this process should be capability within the completed in the next two weeks. The size and structure of the organisation…re availability of PMO and Improvement Team is now better understood but there senior programme managers… remains a high number of current vacancies and roles that are work being undertaken to address being supported by PWC. The vacancies are approved and this issue within PMO and DMO. awaiting final approval to advertise, if approved it will take approx An update would be provided at the 3-4 months before any additional capacity arrives. next meeting. 30.9.19 Agreed to keep action open.

16.10.19 A project plan is being drafted that will be submitted to the next FRG meeting on 29.10.19.

24.10.19 Circulate updated plan to members as discussed at FRG 21.11.19 Outstanding 27.11.19 The PMO has now transferred from an external PWC team to an experienced interim capability and the next stage will be substantive recruitment. Committed costs were presented to the FRG meetings in October and November and the capability and December capacity required is under review and a proposal will be presented Outstanding to FRG on 11th December and circulated to F & P members.

4.12.19 Discussion ensued on the third phase of the programme 11.12.19 and recruitment to substantive posts. It was noted that the transition from Recovery resource to transformation was also subject to Executive discussion. It was agreed to provide a 2

programme cost update to F&P Committee 19.12.19

11.12.19 The Recovery Programme cost paper is on the in- Feb 2020 committee agenda for December F&P and a paper on the proposed PMO and SI team structure will be reviewed by the Executive team in January and will be brought to the F&P Committee in February. Actions from 30.9.19 meeting: Adrian FP19/215.3 Annual Plan 16.10.19 Endoscopy update is included on RTT paper on agenda Thomas Monitoring Report Provide an update on the 20.11.19 A diagnostics sustainability paper will be brought to F&P in associated milestones for November endoscopy and diagnostics sustainability to the next meeting, 24.10.19 The Chairman emphasised there was to be no slippage and assuring the Committee in presentation to the November meeting around the planning capability to deliver what is required 19.11.19 AT updates: Radiology Milestone 2 (March 2020) in the Annual Plan Monitoring Report is - Develop capacity plan for future demand (equipment and staff). Kendall Bluck have been reviewing Radiology Services and their report is to be used to inform the proposal for sustainable radiology services in time for the Milestone date. Insourcing for CT, MR and Non Obstetric Ultrasound was been agreed for the Radiology Service until the end of December 2019 and is being provided by RMS. Insourcing will be required until March 2020 and additional funding for Radiology has been requested from Welsh Government.

26.11.19 North Wales Managed Clinical Services had their accountability meeting last week and confirmed that they have received feedback from Kendall Bluck and are awaiting the final report. It was agreed at the meeting that they will develop a sustainability plan for February. 3

4.12.19 The Chairman requested an update on Diagnostic services

Mags FP19/217.3.3 Referral to 20.11.19 20.11.19 Business has been deferred from November agenda Barnaby Treatment > Ensure eyecare business case is 20.11.19 Work to develop ophthalmology services continues with Mark submitted to November F&P the £400k procurement of 11 field analysers to test peripheral Wilkinson vision. The Board is performing well in our work to risk stratify patients. Our next challenge – flagged with health economies at the recent accountability reviews – is to ensure that we now book on this basis. Some thought is being given as to whether a full and and complete business case is required or whether this may be more of a piece of service improvement work. There is currently no timescale therefore for a business case.

Jan or Feb 4.12.19 Agreed to provide presentation on Eye Care Services to 15.1.20 or please future meeting 19.2.20 advise 11.12.19 Performance team confirmed are working towards Jan 2020 preparation of paper for January F&P meeting Mark FP19/217.3.3 Referral to 30.10.19 The Urology business case is dependent upon the national Wilkinson Treatment procurement of the urology robot and so the business case will not Ensure urology and orthopaedics be ready for presentation at November Board. The Orthopaedics business cases are submitted to business case will go through the revised business case process November Board and we will continue to keep the Board and WG informed on the recruitment of the 6 Orthopaedic consultants and the development of the programme business case.

25.11.19 UROLOGY - Recent discussions with clinical teams have indicated there is no clear consensus on the preferred service model, and without this, it will not be possible to complete a business case although drafting work continues.

25.11.19 ORTHOPAEDICS - 5 out of the 6 new (Welsh 4

Government Part Year Effect funded ) consultants have been appointed. Demand and capacity plan is being revised in light of forecast end of year performance. Intention is to complete PBC for submission to December F&P and January HB (subject to Exec Team, F&P and HB meetings taking place as per current timetable)

11.12.19 Orthopaedics business case scheduled to be on Item to be December F&P agenda. closed

12.12.19 Revised planning paper for urology approved by the Item to be Committee on 4.12.19 set a new timescale for this business case closed to come to the March Finance & Performance Committee meeting. This will be built into the CoB. Actions from 24.10.19 meeting: Sue Hill FP19/236 Finance Academy December Moved to January agenda due to short December meeting Jan 2020 Forecasting Best Practice Guide meeting A plan to implement the guidance (11.12.19) would be provided In December January meeting Sue Hill FP19/238 Resource Allocation 11.12.19 20.11.19 Update - The resource allocation has not been finalised Jan 2020 Provide to members when formula 11.12.19 This should have been issued in time to be brought to finalised F&P in January Sally FP19/239 Annual plan progress 11.12.19 25.11.19 – narrative has always been included on red rated plan Item to be Baxter > monitoring actions; feedback on completeness and levels of assurance on the closed Mark Provide clarity on whether narrative is always welcomed. Specific additional narrative on Wilkinson milestones are interim or final steps amber rated actions will be included starting with the November and include specific narrative when report to be presented to the December committee. they are due 12.12.19 Incorporated within APPMR Sally FP19/239.3 Annual Plan progress 11.12.19 25.11.19 – narrative has always been included on red rated plan Item to be Baxter > monitoring: actions; feedback on completeness and levels of assurance on the closed Mark Provide more detailed narrative on narrative is always welcomed. Specific additional narrative on Wilkinson all amber and red positions in order amber rated actions will be included starting with the November that the Committee could be report to be presented to the December committee. 5

appraised of how the actions were 12.12.19 Incorporated within APPMR being brought back into alignment and included a sense of achievability. Estates, Digital and Care Closer to Home needed to be focussed on. The Committee also sought greater grip on priorities and the relationship on interdependencies. Sue Green FP19/240.1 IQPR 15.1.20 Briefing to be included within the F&P report for January 2020 and Provide briefing on potential impact Q3 report. Working with colleagues nationally to work through on sickness in respect of changes calculation of impact to unsocial hours payments Deborah FP19/242.4 USC 21.11.19 21.11.19 update Carter  Share Delivery Unit report with  The DU issued the draft report on 21 November, which is members currently in the process of being reviewed before the finalised version is published. 13.12.19 update Feedback has been provided to the DU, a finalised version is awaited. Actions from 4.12.19 meeting: Gary FP19/270.5 Chief Executive December 12.12.19 The Chief Executive fed back the discussion to the Item to be Doherty undertook to feedback discussion Deputy Chief Exec as agreed. closed to Deputy Chief Exec regarding addressing risks of:  Overall financial sustainability of the Health Board  Reputational risk  Overarching delivery of the overall plan Gary FP19/270.6 12.12.19 Following discussion with the Deputy CEO in terms of January Doherty provide a briefing note to members how best to address the key issues raised it was felt that a to address: conversation between the Deputy CEO and key committee 6

 What is the ‘in year’ reporting members was needed prior to sending round a proposed way plan forward. This will be actioned, and a note sent round prior to the  How this would fit for next year January meeting.  The robustness of plan  Consideration of whether planned care ‘Harm’ risks were adequately identified within the corporate register especially in areas of Urology and Endoscopy. Mark FP19/271.2 3 yr outlook and 12.12.19 Based on the assumption this action relates to the need Item to be Wilkinson annual plan update for a health records storage solution to be developed in parallel closed Review if health records storage is although separate to the Ablett business case. The question arose addressed in respect of capital as the timescale for the Ablett business case has changed. The changes health records business case is being developed in the parallel to the same timescale. David FP19/272.2 3 yr outlook and 12.12.19 The CIO is focussing the software opportunities with his Item to be Fearnley annual plan update colleagues from across Wales on 12 December and will report closed Follow up potential domiciliary care back to DIGC next time as part of the discussion around digital software in use within S Wales solutions for integrating community services. Executive Team are Health Board as interim solution looking at the Canterbury model in more depth as part of clinical ahead of WCCIS implementation. strategy work in January.

Mark FP19/272.2 IQPR - monthly 15.1.20 Wilkinson performance trends Present longitudinal view (previous few months) on profile of targets and performance within report to be presented in January Andrew FP19/272.3 IQPR - RTT paper provided for December meeting. If further specific Item to be Kent Respond to questions raised by HB questions, AK to advise. closed Vice Chair Mark FP19/272.3 IQPR - External 12.12.19 - A plan for the external activity based on outturn 2018/19 Item to be Wilkinson Contracts – Consider more (prorata for the month reported) so as to show activity v plan has closed 7

effective presentational format to been added. Further feedback on any aspect of this report is demonstrate activity always welcome. Andrew FP19/272.4 IQPR – RTT Activity v Access to IQPR data going forward will be incorporated Item to be Kent Plan closed Ensure access to IQPR data going forward to ensure correlation in preparation of RTT paper Andrew FP19/272.4 IQPR – Process 15.1.20 Kent Control Include further context highlighted by Andrew Sallows to ensure reporting addresses WG requirements and concerns within report to be presented at January meeting. Andrew FP19/272.4 IQPR – RTT 15.1.20 Sallows Share effective RTT reports by other Health Boards with members and AK before January meeting Andrew FP19/273.5 RTT 15.1.20 Kent Ensure report to January meeting addresses: Demand and Capacity – resources, waiting list additions and improved understanding re HMRC implications

Andrew FP19/273.8 RTT 5.12.19 Kent / Arrange discussion on Andrew  Clarification on definitive RTT Sallows/ number Sue Hill/  Investment – per key decision Emma slide Wilkins  Diary / Timeline confirmation re 8

financial planning before the 5.12.19 Board workshop meeting  Clinical risk and cost issues (Risk v Finance Performance v Deficit)  Provide clarity on what will be delivered (activity forecast) based on £13.8m as committed by WG. Philip FP19/279.2 FRG 5.12.19 The Interim Recovery Director requested to be included in all Item to be Burns Ensure investment requirement is projects and programmes to ensure the right support and/or closed included within key decisions resource is allocated or considered to ensure delivery of any outcomes and outputs.

Any financials will be net of any investment. Mark FP19/283.2 PACU Business Case 19.12.19 12.12.19 Finance colleagues confirm that the table within the Item to be Wilkinson Check salary for Band 8c paper should read 0.60 WTE Clinical Psychologist rather than 1.0 closed Psychologist quoted within WTE. The figure of £55,939 is correct. business case 17.12.19 4 FP19/294 Finance Report Month 8 1 FP19.294 Finance report Month 8.docx

Cyfarfod a dyddiad: Finance and Performance Committee Meeting and date: 19.12.19 Cyhoeddus neu Breifat: Public Public or Private: Teitl yr Adroddiad Finance Report Month 8 2019/20 Report Title: Cyfarwyddwr Cyfrifol: Sue Hill, Acting Executive Director of Finance Responsible Director: Awdur yr Adroddiad Sue Hill, Acting Executive Director of Finance Report Author: Craffu blaenorol: Acting Executive Director of Finance Prior Scrutiny: Atodiadau Appendix 1: Summary of Financial Appendices: Performance Appendix 2: Forecast Appendix 3: Savings Appendix 4: Expenditure Appendix 5: Balance Sheet Appendix 6: Financial Risks and Opportunities Appendix 7: Response to Month 7 Questions Argymhelliad / Recommendation: It is asked that the report is noted, with particular reference to the forecast deficit of £35m and the specific actions in progress to achieve plan. Please tick one as appropriate (note the Chair of the meeting will review and may determine the document should be viewed under a different category) Ar gyfer Ar gyfer Ar gyfer Er penderfyniad Trafodaeth sicrwydd  gwybodaeth /cymeradwyaeth For For For For Decision/ Discussion Assurance Information Approval Sefyllfa / Situation: The purpose of this report is to provide a briefing on the financial performance of the Health Board as at November 2019, and on actions being taken to manage the financial challenge and mitigate risk. Cefndir / Background: The Health Board developed a draft 2019/20 annual deficit plan of £35m. The Financial Recovery programme is supporting delivery of a significant improvement, in line with the £25m control total, and requiring delivery of a further £10m of savings. Welsh Government reporting continues to reflect the initial plan deficit of £35m, in line with their requirements.

Asesiad / Assessment: 1.0 Strategy Implications This paper aligns to the strategic goal of attaining financial balance and is linked to the well-being objective of targeting our resources to those with the greatest need.

1 2.0 Financial Implications 2.1 Summary

Current Month Year to Date Full Year Forecast

Original £2.9m Deficit Original £23.3m Original £35.0m Plan Plan Deficit Plan Deficit

Control £1.6m Deficit Control £18.3m Control £25.0m Total Total Deficit Total Deficit

Actual £3.2m Deficit Actual £27.1m Forecast £35.0m Deficit Deficit

Plan £0.3m Plan £3.8m Plan Nil Variance Adverse Variance Adverse Variance

Control £1.6m Control £8.8m Control £10.0m Variance Adverse Variance Adverse Variance Deficit

Financial Performance and Forecast 2019/20 4.5

4.0

3.5

3.0

2.5 m £ 2.0

1.5

1.0

0.5

0.0 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20

Plan - £35m Stretch Plan - £25m Actual Forecast

Achievement Against Key Targets

Revenue Resource Limit Public Sector Payment  Policy (PSPP)  Savings & Recovery Revenue Cash Balance Plans   Capital Resource Limit  Medium Term Plan 

2.2 Overview

 In month: The Health Board delivered a £3.2m deficit, £0.3m over the original plan. Following three months of consecutive improvement in performance, there has been a deterioration this month. The in-month position is £1.6m in excess of the control total plan.

2  Month 7 saw a considerable under spend against the WHSCC contract, which has not been replicated this month. In addition, costs for Prescribing continue to increase and savings have not delivered to plan. In total, the position has deteriorated from the Month 7 position by £0.5m.

 Year to date: The Health Board is overspent by £27.1m, £8.8m higher than control total plan and £3.8m over the original plan. The key over spending division is Secondary Care, where the non-delivery of savings, agency premium pay costs and other cost pressures are the main causes of the over spend. Further details are included in Appendix 1.

 Forecast: The Health Board’s forecast deficit of £35m is in line with the initial plan but behind the £25m control total plan. The actual position for Month 8 was £0.7m worse than the Month 7 forecast position for November. Despite the downturn in performance in Month 8, the savings pipeline continues to hold a number of schemes that are forecast to deliver in the final quarter of the year. On the basis of the conversion and delivery of these schemes, the £35m forecast deficit is considered achievable. Further details are included in Appendix 2.

 Savings: Savings achieved to date are £13.6m against a year to date plan of £20.6m giving a shortfall of £7m. Additional cost avoidance and efficiency savings of £6.1m have been delivered to date, which offset some cost pressures arising in-year. The original planned deficit is only achievable if the Health Board can convert and deliver 51% of the red schemes, continue to deliver green and amber schemes to planned values, and contain or offset emerging cost pressures. In addition, mitigating savings totalling £1.8m need to be identified to offset the impact of the Health Board’s share of the Welsh Risk Pool risk share contribution. Further details are included in Appendix 3.

2.3 Income and Expenditure

 Income: Most of the Health Board’s funding is Welsh Government allocation through the Revenue Resource Limit (RRL). Confirmed allocations to date total £1,520m, with further anticipated allocations in year of £54m, a total forecast of £1,574m for the year.

 Pay expenditure: Pay costs were inflated in Month 7 for the Medical and Dental pay award and have now returned to just below the average for the year at £62.1m. Expenditure on agency staff for Month 8 is £3.1m a fall of £0.5m on October. There have also been decreases in locum costs of £0.2m and other non- core costs (e.g. cover colleague) of £0.2m. Health Board pay costs are £1.5m under spent for the year to date, reflecting the significant number of vacancies being held.

 Non- pay expenditure: Costs are above the average for the year at £78.8m in the month, with a year to date over spend of £13.7m. Of this, £5m relates to the stretch target. The key area of pressure is Prescribing; analysis of the impact of National Prices is estimated at £2.2m, with a forecast pressure of £3.5m for the full year. In addition, forecasting methodologies indicate that there is a potential risk of up to £3m over the remaining months of 2019/20. In addition to this, Secondary Care drugs continue to over spend, whilst there remains a number of savings targets that have not been allocated to cost areas by the divisions.

3  RTT: The Health Board has received RTT funding of £13.5m for the full year, of which £9.0m has been spent to date. Welsh Government have confirmed that there is no additional RTT funding available for 2019/20 although discussions do still continue. The Health Board has fully committed the remaining £4.5m of funding and is currently assessing the impact and risk on the achievement of treatment targets.

 Further details on expenditure are included in Appendix 4.

2.4 Balance Sheet

 Cash: The Health Board has formally requested £31m Strategic Cash Support from Welsh Government to ensure that essential payments can continue through to March 2020. This is lower than the forecast deficit for the year as the Health Board is currently forecasting that £4m of cash pressures will be managed internally by undertaking a range of cash management actions.

 Capital: The Capital Resource Limit (CRL) at Month 8 is £20.0m. Year to date expenditure is £7.5m against a plan of £8.5m. The year to date slippage will be recovered throughout the remainder of the year. Further details are included in the Capital Programme report

 A summary of the balance sheet is included in Appendix 5.

3.0 Risk Analysis

 There are six risks to the financial position totalling £8.8m. These are detailed in Appendix 6. Offsetting these, there are is one opportunity totalling £10m relating to delivery of stretch target savings.

4.0 Legal And Compliance Not applicable.

5.0 Impact Assessment Not applicable.

4 Appendix 1 – Summary of Financial Performance

 An overall month by month summary of the financial position is shown below, followed by a table showing the split by division.

Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 CUMULATIVE ACTUAL ACTUAL ACTUAL ACTUAL ACTUAL ACTUAL ACTUAL ACTUAL BUDGET ACTUAL VARIANCE £m £m £m £m £m £m £m £m £m £m Revenue Resource Limit (124.9) (123.2) (124.1) (129.3) (124.7) (125.5) (130.5) (126.7) (1,008.9) (1,008.9) 0.0 Miscellaneous Income (10.6) (11.9) (11.1) (11.1) (12.1) (11.3) (11.5) (11.0) (87.2) (90.6) (3.4) Health Board Pay Expenditure 64.6 61.9 62.0 62.3 62.2 62.1 64.7 62.1 503.4 501.9 (1.5) Non-Pay Expenditure 74.8 76.9 76.6 81.8 78.2 77.6 80.0 78.8 611.0 624.7 13.7 Total Against Stretch Plan 3.9 3.7 3.4 3.7 3.6 2.9 2.7 3.2 18.3 27.1 8.8 Stretch Target Offset 5.0 0.0 (5.0) Total Against Original Plan 23.3 27.1 3.8

5 Appendix 1 – Summary of Financial Performance

Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 CUMULATIVE ACTUAL ACTUAL ACTUAL ACTUAL ACTUAL ACTUAL ACTUAL ACTUAL BUDGET ACTUAL VARIANCE £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 WG RESOURCE ALLOCATION (124,954) (123,186) (124,111) (129,295) (124,695) (125,453) (130,519) (126,714) (1,008,926) (1,008,926) 0 AREA TEAMS West Area 13,278 12,998 13,066 14,339 13,470 13,505 14,215 13,777 108,510 108,735 225 Central Area 17,294 17,075 17,051 18,030 17,448 17,475 18,178 18,092 140,166 140,738 572 East Area 19,050 18,928 18,905 20,129 19,420 19,251 20,216 20,062 155,312 156,222 911 Other North Wales 834 1,072 1,206 864 1,224 997 693 758 6,423 6,246 (177) Commissioner Contracts 16,206 16,191 16,647 18,154 19,319 16,881 16,530 17,217 138,735 137,144 (1,591) Provider Income (1,601) (1,768) (1,859) (2,268) (2,154) (2,170) (1,528) (1,626) (13,853) (14,974) (1,121) Total Area Teams 65,062 64,496 65,017 69,248 68,727 65,938 68,304 68,280 535,293 534,111 (1,182) SECONDARY CARE Ysbyty Gwynedd 8,712 8,444 8,392 8,371 8,158 8,031 8,643 8,185 65,868 66,936 1,068 Ysbyty Glan Clwyd 10,392 10,281 10,259 10,469 10,285 10,258 10,971 10,284 78,918 83,199 4,281 Ysbyty Maelor Wrexham 8,908 8,700 8,530 8,773 8,650 8,702 9,080 8,676 68,694 70,020 1,326 North Wales Hospital Services 8,994 8,647 8,584 9,429 6,647 8,517 8,510 8,573 67,154 67,901 747 Womens 3,370 3,282 3,066 3,258 3,294 3,365 3,342 3,278 26,004 26,255 251 Total Secondary Care 40,375 39,354 38,831 40,301 37,034 38,873 40,546 38,997 306,638 314,311 7,673 Total Mental Health & LDS 10,682 10,156 10,145 10,088 10,268 10,969 10,892 10,283 83,714 84,439 724 CORPORATE Chief Executive 162 211 175 172 179 165 183 193 1,444 1,445 0 Estates & Facilities 4,445 4,216 4,119 4,161 3,967 4,029 4,203 4,140 33,074 33,280 205 Utilities & Rates 1,337 1,376 1,337 1,347 1,338 1,388 1,344 1,450 10,378 10,917 539 Executive Director of Finance 845 825 806 853 633 571 1,427 (956) 4,959 5,005 46 Executive Director of Nursing & Midwifery 835 1,021 935 1,029 944 946 891 922 7,127 7,520 393 Executive Medical Director 1,463 1,433 1,461 1,582 1,599 1,619 1,654 1,622 12,597 12,434 (163) Executive Director of Workforce & OD 963 962 951 947 955 896 1,091 891 7,385 7,656 272 Director of Planning & Performance 178 157 169 170 160 128 201 251 1,602 1,415 (187) Executive Director of Public Health 80 110 82 129 98 98 110 102 665 809 144 Director of Corporate Services 0 0 0 0 0 0 0 0 (212) 0 212 Office to the Board 202 195 127 179 185 152 190 188 1,398 1,417 19 Director of Therapies 34 31 31 31 29 28 26 25 289 235 (54) Executive Director of Primary Care & Comm Services 75 75 92 68 55 64 64 77 681 570 (110) Director of Turnaround 90 135 112 148 224 87 255 990 2,164 2,041 (123) Total Corporate 10,709 10,747 10,397 10,816 10,366 10,171 11,639 9,895 83,551 84,744 1,193 Total Other Budgets incl. Reserves 1,951 2,149 3,135 2,523 1,866 2,459 1,878 2,483 18,062 18,445 382 TOTAL - STRETCH PLAN (£25.0m) 3,825 3,716 3,414 3,681 3,566 2,957 2,740 3,224 18,333 27,123 8,790 Stretch Target Offset 5,000 0 (5,000) TOTAL - ORIGINAL PLAN (£35.0m) 23,333 27,123 3,790

MAIN COST PRESSURES Primary Care drugs 2,760 6 Secondary Care drugs 2,126 Unallocated savings - original target plus brought forward 3,852 Unallocated savings - stretch target 5,000 Appendix 2 – Forecast

Scenarios

 The Health Board’s current Monitoring Return forecast is shown below, alongside two forecast scenarios which are based on performance to date. This confirms the scale of the challenge.

Month 7 Forecast/ Month 7 Forecast Forecast Year to Actual Year to 2019/20 Description Date Month 7 Date Month 9 Month 10 Month 11 Month 12 £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 M7 Forecast 23,976 2,515 26,491 2,294 2,085 2,081 2,049 35,000 Updated for M8 Year to date extrapolation 23,899 3,224 27,123 3,390 3,390 3,390 3,390 40,683 Month 8 in-month extrapolation 23,899 3,224 27,123 3,224 3,224 3,224 3,224 40,019 Current forecast 23,899 3,224 27,123 2,213 1,973 1,907 1,784 35,000

 Delivery of forward trajectories and full-year plan is critically dependent on an immediate step change in pace of savings delivery over the remainder of the year. The £35m deficit position will only be realised if savings delivery is at the level currently forecast by the PMO.

Divisional

 Forecasts for the year submitted by the divisions are shown below. The majority of divisions continue to forecast over-spends for the year, outside the budgetary limits set by the Board and therefore beyond their authority.

7 Appendix 2 – Forecast

Full Year Full Year Change In Month 7 Forecast Month 8 Forecast Forecast Annual Year to Date Variance Year to Date Variance Variance Stretch Budget Variance Over Budget Variance Over Budget From Month 7 Target at Month 7 at Month 8 to Month 8 £000 £000 £000 £000 £000 £000 £000 WG RESOURCE ALLOCATION (1,573,137) 0 0 0 0 0 0 AREA TEAMS West Area 163,101 201 1,300 225 1,300 0 (731) Central Area 209,422 390 1,199 572 1,221 22 (1,221) East Area 233,890 749 2,100 910 2,100 0 (849) Other North Wales 9,712 (83) (190) (177) (191) (1) 129 Commissioner Contracts 206,913 (1,324) (843) (1,591) (1,934) (1,091) (7) Provider Income (19,180) (993) (1,093) (1,121) (1,250) (157) 0 Area Wide 0 Total Area Teams 803,858 (1,060) 2,473 (1,182) 1,246 (1,227) (2,679) SECONDARY CARE Ysbyty Gwynedd 96,223 1,027 1,304 1,068 1,261 (43) (505) Ysbyty Glan Clwyd 116,740 3,664 6,114 4,281 6,108 (6) (606) Ysbyty Maelor Wrexham 101,777 1,137 2,000 1,326 2,000 0 (517) North Wales Hospital Services 99,238 601 1,547 747 1,547 0 (1,403) Womens 38,879 183 395 251 395 0 (220) Total Secondary Care 452,857 6,612 11,360 7,673 11,311 (49) (3,251) Total Mental Health & LDS 126,239 847 1,527 724 1,430 (97) (2,627) Total Corporate 124,851 732 2,457 1,193 4,261 1,804 (1,443) Other Budgets (Reserves) 90,332 102 494 382 1,049 555 0 Welsh Risk Pool risk share contribution 0 0 0 0 1,817 1,817 0 Mitigating actions to reduce forecasts (West & YGC) (1,854) (1,194) 660 Pan BCU Green and Amber schemes (3,748) (3,748) Welsh Risk Pool mitigation (1,817) (1,817) Red Risk Schemes (6,457) (4,355) 2,102 TOTAL - STRETCH PLAN (£25.0m) 25,000 7,233 10,000 8,790 10,000 0 (10,000) Stretch Target Offset 10,000 (3,750) (10,000) (5,000) (10,000) 10,000 TOTAL - ORIGINAL PLAN (£35.0m) 35,000 3,483 0 3,790 0 0 0

8 Appendix 2 – Forecast

 Two divisions (West Area and YGC) have an action still outstanding to reduce forecasts back in line with the Month 6 forecast (£0.88m and £5.34m respectively). The total reduction required across the two divisions is £1.194m.

 One division (Corporate) has incurred additional costs in Month 8, which they have highlighted as cost pressures and requested to increase their forecast deficit for a second month. The Corporate forecast will be reviewed and a reduction in run-rate required through delivery of red schemes and escalated daily recovery actions.

 The Welsh Risk Pool pressure, relating to the Health Board’s share of NWSSP’s forecast over spend, requires mitigating actions to cover the cost. The Welsh Risk Pool cost is included in the forecast outturn, but there are no costs in the Month 8 position. This is a very high risk for the Health Board as inability to identify mitigations could impact on the forecast.

 Pan BCU green and amber schemes are those savings schemes that are being driven by Improvement Groups and are not yet identified in divisions. Full delivery of all schemes up to their planned value is required to meet the £35m forecast outturn.

 In addition, £4.4m of red risk schemes are required, equating to 51% of red schemes in the pipeline. To achieve this, there will need to be an escalation of immediate actions to reduce the run rate.

 Divisions that have maintained their Month 7 forecast have done so by covering cost pressures with one-off benefits.

 The divisional forecasts above have been mapped against the estimated impact of red savings schemes to give an indicative monthly forecast. This is shown below. It is noted that:

­ The phasing of divisional forecasts will be further challenged and updated over the next month ­ The red risk schemes forecast is based on 51% delivery of all schemes in the pipeline. Full delivery of all planned green and amber schemes is also required. ­ Many savings schemes are multi-divisional or pan-Health Board (e.g. Workforce Optimisation and Procurement). The allocation of schemes across divisions and expenditure categories will be finalised as the schemes are specified and move to delivery.

9 Appendix 2 – Forecast

Month 8 MONTH 9 MONTH 10 MONTH 11 MONTH 12 CUMULATIVE Year Forecast Indicative Forecast Indicative Forecast Indicative Forecast Indicative Forecast Indicative to Date Actual Additional Actual Actual Additional Actual Actual Additional Actual Actual Additional Actual Actual Additional Actual Actual Forecast Savings Forecast Forecast Savings Forecast Forecast Savings Forecast Forecast Savings Forecast Forecast Savings Forecast £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 WG RESOURCE ALLOCATION (1,008,927) (129,246) 0 (129,246) (130,918) 0 (130,918) (128,706) 0 (128,706) (176,876) 0 (176,876) (1,574,673) 0 (1,574,673) AREA TEAMS West Area 108,735 13,878 (23) 13,855 14,266 (132) 14,134 13,916 (132) 13,784 13,878 (132) 13,746 164,673 (420) 164,253 Central Area 140,737 17,698 0 17,698 18,098 0 18,098 17,397 0 17,397 17,322 0 17,322 211,252 0 211,252 East Area 156,223 19,599 0 19,599 20,471 0 20,471 19,981 0 19,981 20,191 0 20,191 236,465 0 236,465 Other North Wales 6,245 754 0 754 753 0 753 753 0 753 754 0 754 9,259 0 9,259 Commissioner Contracts 137,143 17,102 0 17,102 17,099 0 17,099 17,001 0 17,001 16,955 0 16,955 205,300 0 205,300 Provider Income (14,974) (1,506) 0 (1,506) (1,304) 0 (1,304) (1,304) 0 (1,304) (1,342) 0 (1,342) (20,430) 0 (20,430) Total Area Teams 534,109 67,525 (23) 67,502 69,383 (132) 69,251 67,744 (132) 67,612 67,758 (132) 67,626 806,519 (420) 806,099 SECONDARY CARE Ysbyty Gw ynedd 66,935 7,673 0 7,673 7,711 0 7,711 7,671 0 7,671 7,981 0 7,981 97,971 0 97,971 Ysbyty Glan Clw yd 83,199 9,922 (43) 9,879 9,941 (244) 9,697 9,932 (244) 9,688 10,049 (244) 9,805 123,043 (774) 122,269 Ysbyty Maelor Wrexham 70,019 8,513 0 8,513 8,564 0 8,564 8,422 0 8,422 8,466 0 8,466 103,984 0 103,984 North Wales Hospital Services 67,901 8,131 0 8,131 8,426 0 8,426 8,239 0 8,239 8,520 0 8,520 101,217 0 101,217 Womens 26,256 3,274 0 3,274 3,258 0 3,258 3,247 0 3,247 3,239 0 3,239 39,274 0 39,274 Total Secondary Care 314,310 37,513 (43) 37,470 37,900 (244) 37,656 37,511 (244) 37,267 38,255 (244) 38,011 465,489 (774) 464,715 Total Mental Health & LDS 84,438 10,664 0 10,664 11,241 0 11,241 10,542 0 10,542 10,784 0 10,784 127,669 0 127,669 Total Corporate 84,744 10,864 0 10,864 10,880 0 10,880 10,881 0 10,881 10,901 0 10,901 128,270 0 128,270 Other Budgets (incl. Capital Charges) 18,448 5,407 0 5,407 6,415 0 6,415 6,863 0 6,863 53,890 0 53,890 91,023 0 91,023 Welsh Risk Pool risk share contribution 0 0 0 0 0 0 0 0 0 0 1,817 (1,817) 0 1,817 (1,817) 0 Multi Divisional Schemes 0 0 (448) (448) 0 (2,552) (2,552) 0 (2,552) (2,552) 0 (2,552) (2,552) 0 (8,103) (8,103) TOTAL 27,122 2,727 (514) 2,213 4,901 (2,928) 1,973 4,835 (2,928) 1,907 6,529 (4,745) 1,784 46,114 (11,114) 35,000

Variance over £35m 11,114 0 Variance over £25m 21,114 10,000

10 Appendix 3 – Savings

Savings Plan and Forecast

 The savings programme is based on the planned delivery of schemes. The value of green and amber schemes has risen by £2.9m from £33.7m in Month 7 to £36.6m in Month 8. The overall value of the programme has however reduced by £1.7m in month, reflecting reductions as a result of a re-assessment by the Financial Recovery Group of the likely delivery of pipeline schemes for Continuing Healthcare and outpatients, offset by the introduction of additional Procurement savings and Divisional recovery schemes.

Month 8 Position Red Amber Green Total £m £m £m £m Cash Releasing 1.693 0.434 21.269 23.396

Cost Avoidance 6.584 0.136 14.055 20.775

Efficiency 0.250 0.005 0.712 0.967

Total 8.527 0.575 36.036 45.138

 The original planned deficit is achievable if the Health Board can convert and deliver 51% of the red schemes, plus deliver green and amber schemes at their planned values, and contain or offset emerging cost pressures. In addition, mitigating savings totalling £1.8m need to be identified to offset the impact of the Health Board’s share of the Welsh Risk Pool risk share contribution.

 It should be noted that there is a gap between the planned savings as recorded above and the forecast delivery of savings. Where forecast of schemes has slipped from the plan, work needs to be done to increase delivery or identify additional schemes to make up the shortfall. Amber Green Total £m £m £m Planned savings 0.575 36.036 36.611

Actual/forecast savings 0.401 32.439 32.840

Forecast under delivery against plan 0.174 3.597 3.771

11 Appendix 3 – Savings

Savings Actions

 The Recovery Programme continues to drive the identification and delivery of savings, alongside reduction in expenditure run rates. Key areas of focus are: ­ In Month 7 the first tranche of Improvement Group schemes progressed from red to amber (including procurement savings £1.53m and workforce savings £1.03m). ­ Effective delivery of schemes developed by Improvement Groups needs to be demonstrated from Month 9. It is vital that Improvement Groups, with the support of the PMO, take the Divisions with them through the necessary rapid pace of change to secure delivery of these savings.

 Individual divisions have also continued to progress local schemes in response to the focus on these issues within the Divisional Recovery Meetings.

 The main areas of slippage on savings schemes at Month 8 are Medical rostering / agency and divisional savings.

 Focus is on the conversion of red schemes into green and amber and driving delivery in the rest of the programme. The main areas targeted for converting further savings opportunities from pipeline are: ­ Workforce, ­ Continuing Healthcare, ­ Medicines Management, and ­ Procurement.

Underlying Position

 A key risk to the Health Board is its underlying deficit. The deficit brought forward from 2018/19 was £55.1m. The underlying position carried forward into 2020/21 is showing a significant reduction but is dependent on sufficient recurring savings opportunities being generated to positively impact on next year’s position.

12 Appendix 4 – Expenditure

Pay Expenditure

Total Pay

£70M

£68M

£66M

£64M

£62M

£M £60M

£58M

£56M

£54M

£52M

£50M Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Substantive Agency Bank Locum Other Non Core Overtime Additional Hours WLI's Average Total Pay

13 Appendix 4 – Expenditure

Actuals Cumulative YTD RTT Costs Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 YTD YTD YTD Included 2019/120 2019/120 2019/120 2019/120 2019/120 2019/120 2019/120 2019/120 Budget Actual Variance in Actuals £m £m £m £m £m £m £m £m £m £m £m £m Administrative & Clerical 8.4 8.1 8.1 8.0 8.1 8.1 8.2 8.2 69.7 65.2 (4.5) 0.1 Medical & Dental 14.3 14.0 14.3 14.7 14.7 14.4 16.9 14.5 112.7 117.8 5.1 1.9 Nursing & Midwifery Registered 21.3 20.1 20.1 20.2 19.7 20.0 19.9 19.9 168.9 161.2 (7.7) 0.4 Additional Clinical Services 10.0 9.2 9.3 9.3 9.0 9.2 9.0 8.9 68.3 73.9 5.6 0.1 Add Prof Scientific & Technical 2.5 2.6 2.3 2.4 2.8 2.6 2.7 2.8 21.8 20.7 (1.1) 0.0 Allied Health Professionals 3.7 3.7 3.7 3.7 3.7 3.7 3.8 3.7 29.7 29.7 0.0 0.4 Healthcare Scientists 1.2 1.2 1.1 1.1 1.1 1.1 1.2 1.1 8.9 9.1 0.2 0.0 Estates & Ancillary 3.2 3.0 3.1 2.9 3.1 3.0 3.0 3.0 25.0 24.3 (0.7) 0.1 Savings to be allocated (1.6) 1.6 Health Board Total 64.6 61.9 62.0 62.3 62.2 62.1 64.7 62.1 503.4 501.9 (1.5) 3.0 Primary care 1.9 1.8 2.0 1.9 2.0 1.8 1.9 1.9 13.3 15.2 1.9 0.0 Total Pay 66.5 63.7 64.0 64.2 64.2 63.9 66.6 64.0 516.7 517.1 0.4 3.0

 11.1% (£7.1m) of total in-month pay (11.8% / £60.9m year to date) related to variable pay; agency, bank, overtime, locum, WLI, other non-core and additional hours, £0.8m less than in October. This decrease is due to falls in agency costs (£0.5m), locums (£0.2m) and other non-core costs (£0.2m). Total expenditure on locum staff for Month 8 is £0.6m.

 Expenditure on agency staff for Month 8 is £3.1m, representing 4.8% of total pay, and £0.4m lower than last month. Medical agency costs have decreased by £0.3m to an in-month spend of £1.3m. The decrease is across all areas except for Wrexham Maelor where additional agency usage has been required for ED and Anaesthetics. Nurse agency costs totalled £1.1m for the month, a decrease of £0.1m from last month. The reduction is costs is due to a decrease in the number of escalation beds at Wrexham. Vacancies and increasing sickness absence rates remain the root cause of the majority of agency spend.

14 Appendix 4 – Expenditure

Futher Pay Analysis £68M 17600

£66M 17400

£64M 17200

£62M 17000

£60M 16800 £M WTE

£58M 16600

£56M 16400

£54M 16200

£52M 16000

£50M 15800

Core Pay Agency Bank Locum Other Medical Pay WLIs Overtime Additional Basic Pay Pay Budget Budgeted WTE Actual WTE

15 Appendix 4 – Expenditure

Agency Spend £4.0 M

£3.5 M

£3.0 M

£2.5 M

£2.0 M

£1.5 M

£1.0 M

£.5 M

£.0 M

Ysbyty Glan Clwyd Ysbyty Maelor Wrexham Other Mental Health & LDS Ysbyty Gwynedd East Area Central Area West Area Medical Agency Agency Nursing Other Agency

16 Appendix 4 – Expenditure

 The Workforce Optimisation Portfolio is the overarching mechanism to ensure successful delivery of the Health Board’s workforce initiatives. Recent actions: ­ Medical rostering / job planning / recruitment - external expert’s recommendations have begun to be enacted. ­ External recruitment consultants are sourcing substantive Medical staff. ­ Medical Staff bank is predicted to save over £270,000 this financial year.

 Establishment Control process including Vacancy Authorisation Panel (VAP) / Workforce Authorisation Panel (WAP) continues to give scrutiny of any increased substantive wage spend. For non-core spend the focus remains on filling substantive vacancies, reducing sickness absence and increasing pools of internal temporary staff, particularly in nursing, medical and dental and admin.

 The Health Board’s overall sickness absence rate has reduced to 5.22% (5.29% in Month 7). Percentage of Long Term sickness continues to fall. Focus on priority areas and changes to enhanced pay will reduce short term frequent sickness absence and medium sickness rates in a similar way to the continued reduction in long term absence.

 Successful recruitment of newly qualified staff and experienced staff from other providers has seen nursing vacancy rates fall for three consecutive month. Medical vacancies have increased to 11.1% from 9.4%. A Medical Recruitment Panel has been introduced to give focus on quickly filling vacancies, reducing the vacancy rate and associated agency spend.

 There has been a focus on increasing the capacity of internal temporary staffing: ­ Nursing - actions include auto enrolment of new substantive staff and revised pay rates. These rates are promoted to both encourage existing bank staff to do more shifts and to attract agency staff to bank. ­ Medical - further efforts to move temporary staffing spend from agency to cheaper alternatives via the Medical Staff Bank went live on 11th November. ­ Admin – The A&C staff bank continues grow and is on target to have all temporary staffing via bank by March.

17 Appendix 4 – Expenditure

Non-Pay Expenditure

Non-Pay Expenditure

96

91

86

m 81 £

76

71

66 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19

Actual £m Average Non-Pay

Actuals Cumulative Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Month 7 Month 8 YTD Y T D Y T D 2019/120 2019/120 2019/120 2019/120 2019/120 2019/120 2019/120 2019/120 Budget Actual Variance £m £m £m £m £m £m £m £m £m £m £m Primary Care 16.7 17.0 17.3 16.9 17.4 17.3 18.6 18.1 140.9 139.3 (1.6) Primary Care Drugs 8.2 8.2 8.2 8.2 8.6 8.7 8.8 8.3 64.4 67.2 2.8 Secondary Care Drugs 5.9 6.0 5.6 6.3 5.8 5.9 6.0 6.1 45.5 47.6 2.1 Clinical Supplies 5.3 5.6 5.5 5.9 5.6 5.6 5.7 5.6 44.6 44.8 0.2 General Supplies 1.8 2.3 1.3 5.3 2.6 3.3 2.8 2.5 21.1 21.9 0.8 Healthcare Services Provided by Other NHS Bodies 21.1 21.0 21.5 23.1 22.2 21.5 20.6 21.8 175.2 172.8 (2.4) Continuing Care and Funded Nursing Care 8.3 8.3 8.1 8.0 8.2 8.0 7.9 8.0 64.2 64.8 0.6 Other 5.1 5.9 5.6 5.2 5.0 4.5 7.1 5.6 32.8 44.0 11.2 Capital 2.4 2.6 3.5 2.9 2.8 2.8 2.5 2.8 22.3 22.3 0.0 Total 74.8 76.9 76.6 81.8 78.2 77.6 80.0 78.8 611.0 624.7 13.7

18 Appendix 4 – Expenditure

 Primary Care: The Health Board continues to see cost pressures within Managed Practices particularly in relation to locum GP costs and more recently an increase in the dispensing cost of drugs. Month 7 actual costs were inflated by £1.0m due to the GDS and GMS uplifts, which were fully funded. However cost pressures in GMS have meant that expenditure remains higher than the average.

 Primary Care drugs: This remains one of the Health Board’s key risks. The latest data available (September 2019) shows an increase in Prescribing costs for the Health Board of £2.4m (4.5%) in the rolling 12 month period. Whilst there is a 1.5% increase in the number of items prescribed (1.6% nationally), this only equates to an increased cost of £0.8m. The remaining £1.6m is due to price changes (typically Category M drugs or No Cheaper Stock Obtainable (NCSO)). The impact of National Prices for the Health Board up to Month 8 is therefore estimated at £2.2m, with a forecast of at least £3.5m for the year. For 2019/20 the forecasting methodologies are now indicating a range of outturns for the Health Board from £113m to £115.2m. With the continued price increases in NCSO and Category M, the outturn could increase to £116m. Should the October data indicate a further increase in the Forecasting Methodologies, then then Health Board will need to increase the current £113m forecast and therefore consider and identify mitigating actions in order to avoid increasing the overall Health Board Forecast.

 Secondary Care drugs: Costs have risen by £0.1m from October and are just above the run rate for the year. This primarily relates to an increase in Cancer drugs. However, spend across most Divisions continues to outstrip budgets,

 Healthcare Services provided by Other NHS Bodies: The WHSCC contract performed well in Month 7 as slippage on development funds was been released. Costs in Month 8 have returned to the average for the year.

 Other non-pay expenditure: ­ Unallocated and non-delivering savings schemes are contributing £8.9m to the over spend. These savings targets have all been apportioned to divisions, but the divisions have not allocated them to specific cost areas. This total includes savings from the 2019/20 original £25m target and savings targets brought forward from prior years that did not have recurrent schemes attached to them (total of £3.9m) plus the year to date share of the £10m additional savings for which schemes have not yet been confirmed (£5m). ­ In addition the ‘Other’ category includes year to date over spends on IT costs (£0.9m) and travel (£0.8m), predominantly Non- Emergency Patient Transport Service (NEPTS). ­ Actual costs have fallen in month as Month 7 included the £1.0m cost for the support provided by PwC to the PMO, which has not been replicated in Month 8.

19 Appendix 4 – Expenditure

RTT

Support Expenditure Category YG YGC YWM Other Services Outsource Total £000 £000 £000 £000 £000 £000 £000 Pay Costs 1,210 1,022 199 132 497 - 3,061 Theatre Non Pay 221 184 108 513 Other Non Pay 559 643 60 57 1,266 2,585 Outsourced Activity 1,154 1,154 Insourcing 999 379 300 1,678 Total Expenditure 2,990 2,228 667 189 1,763 1,154 8,991

s Cardiology - 14 14 c i t Gastro / Endoscopy 1,497 648 337 2,482 s

o Ophthalmology 71 - 71 n

g Radiology - 1,763 1,763 a i

D Urology 40 40 Sub Total 1,568 648 391 - 1,763 - 4,370 s t

n Anaesthetics 7 1 18 26 e i t ENT 36 169 - 205 a p

t General Surgery 167 182 2 4 354 u

O Gen Med 2 2

s

e Max Fax 96 - 2 98 s

a Oral 52 52 c y

a Ophthalmology 221 276 69 21 587 D

s Orthopaedics 827 636 178 114 796 2,551 t

n Other - 57 57 e i t

a Urology 112 178 26 331 647 p n

I WPAS Validators 43 - 43 Sub Total 1,422 1,580 276 189 - 1,154 4,621 Total Expenditure 2,990 2,228 667 189 1,763 1,154 8,991

20 Appendix 5 – Balance Sheet

Balance sheet as at Month 8 2019/20 Opening balance M8 2019/20 Movement £000 £000 £000 Non Current Assets: Fixed Assets 627,406 613,520 (13,886) Other Non Current Assets 69,363 68,998 (365) Current Assets: 0 Inventories 16,077 17,082 1,005 Trade and other receivables 66,441 38,182 (28,259) Cash - Revenue 307 (1,306) (1,613) Cash - Capital 3,665 2,245 (1,420) Total Assets 783,259 738,721 (44,538) Liabilities: Trade and other payables 142,428 114,640 (27,788) Provisions 110,432 109,805 (627) Total Liabilities 252,860 224,445 (28,415)

530,399 514,276 (16,123) Financed by: General Fund 402,323 386,200 (16,123) Revaluation Reserve 128,076 128,076 0 Total Funding 530,399 514,276 (16,123)

21 Appendix 6 – Risks and Opportunities

Key Decision Point & Issue Description Risk Owner £m Summary Mitigation ­ Potential risk in relation to the Welsh Risk Pool. NWSSP are forecasting that annual expenditure will exceed the 2019/20 budget by Risk: Welsh Tony Uttley, Interim £9.851m. Welsh NHS organisations will need to take a share of this 1 Risk Pool (1.8) Discussions continue around potential mitigations. Finance Director – pressure. The Health Board’s share of this cost is £1.817m and is ­ Pressure Operational Finance included in the forecast. However there is a risk that the increased savings required to meet this pressure will not be delivered. Lowest forecast methodology is used, giving rise to a possible financial ­ Berwyn Owen, Chief risk. Actual costs to date in 2019/20 are showing a rising run-rate. The risk is reviewed and updated monthly. Pharmacist & Nigel Risk: Emerging issue is Category M price increases, which have been ­ 2 ­ (3.0) There are a wide range of Prescribing Savings Schemes McCann, CFO Prescribing reflected in the risk. ­ in place to manage spend and growth. Prescribing Finance Does not include any potential growth in the number of drug items ­ Lead added to the No Cheaper Stock Obtainable (NCSO) price list. Risk: Rob Nolan, Finance - The financial plan approved by the Board explicitly excluded providing Continuing Divisions are developing cost avoidance schemes to Director – 3 growth funding for CHC. The risk on CHC is primarily in relation to (1.0) ­ Healthcare mitigate against this impact. Commissioning & Older People’s Mental Health. (CHC) Strategy Risk: Under- Green and amber cash releasing savings identified totalled £23.4m, a The Health Board is continuing to identify new schemes Sue Hill, Executive performance ­ ­ 4 shortfall of £1.6m against the initial plan target of £25m. Of these, (2.4) and move existing red schemes into amber and green in of savings Director of Finance £0.8m relates to efficiencies, meaning the total risk is £2.4m. order to close the gap to the initial £25.0m plan target. plans The Health Board’s Single Integrated Clinical Assessment and Triage (SICAT) service was set up at the end of 2018/19 and fully funded by the Eric Gardiner, 5 Risk: SICAT 111 Programme. The service has incurred costs of circa £0.38m in the Finance Director – (0.6) ­ An alternative funding source for SICAT is being sought. first 8 months of the year with a forecast cost for 2019/20 of £0.6m. It Provider Services has been assumed to date that SICAT would be fully funded by the 111 Programme, but this is no longer the case. ­ Further investigations are being undertaken to quantify any potential impact. The Health Board is working to Sue Green, Executive Risk: Junior mitigate this risk through a number of measures. To date There was a significant test legal case focusing on how NHS Director of Workforce 6 Doctor ­ there have been no concerns raised within the Health organisations should address monitoring for junior doctors. & Organisational monitoring Board. A review is in place dating back 6 years assessing Development the substitution and the impact it has on natural breaks. This should help provide further information. Control total of £25m set by the Welsh Government requires a further Opportunity: ­ Work has been initiated through improvement groups, £10m of savings to be made. If schemes can be identified they have ­ Sue Hill, Executive 7 Stretch 10.0 looking at benchmarking and opportunities, to identify the potential to reduce the year end position below the £35m currently Director of Finance Target savings plans to meet these targets. forecast.

Total 1.2

22 Appendix 7 – Response to Month 7 Questions

MONTH 7 FINANCES

Executive Summary – Page 1

The improvement was largely due to a £0.9m benefit on the WHSCC contract, offset by increasing pressures in Prescribing.

With everyone focused on stopping spending and delivering savings, then the £35m remains achievable. This will require commitment and concerted effort by all Executives and across all divisions for the remainder of the year.

Forecast full-year out-turn will be kept under continuous review, with increasingly critical re-assessments from December.

Year to Date and Forecast Overview – Page 2 & 3

The Grip and Control actions arising from the PwC recommendations have been enacted and there continues to be a focus on the remaining actions. The actions undertaken have supported improved practices and governance, as well as controls around expenditure.

The assessment of cost pressures is based on best information from across the organisation at that point. It does change over time, both as a result of factors under Health Board control and influence and as a result of environmental factors which are less so. It is subject to ongoing review and assessment, which in turn builds an evidence base of track record from which to more reliably estimate the potential impact going forward. This is being used to inform the planning and budget-setting process for 2020/21

It is generally expected that Health Boards will manage pressures, and mitigate identified risks. This expectation falls differently on Health Boards depending on their local circumstances and the flexibilities they have within their positions - the less flexibility the harder it is to absorb such pressures. In the case of the Risk Pool, the arrangement was useful for Health Boards as it is more effective to deal with such costs on a pooled basis. However, the pooling has ceased to be effective this year, and Health Boards have now had to revert to account for the pool’s shortfall in their individual positions.

At M7 we reported the potential Risk Pool risk of £2.8m, as advised at the time. At M8 we have not recognised our share of the Risk Pool shortfall in the year to date position, but have included the new estimate of our share in the full year forecast as a realising pressure. We have also recognised the need to find mitigating actions to cover this. The potential exposure advised to us has swung between £0.6m to £2.8m over a 3 month period, and has reduced to £1.8m at Month 8.

23 Appendix 7 – Response to Month 7 Questions

Annual Plan The planning process includes a review of the cost pressures brought forward from 2019/20 and an assessment of new inflation and growth pressures for 2020/21. This exercise is undertaken in conjunction with Divisions and provides an opportunity for a realistic assessment of pressures with appropriate challenge. It is not expected that the Health Board will be able or willing to fully fund individual divisional submissions because it is recognised that budget holders have a responsibility to manage within their budget and make every effort to live within their means. To assist in closing any gap which is identified, each Division will be subject to a deep dive into their draft budgets to clearly identify opportunities to manage budgets more effectively, to identify areas that consistently underspend and to explore how using this financial scope can help to address outstanding pressures. This will be undertaken prior to the start of the new financial year in January.

These show the forecast expenditure run rates before and after forecasted savings are taken into account. There is little difference between the two as savings equate to only 2% of total expenditure; they were an action from Month 6’s Finance and Performance Committee meeting but did not work in practice. The equivalent Month graphs have been removed from the Month 8 Finance Report.

Financial Governance and Control There have been a number of additional controls put in place at YGC by the hospital management team in the last few months. This includes approval in advance of cover colleague shifts and a non-pay panel that meets weekly to look for opportunities.

The site has historical issues of rotas in place above budgeted establishment. A lot of work has been undertaken within ED to reduce the run rate by employing temporary staff into these posts instead of premium cost staff. Whilst the run rate has reduced, the rotas in place are not budgeted and remain a cost pressure.

A number of services have been centralised into YGC and there has been an impact on the costs of other services.

The site has only identified a low value of cash releasing savings against its target (circa. 25%) which is one of the most significant factors causing the failure to reduce overspend to date. The site is significantly behind the other acute hospitals in this respect and needs to catch up. A number of schemes are identified such as transferring orthopaedics off the Abergele site, but it will take some time for this to be implemented.

A desktop review of the actual expenditure and WTEs over the last three years is underway and will be completed, with findings and recommendations before the year end.

24 Appendix 7 – Response to Month 7 Questions

Budget Scrutiny Meetings

Aside from the Financial Recovery programme scheduled meetings, all the divisions have set up additional scrutiny meetings in order to respond to the challenge around financial management, including savings delivery and opportunities to offset cost pressures. The main challenge to the divisions remains the handover of accountability for pan-BCUHB schemes.

There remain eight actions from the PwC Grip and Control recommendations to conclude. Significant work has progressed in all of these areas and this will continue, to ensure sustainable change is achieved.

Forecast Cost Pressures

East Area and Wrexham Maelor have maintained their year-end forecasted position as they have covered any cost pressures with additional savings or one-off benefits. We are clear that our forecasting consistency and capability across the Health Board needs to be improved and this is the subject of a Finance working group.

Budgetary Control – Page 4

Budget Holders have signed their Accountability Agreements which includes their agreed budget for the year. Where a budget holder feels they are not in a position to operate within their budget they have the option to include a narrative within their Accountability Agreement. Budget Accountability Agreements are signed in April as part of the Opening Budget, but taking this financial year as the example, the Divisions were given a collective share of an additional £10m savings target. The Budget Accountability Agreements were not then changed to reflect this, although some divisions have nevertheless demonstrated progress towards achieving these stretch targets.

Accountability meetings are held quarterly between Executives and Divisions which include a review of the individual Division’s financial position. It is suggested / recommended that any material in-year changes to the overall bottom line Divisional Budget (or spending plans) are also reflected in a New / Updated Accountability Agreement, which formally records the reason for the change and the implications of such a change, the source of additional funding for any increase in core spend, etc.

However, it is clear that individual budgets have been set which didn’t reflect the FYE of cost pressures and that the impact of the non-recurrent delivery of savings over several years has been a significant contribution to the Health Board’s current financial position.

25 Appendix 7 – Response to Month 7 Questions

Forecasting

Robust expenditure plans refer to the spending plans that underpin additional funding received from Welsh Government. Additional funding is initially held in a central reserve, and is distributed to the relevant divisions as soon as possible but only once the appropriate use of this funding is established. There should be no bottom line impact overall as the spending plan should underpin the funding provided, although the impact of accounting for the funding and the related expenditure does affect expenditure trends in the relevant costs.

In Month 7 we had significant new funding. This is still being held centrally pending confirmation of appropriate plans.

Potential inconsistencies refer to differences between planned savings included in defined pan-BCU schemes developed through Improvement Groups, and the savings projected within the individual divisions that benefit from these schemes as they contribute to the achievement of their divisional savings targets.

The IGs are now beginning to develop and convert significant pan-BCU wide schemes. A number of these schemes were implemented at speed in Month 7. The datasets that support these schemes and enable their effective tracking and reporting across all the costs and divisions benefiting from them are being developed but lagged behind the schemes’ implementation. In this context, divisional forecast did not fully recognise the full potential benefit of these schemes. The impact of these differences, which have been corrected centrally at corporate level, is shown within the Month 8 Finance Report.

The overall forecasts accordingly recognise the benefit of these pan-BCU wide schemes. It is acknowledged that the datasets referred to above and the related communication between IGs and divisions impacted by these significant schemes needs to be developed further to enhance collective understanding.

Savings – Page 5

The anticipated conversion and delivery of red risk savings is based on information provided by the PMO. It is clear that the £35m deficit position will only be realised if conversion of red schemes and delivery of all savings is at the level currently forecast. WG, through the Monitoring Return, are sighted on this position and are keen that all savings are quickly moved into delivery.

Further escalatory actions are currently in rapid development in order to create further impetus and surety around the delivery of the £35m deficit forecast.

There is also an urgent requirement for the PMO to validate the monthly profile of the red schemes, in order to identify any opportunities to bring

26 Appendix 7 – Response to Month 7 Questions

delivery forward and provide greater assurance around the forecast out-turn position.

The anticipated conversion and delivery of red risk savings is based on information provided by the PMO. This takes into account the work of the IGs and their forecast for the savings that they will deliver. IGs are responsible for meeting their savings plans.

As noted above additional escalatory measures are also being adopted to supplement additional IG schemes development.

The Month 8 in month deficit has necessitated the consideration of more radical cost reduction options in order to deliver the average sub £2m deficit each month in the last 4 months of the year required to deliver the forecast.

Underlying Deficit

This will be going to January F&P Committee, in order to reflect a coordinated assessment in conjunction with the FDU.

We await details of the funding allocations for next year.

Our emerging IGs are critical in identifying and addressing efficiency gains on an ongoing basis.

The Health Board also has a number of sub-optimal structural costs, eg our Estate and asset-related costs amount to over £100m per annum.

The savings programme is supported by information on our areas of inefficiencies which is drawn from both the FDU’s Efficiency Framework and our own Benchmarking analysis. This has been distributed to Improvement Groups and was referenced in the planning workshop as a key source of intelligence regarding opportunities for savings. Savings identified against opportunities highlighted by the FDU will be tracked in year to demonstrate progress in addressing inefficiencies. Clearly progress by our IGs will both reveal and also address identified efficiency and other gains as they develop further and expand their ongoing impact.

Welsh Government will be issuing the details of a new national allocation formula within the 2020/21 Allocation Letter, and we have been told that the allocation of growth will be based on our Outcomes. Within the rollout of the new formula is a commitment to develop the formula down to Cluster level for 2021/22. As a Finance function we have expressed our wish to be involved in the piloting of this work in 2020/21.

27 Appendix 7 – Response to Month 7 Questions

Risks and Opportunities – Page 7

Opportunities

Divisions are still actively trying to identify savings to meet their stretch targets. The opportunity level is reviewed each month and we have increased our risk rating to red in Month 8. This will be reviewed continuously, as will our forecast, as we move closer to the end of the financial year.

Revenue Resource Limit – Page 8

Income and Expenditure

Project leads have been asked to liaise with Welsh Government policy leads to determine the likelihood that funding which is not fully committed will be subject to clawback. If this is the case, there is no detrimental impact as the funding is not currently in the year to date position, nor considered for the forecast. If slippage on funding can be retained then this may have a positive impact on the position. A specific and significant risk relates to committed RTT funding, in light of the current performance trajectory.

Pay Expenditure – Page 9

Pay Award

The pay award has only impacted on actual pay costs and not the variance. Reserves were held to cover the cost of the pay award and have been released to match actual costs, so there was no impact on the position.

Agency and Locum Costs – Page 10

Establishment

Medical agency costs increased in July and remained at that high level, although we have seen a decrease in November. A combination of using more agency staff to deliver RTT related activity and the implementation of the pension taper relief rules has led to an increase in medical agency staff usage over recent months. This should start to reduce again with the implementation on the Medical Staff Bank.

Substantial work is underway through multiple workstreams with the WIG’s oversight. Onboarding the additional staff costs that will support the identified savings are subject to strong establishment controls. Steps are being taken to carefully manage further third party costs that support savings realisation, which tend to be front-end loaded (eg permanent candidate finders fees) relative to prospective savings, to ensure their incidence close to year end does not compromise in-year savings.

28 Appendix 7 – Response to Month 7 Questions

The Kendal Bluck work has taken longer than originally planned but the final reports are now being fed back to the Health Board and discussed with the management teams. Some of the findings in the reports will challenge the Health Board to operate different models but have large savings attached to them. There is Executive support for this scheme to be delivered this year.

Some of the increased cost will be funded from the Winter Plan in the short term while the staffing structures are reviewed for the longer term.

The nursing workforce is also being reviewed in parallel with the medical staffing as they need to operate as a single integrated team to be successful.

The delivery of the WIG schemes in the current financial year is critical as they should deliver significant reductions in pay budgets for 20/12.

Non-Pay Expenditure – Page 12

Primary Care

These uplifts have only impacted on actual costs and not the variance. Funding was received in Month 7 to cover the cost of the uplifts and has been brought into the position to match actual costs, so there is no impact on the position.

Other Non-Pay

These savings have been allocated to the divisions and it is the responsibility of the divisions to identify savings schemes to meet these targets. When recurrent schemes have not been identified, divisions will hold those savings targets on a savings subjective within one or more of their cost centres. As recurrent schemes are identified, these targets will be moved to the relevant subjectives. Stretch targets that have not been covered by converted savings schemes are also held centrally within divisions.

The coding of savings within divisions is being reviewed for 2020/21.

RTT – Page 13

The £7.740m spent to date on RTT is included in the figures in the rest of the Finance Report. An additional £6.1m has been committed, to bring total commitment to £13.8m. This committed expenditure has not yet been spent, so is not reflected in the year to date financial position, but is included in expenditure forecasts.

29 Appendix 7 – Response to Month 7 Questions

Performance data is included in the IPQR report. We will consider improved ways of presenting plan and actual financial and non-financial performance going forward.

Balance Sheet – Page 14

Reserves

In previous years the reserves have been managed and held centrally but this year, where it was practical, we have allocated reserves to divisions. The strategy is to only hold reserves centrally where there is a clear advantage in doing so. The establishment of contingency reserves is addressed in annual planning and budget-setting.

The utilisation of reserves is managed by the Directors of Finance, who have pan-BCU responsibilities and ensure that the reserves are responsibly reviewed and released when appropriate.

See also comments above in relation to “…robust expenditure plans…”.

The opening contingency reserve was set at £2.4m. Of this £0.7m has been released to fund specific unexpected cost pressures such as increases in Losses and Compensation Claims. In addition to this, a further £1.3m has been phased in to support the financial position.

30 31 5 FP19/296 2019/20 Annual Plan Progress Monitoring Report 1 FP19.296a APPMR.docx

1

Cyfarfod a dyddiad: Finance & Performance Committee Meeting and date: 19.12.19 Cyhoeddus neu Breifat: Public Public or Private: Teitl yr Adroddiad Annual Plan Progress Monitoring Report (APPMR) Report Title: Cyfarwyddwr Cyfrifol: Mr Mark Wilkinson Executive Director of Planning & Responsible Director: Performance Awdur yr Adroddiad Dr Jill Newman, Director of Performance Report Author: Craffu blaenorol: This paper has been scrutinised and approved by the Prior Scrutiny: Executive Team and the Executive Director of Planning and Performance. Atodiadau 1. APPMR Appendices: Argymhelliad / Recommendation: The Finance & Performance Committee is asked to note the report.

Ar gyfer Ar gyfer Ar gyfer Er penderfyniad Trafodaeth sicrwydd gwybodaeth /cymeradwyaeth  For Decision/ For For For Approval * Discussion* Assurance* Information* Sefyllfa / Situation: This report provides a self-assessment by the executive leads of the progress being made in delivering the key actions contained in the 2019/20 Operational plan.

Cefndir / Background: The operational plan has a number of key actions required to be delivered during 2019/20. The Executive lead reviews on a monthly basis progress against their areas for action and RAG-rates progress. Where an action is complete this is RAG rated purple, where on course to deliver the year end position the rating is green. Amber and red ratings are used for actions where there are risks to manage to secure delivery or where delivery is no longer likely to be achieved. For Amber and Red rated actions a short narrative is provided. The plan was reviewed at the finance and performance committee in November and a number of the original actions revised. These revisions have been included in this report. 2

Asesiad / Assessment Strategy Implications Delivery of the operational plan actions is key to implementation of the Boards strategy

Financial Implications Delivery of the operational plan within the budget set by the Health Board is part of ensuring resources are well-managed and care effectively provided within the allocated resources.

Risk Analysis The RAG-rating reflects the risk to delivery of key actions

Impact Assessment The operational plan has been Equality Impact Assessed. Cover Page

1 FP19.296b Annual Plan Progress Monitoring Report - November 2019 v0.8.pptx Three Year Outlook and 2019/20 Annual Plan: Monitoring of Progress against Actions 1

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Table of Contents

Table of Contents.. 2

Cover 1 Workforce Matrix 12 Content 2 Workforce Exception Report 13

About this Report 3 Estates Matrix 14

Health Improvement & Health Inequalities Matrix 4 Estates Exception Report 15

Health Improvement & Health Inequalities Exception 5 Digital Health Matrix 16 Report Care Closer to Home Matrix 6 Digital Health Exception Report 17

Care Closer to Home Exception 7 Digital Health Exception Report 18

Planned Care Matrix 8 Finance Matrix 19

Planned Care Exception Report 9 Finance Exception 20

Unscheduled Care Matrix 10 Further Information 21 Unscheduled Care Exception Report 11

Three Year Outlook and 2019/20 Annual Plan Monitoring of progress against Actions for Year One (2019/20)

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly About This Report

About this Report.. 3 This report presents performance as at the end of October 2019 against the 2019/20 Annual Plan actions, and is presented in the same order as the plan i.e. health improvement and health inequalities, care closer to home, planned care, unscheduled care, workforce, digital, estates and finance.

The ratings have been self assessed by the relevant lead executive director. All the ratings have been reviewed and approved by the lead executive.

Where a red or amber rating is applied in any month, a short narrative is provided to explain the reasons for this and actions being taken to address.

To interpret this report, it is necessary to note the basis of the rating which provides a succinct forecast of delivery, combined with an assessment of relative risk. Future milestone markers are included as M in the matrix to indicate when elements of actions contained in the report were due for completion. Many of the actions have multiple milestones to support delivery of the year end position. Only when all milestones are complete can the action be achieved.

Feedback is welcomed on this report and how it can be strengthened. Please email [email protected].

Three Year Outlook and 2019/20 Annual Plan Monitoring of progress against Actions for Year One (2019/20)

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Programme: Health Improvement & Health Inequalities

Health Improvement & Programme. 4 Health Inequalities Matrix

Three Year Outlook and 2019/20 Annual Plan Monitoring of progress against Actions for Year One (2019/20)

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly About This Report

Programme.. Health Improvement & Health Inequalities 5 Exception AP008 - Partnership plan for children progressed with a strong focus on adverse childhood experiences Improved partnership working is taking place across children’s services. All services are gradually focusing their work with an ‘ACE aware and trauma informed’ approach. This particularly takes place within our services for Children who are Looked After (LAC) where there is significant multiagency team work to enable earlier intervention. This is as a result of the Children’s Transformation Bid investment. Partnership working is also evident for the implementation of the Additional Learning Needs (ALN) Act, with work taking place to develop the role of the DECLO. More recently a multi- disciplinary arrangement has been agreed between the health board and third sector partners in the development of an On-call rota for the provision of care to children at the End of their Life, as expected within the palliative care standards. While progress is being made there are risks to delivery which mean that the overall action remains amber at present.

Three Year Outlook and 2019/20 Annual Plan Monitoring of progress against Actions for Year One (2019/20)

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Programme: Care Closer to Home

Programme.Care Closer to Home Matrix 6

Three Year Outlook and 2019/20 Annual Plan Monitoring of progress against Actions for Year One (2019/20)

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly About This Report

Programme..Care Closer to Home Exception 7

AP014 Model for health and well-being centres created with partners, based around the “home first” ethos Work on this action is progressing, but presently on is based on three footprints, and the approach is not yet sufficiently collated into a single model for this action to be considered as green, although good progress towards achieving the action continues.

AP016 Plan and Deliver Digitally Enabled Transformation of Community Care - Procurement delays related to IT, alongside the multi-partner approach and requirement for system upgrades in a number of areas have resulted in there being some slippage on the delivery of this action. This is therefore rated amber.

Three Year Outlook and 2019/20 Annual Plan Monitoring of progress against Actions for Year One (2019/20)

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Programme: Planned Care

Programme.Planned Care Matrix 8

Three Year Outlook and 2019/20 Annual Plan Monitoring of progress against Actions for Year One (2019/20)

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly About This Report

Programme..Planned Care Exception 9

AP021: Implement preferred service model for acute urology services Task group have been meeting re the assisted robotic service in urology, the model for Urology continues to be worked on and the operational difficulties are being worked through AP022: Business case, implementation plan and commencement of enabling works for Orthopaedics The orthopaedic 1st wave of consultants have been recruited and commence in new year. The orthopaedic business case is being reviewed at this current time and early work around theatre capacity has commenced AP023: Transform Eye Care Pathway The eye care improvement work is progressing on time with the cataract pathway now embedded on all three sites, the glaucoma pathway re-design commencing during December and with tender evaluation scheduled for early January to develop the primary care shared care model and the wet AMD facility on schedule to deliver at the end of December 2019. However the progress is amber rated as there are risks which are needing to be managed both locally within BCU and with slippage on the national programme of work. For example the national digital eye care procurement is awaiting award of contract, which was originally planned for October 2019 and the e-referral project is subject to further decision as to the preferred option. Locally the training requirements for non-medical staff combined with the need to ensure image transfer from optometry to hospital eye services can be achieved will mean that the 2019/20 benefits from the shared care arrangements will originate from referral refinement with benefits from patient monitoring and management arising in 2020/21 once staff have completed higher level training and have signed off competencies. A full briefing paper on progress will be provided to the Finance & Performance committee in January 2020. AP024: Rheumatology Service Review Good recent progress, with board paper imminent, but as this was due in July 2019, the action can only remain Amber. AP025: Systematic Review and Plans developed to address sustainability for all planned care specialties: Work is continuing on the 2019/20 delivery plan. Demand and Capacity analysis for 2020/21 across all specialties is progressing to contribute to the operational plan. The full systematic review of all services will not be completed in accordance with the plan, priority is being given to those specialities with the greatest challenge to delivery. AP025: Endoscopy Amber There is a plan in place to deliver the end of year position of 700 over 8 weeks. This is now operational following the commencement of additional insourcing at YGC and Wrexham. However it is dependent upon the allocation of additional resource as highlighted in the RTT paper discussed at F&P on 4th December 2019. AP025: Systematic Review and Plans developed to address sustainability for all planned care specialties: Work is continuing on the 2019/20 delivery plan. Demand and Capacity analysis for 2020/21 across all specialties is progressing to contribute to the operational plan. The full systematic review of all services will not be completed in accordance with the plan, priority is being given to those specialities with the greatest challenge to delivery.

Three Year Outlook and 2019/20 Annual Plan Monitoring of progress against Actions for Year One (2019/20)

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Programme: Workforce

Programme .Unscheduled Care Matrix 10

Three Year Outlook and 2019/20 Annual Plan Monitoring of progress against Actions for Year One (2019/20)

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly About This Report

Programme..Unscheduled Care Exception 11 AP031 Demand: Workforce shift to support Care Closer to Home – Community Resource Teams (CRTs) and Admission and Discharge Team ( ADT ) in ED across all three EDs. Work continues through financial recovery works to improve the impact of these services to provide more care closer to home AP039 Stroke Services This action remains red rated as it has not been possible to find a route to resource the business case in 2019/20. However, progress has been made in implementing aspects of year 1 of the business case. As such the thrombectomy service ( clot retrieval) has been expanded to provide a seven day per week service from November 2019. The health board has been successful in its bid for rehabilitation assistants and is moving forward to recruit 2wte assistants for each acute site so as to increase the acute therapeutic time patients receive and support patient optimal recovery and early discharge. The consultants home-based technology has been improved to support prompt decision making in relation to opportunities for thrombolysis. Work is continuing to include the implementation of the early supportive discharge and rehabilitation model within health economy plans for 2020-2021. AP030 Demand: Enhanced Care Closer to Home Pathways – Improvements are being made in Emergency Departments (ED) to provide timely care although slower than planned. New ED escalation triggers and action cards implemented across all sites. Targeted gold level command and control work has commenced across all three EDs to improve patients access to timely ED care. AP033-Improved crisis intervention services for Children – Out of hours provision for young people in distress is being reviewed across Wales by the DU. We are working in partnership with Local Authorities to address the missing middle of services for young people with both health and social care needs AP034 –Flow- Milestone delivered at Ysbyty Glan Clwyd (YGC) and Ysbyty Wrecsam Maelor (YWM). Ysbyty Gwynedd (YG) has opened the new ED unit but models of care are still being finalised to fully operationalise the space. Plans for these to be implemented in December 2019. Work to reduce outliers in Wrexham has been successful through achievement of new acute floor. Part of the gold level command and control has been focused on ensuring the patient is in the right bed, first time and supporting teams through making bed allocation decisions. Strategic plans in place to look at how we can use the Christmas period to re-balance patients in the Hospital as we are likely to be the lowest occupied on Christmas Eve. Engaged with National ‘Every Day Counts’ work although delay to National agreement on discharge pathways and engaging with social care. AP038 –Discharge Ongoing work with local authorities, recognition there is a shortage in provision of package of care. Regional Partnership Board winter funding to support. Home First principles being embedded through financial recovery work, delays impacted by resource. Long length of stay reviews in Acute and Community Hospitals is multi-agency and is identifying areas where community beds are inappropriately used and work is underway to ensure Home First approach is maximised as part of financial recovery work. This commenced in West late November. What matters conversations are happening but not consistently within 24 hours and further work is needed on discharge planning.

Three Year Outlook and 2019/20 Annual Plan Monitoring of progress against Actions for Year One (2019/20)

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Programme: Workforce

Programme .Workforce Matrix 12

Three Year Outlook and 2019./20 Annual Plan Monitoring of progress against Actions for Year One (2019/20)

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Workforce Exception

Programme..Workforce Exception 13

AP043 - Deliver Year One Workforce Optimisation Objectives - reducing waste and avoidable variable/premium rate pay expenditure. Demonstrating value for money and responsible use of public funds - Progress has been achieved in areas such as Retention Improvement Plan in place and actions progressing, N&M bank capacity increased through revised rates and auto-enrolment, Establishment Control (EC) system via electronic portal enabling effective vacancy control, Workforce Optimisation Programmes and associated PIDs are in place and overseen by the Workforce Improvement Group (WIG). However this objective remains Amber as whilst work programmes are all being vigorously pursued and some schemes are green there are still programmes in early stages of development. Next Steps: Continued oversight and delivery of all Workforce Optimisation programmes including: Medical Productivity & Efficiency, Nursing; Midwifery and AHP Productivity & Efficiency, Non Clinical Productivity & Efficiency and Overarching / T&Cs Application.

AP044 - Deliver year one Health & Safety Improvement programme, focussing on high risk / high impact priorities whilst creating the environment for a safety culture The gap analysis of legislative compliance has been completed in Q2. This objective remains amber as the review of 31 pieces of legislation indicated there was a lack of compliance in 15 pieces of legislation, partial compliance with 13 and fully compliant with only 3. Next Steps: comprehensive set of action plans has been developed to address the shortfalls in key areas of risks described above. The most significant risks are on the risk register and will be monitored by the Strategic Occupational Health & Safety Group. Plans to develop an accredited Occupational Health Service are underway through the Safe Effective Occupational Health Standards (SEQOSH), this will be implemented in June 2020. A comprehensive set of policies will form the basis of the next 12 months work that are realistic and clear on roles and responsibilities.

AP049 - Provide ‘one stop shop’ enabling services for reconfiguration or workforce re-design linked to key priorities under Care Closer to Home; excellent hospital services Some aspects of this objective have been achieved (e.g. further developing guidance to assist managers to take ownership of actions, increasing organisational capacity in regards to Equality Impact Assessment knowledge and understanding). However this objective remains amber as whilst teams across W&OD have deployed a multi team intervention model in support reconfiguration/ workforce redesign in areas such as sickness management and in support of various workforce PIDS this model has not been formalised and publicised. Next Steps: W&OD will continued multi team support to Workforce Optimisation programmes and will document this approach in order to develop this into an ‘offer’ which can be publicised to areas planning significant change.

Three Year Outlook and 2019/20 Annual Plan Monitoring of progress against Actions for Year One (2019/20)

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Programme: Estates Strategy

Programme.Estates Strategy Matrix 14

Three Year Outlook and 2019/20 Annual Plan Monitoring of progress against Actions for Year One (2019/20)

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly About This Report

Programme..Estates Strategy Exception 15

Vale of Clwyd removed from programme for this year as reported last month and Ablett and Central Medical Records programmes reset, as reported last month

AP071 – Hospital Redevelopment

This plan action comprised three elements: • Review Abergele Hospital – this is actively underway. • Progress redevelopment plans for the Wrexham Maelor – a new timescale has been approved for a programme business case to fully reflect the digitally enabled clinical strategy ie first quarter 2020/21. • Progress development plans for Llandudno Hospital – this is actively underway.

AP073 - Residences

On 17th December a meeting is taking place with selected North Wales housing providers to explore a potentially ground breaking collaboration between health and housing. We are seeking to address the principal risk to the delivery of a business case to improve the quality of the Board’s ageing residential accommodation i.e. capacity and (to some extent) capability to develop a supportable proposal. The Quarter 4 timescale for production of a business case is at risk and the next few weeks will determine whether it can be achieved.

Three Year Outlook and 2019/20 Annual Plan Monitoring of progress against Actions for Year One (2019/20)

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Programme: Digital Health

Programme.Digital Health Matrix 16

Three Year Outlook and 2019./20 Annual Plan Monitoring of progress against Actions for Year One (2019/20)

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly About This Report

Programme..Digital Health Exception 17

AP052 WCCIS

The WCCIS (Welsh Community Care Information Solution) implementation has been delayed since March 2017 pending resolution of significant functional issues. The WCCIS Programme Committee agreed to pursue implementation despite gaps in functionality, once key prerequisites were met, and providing an interim reduction in costs could be negotiated. An initial pilot implementation was planned to explore product capabilities and inform the potential for a wider rollout. Commercial negotiations were hindered by the supplier’s requirement for BCU to scale up to the full contract value within a 12 month period, without any reciprocal commitment to deliver on product functionality. The Commercial Group ultimately advised BCU in August 2019 to cease negotiations pending agreement on a Functional Development Roadmap (FDR). In the interim, agreement has been reached to progress the pilot a prototype implementation, using Local Authority licenses. Planning and preparatory work is underway, and implementation is expected to begin around April 2020. The prototype will focus in establishing the requirements of the CRTs and will inform wider planning of the Welsh Community Care Information System.

This Action has now been removed from the 2019/20 Plan and been incorporated into the 2020/21 Annual Plan.

Three Year Outlook and 2019/20 Annual Plan Monitoring of progress against Actions for Year One (2019/20)

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly About This Report

Programme..Digital Health Exception 18

AP056: Good Record Keeping/Management Deputy Head of Health Records post (8b) has been recruited to internally with formal start date of 1st October. The B7 Project Manager requirement has been confirmed in principle and funding is being secured through the HASCAS & Ockenden Board. As soon as able to start the work, Mental Health Services will be the priority area - aim to complete this section by March 2020.

AP058: Deliver Capital Programme for 2019 2020 as defined within plans The discretionary programme is progressing as planned with progress being made in all expected areas. The programme was subject to change control at the end of QTR2 via the Capital Programme Management Team to reflect the removal of the paging systems replacement project and emerging priorities for spend which include Health Records racking and Telephone Switches.

AP059: Provision of infrastructure and access to support Care Closer to Home The group lead by BCU to facilitate standard access to "home networks" for community resource teams have identified 6 Work streams for the provision of ICT infrastructure; • Formalising IT Service Desk call logging procedures and service agreements • Federating Active Directory across 6 Local Authorities and implementing trust relations with BCUHB Nadex • Implementation of Wide Area Networks, Local Area Networks and Govroam wireless networks into required sites • Implementation of telephony solutions for each of the identified sites e.g. Interactive Voice Response call routing & Contact Centres as required • Implementation of shared managed print solutions for all partner organisations at sites • Deployment of Office 365 and MS Teams to enable collaborative working for the various partner organisations. A capital business case is under development to enable work, data from CRT teams is required to complete. This is taking longer to gain than anticipated.

AP060: Support Eye Care Transformation Assistant Business Analyst (Band 5) appointed in Qtr. 2. Commenced 4th November. Induction underway. Further discussions on "requirement" gaps / resource may be required. Meetings scheduled.

Three Year Outlook and 2019/20 Annual Plan Monitoring of progress against Actions for Year One (2019/20)

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Programme: Finance

Programme.Finance Matrix 19

Three Year Outlook and 2019./20 Annual Plan Monitoring of progress against Actions for Year One (2019/20)

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Finance Exception Report

Programme..Finance Exception 20

AP075 Governance Work is continuing on developing the Governance framework of the Health Board, the revised draft Clinical Risk Strategy is on target for implementation in April 2020 .The work to date has highlighted a number of issues to be addressed and posed 6 emergent risk management themes which need to be considered in order to compliment the work on the overall governance framework.

AP076 - Grip and control Progress is being made against the Financial Recovery Action Plan. We will successfully single out remaining critical areas of attention if we are to accurately focus energy on the correct key action for the remainder of the year, and to build financial governance capability for the future.

AO077 - Planning Performance against in-year financial plan (including savings programme) is being tracked. Accurate trajectories and forecasts to recover YTD position will be critical in focusing and driving cost/savings actions by divisions over the remainder of the year. Planning cycle for future years is underway. We are learning lessons from current year planning, in-year performance to date, and from Financial Recovery programme to better inform future planning.

AP078 - Procurement Efficiency framework and other opportunities are being scoped and accessed. Conformance with procurement requirements is being monitored and any deviations reported. Lessons from this year show that utilising national frameworks and All-Wales approaches via NWSSP is not sufficient to guarantee meeting the Health Board’s financial targets. Engagement with NWSSP on All-Wales approaches has begun with DOF and new Director of Procurement, to identify any potential new approach and scale.

Three Year Outlook and 2019/20 Annual Plan Monitoring of progress against Actions for Year One (2019/20)

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Appendix A: Further Information

Appendix A: Further Information. 21

The Annual Plan is included on page 423 of the March 2019 Health Board papers.

The link to these papers is shown below:

http://www.wales.nhs.uk/sitesplus/documents/861/Agenda%20bundle%20Health%20Board%2028.3.19%20%20V2.0%20updated%2022.3.19-min.pdf

Three Year Outlook and 2019./20 Annual Plan Monitoring of progress against Actions for Year One (2019/20)

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly 6 FP19/297 Integrated Quality and Performance report Month 8 1 FP19.297a IQPR cover November 2019 FINAL.docx

Cyfarfod a dyddiad: Finance & Performance Committee Meeting and date: 19.12.19 Cyhoeddus neu Breifat: Public Public or Private: Teitl yr Adroddiad Integrated Quality & Performance Report (IQPR) Report Title: Cyfarwyddwr Cyfrifol: Mark Wilkinson Executive Director of Planning & Responsible Director: Performance Awdur yr Adroddiad Dr. Jill Newman, Director of Performance Report Author: Craffu blaenorol: This paper has been scrutinised and approved by the Prior Scrutiny: Executive Director of Planning and Performance. Atodiadau None Appendices: Argymhelliad / Recommendation: The Finance & Performance Committee is asked to scrutinise the report and to consider whether any area needs further escalation to be considered by the Board. Ar gyfer Ar gyfer Ar gyfer Er penderfyniad Trafodaeth sicrwydd gwybodaeth /cymeradwyaeth  For Decision/ For For For Approval * Discussion* Assurance* Information* Sefyllfa / Situation: Please refer to Executive Summary contained within the IQPR Cefndir / Background: Our report outlines the key performance and quality issues that are delegated to the Finance & Performance Committee. The summary of the report is now included within the Executive Summary pages of the IQPR and demonstrates the areas that are challenged in relation to delivery of the expected standards of performance, together with the actions being taken to address the performance.

The Financial Balance is discussed in detail in the Finance Report.

Asesiad / Assessment Strategy Implications The performance measures within the IQPR are aligned with the Annual Plan and identified as the key performance indicators in monitoring and managing the Health Board’s strategy.

Financial Implications The delivery of the performance indicators contained within our annual plan will have direct and indirect impact on the financial recovery plan of the Board. Our operational plan is aligned to our resource allocation for delivery

Risk Analysis The RAG-rating reflects the performance against the Plan. Where there aren’t Plan Profiles, the performance is measured against the national target.

Impact Assessment The operational plan has been Equality Impact Assessed. The Finance & Performance Committee is asked to scrutinise the report and to consider whether any area needs further escalation to be considered by the Board. 1 FP19.297b IQPR November 2019 FINAL v1.0.pdf Integrated Quality and Performance Report – Finance & Performance Committee 1

November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Table of Contents.. 2

Cover Page 1 Stroke Care Graphs 26 Table of Contents 2 Stroke Care Report page 1 27 About this Report: Section 1: Report Structure 3 Stroke Care Report page 2 28 About this Report: Section 2: Report Content 4 Emergency Department inc Minor Injuries Units 4 Hour Waits: Graphs 29 Overall Summary Dashboard 5 Emergency Department inc Minor Injuries Units 4 Hour Waits: Report 30 Performance Summary – Page 1 6 Emergency Department: Number of 12 hour breaches: Graphs 31 Performance Summary – Page 2 7 Emergency Department: Number of 12 hour breaches: Report 32 Performance Summary – Page 3 8 Ambulance Handover: Number of Breaches over 1 hour: Graphs 33 Chapter 1 – Summary Planned Care 9 Ambulance Handover: Number of Breaches over 1 hour: Report 34 Referral to Treatment (RTT) Graphs 10 Delayed Transfers of Care Graphs 35 Referral to Treatment (RTT) Report 11 Delayed Transfers of Care Report 36 Referral to Treatment (RTT) Waiting List 12 Chapter 3 – Summary Finance & Resources 37 Referral to Treatment (RTT) Projection 13 Agency and Locum Spend Graphs 38 Cancer: Graphs 14 Agency and Locum Spend Report 39 Cancer: Report 15 Financial Balance Graph 40 Diagnostic Waits: Graphs 16 Financial Balance Report 41 Diagnostic Waits: Report 17 Sickness Absence Graphs 42 Follow up Backlog Graph 18 Sickness Absence Report 43 Follow up Backlog Report 19 PADR Graphs 44 Eye Care Measure Report 20 PADR Report 45 Activity v Plan Report Page 1 21 Mandatory Training Graphs 46 Activity v Plan Report Page 2 22 Mandatory Training Report 47 Activity v Plan Report Page 3 23 Chapter 4 – Summary Primary Care 48 Activity v Plan Report Page 4 24 Dental Care Report 49 Chapter 2 – Summary Unscheduled Care 25 Proposed new Measures for Primary Care 50 Appendix A: Further Information 51

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly About this Report.. Section 1: Report Structure 3

This Integrated Quality & Performance Report (IQPR) provides a clear view of current performance against a selected number of Key Performance Indicators (KPI) that have been grouped together to triangulate information. This report should be used to inform decisions such as escalation and de-escalation of measures and areas of focus. Actions for escalation should be captured in the Chair’s report for the Board and minutes of the committee.

The measure code relates to the code applied within the NHS Wales Annual Delivery Framework, which Welsh Government hold the Board accountable for delivering. A key difference in the structure of the IQPR for 2019/20, in comparison to 2018/19 is that it is that the report reflects the organisational priorities as set out in the Annual Plan approved by the Board. The report maps each of the measures included against the corresponding work programme within the Annual Plan for 2019/20. This is done via a reference number in the 4th column of the Measure Component Bar.

The actual performance reported is compared to the BCU plan in the first instance, with the background colour used to depict whether the performance is better or worse than planned. The national target is shown so that performance can be compared against expected national standards and locally agreed plans. Performance from April 2019 to date is also shown in the Measure Component Bar together with the position reported for the same reporting period in the previous year. The Wales Benchmark position is acquired from the Chief Executive Officer Papers published by Welsh Government and is usually at least one month in arrears.

Status Key:  Performance has improved since last reported  Performance as got worse since last reported  Performance remains the same as last reported Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly About this Report.. Section 2: Report Content 4

Profiles For each key performance indicator the accountable Executive Director has confirmed the profile of performance expected to be delivered during the year based on the actions and resourcing set out in the annual plan. The report tracks performance against this profile and as such the Red Amber Green (RAG) rating applied are for performance against the Plan. Where a local plan profile is not available the RAG rating will relate to the National target ,which is presented alongside each indicator on the chapter Summary pages. The frequency of reporting of indicators is set out in the NHS Annual Delivery issued by Welsh Government and this frequency is reflected in the reporting with some indicators annual, others bi-annual, quarterly, bi-monthly or monthly.

Escalated Exception Reports When performance on a measure is worse than expected, the Lead for that measure is asked to provide an exception report to assure the relevant Committee that a)the reason for the under-performance is understood , b) that a plan and set of actions in place to improve performance, c) that there are measurable outcomes aligned to those actions and d) that they have a defined timeline/ deadline for when performance will be 'back on track’. Although the exception reports are scrutinised by Finance & Performance Committees, there may be instances where they need to be ‘escalated’ to the Board via the Committee Chair.

Longitudinal view of performance Where possible the committee is provided with a longitudinal view of performance against each indicator . Run charts and Statistical Process Control (SPC) charts are used to assist with the visualisation of performance overtime and to provide an understanding of normal variation within the month to month performance. This will assist with tracking performance over time, identifying unwarranted trends and outliers and fostering objective discussions rather than reacting to ‘point-in-time’ data.

Cycle of business This report attempts to set out the actions in the operational plan and the associated measures which come under the terms of reference for this committee to scrutinise during 2019/20. Key performance indicators have been reviewed again in during October 2019 and the amendments ratified by the November Board. These profiles replace the previous key performance indicators and will be used to track and RAG rate performance against from November 2019. Where monthly measures are reportable to this committee the November data is included in this report. For other measures the data provided relates to the latest validated and submitted reporting period. Where data is not currently available the measure is greyed out in the report.

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Performance Executive Summary.. Page 1

The committee are asked to note that mandatory training has been compliant with the national delivery requirement and our BCU plan for the last 3 months and therefore should be stood down from exception reporting in accordance with the Board’s performance management strategy.

The executive team would draw the attention of the committee to three main performance themes contained in the report: timely access to planned care, unscheduled care and the use of our resources.

Planned Care. For Planned Care this report shows both the level of performance against the national targets for 36weeks and 95% of patients waiting less than 26 weeks. The performance on RTT has continued to deteriorate during November with 757 more patients waiting in excess of 36 weeks. Given the additional expenditure on RTT already taken place during 2019/20 the resource remaining for additional internal or outsourced activity over the next 4 months is limited and therefore the Executives are reviewing the affordability of further opportunities for improvement. The current forecast position for year end remains at 11,799 whilst this review takes place.

The underlying size of the overall waiting list is shown overtime, demonstrating a consistency in the pattern of the waiting list volume month on month but a higher volume of patients waiting this year compared to last year and that the difference in size of waiting list has grown at an increasing rate each month this year. This is reflected in the growth in the over 36 week cohort of patients requiring treatment before year end, which is also included in the report. A more detailed RTT report focussing on the balance of harm reduction, RTT target delivery and resource requirements is included in the papers for the Committee this month and should be referred to for additional information.

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Performance Executive Summary.. Page 2 6

The diagnostic 8 week waits have improved slightly in November, with the greatest improvement being seen in endoscopy. Two of the three sites expect to eliminate the backlog of surveillance patients and so support it being given to enable patients at the Wrexham site to have investigations carried out in Ysbyty Glan Clwyd (YGC). The insource capacity is being focussed on the long waits and surveillance patients on the Wrexham site, with planned additional capacity for 27 lists per week to take place between the middle of December and year end. Cancer 31 day performance recovered this month to deliver the national target. The 62 day target remains below both the national target and our local planned profile. The backlog of patients over 62 days remains stable at 88 patients. The challenges to reduction of this backlog relate to : sustainable urological surgery capacity, and delivery of endoscopy and gastro-enterology services.

Planned Care Performance against Plan - Rolling 12 months to 30th November 2019 BCU HB Target Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Plan 5,714 6,838 7,465 7,961 8,846 8,021 7,227 7,683 AP RTT over 36 wks 0 Actual 6,932 7,144 8,034 7,826 6,004 6,870 7,499 7,998 8,900 10,167 10,052 10,768 11,525 Diagnostics 8wks Actual 0 1,275 1,486 2,116 2,123 2,277 2,548 2,857 2,827 2,793 2,957 2,816 2,443 2,233 Plan 73,000 73,000 72,000 71,000 70,000 87,712 86,835 85,967 81,890 79,924 Followup Overdue 0 Actual 80,712 84,769 83,473 82,483 87,712 88,210 88,079 88,511 88,648 91,288 90,569 89,909 89,235 Plan 89.00% 90.00% 90.00% 91.00% 92.00% 82.00% 83.00% 84.00% 84.00% 84.00% 85.00% 85.00% 85.00% Cancer 62 Day 95% Actual 80.90% 87.20% 84.40% 808.00% 87.60% 82.20% 81.50% 80.40% 84.90% 86.00% 82.60% 82.90% Plan 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% Cancer 31 Day 98% Actual 99.50% 98.10% 97.40% 98.90% 97.20% 100% 98.30% 98.30% 99.50% 98.10% 96.40% 99.50% Single Cancer Pathway 78.00% 80.00% 76.00% 77.00% 75.00% Amber is used where performance is within 3% of Plan There is no set target for Single Cancer Pathway Cancer is reported 1 month in arrears

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019 Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Performance Executive Summary.. Page 3 7

Unscheduled care The end of November 4 hour combined ED and MIU performance delivered in accordance with our planned profile. The other key performance indicators for unscheduled care did not deliver the revised planned position. The Cat A 8 minute response time dipped below the national 65% target for the first time this financial year.

Work continues to deliver the USC as outlined in Building Better Care and supported by the National ED Quality and Delivery Framework. The bed reconfiguration for the Wrexham site have been completed and these together with the Gold Command did demonstrate initial improvement in performance on the site. This included a reduction in the number of outliers, the level of escalation and the ED congestion. This hasn’t been fully sustained and further work is progressing to ensure grip and control is in place. Gold command has been implemented in YGC and this is also showing early improvements with flow of patients being re-established. Work is being supported with a workforce review being undertaken through Kenall Bluck.,

Unscheduled Care Performance against Plan - Rolling 12 months to 30th November 2019 BCU HB Target Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Plan 88.0% 90.0% 85.0% 85.0% 85.0% >= 74% >= 75% >= 76% 74.0% 75.0% 76.0% 77.0% 72.0% 4 Hour 95% Actual 71.68% 67.64% 66.94% 72.50% 71.11% 69.48% 71.21% 71.49% 73.72% 73.04% 71.68% 71.15% 72.12% Plan 850 800 1,000 1,000 900 1,500 1,395 1,290 1,209 1,085 990 961 1,320 12 Hour 0 Actual 1,404 1,553 1,989 1,430 1,635 1,743 1,660 1,444 2,044 1,786 1,977 1,757 1,786 1 Hour Ambulance Plan 1,055 1,100 1,080 1,092 900 540 341 270 248 186 120 404 446 0 Handover Actual 404 446 691 358 438 700 616 447 811 694 896 809 792 Plan 77.0% 74.0% 71.0% 73.0% 75.0% 65.0% 65.0% 65.0% 65.0% 65.0% 65.0% 65.0% 65.0% Cat A 8 Minutes 65% Actual 68.5% 74.7% 72.2% 75.0% 70.4% 70.0% 70.2% 69.0% 68.0% 69.6% 69.0% 68.9% 62.9% Note: Amber has been applied where performance is within 3% of Plan.

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly 8 Overall0 Summary . 0 Improved Code Measure Status Annual Plan National 12 Profile Target DFM072 Emergency Department 4 Hour Waits (inc MIU) 72.13%  >= 72% >= 95% All DFM025 Delayed Transfers of Care (DToC): MH 16 <= 12 Reduce Chapters  DFM054 Diagnostic Waits: > 8 Weeks 2,233  AP 0 24 DFM063 Cancer: 31 Days (non USC Route) 99.5%  >= 98% >= 98% DFM055 Follow-up Waiting List Backlog 89,235 <= 81,890<= 74,555 0 00  0 4 2 4 2 Of Most Concern Unscheduled Planned Finance & Primary Code Measure Status Annual Plan National Care Care Resources Care Profile Target

7 7 6 4 DFM053 Referral to Treatment (RTT): > 36 Weeks 11,525 AP 0 0 0  All Measures RAG Timeline 2019/20 DFM053 Referral to Treatment (RTT): < 26 Weeks 78.08% AP >= 95% November 2019  30 25 DFM070 Ambulance Response within 8 minutes 62.90% >= 65% >= 65% 20  15 10 DFM026 Delayed Transfers of Care (DToC): non-MH 105 <= 28 Reduce 5  0 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 LM002F Finance: Position against Financial Balance £27.1m  <= £23.3m <= £25m Red Amber Green No Data Integrated Quality and Performance Report AP = Awaiting Profile Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 1 – Summary . Planned Care 9

Code Measure Status Annual Plan National 0 Profile Target 2 0 DFM052 Referral to Treatment (RTT): < 26 Weeks 78.08%  AP >= 95% Planned DFM053 Referral to Treatment (RTT): > 36 Weeks 11,525  AP 0 Care LM053a Referral to Treatment (RTT): > 52 Weeks 3,177  AP 0 0 7 DFM054 Diagnostic Waits: > 8 Weeks 2,233  AP 0 1 DFM055 Therapy Waits: <= 14 Weeks 0  0 0 RTT 1 Other DFM056 Follow-up Waiting List Backlog 89,235  <= 81,890<= 74,555 4 Cancer DFM057 Ophthalmolgy R1 64.01% AP >= 95% 2 00  1 DFM063 Cancer: 31 Days (non USC Route) 99.50%  >= 98% >= 98% Chapter 01 - Planned Care RAG Timeline 2019/20 November 2019 DFM064 Cancer: 62 Days (USC Route) 82.90% >= 95% >= 95% 10  8 Cancer: 62 Day Single Pathway (inc DFM065 75.00% AP Improve 6 Suspensions)  4 2 0 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Red Amber Green No Data Integrated Quality and Performance Report AP = Awaiting Profile Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 1 – Planned Care Referral to Treatment: Graphs 10

Same National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Actual Status Period Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Last Year

DFM05 The percentage of patients waiting less >= 95% AP024 AP Nov-19 78.08% 7th 84.05% 83.21% 82.22% 83.00% - 82.00% 80.24% 79.94% - 78.65% 78.08% 0.00% - 0.00% 0.00% 0.00% - 2 than 26 weeks for treatment 

DFM05 The number of patients waiting more than 0 AP024 AP Nov-19 11,526 7th 6,932 6,768 7,396 7,886 - 8,900 10,167 10,052 - 10,768 11,526 0 - 0 0 0 - 3 36 weeks for treatment  The number of patients waiting more than LM053a 0 AP024 AP Nov-19 3,177 N/A 2,356 2,369 2,540 2,506 - 2,496 2,621 2,730 - 2,880 3,177 0 - 0 0 0 - 52 weeks for treatment 

BCU Level - RTT Waits % <= 26 Weeks: November 2019 BCU Level - RTT Waits Number > 36 Weeks: November 2019 100% 14,000 95% 12,000 90% 10,000 8,000 85% 6,000 80% 4,000 75% 2,000

70% 0

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May-18 May-19 RTT 26W % Target Control Line Upper Control Limit Lower Control Limit RTT Over 36W Target Control Line Upper Control Limit Lower Control Limit

Why we are where we are: The Board has observed significant reduction in additionality delivered internally through Waiting List Initiatives (WLI), it is mainly due to changes in Her Majesty’s Revenue & Customs (HMRC) rules on personal pensions. This level of reduction in activity when compared like for like when compared against 2018/19 has caused an increase over 36 weeks backlog.

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 1 – Planned Care Referral to Treatment: Narrative 11

Actions Outcomes Timeline

Improved data quality. Reduction in Waiting List (WL) 1. Referral to Treatment (RTT) cross site validation of Stage 1 patients. 31st December 2019 by 5%

Operational tool in place to manage RTT performance 2. Development of weekly planned care dashboard in real time. This is being used to drive weekly 30th January 2019 management meetings. 3. Outsourcing 750 Orthopaedics. All 750 transferred and progressing to Reduce 750 backlog cohort in Orthopaedics 31st March 2020 treatment. Further 152 capacity in Orthopaedics, 890 in 4. Use of insource and outsource capacity 31st January 2019 Ophthalmology and 50 in Dental 5. Improve scheduling based on clinical urgency and waiting time Reduction in RTT backlog 28th February 2020 chronology

6. Training: assessment of organisational knowledge and Mainstream RTT Training programme in place to support RTT rules 31st December 2019 training programme • Virtual PROMs in Orthopaedics in place 7. Implementation of schemes to free up follow up capacity for services, e.g. • SoS (access as and when required by the patient) 31st March 20120 Supported Discharge, virtual results review clinics in Rheumatology in the West • FU backlog reduction by 15%

8. External resource to validate Follow Up (FU) backlog FU backlog reduction by 15% 28th February 2020

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 1 – Planned Care Referral to Treatment: Narrative 12

The RTT total waiting list size is 4,274 greater in November 2019 than it was in November 2018. The rate of increase each month is rising from 0.8% increase between April 2018 to April 2019 to the 4.35% increase seen comparing November to November positions

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 1 – Planned Care Referral to Treatment: Projection 13

Betsi Cadwaladr 36 Week Cohort Reduction Projection 90,000 Cohort Date: 31/12/2019 - Comparison to Same Quarter Last Year All Specialties (All Stages) 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000

0

29/04/2019 06/05/2019 13/05/2019 20/05/2019 27/05/2019 03/06/2019 10/06/2019 17/06/2019 24/06/2019 01/07/2019 08/07/2019 15/07/2019 22/07/2019 29/07/2019 05/08/2019 12/08/2019 19/08/2019 26/08/2019 02/09/2019 09/09/2019 16/09/2019 23/09/2019 30/09/2019 07/10/2019 14/10/2019 21/10/2019 28/10/2019 04/11/2019 11/11/2019 18/11/2019 25/11/2019 02/12/2019 09/12/2019 16/12/2019 23/12/2019 30/12/2019 31/12/2019 Previous Year Cohort Volume Projection Actual Cohort Volume EndEoY of Commitment Year Commitment

The overall growth in the waiting list is a function of the mismatch between demand and activity delivered month on month. This then contributes to the increase the volume of the over 36 week cohort that needs to be treated. The average number of over 36 week pathways closed in 2019/20 has increased to 1,950 per month (2018/19 average 1,763). This shows that on average 187 more long waiting patients commence treatment each month, this shows evidence of treatment in turn. Therefore a straight line forward projection to year end would suggest if activity in 2019/20 replicated that of 2018/19 the cohort could be reduced by c8,100. However given constraints on activity experienced in 2019/20 it is unlikely that this level of activity can be replicated this year and so this level of cohort reduction is unlikely to be achieved

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 1 – Planned Care Cancer: Graphs 14

Same National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Actual Status Period Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Last Year

The percentage of patients newly diagnosed with cancer, not via the urgent DFM06 route, that started definitive treatment within >= 98% AP026 >= 98% Oct-19 99.50% 5th 98.40% 100% 98.44% 98.33% - 99.49% 98.15% 96.40% - 99.50% 0% 0% - 0% 0% 0% - 3 (up to & including) 31 days of diagnosis  (regardless of referral route)

The percentage of patients newly diagnosed with cancer, via the urgent DFM06 suspected cancer route, that started >= 95% AP026 >= 85% Oct-19 82.90% 3rd 85.80% 83.23% 81.55% 81.05% - 84.88% 86.62% 82.60% - 82.90% 0.00% 0.00% - 0.00% 0.00% 0.00% - 4 definitive treatment within (up to &  including) 62 days of receipt of referral

Percentage of patients starting first DFM06 definitive cancer treatment within 62 days Improve AP026 AP Oct-19 75.00% 2nd New 19/20 77.10% 79.00% 78.00% - 77.00% 76.00% 77.00% - 75.00% 0.00% 0.00% - 0.00% 0.00% 0.00% - 5 from point of suspicion 

BCU Level - Cancer Waiting Times - 31 Day - October 2019 BCU Level - Cancer Waiting Times - 62 Day from Receipt of Referral - October 2019 100.00% 100.00% 98.00% 96.00% 95.00% 94.00% 92.00% 90.00% 90.00% 88.00% 85.00% 86.00% 84.00% 80.00% 82.00%

80.00% 75.00%

Jul-18 Jul-19

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May-18 May-19 Actual Target Control Line Upper Control Limit Lower Control Limit Actual Target Control Line Upper Control Limit Lower Control Limit

Why we are where we are: In October the Health Board improved its performance and met the 31 day target; performance improved very slightly against the 62 target with the main delays being due to delays to first appointment, in particular for breast and urology patients. In addition there were delays to major urology surgery cases.

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 1 – Planned Care Cancer: Narrative 15

Actions Outcomes Timeline

1. Prioritise endoscopy capacity for Urgent Suspected Cancer (USC) and other clinically urgent patients; provide additional capacity via insourcing (contracts All USCs to be booked within 2 weeks 31st December 2019 agreed and to provide additional sessions from end November)

2. Hold additional breast rapid access clinics; ensure patients offered transfer to alternative site if shorter wait to ensure equalised waiting times; continue All USCs to be seen within 3 weeks 31st December 2019 recruitment process for consultant breast radiologists and consider insourcing option

3. Agree urology surgery capacity plan for major surgery and to recover urology All surgery within 31 days of decision to treat 31st January 2020 haematuria clinic waiting times position All USCs to be seen within 3 weeks

4. Track all patients on a USC pathway in order to ensure all delays are Continuation of backlog reduction to under 75 31st December 2019 escalated and remedial action taken as appropriate Improve 62 day performance to 90%

5. Appoint tracking staff to ensure all patients tracked from point of suspicion Improved single cancer pathway performance 31st January 2020

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 1 – Planned Care Diagnostic Waits: Graphs 16

Same National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Actual Status Period Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Last Year

DFM05 The number of patients waiting more than 0 AP024 AP Nov-19 2,233 7th 1,275 2,548 2,857 2,827 - 2,793 2,957 2,816 - 2,443 2,233 0 - 0 0 0 - 4 8 weeks for a specified diagnostic 

BCU Level - Diagnostic Waits Number of Breaches: BCU DIagnostics - Number of Breaches over 8 Weeks November 2019 October 2017 to October 2019 by Service 4,500 4,000 3,500 3,000 3,500 2,500 3,000 2,000 2,500 1,500 2,000 1,000 1,500 500 1,000 0 500

0

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Aug-18 Sep-18 Aug-19 Sep-19 May-19 May-18 Cardiology Total Diagnostic Endoscopy Total Imaging Total Actual Target Control Line Upper Control Limit Lower Control Limit Physiological Measurement Total Radiology - Consultant referral Total Radiology - GP referral Total Neurophysiology Total Grand Total

Why we are where we are: Endoscopy: Lack of sufficient capacity mainly in WMH continued to be challenging in managing increase in demand. There has also been severe delays in implementation of solutions; such as Vanguard due to issue with water testing. Further increase in capacity has been arranged through numbers of insourcing options, this capacity has come on line during December and should create 27 additional lists per week. Radiology: Insufficient capacity for CT, MRI and US to meet underlying demand growth pressures. Insourcing capacity is secured to address majority of capacity gap, but some constraints remain around cardiac and breast sub speciality capacity. Locum and substantive recruitment attempts have not been successful to date.

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 1 – Planned Care Diagnostic Waits: Narrative 17

Actions Outcomes Timeline

Endoscopy 1. Improve scheduling based on clinical urgency and waiting Reduction in routine >8 weeks and Surveillance backlog 31st December time chronology Additional capacity to reduce routine >8 weeks and Surveillance backlog. 2. Insourcing solutions for all three sites 31st December This is now in place from 02/12/2019 3. Recruitment of Gastroenterology locum consultant in West. This is now in place and started demonstrating an improved 127 additional capacity a month 31st October position. 4. Complete specialty level Demand &Capacity (D&C) to Site level D&C by modality in place. The first draft has been completed by 31st December 2019 identify sustainable gap as well as gap for backlog clearance information. Awaiting sign off Reduction in Surveillance Backlog in East. This is in place. The Vanguard 5. Pooling of Surveillance patients from East to West and Capacity in Ysbyty Glan Clwyd (YGC) is being used for Wrexham Maelor 31st December Centre Hospital WMH) patients. Radiology 1. Continue with insourcing through framework contract within Maintain capacity for Computerised Tomography (CT), Magnetic Resonance 31st December available resources Imaging (MRI) and US scanning 2. Secure contract and resource for consultant mammographer 31st December- continuing to Additional breast US capacity Ultra Sound (US) sessions in YGC 31st March 2020 3. Completion of Kendall-Bluck Review of radiology services Inform the basis for proposal for sustainable radiology services 16th December

4. Completion of proposals for sustainable radiology service Develop sustainable staffing/activity model 28th February 2020 Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 3a – Planned Care. Follow Up Waiting List Graphs 18

Same National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Actual Status Period Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Last Year

The number of patients waiting for an DFM05 outpatient follow-up (booked and not <= 74,555 AP024 <= 81,890 Nov-19 89,235 7th 80,712 88,210 88,079 88,511 - 88,648 92,067 90,569 - 89,909 89,235 0 - 0 0 0 - 6 booked) who are delayed past their agreed  target date for planned care specialities

BCU Level - Number of Follow Up Backlog: October 2019 110,000 100,000 90,000 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000

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Why we are where we are: Data quality issue related to WPAS (Wales Patient Administration System) implementation and ongoing shortfall in capacity to manage patient pathways in Referral to Treatment (RTT), Urgent Suspected Cancer (USC) and Follow Up (FU). There was also delay in implementing Patient Reported Outcome Measures (PROMs) FU in orthopaedics as well as external support for FU validation. This has now been in place and mobilisation plan is being worked through.

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 3a – Planned Care. Follow Up Waiting List - Narrative 19

Actions Outcomes Timeline

15% reduction on Follow Up (FU) 100% overdue 1. Stable Glaucoma Monitoring via Virtual Clinics and Cataract Direct to Listing backlog ( note 18.6% reduction has been achieved 28th February 2020 Pathway redesign by end of November and therefore on course to deliver year end target)

2. Cross site validation of all stage 1 patients – validation team commenced Improved data quality. Reduction in Waiting List 30th December 2019 during December (WL) by 5%

3. Training: assessment of organisational knowledge and Mainstream Referral Training programme in place to support RTT rules 31st December 2019 to Treatment (RTT) training programme

• Virtual Patient Reported Outcome Measures (PROMs) in Orthopaedics in place 4. Implementation of schemes to free up follow up capacity for services, e.g. • SoS (Service access as required by patient) in 31st March 2020 Supported Discharge, virtual results review clinics Rheumatology in the West • FU backlog reduction by 15%

5. External resource to validate FU backlog – Validation provider commenced in FU backlog reduction by 15% 28th February 2020 November 2019

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 3a – Planned Care. Eye Care Measure 20

Same National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Actual Status Period Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Last Year

95% of opthalmology R1 patients who are DFM05 waiting within their clinical target date or >= 95% AP022 AP Nov-19 64.01% 7th New 19/20 - - - - 63.40% 65.00% 63.07% - 64.30% 64.01% 0.00% - 0.00% 0.00% 0.00% - 7 within 25% in excess of their clinical target  date for care or treatments Actions Outcomes Timeline

1. Appointment of Assistant Assistant Business Analyst recruited by informatics who will support the Eye Care Measures Programme 2-3 days per week. January 2020 Business Analyst

2. Light Touch Tender for Overarching Specification agreed for Community Optometry ODTCs, also detailed specification for referral refinement service and Community Optometry Ophthalmic management of stable glaucoma supported by clinical governance case reviews with Consultant Ophthalmologists. Tender published January 2020 Diagnostic & Treatment Centres 3rd December. Selection 2nd January and clarification interviews 9/10 January 2020. ODTCs appointed by 10th January 2020. (ODTCs) Dependent upon funding being secured. 3. Glaucoma working parties Glaucoma working parties include community optometrist and will undertake clinical validation of the Glaucoma outpatient waiting list established in East and West HES backlog. Reviewing patients who may be suitable for community Optometrist support or self management. All sites are arranging December 2019 sites; and in Central by end additional clinics to review and reduce the backlog waiting list commencing with the longest waiting R1 patients. Clinics will run – March 2020 December. December 2019 – March 2020 4. Eye image data sharing Dicom pilot (system for capturing and transferring High Definition images) successful and Ophthalmologists happy with the quality of between Community ODTCs and images transmitted. Feedback to Welsh Government Digitalisation Programme Manager. Next steps being explored. If feasible this will March 2020 HES make a step change in shared care working and virtual patient review by HES

Director of Performance presented to the Cross Party Group on Vison on the transformation plan for N Wales Eye Care and the 5. Presentation to Cross Party 12th November spending plans for the non recurrent revenue funding for reducing the backlog outpatient waiting list; the eye care measures Group on Vision 2019 transformation fund and the sustainable business case for Integrated Medium Term Plan (IMTP) support. 30th November 6. Cataract Pathway The cataract pathway has now been embedded as a direct referral service from optometrists thus reducing outpatient attendances. 2019

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019 Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 3a –Planned Care Internal BCU Activity v Plan 21

BCU Activity versus Plan 2019/20 Year to Date - 30th November 2019

West Central East BCU Total Plan Actual Diff % Diff Plan Actual Diff % Diff Plan Actual Diff % Diff Plan Actual Diff % Diff Emergency Inpatients 17,805 18,272 467 3% 21,758 23,296 1,538 7% 24,800 24,830 30 0% 64,363 66,398 2,035 3% Elective Daycases 7,469 7,789 320 4% 8,472 9,698 1,226 14% 5,630 4,552 -1,078 -19% 21,570 22,039 469 2% Elective Inpatients 3,866 3,737 -129 -3% 2,763 3,605 842 30% 2,847 3,060 213 7% 9,477 10,402 925 10% Endoscopies 4,302 7,482 3,180 74% 2,397 2,452 55 2% 3,894 3,618 -276 -7% 10,593 13,552 2,959 28% MOPS (Cleansed DC) 790 840 50 6% 650 311 -339 -52% 217 230 13 6% 1,657 1,381 -276 -17% Regular Day Attenders 6,952 7,065 113 2% 10,988 10,735 -253 -2% 14,564 12,880 -1,684 -12% 32,504 30,680 -1,824 -6% Well Baby 1,238 1,143 -95 -8% 1,064 992 -72 -7% 1,298 1,307 9 1% 3,600 3,442 -158 -4% New Outpatients 48,009 50,093 2,084 4% 69,008 68,028 -980 -1% 61,917 64,784 2,867 5% 178,934 182,905 3,971 2% Review Outpatients 96,991 97,127 136 0% 117,352 119,799 2,447 2% 143,038 147,889 4,851 3% 357,381 364,815 7,434 2% Pre-Op Assessment 6,523 6,327 -196 -3% 6,862 6,581 -281 -4% 9,387 8,952 -435 -5% 22,772 21,860 -912 -4% New ED Attendances 50,799 53,718 2,919 6% 62,407 63,164 757 1% 45,233 45,055 -178 0% 158,439 161,937 3,498 2% Review ED Attendances 665 697 32 5% 923 929 6 1% 2,925 2,788 -137 -5% 4,513 4,414 -99 -2% Grand Total 245,409 254,290 8,881 4% 304,644 309,590 4,946 2% 315,750 319,945 4,195 1% 865,803 883,825 18,022 2% Please note : East's, Nephrology, Regular Day Attenders figures are obtained from a manual source and are one month in arrears - November 2019 activity is missing from the above figures.

This table shows all internal delivered activity in the categories and so includes activity delivered by non-medical staff in clinic setting. This activity includes activity that is undertaken without being on an elective waiting list and so does not match to the high level RTT monitoring report. For instance within outpatients new attendances include patients for whom an appointment is arranged on the day by the GP ( known as walk-in patients). This activity is included in the above data but is not waiting list activity and is not included in the planned capacity to deliver RTT new outpatient requirements.

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly External Contracted Activity Chapter 3a – Planned Care Key Providers 22

Elective Inpatient & Emergency Follow Up Activity up to Daycase (inc. Inpatient (inc. New Outpatient Provider Outpatient and including:* Endoscopy) Maternity) Plan Actual Plan Actual Plan Actual Plan Actual Countess of Chester NHS Foundation Trust Oct 4,286 3,812 4,253 4,010 11,778 10,243 26,232 25,047 Robert Jones & Agnes Hunt NHS Foundation Trust Oct 1,518 1,421 22 26 3,907 3,998 10,525 10,113 Hywel Dda LHB Oct 586 685 617 602 707 745 1,403 1,522 Royal Liverpool and Broadgreen University Hospitals NHS Trust Sep 586 528 94 89 838 798 3,297 3,255 Wirral University Teaching Hospital NHS Trust Oct 535 387 111 103 272 264 891 905 Shrewsbury & Telford Hospitals NHS Trust Oct 109 95 84 82 1,032 912 1,244 1,081 IP - Sep Aintree University Hospital NHS Foundation Trust 220 231 57 43 406 358 1,188 1,126 OP - Oct IP - Sep The Clatterbridge Cancer Centre NHS Foundation Trust 114 180 25 18 202 195 4,489 4,663 OP - Oct University Hospital of North Midlands NHS Trust Oct 40 41 137 171 215 286 302 328 University Hospital of South Manchester NHS Trust Liverpool Women's NHS Foundation Trust Oct 24 21 63 60 278 337 740 820 Shropshire Community Health NHS Trust Oct 7 0 23 11 13 7

*All data relates to the period April to October 2019 for outpatient activity.

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 3a –Planned Care RTT Core Activity v Plan 23

RTT Core Activity V Plan - 1st April 2019 to 8th December 2019

Stage 1 (New Outpatient) Core Activity Against Plan *Ophthalmology data is Stage 4 (inpatient / Daycase) Core Activity Against Plan excluded while work RTT Plan Actual Difference Plan Specialty concludes on reconciling data Specialty Admissions YTD YTD from Plan YTD from YG. Achieved General Surgery 12,428 13,223 795 General Surgery 3,937 3,913 Urology 5,240 4,437 -803 Urology 2,171 2,122 Trauma & Orthopaedics 8,823 7,117 -1,706 Trauma & Orthopaedics 3,734 3,944 ENT 9,651 9,607 -44 ENT 2,160 2,258 Maxillo-Facial Surgery 4,057 3,890 -167 Maxillo-Facial Surgery 1,011 911 Restorative Dentistry 228 145 -83 Pain Management 475 597 Orthodontics 818 560 -258 Gynaecology 1,648 1,642 Pain Management 1,338 967 -371 Total 15,136 15,387 General Medicine 882 1,435 553 Gastroenterology 3,004 3,595 591 Summary: Internal Delivery of core activity aligned to the declared internal capacity is shown above. Endocrinology 1,543 1,577 34 The three site access meetings have been strengthened with the site directors expected to chair these Cardiology 5,118 5,685 567 weekly meetings of activity delivered and scheduled in accordance with the plan. Additional support has Dermatology 7,107 7,962 855 been requested from the DU to aid the development of this approach on the Wrexham site. The fortnightly Respiratory Medicine 2,087 2,374 287 Access meetings will be chaired by the Interim Assistant Director for planned care and the Director of Nephrology 815 717 -98 Performance to increase the level of confirm and challenge and ensure that Pan BCU capacity utilisation can Rheumatology 2,066 1,263 -803 be improved. Paediatrics 5,788 6,133 345 Work is underway to develop the provider site activity plans for 2020/21 with commissioner based challenge Geriatric Medicine 2,355 1,614 -741 expected to take place within the next month. These are aimed to test the operational thinking and support Gynaecology 6,333 6,083 -250 development of sustainable service plans aligned to clinical pathway re-design. Child & Adolescent Psychiatry 4,909 4,909 0 Total 79,680 78,384 -1,296 Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly RTT additional activity Chapter 3a – Planned Care. 24 and cost Summary totals RTT Additional Activty and Cost per Stage - April to November 2019 Hospital / M01 M02 M03 M04 M05 M06 M07 M08 TOTAL Stage 1 Stages 2&3 Stage 4 Site £'000 £'000 £'000 £'000 £'000 £'000 £'000 £'000 Specialty 416 466 425 342 333 238 376 395 2,990 New OPD Investigations etc. IP & DC YG YGC 220 265 340 234 461 254 272 183 2,228 274 42 240 General Surgery YMW 133 122 37 76 21 72 95 110 666 Urology 620 350 232 North Wales 180 228 178 233 229 239 235 241 1,763 Orthopaedics 11 0 655 Area - 17 176 -4 189 141 118 165 68 101 72 169 321 1,155 ENT 419 0 200 Outsource Total 1,090 1,216 1,321 949 1,144 874 1,147 1,250 8,990 Ophthalmology 1867 0 760 Max Fax / Oral Surgery 347 0 114 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 FYTD Activity Validation (YGC) £7,249 £7,249 £7,249 £7,249 £7,249 £7,249 £43,494 Cardiology 0 144 0 Gastro Vanguard £0 £7,227 £0 £0 £0 £0 £7,227 Dermatololgy 0 0 0 Other Diagnostics (Pathology / Radiology) £180,200 £227,599 £177,522 £233,019 £228,718 £238,516 £235,419 £242,125 £1,763,118 Gastro 1459 0 0 Physio £132,806 £132,806 Endoscopy 32 5,829 0 Optometry £16,493 £40,174 £56,667 Pain 0 0 20 Dietetics £3,781 -£3,781 £0 Total Activity 5029 6,365 2,222 Transport £3,846 £1,942 £4,471 £2,000 £6,000 £18,259 Total £187,449 £258,568 £361,532 £240,333 £237,909 £250,236 £237,419 £248,125 £2,021,571 General Surgery £28,889 £7,977 £318,613 Urology £57,461 £42,176 £596,485 Summary: The total resource claimed against RTT funding in 2019/20 amounts to £8.99m at the end Orthopaedics £1,034 £0 £2,394,103 of month 8. This resource has delivered 5,029 outpatients, 6,365 diagnostic and follow up ENT £38,000 £0 £166,980 appointments and 2,222 in-patient or day case treatments. Ophthalmology £188,950 £0 £457,525 It is noted that not all additional outpatient or diagnostics appointments will have resulted in Max Fax / Oral Surgery £29,532 £0 £120,189 Cost commencement of treatment. Patients treatment can commence in outpatients or via a procedure £0 £13,993 £0 Cardiology being undertaken and so it is normal for patients to convert from one stage on their pathway prior to Dermatology £0 £0 £113 treatment commencing. Gastro £221,690 £0 £0 Endoscopy £0 £2,279,273 £0 Pain £0 £0 £6,782 Integrated Quality and Performance Report Total Spend £565,555 £2,343,419 £4,060,789 Finance & Performance Committee Version November 2019 Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 2 – Summary . Unscheduled Care 25

Annual Plan National 00 Code Measure Status 4 Profile Target DFM066 Stroke Care: Admission within 4 Hours 50.00%  >= 50% >= 55.5% Unscheduled DFM067 Stroke Care: Review by consultant 24 Hours 82.60%  >= 85% >= 84% Care DFM068 Stroke Care: Access to Speech Therapy 54% AP Improve 0  2 DFM069 Stroke Care: 6 Month Follow up Assessment 22.30% N/A AP Improve Stroke 7 Care Other DFM070 Ambulance Response within 8 minutes 62.90%  >= 65% >= 65% 2 1 1 ED & DFM071 Ambulance Handovers within 1 Hour 792  <= 404 0 0 Ambulance DToC 0 0 DFM072 Emergency Department 4 Hour Waits (inc MIU) 72.13% >= 72% >= 95% 3 2  00 DFM073 Emergency Department 12 Hour Waits 1,786  <= 1,320 0 Chapter 2 - Unscheduled Care RAG Timeline00 2019/20 November 2019 DFM074 Hip Fracture Survival 30 days 84.80% AP Improve 10  8 DFM025 Delayed Transfers of Care (DToC): MH 16  <= 12 Reduce 6 4 DFM026 Delayed Transfers of Care (DToC): non-MH 105  <= 28 Reduce 2 0 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Red Amber Green No Data

Please note: Timeline graphs based on when Out of Hours was under Integrated Quality and Performance Report Unscheduled Care Chapter. Will be reviewed for next month. Finance & Performance Committee Version November 2019 Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 2 – Unscheduled Care Stroke Care: Graphs 26

Same National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Actual Status Period Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Last Year

Percentage of patients who are diagnosed DFM06 with a stroke who have a direct admission >= 55.5% AP038 >= 50% Nov-19 50.00% 1st 41.70% 53.20% 55.00% 69.00% - 56.00% 59.30% 61.40% - 51.20% 50.00% 0.00% - 0.00% 0.00% 0.00% - 6 to an acute stroke unit within 4 hours of the  patient's clock start time

Percentage of patients who are assessed DFM06 by a stroke specialist consultant physician >= 84% AP038 >= 85% Nov-19 82.60% 5th 82.83% 79.80% 80.40% 81.00% - 88.00% 75.90% 85.70% - 82.10% 82.60% 0.00% - 0.00% 0.00% 0.00% - 7 within 24 hours of the patient's clock start  time

Percentage of stroke patients receiving the DFM06 required minutes for speech and language Improve AP038 AP Nov-19 53.90% 2nd - 65.00% 70.00% 69.00% - 70.00% 62.30% 59.00% - 56.70% 53.90% 0.00% - 0.00% 0.00% 0.00% - 8 therapy 

DFM06 Percentage of stroke patients who receive Qtr 1 Improve AP038 AP 22.30% N/A N/A 25.70% - - - 22.30% - - - 0.00% - - - 0.00% - - - 0.00% 9 a 6 month follow up assessment 19/20

BCU Level - Stroke Care - Admissions within 4 Hours: BCU Level - Stroke Care - Consultant Assessd within 24 Hours: November 2019 November 2019 100% 100% 90% 90% 80% 80% 70% 70% 60% 60% 50% 50% 40% 40% 30% 30% 20% 20% 10% 10%

0% 0%

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May-18 May-19 Actual Target Control Line Upper Control Limit Lower Control Limit Actual Target Control Line Upper Control Limit Lower Control Limit

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 2 – Unscheduled Care Stroke Care - Narrative 27

Why we are where we are and outcomes of the recent National Stroke Audit

DFM066 Admission to Stroke Unit within 4 Hours: Performance to the Acute Stroke Unit (ASUs) has seen a dip in month in Wrexham and significantly in Ysbyty Glan Clwyd (YGC) with Ysbyty Gwynedd (YG) showing slight improvement. The deterioration in Wrexham is aligned to the sickness in the Stroke Coordinator Team, with just one available in November. Additionally Unscheduled Care pressures have resulted in the ring fenced beds being used for non stroke patients more frequently, resulting in Breaches on the clinical standard. In YGC, it is the Unscheduled Care pressures, with the impact on the ring fenced beds as in Wrexham.

DFM067 Assessment by a Stroke Specialist Consultant in 24 hours has seen a minor deterioration overall in BCU with YG having an 8% deterioration, YGC static and Wrexham 3% improvement. As always, this relates to weekend assessments and depends on whether the Stroke Consultants are On Call for General Medicine at their Site over a weekend and will then do the assessment. If they are not On Call then the standard is breached for anyone who is admitted from a Friday evening to late on Sunday

DFM068 The % of patients receiving the required Minutes for Speech and Language Therapy data for November is not available. For October, BCU position was 2% worse than September 2019. There was an improvement in East, but deterioration in West and Centre. Both of these were due to staffing issues in month

DFM069 The % of patient who receive six month reviews: current data is not available

The Organisational Audit was conducted on the 3rd June 2019. The recently received results are currently being analysed by Sites and show the following levels of performance out of 10 : YG -6, YGC -4, Wrexham -3. YG has achieved the highest audit score across Wales. The quarterly Sentinel Stroke National Audit Programme (SSNAP) scores for July-September 2019 show that YG and YGC have retained their levels as C and B respectively whereas Wrexham has improved to achieve a B score.

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 2 – Unscheduled Care Stroke Care - Narrative 28

Actions Outcomes Timeline

1. Continue to highlight need to retain 2 ring fenced beds at Safety Huddles/bed meetings and Immediate with daily Safely with Site Management Teams. All wards to agree list of patients at daily Board rounds appropriate Improved compliance against the 4 hour Huddles and bed meetings. to out-lie if required to create Stroke beds and Ward Sisters/Matron/Stroke Coordinators/Ops Standard and the Sentinel Stroke National ED awareness ongoing Teams to focus on ensuring beds available. Awareness sessions in Emergency Department (ED) Audit Programme (SSNAP) Scores month on month. to continue to highlight need for early referral to Stroke Team Greater compliance with the Standard if 2. Options paper for implementation of virtual weekend ward rounds has been submitted to adjustments made to GIM rotas and remote Secondary Care and Area Teams for discussion but this is not achievable without an increase in access in place. Without agreement, rota is Options paper submitted, the number of Consultants on the Stroke Out of Hours (OOH) rota and an adjustment to their not sustainable. Short Term agreement for discussions continue in commitment to the General Internal Medicine (GIM) On Call rotas. Adjustment has been made in October rota but there will be no or September. East but not agreed in West and Centre. Remote access for reviewing of patients and images significantly reduced OOH Service from from home is now being funded by Area Teams November unless solution is reached 3. Deep dive of Speech & Language Therapy (SALT) performance for East in September and October 2019 has been done. Comparison of staffing and processes across BCU September and Understanding of reasons for low investigating possibility of independent review of processes in North Wales. Meeting in December performance in East and options for December 2019 2019 to ensure parity in application of Eligibility. Delivery Unit (DU) undertaking mapping review of improvement. Parity of Eligibility. Therapy Standards, date awaited. 4. Additional clinics that were due to be run from September in East to support clearance of Additional clinics from backlog which was due to vacancies have not happened due to sickness. Stroke Association have Reduction in backlog and greater compliance September. In East undertaken additional weekly clinic to support from September for 3 months and then review if with standard Process review for West need to extend. Stroke Association are now working to same model in West and Centre and Centre in September supporting the reviews as in East

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 2 – Unscheduled Care ED & MIU 4Hour Waits: Graphs 29

Same National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Actual Status Period Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Last Year

The percentage of patients who spend less than 4 hours in all major and minor DFM07 emergency care (i.e. A&E) facilities from >= 95% AP033 >= 72% Nov-19 72.13% 5th 71.53% 69.44% 71.21% 71.38% - 73.72% 73.04% 71.63% - 71.15% 72.13% 0.00% - 0.00% 0.00% 0.00% - 2 arrival until admission, transfer or  discharge BCU

BCU Level - Emergency Department (inc MIU) 4 Hour Waits: West - Emergency Department (inc MIU) 4 Hour Waits: November 2019 November 2019 100% 100% 90% 90% 80% 80% 70% 70% 60% 60% 50% 50% 40% 40% 30% 30% 20% 20% 10% 10%

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Central - Emergency Department (inc MIU) 4 Hour Waits: November 2019 East - Emergency Department (inc MIU) 4 Hour Waits: November 2019 100% 100% 90% 90% 80% 80% 70% 70% 60% 60% 50% 50% 40% 40% 30% 30% 20% 20% 10% 10%

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May-18 May-19 Actual Target Control Line Upper Control Limit Lower Control Limit Actual Target Control Line Upper Control Limit Lower Control Limit

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 2 – Unscheduled Care ED & MIU 4Hour Waits: Narrative 30 Actions Outcomes Timeline YSBYTY GWYNEDD • Increased senior clinical presence in Emergency department during the out of hours period • Reduce Emergency department 4 hour breaches attributed to doctor waits to a maximum 31st March continues as staffing allows of 20 per day 2020 • Reduce non-admitted breaches to a maximum of 15 per day to increase non-admitted • 2 hour Safety huddle in Emergency department embedded with increase to hourly during peak performance to 90% 31st demand. • Information Technology (IT) issues now resolved regarding data capture of Left December • Information support to validate left without being seen as impacting on over reporting of 4 hour Emergency Department Without Being Seen (LEDWBS) onto PiMS/IRIS. Retrospective 2019 breach numbers cleansing of the data from September currently underway. Assurance from the Informatics team that the data for December will be accurate at time of reporting. • Emergency department observation unit staffed 7 days per week from 18.11.19, with increased bed numbers and ability to flex in times of demand. 31st • Interim HoN EC post appointed to with ability for immediate start, this coupled with the start of the • Reduce admitted breaches to a maximum of 18 per day (compared to current 20 per day) December newly appointed Clinical Director will support the Directorate to make rapid improvements • Implement and embed an admission avoidance culture within the new front door facility 2019 • ICAN/Red Cross and fit to sit, and a dedicated area for the 9th CRT will be incorporated into the front th YSBYTYdoor footprint GLAN CLWYDand operational by 16 December 2019. The review of the ward administrator role has been undertaken with changes agreed to hours of work, and redistribution of some tasks. This will enable an increased focus upon: • Ensuring treatment plans are completed within the first 2 hours Increased grip and control leading to improvements in non-admitted performance up to 80%. • Ensuring that any decision to admit or discharge are made within the first 3 hours. 31st • Non-admitted performance December Paediatric breaches reducing to 1 or 2 per day, working towards an ultimate goal of being a 2019 The design phase of the protected minors work is close to completion with agreement on the model never event. and cohorting of patients. This will include • Identified teams for minors, majors, resus and START. • Allocated resource to paediatrics in out of hours period WREXHAM MAELOR 31st • Streamline the paediatric pathway in ED including directing to ward for PAU care • Reduce paediatric breaches to 3 maximum per day (allowing for clinical exceptions) December 2019 31st • Embed ED escalation process including the 2 hourly safety huddle with clear actions for the day • Reduced non-admitted breaches by 50% (maximum 15 a day) to increase non-admitted January working within the 4 hour standard performance to 85% 2020 • Reduced non-admitted breaches by 50% (maximumNovember 15 a day) to increase non 2019-admitted 31st • Use Clinical Decisions Unit for ED patients only performance to 85% December • Improved patient experience and outcome 2019 Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 2 – Unscheduled Care ED 12 Hour Breaches: Graphs 31

Same National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Actual Status Period Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Last Year

The number of patients who spend 12 DFM07 hours or more in all hospital major and 0 AP037 <= 1,320 Nov-19 1,786 7th 1,405 1,743 1,594 1,445 - 2,044 1,708 1,977 - 1,757 1,786 0 - 0 0 0 - 3 minor care facilities from arrival until  admission, transfer or discharge BCU

BCU Level - Emergency Department 12 Hour Waits: West - Emergency Department 12 Hour Waits: November 2019 November 2019 3,000 700 2,750 2,500 600 2,250 500 2,000 1,750 400 1,500 1,250 300 1,000 200 750 500 100 250

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Central - Emergency Department 12 Hour Waits: November 2019 East - Emergency Department 12 Hour Waits: November 2019 1,100 1,100 1,000 1,000 900 900 800 800 700 700 600 600 500 500 400 400 300 300 200 200 100 100

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Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 2 – Unscheduled Care ED 12 Hour Breaches: Narrative 32 Actions Outcomes Timeline YSBYTY GWYNEDD • Support deliver of maximum 6 > 12 hour breaches per day • Introduction of outlier clinical management team for cohort ward to support timely senior decision • Increased number of morning discharges from wards improving flow from 31st December 2019 making . Emergency department and Acute medical admissions unit 31st December 2019 • Full implementation of community length of stay reduction model (Tuag Adref) • Reduce number of Medically fit for discharge in Ysbyty Gwynedd by 50%

• Increased Emergency department nurse in charge attendance at site mini-huddles throughout the • Reduction in > 12 hour Emergency department breaches through improved day escalation process 31st December 2019 • Joint secondary care and area review of unscheduled care escalation procedures 6.12.19 • Increase the number of patients discharged from the front door • Increase capacity of the Tuag Adref team to include staffing linked to the 9th CRT

YSBYTY GLAN CLWYD The site wide escalation framework is operational. This includes: Clearer processes for escalation and de-escalation, with ED being the final point • Escalation triggers and actions for ED 9th December 2019 of escalation as opposed to the first. • Escalation actions for medicine in support of ED and flow • Escalation actions for surgical directorate in support of ED and flow Work on ‘queueing out’ of EQ via an area in Recovery 1 is progressing. Current challenges being worked upon include 31st December 2019 Decompression of ED, with 9 moves out of EQ by 9am each morning • Design work and build of the toilet facility • Staffing model required Increased compliance with PDD with 90% of patients expected to have one set There is a refreshed focus upon Board Rounds with members of the HMT attending to offer support within 24hrs of admission. Earlier discharge in line with SAFER principles 31st January 2020 and constructive feedback on how they can all be delivered to the same standard. leading to 30% of discharges happening before midday. WREXHAM MAELOR

31st December 2019 • Embed the Acute Floor care model principles • Reduced 12 hour breaches

31st December 2019 • Improve the site function and management through Head of Site leadership • Improved patient flows reducing outlying, escalation and 12 hour waits

• Improved flow by 08:30 with minimum of 8 beds freed and 45% discharged by 31st January 2020 • Improve ward discharge management including golden patients identified the day before 10:30 and 55% by 12:30

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 2 – Unscheduled Care Ambulance Handovers: Graphs 33

Same National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Actual Status Period Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Last Year

DFM07 Number of ambulance handovers over one 0 AP029 <= 404 Nov-19 792 4th 404 696 614 447 - 811 694 896 - 809 792 0 - 0 0 0 - 1 hour BCU 

BCU Level - Ambulance Handovers over 1 Hour: November 2019 West - Ambulance Handovers over 1 Hour: November 2019 1,750 700 1,500 600 1,250 500 1,000 400 750 300 500 200 250 100

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Nov-17 Sep-18 Dec-18 Aug-19 Nov-19 Dec-17 Aug-18 Nov-18 Sep-19 May-19 May-18 Actual Target Control Line Upper Control Limit Lower Control Limit Actual Target Control Line Upper Control Limit Lower Control Limit Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 2 – Unscheduled Care Ambulance Handovers: Narrative 34

Actions Outcomes Timeline YSBYTY GWYNEDD • Emergency department escalation to include ambulance handover standard • > 60 minute ambulance handover a never event 31st December 2019 operating procedure (in line with East) • Additional handover screens in Acute Medical Assessment Unit (AMAU), • Eliminate delays for dual pin entry. 1st December 2019 Emergency Department (ED) Majors and Minors.

YSBYTY GLAN CLWYD

The process and location has been agreed with Welsh Ambulance Service NHS Trust (WAST) for them to look after patients in ED. The Work Initiation Document Improved availability of ambulance resources to respond to emergency calls has been updated accordingly. within the 8 minute target. 31st December 2019 Specific actions for delayed ambulance handovers have been included in the An initial 20% reduction in 1hr delays leading towards a zero tolerance approach. new site escalation framework.

WREXHAM MAELOR

• Sustain the current ambulance handover times and strengthen performance • Nil 60 minute delays 31st January 2020

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 2 – Unscheduled Care Delayed Transfers of Care Graphs 35

Same National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Actual Status Period Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Last Year

DFM02 Number of health board mental health Reduce AP031 <= 12 Nov-19 16 6th 16 9 5 12 - 17 24 24 - 18 16 0 - 0 0 0 - 5 delayed transfer of care 

DFM02 Number of health board non mental health Reduce AP037 <= 28 Nov-19 105 7th 81 77 68 68 - 74 87 - 72 105 0 - 0 0 0 - 6 delayed transfer of care 

BCU Level - Delayed Transfers Of Care (Non-MH): BCU Level - Delayed Transfers Of Care (Non-MH): Number of Patients - November 2019 Number of Beddays - November 2019 150 4,000 140 130 3,500 120 110 3,000 100 90 2,500 80 70 2,000 60 50 1,500 40 1,000 30 20 500 10

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BCU Level - Delayed Transfers Of Care (MH): BCU Level - Delayed Transfers Of Care (MH): Number of Patients - November 2019 Number of Beddays - November 2019 40 3,000 35 2,700 2,400 30 2,100 25 1,800 20 1,500 15 1,200 10 900 600 5 300

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Why we are where we are: Lack of availability within the Community of general residential and nursing home beds and Elderly Mentally Infirm (EMI) residential and Nursing home beds. Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 2 – Unscheduled Care Delayed Transfers of Care - Narrative 36

Actions Outcomes Timeline Improved communication and discharge planning 1. Implement Delayed Transfer of Care (DTOC) Action Plan, Reduction in days delayed /bed days lost once Medically Fit for weekly reviewing weekly with Senior Leadership Team Discharge (MFD) Improved joint working with local authorities

2. Weekly Multi Disciplinary Team (MDT) DTOC meetings - improve Process to agree required actions to reduce the numbers of Process undertaken on a weekly basis communication and remove blockages patients medically fit but who are waiting in a hospital bed.

3. Review of all patients who have been away from home 14 days+ in acute/community; escalation & review by HMT to identify Identify reasons for delay and escalate to Senior Leaders Process undertaken on a weekly basis any trends.

4. Acute & Community teams to identify alternative pathways to Increased capacity to ensure timely discharge weekly support/improve patient journeys.

5. Support wards to reinforce Home First and What Matters Ensure a focus on early, safe discharge weekly

6. Daily safety brief attended by all departments to identify Integrated working between Area and Acute services in the co- Daily problems relating to patient flow. ordination of discharges

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 3 – Summary . Finance & Workforce 37

0 Annual Plan National Code Measure Status 3 0 Profile Target DFM084 Quantity of Biosimilar medicines prescribed 73.30%  ND Improve Finance & Resources DFM085 Critical Care Bed days Lost to DToC 18.20% N/A N/A Improve DFM087 PADR Rate (%) 75.2%  >= 78% >= 85% 7 DFM088 Staff agreed PADR helps improve 54.0% N/A N/A Improve 0 3 DFM089 Staff engagement Score 3.76 N/A N/A Improve Finance Workforce Other DFM090 Mandatory Training (Level 1) Rate (%) 84.58%  >= 85% >= 85% 1 4 2 DFM091 Sickness absence rates (% Rolling 12 months) 5.22% <= 4.46% <= 4.31% 00 00 

Chapter 3 - Finance & Resources RAG Timeline 2019/20 DFM092 Staff happy for BCU to treat Friends/Relatives 67.00% N/A Improve November 2019  10 LM001F Finance: Agency & Locum Spend £3.66m AP TBA 8  6 LM002F Finance: Position against Financial Balance £27.1m <= £23.3m <= £25m 4  2 0 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Red Amber Green No Data Integrated Quality and Performance Report AP = Awaiting Profile N/A A = Not Applicable - Annual Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 3 – Finance & Workforce Agency and Locum Spend Graphs 38

Same National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Actual Status Period Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Last Year Cost of Agency & Locum spend within LM001F TBA NIP AP Nov-19 £3.66m N/A £2.7m £2.6m £3m £3.7m - £4.1m £4.2m £3.96m - £4.34m £3.66m £0 - £0 £0 £0 - Month 

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 3 – Finance & Workforce Agency and Locum Spend - Narrative 39 Actions Outcomeses Timeline Agency as a percentage of total pay bill has significantly reduced Detailed timelines are contained in the this month (currently 4.8% Nov 19, Previously 5.3% Oct 19). Agency Workforce optimisation portfolio and spend for Nov 19 was £3,056,788, much improved from £3,525,720 accompanying PIDs. Impacts are expected 1. Focus remains on filling substantive vacancies, reducing sickness in Oct 19. Locum spend for Nov 19 at £606,529, much lower than to build from December onwards. absence and increasing pools of internal temporary staff , particularly £811,642 in Oct19 and now at a historic low level. Revised attendance improvement plan has in nursing, medical and dental, A&C. The BCU overall sickness absence rate has reduced (currently detailed actions / timelines around themes of 5.22% Nov 19, Previously 5.29% Oct 19). Data Analysis, Sickness Administration, The Workforce Optimisation Portfolio is the overarching mechanism to The BCU overall vacancy rate has increased (currently 8.8% Nov Active Absence Support and Preventative ensure delivery of BCU wide workforce initiatives. This is managed by 19, Previously 8.5% Oct 19). Successful recruitment of newly qualified Action. the Workforce Improvement Group (WIG) and consists of : staff and experienced staff from other providers has seen N&M Medical Recruitment Panel has been Medical Productivity, Nursing, Midwifery & AHP Productivity, Non- vacancy rates fall for three consecutive month (now 10.5%, last month introduced (Dec 19) to give focus on quickly Clinical Productivity and Terms & Conditions Application Productivity. 11.3%) , unfortunately M&D have increased to 11.1% from 9.4%. Loss filling M&D vacancies, reducing the M&D of 18.53 FTEs along with increase in budget FTE of 7.51 resulted in vacancy rate and associated Agency spend. this increase (half the loss and majority of the increase was at YMW) 2. Work is on-going to increase the capacity of BCU internal temporary Increased N&M Bank Usage - The 13,037 N&M hours delivered in staffing as an alternative to Agency. Nov 2019 was 758 more than same period last year mitigating agency Auto enrolment of new N&M starters, N&M - auto enrolment to the bank and revised pay rates. costs and improving safety. continued promotion of revised pay. A&C A&C - bank has been set up and is being expanded to include all staff bank programme to conclude Feb 2020. directly employed BCU A&C temporary staff by February 2020 (currently The introduction of the Medical Staff Bank will reduce M&D agency, on zero hours contracts in divisions). the MSB went live part way through November the impact on Agency Implementation (Nov 19) and expansion of M&D - In further efforts to move temporary staffing spend from Agency spend will be seen in December 2019 and will build as the MSB the Medical Staff Bank. to cheaper alternatives a Medical Staff Bank went live on 11 Nov 2019. expands and as outlier areas in terms of rates are addressed. Anticipated reduction of M&D vacancies in key specialisms via M&D programmes plan to deliver savings. 3. External consultancy services are analysing Medical spend and implementation of Kendal- Bluck recommendations, use of external Including external agencies sourcing M&D advising areas of potential improvement including: review of medical recruitment to source substantive M&D staff. Medical Recruitment staff. Continued expansion of Medical Staff rotas, review of job planning process, introduction of medical and dental Panel introduced (Dec 19). Recommendations of M&D rota reviews Bank. Impacts on run rates defined in PIDs bank, external specialist M&D recruitment. are being validated and implemented. to deliver from December 19 onwards.

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 3 – Finance & Workforce Financial Balance 40

Same National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Actual Status Period Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Last Year

% Cumulative Deficit Position against the LM002F <= £25m NIP <= £23.3m Nov-19 £27.1m N/A £3.83m £7.54m £10.96m - £14.64m £18.20m £21.16m - £23.9m £27.1m £0 - £0 £0 £0 - planned Financial Balance 

Financial Performance and Forecast 2019/20 4.5

4.0

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Plan - £35m Stretch Plan - £25m Actual Forecast

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 3 – Finance & Workforce Financial Balance: Narrative 41

Actions Outcomes Timeline The savings programme continues to remain a key focus area. In month the value of green and amber schemes increased by £2.9m. The overall value of the programme however reduced by £1.7m in month following a reassessment of two 1.Identify the full savings programme to meet the planned schemes by the Financial Recovery Group. The original planned deficit is 31st January 2020 savings requirement. considered achievable if the Health Board can convert and deliver 51% of the remaining red schemes, and deliver the green and amber schemes at their planned values alongside containing emerging cost pressures. A comprehensive financial recovery action plan (FRAP) programme has been in 2. Ensure the Health Board implements the full suite of Grip place since July and is monitored through the Financial Recovery Group to and Control actions to ensure all expenditure is necessary and 28th February 2020 ensure timely progression of any incomplete actions and scrutiny of the complete is effectively supporting clinical services. actions. Progress against plan is being monitored at both divisional and board level. The Committee and Board reports have been updated to provide additional clarity on 3.Ensure the recovery programme progresses at pace. progress and areas requiring priority attention. The format and content of the 31st December 2019 reports will continue to be reviewed to ensure clear and relevant messages are highlighted, to support the necessary decision making process. Both internal and external factors are being reviewed to support both the current year recovery and 20/21 integrated planning process. An additional cost pressure 4. Identify emerging expenditure pressures to ensure informed relating to the Welsh Risk Pool, which was previously recognised as a risk, has 28th February 2020 decisions are taken. now been confirmed and mitigating actions need to be identified to offset the cost pressure, which is now a high risk to delivery of the forecast deficit. 5. Identify and deliver further savings schemes to support The Financial Recovery programme continues to work with Divisions and 31st January 2020 delivery of the £25m control target. Improvement Groups to deliver the additional £10 of savings schemes.

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 3 – Finance & Workforce Sickness Absence Graphs 42

Same National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Actual Status Period Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Last Year

DFM09 Percentage of sickness absence rate of <= 4.31% AP043 <= 4.46% Nov-19 5.22% 3rd 4.95% 4.92% 5.05% 5.10% - 5.13% 5.16% 5.22% - 5.29% 5.22% 0.00% - 0.00% 0.00% 0.00% - 1 staff 

Why we are where we are: Overall absence has seen a decrease of 0.7%. Days lost to Long Term (LT) continues to fall - There has been particular focus on LT sickness, this has resulted in days lost and percentage off LT falling (Percentage - 3.22% (Nov 19) from 3.87% (Oct 19)). Focus on priority areas and changes to enhanced pay will reduce short term frequent sickness absence and medium sickness rates in a similar way to the continued reduction in long term absence.

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 3 – Finance & Workforce Sickness Absence - Narrative 43

Actions Outcomes Timeline 1. Revised attendance improvement plan being enacted with The BCU overall sickness absence rate has reduced (currently 5.22% Nov 19, Support and trajectories remain in detailed actions / timelines around themes of Data Analysis, Previously 5.29% Oct 19). place to deliver 4.2% by the end of Sickness Administration, Active Absence Support and All divisions reported reduced sickness reducing with the one exception of Women’s March 2020, however reaching this Preventative Action. which increased. remains in doubt..

Percentage off Long Term (LT) continues to fall - There has been particular focus Progress against trajectories is on LT sickness, this has resulted in percentage off LT falling to 3.22% (Nov 19) from 2. Priorities of Long Term / Stress / MSK – remain in place, as actively monitored. Further impact 3.87% (Oct 19). Focus on priority areas and changes to enhanced pay will reduce does the support for hotspots and support for all absences over of interventions should be seen in short term frequent sickness absence and medium sickness rates in a similar way to 12 weeks. Jan 2020. the continued reduction in long term absence. This is likely to result in a 0.2% drop from the baseline at October 2019 to February figures. 3. Staff members who have had have reached and exceeded the agreed sickness absence prompts have been identified with Short term frequent sickness absence rates will reduce giving a 0.2% drop from the The impact of these interventions active support being given to managers and staff to reduce baseline at October 2019 to February figures. should be seen in Jan 2020. absence levels and prevent reoccurrences of absence. Sickness levels across the health board prior to the enhancements being reinstated 4. Changes to Enhanced pay during sickness absence from 1st were at 4.3%, since June 2018 when enhancements were brought back in we have Dec 2019 for initial reduction of October 2019 with payments for sickness absence paid as basic seen a steady increase in sickness levels despite intensive support and interventions. 0.2% for “on hold” position. pay for absences of less than three months in length. National Although only a temporary measure for now putting enhancements “on hold” has agreement which reverts back to the position prior to June 2018. preceded a reduction in absence levels expected to continue as staff groups most impacted by this feel the effect. 5. Occupational health have introduced rapid access referral Occupational Health ‘fast track’ pathways for staff in the following disciplines: Mental Health, Rapid access to services will enable staff to either remain in work for return to work number referred available from Q3 Counselling, Physiotherapy, CMATS – orthopaedics / pain clinic / sooner. and turnaround times available from rheumatology, Radiology (scans), Drug & Alcohol, Podiatry and Q4. Dermatology Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 3 – Finance & Workforce PADR (Appraisals) Graphs 44

Same National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Actual Status Period Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Last Year

Percentage of headcount by organisation who have had a Personal Appraisal and DFM08 Development Review (PADR)/medical >= 85% AP046 >= 78% Nov-19 75.20% 3rd 59.39% 66.90% 68.80% 70.00% - 72.00% 73.00% 74.10% - 73.50% 75.20% 0.00% - 0.00% 0.00% 0.00% - 7 appraisal in the previous 12 months  (excluding doctors and dentists in training)

Why we are where we are: Compliance has improved this month by 1.7% to 75.2%. 10 divisions continue to see increases with only 3 seeing slight decreases. Estates & Facilities continue to make good progress with an increase again this month from 61.9% to 69.9%.

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 3 – Finance & Workforce PADR (Appraisals) - Narrative 45 Actions Outcomes Timeline 1. Provided each Division with a full report of PADR status including The BCU overall PADR compliance rate has detail on staff in date, within 4 month expiry, out of date 12-24 increased, 75% Nov 19 (74% Oct 19) this is months, out of date 24 months+ and never had a PADR and also significantly improved from last year (59% Nov 18). highlighting priority areas to focus on. Providing the detailed breakdown to all divisions has led to 16 out of 23 divisions seeing an increase in All actions completed during Attended 2 matron and ward manager meetings to raise awareness compliance over the month. Some large divisions such November. PADR self-learning of new PADR paperwork and resources and be available to answer as Estates & Facilities have seen a significant guide to be communicated widely any queries staff may have. increase of 8%. during December Positive responses to attending matron and ward Developed PADR self-learning guide for appraisers which includes managers meetings confirming the new PADR information on PADR principles, paperwork and best practice paperwork and process to be more user friendly and less repetitive. 2. Tailored session to be held with teams that have been identified as Working with teams who have low compliance to being low in compliance from data analysis including Theatres YGC, identify root cause of low compliance and solutions will Sessions to be held during and teams within Estates & Facilities. Sessions to look at identifying ensure good practice is adopted for sustainable PADR December root cause of low compliance and solutions to improvement in moving compliance in moving forward forward and Group PADR facilitation Workshops with managers contributes towards 3. Facilitated workshops held with managers attending Institute of ensuring they feel confident with the new resources to Sessions to be held during Leadership & Management (ILM) Qualifications conduct more meaningful PADR’s with their teams and December are given the opportunity to ask any questions they may have around PADR

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 3 – Finance & Workforce Mandatory Training Graphs 46

Same National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Actual Status Period Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Last Year

Percentage compliance for all completed DFM09 Level 1 competencies within the Core >= 85% AP046 >= 85% Nov-19 84.58% 1st 83.00% 84.10% 85.00% 84.00% - 85.00% 85.00% 85.00% - 84.00% 84.58% 0.00% - 0.00% 0.00% 0.00% - 0 Skills and Training Framework by  organisation

Why we are where we are: Targeted support has ensured compliance for November is only marginally short of the national compliance target of 85% at 84.58%.

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 3 – Finance & Workforce Mandatory Training - Narrative 47 Actions Outcomes Timeline Compliance for November nearly achieving 1. the national compliance target of 85% Compliance for November has reached the national compliance target (84.58% Nov 2019).. By identifying specific again of 85% . As projected timeline figures identify a possible drop clinical areas and staff groups where We anticipate remaining at / or again to 84% over the next quarter, work is taking identifying specific compliance will fall will prevent the target near 85% target areas and staff groups where compliance will drop and delivering dropping below the 85% national target rate. training as required This will inform all SME’s of the training schedules required to meet projected demand. 2. By Identifying to specific managers their staff Completion of an audit of Section 6, WP30, Statutory and Mandatory who are non-compliant with section 6 of the Audit commenced December training policy has commenced beginning of December 2019, The policy along with offering relevant advice and 2019 with other areas random Audit will concentrate for December 2019 on Ysbyty support will maintain and increase the current receiving audit over the Gwynedd. With 8 other Audits to follow to include Ysbyty Glan Clwyd, compliance rate. following 7 months. Wrexham Maelor hospital, Estates & Facilities, Mental Health, Areas West, Central & East.

3. By developing a more robust plan with follow Implement a more robust action plan for addressing no significant rise up reports will address the concern of no We anticipate maintaining the in training compliance within the following areas: significant increase in compliance within these 85% target over the winter 1. Medical & Dental particular areas. months. 2. Estates & Facilities

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 4 – Summary . Primary Care 48

0 Code Measure Status Plan this National 0 2 Period Target DFM049 OOH Assessment within 1 Hour 91.10%  AP >= 90% DFM050 OOH Very Urgent Seen within 1 Hour 100% AP >= 90% Primary Care  DFM047 Convenient GP Appointment 37.50% N/A N/A Reduce 00 4 DFM048 GP Practice Open 5pm to 6.30pm 0.00%  AP Improve GP Dentist DFM051 Accessed NHS Dentist 49.25%  AP Improve DFM086 Dentist Follow Up 36% AP Reduce 2 Out of 2  Number of CHC & Joint funded Packages 0 Hours 0 LM101 1,788 0 0 0 of Care  2 Cumulative cost of CHC & Joint funded 000 LM102 £59.46m 0 0 Packages of Care  Chapter 4 - Primary Care RAG Timeline 2019/20 November 2019 LM103 Total number of Emergency Admissions 7,380 0 0 10  8 Total Number of Emergency Admissions LM104 2,411 0 0 6 with an Average Length of Stay of 0  4 Average Length of Stay for Emergency LM105 5 0 0 2 Admissions: Acute Sites  0 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 LM106 Average Length of Stay: Community 27  0 0 Red Amber Green No Data

Please note: Timeline graphs based on when Out of Hours was under Integrated Quality and Performance Report Unscheduled Care Chapter. Will be reviewed for next month. Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 4 – Primary Care Dental Care Report 49

Same National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Actual Status Period Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Last Year

Percentage of the health board population DFM05 regularly accessing NHS primary dental Improve AP007 AP Nov-19 49.25% 6th 49.30% 49.30% 49.30% 49.30% - 49.30% 49.30% 49.30% - 49.23% 49.25% 0.00% - 0.00% 0.00% 0.00% - 1 care  # Percentage of adult dental patients in the DFM08 health board population re-attending NHS Qtr 2 Reduce AP007 AP 36.30% 7th New 19/20 - - - 0.00% - - - 36.30% - - - 0.00% - - - 0.00% 6 primary dental care between 6 and 9 19/20  months

Actions Outcomes Timeline

1. Funding has now been secured for the procurement of dental Commissioning approval will now be sought from Finance & February 2020 activity for the central Bangor/Menai Bridge locality Performance Committee

2. Additional funding unscheduled daytime access sessions will be commission from 1st January 2020 to 31st March 2020 for 8 £50K to be assigned immediately January 2020 practices aligned to Emergency Dental Service (EDS) provision

3. Welsh Government Contract Reform Innovation funding will be £157K programme funding for 5 years developed through assigned to qualifying practices to commission 8 scheduled access an Service Line Agreement (SLA) agreement with the January 2020 sessions liaising with Private Contractors (PC) & EDS colleagues Health Board

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Chapter 4 – Primary Care Proposed New Measures 50

Same National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Actual Status Period Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Last Year

Number of CHC & Joint funded Packages LM101 Nov-19 1,788 N/A 1,915 1,830 1,841 1,849 1,839 1,844 1,825 1,811 1,785 #REF! #REF! #REF! #REF! of Care 

Cumulative cost of CHC & Joint funded LM102 Nov-19 £59.46m N/A £61.71m £7.54m £15.08m £22.62m £30.29m £34.72m £45.00m £52.50m £59.46m Packages of Care 

LM103 Total number of Emergency Admissions Nov-19 7,380  N/A 7,917 7,857 7,947 7,880 7,934 7,515 7,377 7,885 7,380

Total Number of Emergency Admissions LM104 Nov-19 2,411 N/A 2,238 2,166 2,169 2,014 2,148 1,857 1,938 2,242 2,411 with an Average Length of Stay of 0 

Average Length of Stay for Emergency LM105 Nov-19 5.3 N/A 5.2 5.6 5.4 5.3 5.4 5.4 5.5 5.6 5.3 Admissions: Acute Sites 

LM106 Average Length of Stay: Community Nov-19 27.0  N/A 29.0 27.0 28.5 29.1 30.0 26.9 30.3 27.8 29.0 * = Rated against same period previous year The Health Board is a provider of integrated care across primary, community, mental health and secondary care parts of patients pathways. Much of the data within the organisation relates to hospital care. However, our strategic direction it to provide care closer to home for our population. National indicators for access to primary care are in development and will be included in IQPR reports from April 2020. However the above local indicators are included to reflect some of the work being undertaken through the care closer to home and unscheduled care improvement groups. The Continuing Health Care indicator is included to monitor the level and cost of provision for our population.

The level of emergency admissions reflects the whole system approach to unscheduled care, ability of primary and community services to manage patients close to home and effectiveness of admission avoidance schemes. The zero day length of stay acts as an indicator on the effectiveness of ambulatory care services and the ability of primary and community care to support patients return to their normal place of residence. The average length of stay data is useful in assessing the ability to support patient flow through the whole system and facilitate patients to return to their residence at the earliest opportunity. As this is an introductory report the data presented is for information in this report , with the expectation that future reports will include information on actions, expected outcome and timescales from the improvement groups in future reports. Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly Appendix A: Further Information. 51

Further information is available from the office of the Director of Performance 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

Integrated Quality and Performance Report Finance & Performance Committee Version November 2019

Put patients first  Work together  Value and respect each other  Learn and innovate  Communicate openly and honestly 7.1 FP19/298 Bryn Beryl Integrated Dementia & Adult Mental Health Centre Capital Business Case 1 FP19.298a Bryn Beryl business case december 2019 (2).docx

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Cyfarfod a dyddiad: Finance and Performance Committee 19.12.19 Meeting and date: Cyhoeddus neu Breifat: Public Public or Private: Teitl yr Adroddiad Bryn Beryl Integrated Dementia & Adult Mental Health Centre Report Title: Capital Business Case Cyfarwyddwr Cyfrifol: Mr Mark Wilkinson, Executive Director of Planning and Performance Responsible Director: Awdur yr Adroddiad Mr Neil Bradshaw, Assistant Director of Planning and Performance - Report Author: Capital Craffu blaenorol: This business case has been recommended for approval by the Prior Scrutiny: Estates Improvement Group and the Executive Team Atodiadau Appendix 1 – The capital business case Appendices: Appendix 2 – Equality Impact assessment Argymhelliad / Recommendation: The Committee is asked to approve the capital business case for the Bryn Beryl Integrated Dementia & Adult Mental Health Centre Please tick one as appropriate (note the Chair of the meeting will review and may determine the document should be viewed under a different category) Ar gyfer Ar gyfer Ar gyfer Er penderfyniad √ Trafodaeth sicrwydd gwybodaeth /cymeradwyaeth For For For For Decision/ Discussion Assurance Information Approval Sefyllfa / Situation: In summary, this business case sets out the rationale for the development of an integrated Dementia and Adult Mental Health Centre on the Bryn Beryl site.

Cefndir / Background: Until the recent move to a temporary leased site (Hafod Lon) owned by Gwynedd Council, Dementia / Older Persons Mental Health (OPMH) services for the Llyn area were fragmented across several sites (Ala Road, Hafan in Bryn Beryl and Cilan) within extremely poor accommodation. The Dementia day service in Ala Road was the last remaining service on the Ala Road Health Centre site in Pwllheli, however a site risk assessment carried out in June 2018 assessed the health and safety risks to be too high for service users and staff to remain on the site. This decision meant that urgent temporary accommodation needed to be found. At the same time, accommodation was also needed for the Hafan Unit Dementia service in Bryn Beryl (to allow for ward extension and refurbishment work to start in August 2018).

The Hafod Lon site - former special needs school (now named Hafod Hedd by the OPMH Service) was identified and is being leased (at nil rent paying service costs only) from Gwynedd Council on a short term basis.

Adult mental health (AMH) services are currently located in Cilan Mental Health Resource Centre a Health Board owned premises in the centre of Pwllheli, which also has significant health and safety 2 risks in terms of its condition, compliance with statutory regulations (e.g. DDA) and overall suitability for the delivery of modern health care. The need to create permanent location for the OPMH team affords the opportunity to rationalise all OPMH / AMH accommodation in this area into one centre on a single site and ensure that any proposed development integrates both local different stage dementia services as well as adult mental services. This proposal (as well as enabling the disposal of Ala Road) would ultimately enable the disposal of the Cilan site generating running cost efficiencies.

The overall aim of this development is therefore to bring together two different stage dementia services together with the Cilan adult mental health service, into one location and one centre.

Asesiad / Assessment & Analysis Strategy Implications

The North Wales Mental Health Strategy aims to ensure there is promotion of health and well-being for everyone; prevention of mental ill-health and early intervention when needed and the delivery of joined-up and recovery-focused care. The Strategy focuses on integrating as much as possible – across disciplines, across agencies and across services, in both planning and delivering services, with a view to reducing fragmentation.

A key strand of the Health Board’s ‘Living Healthier, Staying Well Strategy’ (LHSW) is the delivery of Care Closer to Home. An integrated centre for OPMH and AMH services will enable service users to access the most appropriate element of the service easily and seamlessly, providing continuity of care, and a 'wraparound' approach to care. People can 'step up and step down' within the services depending on their need at the time, a flexible approach within both the adult mental health service and the dementia service. Separate locations and buildings for OPMH and AMH services are currently fragmenting services for service users and their families. An integrated centre for dementia and adult mental health services will provide easier access for local people to ensure.

Financial Implications

The Capital Cost of the preferred option to develop a new extension to house an integrated dementia and adult mental health centre at the back of the Bryn Beryl site is £1,309,989. Welsh Government have confirmed a capital grant of £812,928 from the Integrated Capital Fund (ICF) in support of the proposal. There is a remaining shortfall in capital of £497,061 which would require support from the Health Board discretionary capital allocation.

The estimated revenue / running costs relating to the new build extension (360m²) are £24,440. Annual savings of £45,766 have already been realised through the relocation from Ala Road (subject to final disposal of the site). The anticipated savings arising from the closure of Cilan Mental Health Resource Centre as well as the rental costs of the Hafod Hedd site (Gwynedd Council) are £30,421 which when offset against the estimated running costs of the new Centre still mean the generation of savings of just under £6,000 per annum.

Capital receipts will be generated from the sale of the two Health Board sites and there value are currently subject to valuation by the District Valuer.

Risk Analysis If the Health Board does nothing, then local provision of dementia and adult mental health services in the Llyn area faces the following risks and issues; 3

 Dementia and AMH services will continue to be delivered within unsuitable, unfit for purpose accommodation, with poor accessibility and failing statutory compliance (Cilan)  Less than optimum integration of Dementia and AMH services for the Dwyfor population resulting in services continuing to be delivered from three separate sites / locations, which ultimately results in poor continuity of care  No capacity to expand and develop services – OPMH would like to run an additional post diagnostic group, extra clinics for OPMH and AMH, new carers’ drop-in groups  Perpetuation of the status quo with dementia services being accommodated in temporary / leased accommodation (not a viable long term option), as Gwynedd Council wish to sell the site ultimately. In addition, the leasing / purchase of an additional site by BCU is not in line with its LHSW and Estates Strategies.  Ongoing inefficient use of resources – running sites which are unnecessary, poor quality and non-compliant with statutory regulations  Missed opportunity to utilise ICF capital from Welsh Government to improve services for vulnerable client groups

Impact Assessment

A formal equality impact assessment has been undertaken as the attached Appendix 2.

Board and Committee Report Template V1.0 December 2019.docx 1 FP19.298b FINAL BB Integrated Dementia AMH Centre buisess case 18 Nov 19 (V9 Updated Costs).docx

Betsi Cadwaladr University Health Board Capital Business Case Guidance and Template

Bryn Beryl Integrated Dementia & Adult Mental Health Centre

Capital Business Case

1 | P a g e Betsi Cadwaladr University Health Board Capital Business Case Guidance and Template Business Case Template

Division West Area Development or Bryn Beryl Integrated Dementia & Adult Mental Scheme Health Centre Author/s Christine Rudgley / West Area Team / OPMH & AMH Services Version 9 Date 18th November 2019

1. Executive Summary 1.1 Headline information

 What do we want to do ?

 We need to provide permanent accommodation for Older People’s Mental Health (OPMH) and Adult Mental Health (AMH) service users and staff in the Dwyfor / Llyn peninsula area - OPMH / dementia services from Ala Road Health Centre and Hafan Unit on the Bryn Beryl site transferred to a temporary council owned site just outside Pwllheli in Summer 2018. The services transferred following the closure of Ala Road Health Centre (due to significant Health & Safety risks) and the need to vacate Hafan Unit to enable the recent Ysbyty Bryn Beryl ward reconfiguration and refurbishment to take place.  We want to use ICF capital to develop new, purpose-built facilities (an extension) on the Bryn Beryl site to accommodate local OPMH and AMH services users and staff.  We want to deliver more day assessment services for people in all stages of dementia, including people experiencing significant behaviour and psychological symptoms of dementia, as well as more group and individual therapy for adult mental health service users. We also want to provide integrated office accommodation for Health and Local Authority OPMH and AMH community staff.

 Why do we want to do it ?

 Modern, fit for purpose accommodation – we want to provide purpose built facilities and a suitable therapeutic environment to meet the needs of our vulnerable OPMH and AMH client groups  Improved integration - Integrating dementia and AMH services in one building enables people to access the most appropriate element of the service easily and seamlessly, providing continuity of care, and a 'wraparound' approach to care – ultimately increasing the number of patients cared for within their own communities with reduced need for hospital admission. Integration also significantly improves communication between community teams and agencies.  Reduced service fragmentation - OPMH and AMH services in Dwyfor are currently fragmented across previously three (and now two) sites. One centre will provide a single point of access.  Increased clinical capacity through expanded accommodation to see more dementia and AMH service users locally in line with the Mental Health Measure, the Health Board’s Care Closer to Home strategic objective and projected future demand.  Strategic alignment – Building a new integrated centre on the Bryn Beryl site is in line with BCUHB strategic direction (Living Healthier, Staying Well) in terms of Care Closer to

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Home - caring for people with dementia / AMH conditions for longer in their own communities, as well as the North Wales Mental Health Strategy (promoting integration and less fragmentation) and the Health Board’s Estates Strategy – investing in Bryn Beryl as a level 1 Health & Wellbeing hospital / centre.  Rationalise estate and generate efficiencies - We would like to get rid of existing, poor community estate and replace with modern, fit for purpose, efficient facilities in line with the Health Board’s Estate Rationalisation Strategy

 How much will it cost ?

 Capital Cost - The preferred option to develop a new extension to house an integrated dementia and adult mental health centre at the back of the Bryn Beryl site is £1,309,989.  Funding - An ICF capital allocation of £812,928 has already been formally approved by WG for this project to be spent in 2019/20 and 2020/21.  Capital shortfall - There is a remaining shortfall in capital required of £497,061. potentially to come from Health Board discretionary capital which would be required in 2020/21.  Revenue costs - The estimated revenue / running costs relating to the new build extension (360m²) are £24,440.  Savings - The annual savings generated from the closure of Ala Road are £45,766 and have already been realised in 18/19. The anticipated savings arising from the closure of Cilan Mental Health Resource Centre (MHRC) as well as the rental costs of the Hafod Hedd site (Gwynedd Council) are £30,421 which when offset against the estimated running costs of the new Centre still mean the generation of savings of just under £6K per annum.  Capital receipts - The capital receipts generated from the sale of the two BCU sites are subject to a DV valuation.

 What are the benefits ?

 Modern, expanded, fit for purpose accommodation to meet OPMH (Dementia) & AMH service user and staff needs  More integrated and improved patient care for OPMH Dementia and Adult Mental Health service users as a result of co-location - leading to improved continuity of care for service users, less duplication and better communication between services  Increased capacity by up to 10-15% to deliver both group and individual therapy as required under the Mental Health Measure and in line with increasing demographic demand  Care closer to home - supporting more accessibility in the community as set out in the national Dementia Strategy, the Mental Health Measure, the Health Board’s Living Healthier, Staying Well (LHSW) Strategy and the Estates Strategy through investment in the Ysbyty Bryn Beryl site as a Level 1 community hospital / health & wellbeing facility, providing integrated dementia and AMH services as locally as possible  Estate efficiency and rationalisation - improving the quality and efficiency of the estate through the rationalisation of poor community sites, reduced backlog maintenance, reduced running costs and achievement of statutory and regulatory compliance

 How are we going to measure success?

 More integrated care – we will measure the anticipated improvement in continuity of care and communication between teams through patient and staff questionnaires  Improved capacity - to deliver group and individual therapy to Dementia and AMH service users will be measured in terms of increased clinical contacts / assessments over time

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 Fit for purpose accommodation and a therapeutic environment will be measured on completion of the new centre (achieving statutory compliance and service standards) and adjacent dementia garden and through service user questionnaires  Care closer to home - we will measure the increased numbers of OPMH / AMH service users who are supported to remain self-caring avoiding admission to hospital  Delivery of savings – we will demonstrate efficiencies from the closure and ultimate disposal of two poor, inefficient community sites and from securing the sale of these sites.

Recommendation:

It is recommended that this business case to develop an integrated Dementia and Adult Mental Health centre on the Ysbyty Bryn Beryl site is approved, as it delivers a full range of benefits in terms of the improvement of patient care as outlined above, is strategically aligned to both national and organisational strategies, is less expensive than the do nothing option and secures financial efficiencies related to estate rationalisation.

It is proposed that the development be funded from a combination of Welsh Government ICF capital and Health Board discretionary capital, as set out above. Whilst there will be estates related revenue implications resulting from the capital development, these costs would have been offset against the closure of Ala Road Health Centre in 2018/19 and the savings have already been realised. Therefore the revenue impact of the development will not occur until 2021/22 and will be offset against the savings related to the closure and sale of Cilan. The net effect is expected to be just under £6,000 savings per annum.

1.2 Approval Process

This business case will be processed in accordance with the Procedure Manual for Managing Capital Projects. It will require local approval in the first instance from the West Capital Group and the West Area Leadership Team. Subsequently, the case will require approvals from the Health Board’s F&P Committee and Board. The proposal has already received formal approval from Welsh Government in terms of the capital allocation of £812,928 (from ICF capital monies). The intention is that the balance in funding will come from the Health Board’s discretionary capital allocation in 2020/21, subject to Estates Improvement Group, Executives, F&P Committee and Board approval.

2. The Strategic Case 2.1 Overview of the Business Case

In summary, this business case sets out the rationale for the development of an integrated Dementia and Adult Mental Health Centre on the Bryn Beryl site. It has been developed by the West Area Operational Improvement Lead in conjunction with the Assistant Project Support Manager, Estates Senior Project Manager, Area Chief Finance Officer and service leads for OPMH and AMH services.

Background / Context

Until the recent move to a temporary leased site (Hafod Lon) owned by Gwynedd Council, Dementia / OPMH services for the Llyn area were fragmented across several sites (Ala Road, Hafan in Bryn Beryl and Cilan) within extremely poor accommodation. The Dementia day service in Ala Road was the last remaining service on the Ala Road Health Centre site in Pwllheli, however a site risk assessment carried out in June 2018 assessed the health and safety risks to be too high for service users and staff to remain on the site. This decision meant that urgent temporary accommodation needed to be found. At the same time,

4 | P a g e Betsi Cadwaladr University Health Board Capital Business Case Guidance and Template accommodation was also needed for the Hafan Unit Dementia service in Bryn Beryl (to allow for ward extension and refurbishment work to start in August 2018).

The Hafod Lon site - former special needs school (now named Hafod Hedd by the OPMH Service) was identified and is being leased (at nil rent paying service costs only) from Gwynedd Council on a short term basis. Already the two different stage dementia services are enjoying the benefits of integration, as well as the improved environment and larger space for the service users and staff. However if Hafod Lon were to become the permanent location for Dementia services, the Health Board would need to purchase the site from Gwynedd Council and it would require more extensive refurbishment (estimated at £800K minimum including the site purchase).

Cilan MHRC is a Health Board owned premises in the centre of Pwllheli, which also has significant health and safety risks in terms of its condition, compliance with statutory regulations (e.g. DDA) and overall suitability for the delivery of modern health care. Some OPMH Team office accommodation, as well as clinical and office space for Adult Mental Health Services / Team are housed in Cilan. It would seem sensible to take this opportunity to rationalise all OPMH / AMH accommodation in this area into one centre on a single site and ensure that any proposed development (this business case) integrates both local different stage dementia services as well as adult mental services. This proposal (as well as enabling the disposal of Ala Road) would ultimately enable the disposal of the Cilan site generating running cost efficiencies. Originally the Hafan service was planned to relocate temporarily to Ala Road, however this was no longer possible. The site is now decommissioned and the running cost savings are being incurred by Operational Estates

There is therefore a requirement to find a permanent integrated accommodation solution for both Dementia and AMH services. The overall aim of this development is therefore to bring together two different stage dementia services together with the Cilan adult mental health service, into one location and one centre. The new Centre will provide modern, purpose built accommodation and an improved environment for local Older People’s Mental Health (OPMH) and Adult Mental Health (AMH) service users and staff, previously located in very poor conditions in three separate buildings on three separate sites. The co-location of OPMH and AMH services and staff in one centre, as well as with several members of local authority staff will significantly improve the integration of and communication between services, which should positively impact on the delivery of patient care.

Strategic context

The national Dementia Strategy focuses on the need to provide high quality, person-centred care to people living with dementia and those affected by it, to support the creation of dementia- friendly communities and to listen and respond to people with dementia. The provision of facilities and a therapeutic environment that are purpose built to meet the needs of people with dementia is paramount. The model focuses on the need to ‘support people to remain self-caring avoiding admission to hospital’ - whether general or psychiatric - whenever possible and facilitate timely discharge from hospital (with the right care or support at home), as an admission to hospital can be devastating for a person with dementia.

Welsh Government’s Mental Health Measure requires health boards to provide timely assessments and interventions to significant numbers of individuals in the locality. Current estate provision is limited in terms of capacity. This provision will provide much increased capacity to deliver group therapy and individual care close to home.

5 | P a g e Betsi Cadwaladr University Health Board Capital Business Case Guidance and Template

The North Wales Mental Health Strategy aims to ensure there is promotion of health and well- being for everyone; prevention of mental ill-health and early intervention when needed and the delivery of joined-up and recovery-focused care. The Strategy focuses on integrating as much as possible – across disciplines, across agencies and across services, in both planning and delivering services, with a view to reducing fragmentation.

A key strand of the Health Board’s ‘Living Healthier, Staying Well Strategy’ is the delivery of Care Closer to Home. An integrated centre for OPMH and AMH services will enable service users to access the most appropriate element of the service easily and seamlessly, providing continuity of care, and a 'wraparound' approach to care. People can 'step up and step down' within the services depending on their need at the time, a flexible approach within both the adult mental health service and the dementia service. Separate locations and buildings for OPMH and AMH services are currently fragmenting services for service users and their families. An integrated centre for dementia and adult mental health services will provide easier access for local people to ensure.

2.2 The Current Service

Older People’s Mental Health Services

Population, Geography & Demographics Dwyfor has a population of around 25,000. The area has an older population than the North Wales average, with 27% aged 65 years and over and just over 4% aged 85 years and over.

A higher proportion of the population of Dwyfor (registered primary care cluster population) live in a rural area than the Arfon and Meironnydd Primary Care Cluster areas and the average across North Wales.

South Gwynedd OPMH services currently use two bases in the Dwyfor area. The ‘Cilan’ building in Pwllheli provides office space for the three community psychiatric nurses, psychologist and support worker. ‘Hafod Hedd’ in Y Ffor is the temporary location of the day assessment services, which provides a tiered model of care depending on the service user’s level of need, housed within the same building. The consultant psychiatrists’ clinic is also held there once a week.

Day assessment services are open Monday to Friday from 9am to 5pm. They offer ongoing assessment and treatment in the form of cognitive stimulation for people with dementia. There are three main ‘groups’ of people who attend on different days or different areas of the building, depending on their need. Service users usually attend 2 or 3 times a week, however this can be increased in times of crisis in a ‘step-up, step-down’ manner. As such, day assessment is considered an alternative to hospital admission, and our number of admissions to the psychiatric inpatient unit in Llangefni has greatly reduced since the establishment of this service. We also acknowledge that although respite for carers is not the main focus of this service, it is by nature offering short term respite for carers.

Clinic/patient numbers per week In terms of day assessment, there is capacity for 24 service users to attend three times per week and 12 service users attending twice a week. This equates to 96 patient contacts / attendances per week for dementia day assessment services. The separate OPMH outpatient clinic is held weekly with usually between 5 and 8 service users attending.

Current staffing levels

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Our staffing establishment is as follows: 1 x band 6 RMN 2 x band 5 RMN 3 x band 3 HCSW Social services provide two support workers three times a week.

Location, current buildings, condition of the properties

OPMH services for the Llyn population are currently provided from the leased Gwynedd Council owned Hafod Hedd site in Y Ffor (just outside Pwllheli). The leasing of this site is a temporary arrangement arising from the need to find emergency accommodation for the Ala Road Joint day assessment service in May / June 2018, as a result of the outcome of the health & safety risk assessment of the Ala Road site (which advised the need to close the site as soon as possible). At the same time, there was also a need to relocate the early stage dementia service from the Hafan Unit in Ysbyty Bryn Beryl to allow the ward refurbishment works to start in September 2018. Both service transfers have been achieved without any loss or reduction in services for patients.

Hafod Hedd is a single storey site offering large spaces for services and is in semi reasonable condition for a temporary service, however it is not suitable in its current state as permanent accommodation. Some very minor upgrading (painting / suspended ceilings etc) was undertaken in 2018 before occupation. Cilan MHRC is a Health Board owned three storey terraced townhouse type premises in the centre of Pwllheli, with no lift and some adjacent car parking at the back. The site has recently been assessed as having significant health and safety risks in terms of its condition, compliance with statutory regulations (e.g. DDA) and overall suitability for the delivery of modern health care.

Dementia model of care

 The Population Needs Assessment identifies that there needs to be a clear pathway from assessment and diagnosis of dementia through to ongoing support and end of life care. The OPMH service is also required to support the community hospitals and care homes caring for people with dementia.  The model focuses on Supporting people to remain self-caring avoiding admission to hospital - whether general or psychiatric - whenever possible and facilitating timely discharge from hospital (with the right care or support at home) is vital, as an admission to hospital can be devastating for a person with dementia.  The right care and support does not just focus on levels of ‘functioning’ or daily living tasks but also 'what matters' to people – such support (getting out and about, retaining social contact) often falls to friends, family and neighbours, which is why supporting carers is an important aspect of this project.  Social isolation is known to have a negative effect on both physical and emotional health, the creation of this specialist mental health facility will be an opportunity to encourage people with mild mental health problems to engage with voluntary agencies to potentially prevent problems escalating into serious mental illness.  Fragmented services in different locations do not enable the delivery of the right model of dementia care. Co-locating services together under one roof will enable the person to access the most appropriate element of the service easily and seamlessly, providing continuity of care, and a 'wraparound' approach to care - people can 'step up and step down' within the services depending on their need at the time, a flexible approach within both the adult mental health service and the dementia service.  Integrating services in one building also provides an opportunity to undertake a further assessment and thus contribute towards maintaining the individual who is living with

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dementia in the community for a longer period of time, increasing the number of patients cared for within their own homes with reduced need for hospital admission.

Gaps in existing service provision

 Need for additional post diagnostic therapy group for people recently diagnosed with dementia – this will be able to be established in the new centre, as there will be suitable, available space (12 new clinic spaces per week)  Space for carers to ‘drop in’ if they need support and advice - there will be a designated space in the new centre for a new Carers’ drop in group  VC facilities – new video-conferencing facilities will be included within the Project’s equipment  Limited usable outside space - a new dementia garden is planned outside the new Centre for use by service users and staff  Space for third agency organisations to offer services – there will be an increase in clinic and interview rooms for use by OPMH & AMH services, as well as relevant third sector organisations.  Inadequate meeting/training space – a large meeting / training room has been included within the new centre plans  Evenings and weekends – Future service plans include looking at the implementation of an out of hours service to meet service user needs (the business case is not dependent on securing these funds)  Admin cover – additional administration cover is also a future requirement but again is not business case dependent.

Adult Mental Health Service (Cilan)

Population, geography & demographics As mentioned above, Dwyfor has a population of around 25,000. It is estimated that one in four people experience common mental health problems or suffer from anxiety and depression at some point in their lives, and this has a significant impact on the adult working population. One in three GP consultations is also estimated to be mental health related.

Location and current buildings The South Gwynedd Adult Community Mental Health Team (CMHT) is based at Ysbyty Alltwen, Tremadog. There is also a satellite base at Plas Brith in Dolgellau, and staff work from various GP surgeries and third sector buildings across the area. The CMHT does have access to Cilan Mental Health Resource Centre (MHRC) in Pwllheli on a peripatetic basis, but the CMHT services currently provided at Cilan are limited as the building is no longer fit for purpose. In Cilan the office space is being used by the CMHT on a daily basis, however the interview rooms are shared with the other services who operate from Cilan. Room availability is therefore limited. This means that new to service clients cannot presently be seen in Cilan or clients who are known to potentially present as a risk. The lack of space in Cilan has meant that local people are having to travel to access AMH services. Both the Consultant Psychiatrist and Clinical Psychologist have moved their clinics to Ysbyty Alltwen. There are no inpatient adult mental health beds in South Gwynedd. Clients requiring inpatient care are admitted to the Hergest Unit in Ysbyty Gwynedd.

Clinic Capacity & Current Staffing  The Psychiatrist has one Dwyfor clinic (for Cilan clients) in Alltwen per week (7 slots).

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 The Psychologist undertakes three clinics per week for Dwyfor (Cilan) clients (5 slots per day).  The Primary Care Mental Health Team currently conduct assessments across GP surgeries / third sector (Felin Fach). This is problematic as the staff are dependent on third party room availability and need to fit in with what is available. This in turn result is appointments being delayed due to lack of rooms.  The Primary Care Mental Health Team has two practitioners working in Dwyfor. They see 20 clients each per week. The sessions include assessments and intervention.  There are six secondary care CMHT workers based in Dwyfor. Client numbers are less due to travel as most appointments are conducted at the home address. Secondary Care workers also attend the ward round in Bangor and other meetings. They see approximately 16 clients each per week.

The service would like to establish a depot clinic / physical health monitoring clinic one morning per week in Dwyfor. Depots are currently undertaken at CILAN or clients homes. The physical health monitoring would entail Blood Pressure/ weight monitoring/ health promotion, smoking cessation. ECGs.

Adult Mental Health Issues / Gaps in existing service provision

 Lack of clinic capacity with Dwyfor clients having to travel further to Psychiatrist and Psychologist clinics in Alltwen resulting in higher DNA rates – Capacity will be increased within the new Centre with these clinics being able to transfer back so that clients can be seen locally.  Unfit for purpose building (Cilan) in terms of layout and general condition – the new Centre will provide modern, purpose built facilities which have statutory compliance  Challenges arising from housing OPMH / AMH services with Children’s services in close proximity in the same building (Cilan) – It is proposed to relocate Children’s office / admin services to the Bryn Beryl site (when Cilan closes) and to secure interview space in central Pwllheli in Ffordd y Cob.  Limited access to suitable appointment/ interview rooms in Cilan - resulting in ineffective appointment system and poor short notice access for urgent and crisis appointments. This will be addressed in the new Centre.

2.3 The Case for Change

2.3.1 Business Needs – the gap between where we want to be and where we are now

As indicated previously, national, organisational, Mental Health and local West Area plans prioritise the need to deliver care as close to home as possible in community settings and to integrate services wherever possible with those provided by other agencies. Currently both OPMH and AMH services are fragmented in the Dwyfor area which affects access for vulnerable client groups. The aim is to deliver a single point of access to integrated services to ensure easier, more timely assessments and interactions for the local population. Co-locating and working closely with local authority and third sector colleagues will also facilitate the move towards a seven day service.

In terms of estate, neither the current Health Board estate (in Bryn Beryl and Cilan) nor the leased Hafod Lon premises are able to optimally support the delivery of modern, integrated services to fully meet current and future service needs. The leased facilities require a significant upgrade to effectively support the delivery of modern dementia and adult mental health services.

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Whilst this is feasible, the site would need to be purchased first and the existing footprint would limit the design potential to some extent. In addition, there is no capability to extend the existing Cilan premises to increase capacity and the building itself is unsuitable for modern health care delivery and is in very poor condition. This means that the building is more costly to run and is incompatible with our aspiration to provide services of the highest quality. In terms of dementia and adult mental health services, the current provision of accommodation does not meet the needs of service users and staff.

The key issues affecting the optimum delivery of OPMH / Dementia and AMH services which would be overcome through the development of a new integrated Dementia and Adult Mental Health Centre on the Bryn Beryl site serving the local wider Pwllheli / Llyn peninsula community are as follows:

Poor quality (not purpose built) accommodation in terms of accessibility, suitability and fabric of premises

Hafod Lon (currently housing the two different stage dementia services) is a single storey building that was originally a special needs school. Whilst the current dementia service accommodation in Hafod Lon has undergone a very minor upgrade (some painting and some new suspended ceilings) and represents a definite improvement on the very poor Ala Road accommodation, it is not purpose built and would need fairly significant refurbishment to meet existing and future dementia service needs.

Specific issues include:

 The building is leased so would need to be purchased by BCUHB before significant investment in refurbishment could be undertaken.  The acquisition of another site is not in line with the Health Board’s estate rationalisation strategy  The internal fabric of the building requires significant upgrading to make it fit for modern health service delivery and more dementia friendly.  Alterations would need to be made to accommodate clinic rooms and office space for AMH services  The current site access is single lane and not ideal.

Fragmentation of services and poor integration

The location of dementia and adult mental health services in several sites across the area presents problems. By co-locating on the Hafod Lon site the two different stage dementia services including two local authority colleagues (from Ala Road and Hafan Unit), integration has improved already for both service users and staff. However, this could be much improved as some OPMH staff remain in Cilan along with AMH Teams and AMH clinic accommodation. The issues are as follows:

 Fragmentation of services leading to difficult / confusing access for service users and carers and less than optimum continuity of care. This makes it more difficult to offer service users the preferred model of care – the ‘wraparound’ approach. If services are under one roof, this enables the person to access the most appropriate element of the service easily and more seamlessly;  Lack of integration between OPMH and AMH clinical teams, leading to extended communication chains, greater duplication and poorer patient outcomes.  There is a need to integrate more with third sector organisations to improve seven day access / crisis support

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Lack of space / capacity: overcrowding & an inability to expand services

In the leased Hafod Lon building, dementia services have more space to expand although the space requires refurbishment. However Cilan, which currently houses OPMH and AMH Team offices and AMH clinical rooms and some Children’s services (offices, record storage and clinic rooms), is cramped and has no room to expand. Some AMH services (Pyschiatrist and Psychologist clinics) have had to re-locate to Alltwen temporarily, as there is no suitable clinic space in Cilan. It is a three storey town house with accessibility issues (no lift). It has recently been risk assessed as requiring substantial investment to bring up to standard. Specific issues as a result of this lack of space include the following:

 The lack of space restricts the ability of OPMH and AMH services to expand in terms of clinic space and office space e.g. new post diagnostic dementia group, additional clinics, new Carers’ drop in groups;  Some services have had to move to Alltwen (which is not easily accessible for the Llyn population) including Consultant Psychiatrist & Psychologist clinics and this has impacted negatively on DNA rates  Whilst Dementia services can expand in Hafod Lon, this requires investment and is currently a leased building.  It is not ideal to house OPMH, AMH and Children’s services in close proximity in the same building (Cilan). It would be preferable to house Children’s services separately.  The lack of a dedicated meeting or training room in Cilan limits the ability to carry out Continuing Professional Development for existing staff and inductions for new staff, as well as restricting team meetings, BCUHB liaison groups and patient group meetings.

Lack of parking at current premises

Whilst there is some parking capacity on the Hafod Lon site, there are issues with the single road access from the main road. Cilan MHRC is a town centre site in Pwllheli and has few car parking spaces for service users and carers.

2.3.2 The Risks of continuing Business as Usual

If the Health Board does nothing, then local provision of dementia and adult mental health services in the Llyn area faces the following risks and issues;

 Dementia and AMH services will continue to be delivered within unsuitable, unfit for purpose accommodation, with poor accessibility and failing statutory compliance (Cilan)

 Less than optimum integration of Dementia and AMH services for the Dwyfor population resulting in services continuing to be delivered from three separate sites / locations, which ultimately results in poor continuity of care

 No capacity to expand and develop services – OPMH would like to run an additional post diagnostic group, extra clinics for OPMH and AMH, new carers’ drop-in groups

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 Perpetuation of the status quo with dementia services being accommodated in temporary / leased accommodation (not a viable long term option), as Gwynedd Council wish to sell the site ultimately. In addition, the leasing / purchase of an additional site by BCUHB is not in line with its LHSW and Estates Strategies.

 Ongoing inefficient use of resources – running sites which are unnecessary, poor quality and non-compliant with statutory regulations

 Missed opportunity to utilise ICF capital from Welsh Government to improve services for vulnerable client groups

2.3.3 Potential Business Scope and Key Service Requirements

This business case seeks to address the bringing together of OPMH and AMH services located in the Dwyfor / Llyn peninsula area into one fit for purpose building / new centre on the Ysbyty Bryn Beryl site. The overall aim is to integrate OPMH and AMH services and community teams including local authority and third sector colleagues into one building to improve continuity of care and communication for service users and staff. The new Centre will also provide increased clinical capacity ensuring future service sustainability. This development will also enable the Health Board to rationalise poor quality, community estate, and generate site running cost efficiencies

2.3.4 Investment Objectives, Benefits & Risks

The investment objectives for this project are as follows:

1. To deliver modern, expanded, fit for purpose accommodation in a suitable environment to meet OPMH (Dementia) & AMH service user and staff needs 2. To deliver improved integration of different stage OPMH Dementia services and Adult Mental Health services through co-location which leads to improved continuity of care for service users and better communication between services 3. To ensure strategy alignment with the national Dementia Strategy and Mental Health Measure, the North Wales Mental Health Strategy, the Health Board’s Living Healthier, Staying Well Strategy and the Estates Strategy by investing in the Ysbyty Bryn Beryl site as a Level 1 community hospital / health & wellbeing facility, providing integrated dementia services as locally as possible 4. To improve the quality and efficiency of the estate through the rationalisation of poor sites, reduced backlog maintenance, reduced running costs and achievement of statutory and regulatory compliance

Main benefits Criteria

This section describes the main outcomes and benefits associated with the implementation of the potential scope in relation to business needs. The four categories of benefit are as follows:

The following table summarises the benefits arising from each of the investment objectives which were identified above:

Investment Objectives Stakeholder Benefit Group

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Investment Objective 1: Patients will benefit from the improved physical environment in terms of: To deliver modern, expanded, fit for purpose Functional suitability; Patients accommodation in a Dementia friendly space / design; suitable environment to meet OPMH & AMH service Increased space for assessment, clinics user and staff needs; and activities;

It will improve staff morale and operational Health Board management of service; meets national and Staff: clinical / local policy objectives to transfer services administration as close to people’s homes as possible.

Health It supports the delivery of BCUHB’s Living Community / Healthier, Staying Well Strategy & Others associated Estates Strategy.

Investment Objectives Stakeholder Benefit Category of Group Benefit

Investment Objective 2: Patients will benefit from Qualitative more service integration benefit To deliver improved through improved integration of different stage continuity of care, better OPMH Dementia services Patients communication between and Adult Mental Health services and teams which services through co-location ultimately leads to on a single site; improved outcomes for patients.

It meets national and local policy objectives to improve integration through co-location of services.

Health Board OPMH & AMH Teams will Staff: clinical / be co-located with LA administration OPMH colleagues which will improve integration and communication. Opportunity for staff and services to share facilities – offices, meeting rooms, kitchen, toilets etc

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It supports the delivery of Quantifiable WG’s Dementia Strategy benefit and Mental Health Measure, as well as the North Wales Mental Health Strategy in terms Health of integration and Community / improved accessibility Others and the Health Board’s LHSW Strategy in terms of Care Closer to Home, Estates Strategy and West Area Operational Plan (CCTH).

Investment Objectives Stakeholder Benefit Category of Group Benefit

Investment Objective 3: Patients will benefit from Qualitative a local service that is benefit To support the health service more integrated and less model configuration as set fragmented – easier to Patients out in the Health Board’s access, housed in fit for LHSW Strategy and Estates purpose, quality facilities. Strategy by investing in the This is likely to lead to Ysbyty Bryn Beryl site as a improved outcomes. Level 1 facility, to provide integrated dementia services Health Board It meets national and as locally as possible Staff: clinical / local policy objectives to administration integrate services.

It supports the delivery of national strategies for dementia and mental Health health and BCU’s Mental Community / Health Strategy, the Others LHSW Strategy, Estates Strategy & West Area Operational Plan 2019/20

Investment Objectives Stakeholder Benefit Category of Group Benefit

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Investment Objective 4: Patients will benefit from Quantifiable the improved physical benefit To improve the quality and environment in terms of: efficiency of the Estate through estate Functional suitability; rationalisation, by reducing backlog maintenance, Fire safety compliance; Patients reducing running costs and Accessibility; achieving statutory and regulatory compliance; Ease of use for those suffering from Dementia;

Reduced risk of infections.

Staff will benefit from working in an improved physical environment as above. The Health Board will comply with the objectives of the estates condition and performance survey in regard to national performance indicators. Health Board The building will meet key Staff: clinical / HTM and HBN administration requirements.

The Estate will be rationalised (Ala Road already closed, future closure of Cilan) and Cash releasing therefore generate benefit running cost efficiencies through the disposal of Ala Road Health Centre Non-cash and Cilan MHRC releasing benefit The Llyn / wider Pwllheli Health community will benefit Community / from a modern purpose- Qualitative Others built building. benefit

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Potential Main risks The potential main risks associated with the proposed development are shown below, together with their counter measures.

Main Risk Counter Measure

Strategic

Failure to gain BCUHB approval of . Planning Dept and Capital Planning Team are Business Case aware that business case is being developed. . ICF capital funding has been formally approved by WG for this Project. Tenders are returned with higher than . Explore potential with Planning Team for other expected costs (higher than ICF sources of potential funding (discretionary capital sum approved in principle) capital) to bridge any cost differential between with potential outcome being the tendered cost and ICF approved capital option for a smaller (less integrated) allocation scheme is taken forward . Maintain close dialogue with WG ICF Capital Lead to clarify whether any additional ICF capital might be available (20/21) . Explore potential for value engineering without significantly affecting project benefits . Explore potential for pursuing alternative option within ICF capital allocation - the purchase and refurbishment of Hafod Lon / Hedd site Revenue costs are higher than . Consider importance of scheme in terms of anticipated savings service improvement for vulnerable patient groups, estate rationalisation opportunities and the development within overall DCP of the Bryn Beryl site and the need to move forward Model of Care

Inability to include AMH services . Building design to identify shared OPMH / within project to further improve AMH facilities / rooms where appropriate and integration and estate rationalisation, include expansion space at the outset as well as include some expansion for . Bryn Beryl to have an agreed site future flexibility for integrated model of development control plan. care to develop

Commissioning

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Disruption to services during . Dementia services to remain on leased Hafod construction works and during Lon site and AMH services to remain in Cilan transfer to new Centre MHRC until completion of capital works (extension of Hafod Lon lease period already agreed in principle with Gwynedd Council) . Actual relocation of services to new Centre to take place over a weekend period . BCUHB to continue to monitor targets/normal provision of care.

2.4 Proposed Service Development

The proposal is to develop a new build / extension at the back of the Ysbyty Bryn Beryl site to integrate local OPMH and AMH services into a single centre. This development will address the current service issues outlined above in the Case for Change, as well as the investment objectives already identified. The proposed centre will be located at the rear of the Bryn Beryl site adjacent to the former Llyn Ward building and will provide expanded, purpose built accommodation and a therapeutic environment for dementia and adult mental health service users and staff. The development will allow the co-location of two different stage dementia services (joint with the local authority) together with the Adult Mental Health service to create a new, integrated centre on the Bryn Beryl site. This model will facilitate the delivery of more streamlined care, improved communication between teams and operational efficiencies.

The Older People’s Mental Health and Adult mental Health services to be delivered from the new Centre will be provided by the existing OPMH and AMH Teams. No additional staffing / posts are anticipated to deliver the full range of services from the new Centre.

The bringing together of OPMH and AMH services onto the current leased site Hafod Hedd has already facilitated the closure of the Ala Road Health centre site in Pwllheli. In addition, the new Centre will also facilitate the closure of the Cilan MHRC site in Pwllheli, as well as cease the need to lease the Hafod Lon / Hedd site.

The proposal to develop a new, integrated Dementia and AMH Centre in Bryn Beryl is also fully in line with national strategies for dementia and adult mental health and the North Wales Mental Health Strategy to deliver integrated, more accessible care, as well as the Health Board’s LHSW Strategy in terms of delivering care closer to home and caring for people longer in the community, as well as reflecting the principles within the Estates Strategy with regard to the need to invest in the Bryn Beryl site as a level 1 community hospital / health and social care facility.

This development project will make full use of the approved ICF capital allocation (£812,928) and will generate efficiency savings in terms of running costs and cost avoidance associated with backlog maintenance.

There are five options for consideration and the detail is set out in Section 5 in the Options Appraisal section.

2.5 Areas affected by the Proposal, Inter-dependencies

Is project part of a larger programme ?

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The need to invest in the infrastructure and overall refurbishment of the Ysbyty Bryn Beryl site (as a Level 1 health & wellbeing facility / community hospital) has been identified within the Estates Strategy to support ‘Living Healthier, Staying Well’. Phase 1 of this overall refurbishment commenced in August 2018 using BCUHB discretionary capital monies, to bring the two existing wards together into one newly refurbished ward. This work is almost complete and together with Safe Clean Care monies awarded to pay for piped medical gases on the new ward, and the Hospital League of Friends’ funding for an extension to the x-ray corridor, an extensive refurbishment of the inpatient accommodation has now been achieved.

The development of a new build integrated Dementia Centre in a peaceful, self contained setting at the back of the Bryn Beryl site is the next site redevelopment priority. Such a development will allow the service to provide fully integrated services in fit for purpose premises, to transfer off the leased local authority owned Hafod Lon site and to facilitate the closure and disposal of Cilan. It has already facilitated the vacating of the Ala Road site ready for disposal.

Relevant related initiatives

The proposed new integrated Dementia Centre is planned to be constructed as a new build adjacent to the former Llyn Ward at the back of the Hospital site and fits with the proposed development control plan for the Ysbyty Bryn Beryl site. Once Llyn ward transfers to the new ward at the front of the Hospital, the old accommodation will be used to temporarily accommodate Outpatients and Therapies until the final phase of the Bryn Beryl site redevelopment is completed. Part of the old Llyn Ward accommodation (palliative care single rooms) will need to be demolished to make way for the new Dementia Centre. In addition, consideration is being given to accommodating a new Community Dental Unit adjacent to the proposed Dementia Centre – sharing the peaceful location at the back of the site for vulnerable client groups with dedicated parking. The final phase of the Bryn Beryl site redevelopment will potentially include a redeveloped central core to house a large Outpatient Department, larger Minor Injuries Unit and new Therapies and other clinical support service accommodation.

Inter-dependencies

The project is subject to the following dependencies: . Business Case approval from BCUHB and formal approval of ICF capital funding from the Welsh Government (received 13th November 2019).

Constraints The project is subject to the following constraints: . To deliver the project within the allocated capital budget. In terms of ICF capital, this means ensuring spend of the ICF Year 1 (18/19) carried over allocation and the Year 2 allocation by the end of March 2020 and the Year 3 allocation by end of March 2021. . To deliver the project in compliance with current legislation and guidance.

2.6 Milestones and Quantified Benefits

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Benefits Milestones

1. Patient Care

1.1 Optimum environment in purpose built The new facilities will deliver an improved accommodation for Dementia & AMH patient care experience from the outset service users delivering improved patient care experience

1.2 Integrated facility will deliver improved Patient outcomes should improve continuity of care and better gradually as teams will be able to liaise and communication between teams leading interact quickly and more easily (within the to improved patient outcomes same building)

1.3 An integrated centre with co-located Easier access for service users will be services will provide easier access / use realised on opening of the Centre for those suffering from dementia and mental health issues

2. Quality & Safety

2.1 Quality of care (patient outcomes) Patient outcomes should improve should improve as a result of increased gradually from the outset as the benefits of integration – through co-location of co-location become established teams and improved continuity of care

2.2 The new facilities will enable a safer A safer environment will be provided from environment, as a result of much the outset improved physical accommodation which is purpose built, dementia friendly and fully DDA and fire safety compliant

3. Operational

3.1 Clinic / consultation capacity will Clinic attendances for Dementia and AMH increase as there will be more clinic will increase as more clinics are rooms available established.

3.2 AMH DNA rates should decrease as As soon as Psychiatrist Clinic is clinics are provided closer to home transferred from Alltwen to the new Centre, DNA rates will start to improve due to decrease in travelling distance

4. Acceptability to patients, staff, public etc

4.1 Patients will benefit from a local service This will be realised from the outset which is more integrated, less fragmented and easier to access

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4.2 Staff will experience an increase in This will be realised from the outset morale working in an improved physical environment and co-located with other MH teams and colleagues

4.3 The public will benefit from having a This will be realised from the outset single point of access and focus in Dwyfor for Dementia and AMH services

5. Accessibility

5.1 One single integrated centre for This will be realised from the outset Dementia and AMH services in Dwyfor will improve ease of access

5.2 The new accommodation will be fully This will be realised from the outset accessible to all services users and carers and DDA compliant

5.3 Transferring back services temporarily Benefit realised when services transfer located in Alltwen due to lack of clinic from Alltwen – ideally as soon as Centre space will ensure more care is provided opens closer to home

5.4 Car parking will be increased and Some limited car parking for the new improved Centre will be available on completion of the scheme. Additional parking will be available when the final phase of site redevelopment is completed.

6. Effectiveness 1. Patient Care

6.1 The new Centre will provide improved Patient care and staff morale will improve quality of patient care and staff morale from the outset

6.2 The expanded accommodation for Additional capacity will be available Dementia and AMH will increase patient immediately for local services to transfer numbers and ensure future service back from Alltwen and enable services to sustainability grow as needed in line with future demand

6.3 The project will deliver efficiency savings Running cost savings and cost avoidance through site rationalisation (Ala Road will be realised immediately on closure of and Cilan), capital receipts through site each site dispoal and cost avoidance through reduced backlog maintenance

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6.4 The development is fully aligned with the Strategy alignment will be realised from Health Board’s Estates Strategy project outset and will continue with the associated with LHSW – to rationalise ongoing redevelopment of the Bryn Beryl poor estate where possible and develop site and invest in the Ysbyty Bryn Beryl site as a Level 1 facility

7. Deliverability 2. Quality & Safety

7.1 The detailed design /plans have been Tenders / actual costs ready signed off and the scheme has been tendered.

7.2 ICF capital allocation of £812K has Approval of ICF capital allocation received already been formally approved by WG. from WG on 13 Nov 2019. Additional Additional capital will be required to capital (to cover shortfall) to be cover the shortfall to deliver the preferred considered as part of this business case option. submission in Nov / Dec 2019

7.3 Scheme will need to start on site in WG have agreed not to allocate Year 2 January 2020 if it is to achieve full spend ICF allocation until Year 3. Proposed start of ICF carried-over Year 1 (18/19) on site January 2020 and completion by allocation by end of March 20. March 2021

7.4 Site location adjacent to former Llyn Site available now Ward at the back of the Bryn Beryl site is available for new build construction

3. Formulation and Short-listing of Options

3.1 Overview of Options

There are 5 options to consider:

(1) Do nothing / status quo option To continue to lease the Gwynedd Council owned Hafod Hedd site for Dementia services and to remain on the BCUHB owned Cilan MHRC site (for some OPMH staff & AMH services)

(2) Do Minimum option To transfer the dementia services based in Hafod Hedd to the vacated Llyn Ward at the back of the Bryn Beryl site (which was the original proposal as part of the current Phase 1 ward refurbishment plans for Bryn Beryl).

(3) Purchase the Gwynedd Council owned Hafod Hedd site & refurbish to accommodate the two dementia services plus Adult Mental Health from Cilan MHRC To acquire the Hafod Hedd site from the Council (DV valuation £220K) and refurbish the facilities to meet existing and future OPMH and AMH service provision needs. This

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option allows for some service expansion and the sharing of some facilities between OPMH and AMH. This option includes the rationalisation of the Cilan MHRC site.

(4) Development of integrated Dementia Centre on the Bryn Beryl site Option 4 involves the building of a new centre on the Bryn Beryl site to co-locate the two dementia services currently housed in Hafod Hedd. This option does not include AMH services and therefore would not incorporate the rationalisation of the Cilan MHRC site.

(5) Development of integrated Dementia & Adult Mental Health Centre on the Bryn Beryl site Option 5 involves the building of a new centre on the Bryn Beryl site to co-locate the two dementia services together with the Adult Mental Health service (Cilan MHRC). This option allows for ervice expansion and the sharing of some facilities between OPMH and AMH and would incorporate the rationalisation of the Cilan MHRC site.

3.2 Benefits of the Options

The benefits of the options have been grouped under the headings of Patient Care, Quality & Safety, Operational, Acceptability to Patients/Staff/Public, Accessibility, Effectiveness & Deliverability and set out in the tables below:

Options Benefits

1. Patient Care

1.1 Do Nothing / Status Quo  Minimal / no disruption / change to current dementia patient care & AMH care – both in less than satisfactory accommodation  The two different stage dementia services have already achieved some integration, however AMH services remain separately located – fragmented for service users

1.2 Do Minimum  Slightly improved patient care environment for dementia, but AMH environment remains unsatisfactory for patients  The two different stage dementia services will achieve a degree of integration however AMH services remain separately located – fragmented for service users 1.3 Intermediate – purchase Hafod Possible Hedd & refurbish  Patient accommodation for Dementia & AMH services will be made more fit for purpose benefiting all service users and staff  Dementia & AMH services will become more integrated leading to better communication between teams and improved patient outcomes

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 Site setting in Y Ffor is peaceful and therapeutic 1.4 Intermediate – New Build Possible Dementia only Centre  Accommodation will be purpose built to meet dementia service users’ needs – better patient experience  New centre will include expansion affording an improved patient care environment  Dementia services will become more integrated leading to better communication between teams and improved patient outcomes 1.5 Maximum – New Build Preferred Integrated Dementia / AMH  Accommodation will be purpose built to Centre meet dementia & AMH service users’ needs – better patient experience  New centre will include expansion affording an improved patient care environment  Dementia & AMH services will become more integrated leading to better communication between teams and improved patient outcomes 2. Quality & Safety

2.1 Do Nothing / Status Quo  Leased building meets statutory requirements but is in need of more extensive upgrade to ensure quality patient environment

2.2 Do Minimum Meets Q&S minimally

 Slight upgrade to accommodation for the two dementia services only – will minimally meet statutory requirements

2.3 Intermediate – purchase Hafod Meets Q&S requirements Hedd & refurbish  Significant refurbishment will ensure that accommodation for dementia and AMH services is fit for purpose – meets all statutory requirements  Re-design / refurb limited to original building footprint

2.4 Intermediate – New Build Meets Q&S requirements Dementia only Centre  Centre will be purpose built, dementia friendly and fully compliant with statutory regulations

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 Patient environment will be able to be designed to meet the needs of dementia service users

2.5 Maximum – New Build Meets Q&S Requirements Integrated Dementia / AMH Centre  Centre will be purpose built, dementia and AMH friendly and fully compliant with statutory regulations  Patient environment will be able to be designed to meet the needs of dementia & AMH service users

3. Operational

3.1 Do Nothing / Status Quo  Services would not be able to remain long term in a leased Hafod Hedd building – a permanent solution would need to be found.

3.2 Do Minimum  Dementia services would be able to run fully from former Llyn Ward area but no expansion space available for future. AMH services would continue to run out of Cilan, which does not meet statutory regulations. Opportunity is missed to bring services back from Alltwen.

3.3 Intermediate – purchase Hafod Possible Hedd & refurbish  Both Dementia and AMH services would be able to further integrate and fully run from the Hafod Hedd refurbished site.

3.4 Intermediate – New Build Possible Dementia only Centre  Dementia services would fully operate and integrate from the new purpose built facilities with expansion space for future.  AMH services would continue to run out of Cilan, which does not meet statutory regulations.  Opportunity is missed to bring services back from Alltwen.

3.5 Maximum – New Build Preferred Integrated Dementia / AMH Centre

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 Both Dementia and AMH services would be able to fully operate and integrate from the new purpose built facilities.  Expansion space would be incorporated and clinics temporarily located in Alltwen (due to lack of space in Cilan) would be transferred back

4. Acceptability to patients, staff, public etc

4.1 Do Nothing / Status Quo Not acceptable long term

 Whilst the current set-up in Hafod Hedd is an improvement on Ala Road, the accommodation requires significant refurbishment to bring it up to modern health care standards for patients and staff.

4.2 Do Minimum Minimally acceptable

 The two dementia services would be brought together with a limited refurbishment of the old ward accommodation.  There would be less space overall for patients and staff than in staying on the Hafod Hedd site.

4.3 Intermediate – purchase Hafod Acceptable Hedd & refurbish  Patients and staff would benefit from a much improved integrated environment for Dementia and AMH services with more space and light.

4.4 Intermediate – New Build Acceptable Dementia only Centre  Dementia patients and staff would benefit from a purpose built, integrated environment for Dementia services with more space and light and the potential for a dementia sensory garden outside the Centre.

4.5 Maximum – New Build Acceptable Integrated Dementia / AMH Centre  Dementia and AMH patients and staff would benefit from a purpose built, integrated environment for Dementia & AMH services with more space and light and the potential

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for a dementia sensory garden outside the Centre.

5. Accessibility

5.1 Do Nothing / Status Quo Accessible for Dementia, poor access for AMH

 Present accommodation requires refurbishment but meets statutory accessibility regulations. Single lane entry road to Hafod Hedd site not ideal.

5.2 Do Minimum Accessible for Dementia, poor access for AMH

 Limited refurb of part of former Llyn Ward will ensure fully accessible for Dementia patients and staff. AMH services in Cilan will continue to breach regulations in terms of accessibility (with no lift and three floors). Access to back of site not straightforward with limited close parking for service users / carers.

5.3 Intermediate – purchase Hafod Accessible Hedd & refurbish  Significant refurb of Hafod Hedd will ensure full accessibility for Dementia and AMH service users and staff and will be compliant with statutory regulations regarding access.

5.4 Intermediate – New Build Accessible for Dementia, poor access for AMH Dementia only Centre  A purpose built centre for Dementia will ensure the accommodation is fully accessible for Dementia service users and staff and fully compliant with statutory regulation relating to access.  Some additional car parking close to the new Centre will be provided and further spaces will be delivered on completion of the overall site redevelopment  However, AMH service users and staff will remain in Cilan where accessibility is not satisfactory. There is no lift (3 storey building) and no car parking.

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5.5 Maximum – New Build Accessible Integrated Dementia / AMH Centre  A purpose built centre for Dementia will ensure the accommodation is fully accessible for Dementia & AMH service users and staff and fully compliant with statutory regulation relating to access.  Some additional car parking close to the new Centre will be provided and further spaces will be delivered on completion of the overall site redevelopment.

6. Effectiveness

6.1 Do Nothing / Status Quo Not effective

 This will not be an effective long term option for service users and staff, as it is a leased site and in need of refurbishment.

6.2 Do Minimum Not effective

 This option does not include sufficient future proofing in terms of space and does not include AMH services therefore there is no site rationalisation.

6.3 Intermediate – purchase Hafod Partly effective Hedd & refurbish  This is a partly effective option in that it fully integrates both dementia and AMH services in a significantly refurbished building.  However it is not in line with BCUHB estates strategy, as it involves site acquisition as well as site rationalisation.

6.4 Intermediate – New Build Partly effective Dementia only Centre  This is a partly effective option in that it fully integrates dementia services in a purpose built new Centre on the existing Bryn Beryl site – in line with Health Board strategy.  It does not address AMH accommodation issues in Cilan and therefore does not deliver site rationalisation.  This is not an effective option in terms of value for money. There are minimal capital

27 | P a g e Betsi Cadwaladr University Health Board Capital Business Case Guidance and Template

cost (build) savings by not accommodating AMH services within the Dementia Centre.

6.5 Maximum – New Build Effective Integrated Dementia / AMH Centre  This is the most effective option in that it fully integrates both dementia and AMH services in a purpose built new centre on the existing Bryn Beryl site,  It is in line with LHSW and Estates Strategies, delivering services closer to home from a single site and from an existing level 1 community hospital / health and wellbeing site Bryn Beryl  It achieves the rationalisation of the Cilan site.

7. Deliverability

7.1 Do Nothing / Status Quo Not deliverable

 This option is not viable. Gwynedd Council ultimately wish to sell the Hafod Hedd site, so a long term lease is not an option.  This option is also not preferable for BCUHB as it would incur ongoing revenue (lease & service) costs.

7.2 Do Minimum Not deliverable

 The ‘window’ of opportunity for this option has probably now passed. Other services have now transferred to the former Llyn Ward building and one half of the accommodation is now being explored to permanently house a new Community Dental Unit.

7.3 Intermediate – purchase Hafod Deliverable Hedd & refurbish  The site purchase and refurbishment of Hafod Hedd could be completed within the ICF capital allocation.  Refurbishment could be undertaken in phases allowing dementia services to continue on site whilst works in progress, moving across AMH services from Cilan on completion

28 | P a g e Betsi Cadwaladr University Health Board Capital Business Case Guidance and Template

 By closing Cilan, the Health Board will address the site risks regarding health & safety and the significant backlog maintenance requirements, as well as achieving site rationalisation

7.4 Intermediate – New Build Deliverable Dementia only Centre  The site is available (back of Bryn Beryl) however the capital works would not be able to be completed within the ICF capital allocation – potential £300K shortfall (PTE £1,258,811) subject to approved tender cost. Additional capital would be required from discretionary capital in 2020/21.  All works could be completed in single phase with dementia services transferring from Hafod Hedd on completion  As this option does not include AMH services, Cilan would be remain operational – an inefficient unfit for purpose site.

7.5 Maximum – New Build Deliverable Integrated Dementia / AMH Centre  The site is available (back of Bryn Beryl) however the capital works would not be able to be completed within the ICF capital allocation – potential £497K shortfall (Tendered cost) £1,309,989). The additional capital would be required from discretionary capital in 2020/21.  All works could be completed in single phase with dementia & AMH services transferring from Hafod Hedd and Cilan on completion  By closing Cilan, the Health Board will address the site risks regarding health & safety and the significant backlog maintenance requirements, as well as achieving site rationalisation

Based on the above information, two options have been discounted as impracticable in terms of Deliverability and Effectiveness – Option 1 – cannot lease the Hafod Hedd site long term and Option 2 – Llyn Ward not now available to accommodate OPMH services) and have therefore been excluded at this stage. The following short list of options has emerged:

Option 3: Intermediate – Purchase Hafod Hedd & refurbish Option 4: Intermediate – New Build Integrated Dementia Centre

29 | P a g e Betsi Cadwaladr University Health Board Capital Business Case Guidance and Template

Option 5: Maximum – New Build Integrated Dementia & AMH Centre

3.3 Cost & Resource information for the Options

The table below summarises the resource requirements and costs associated with the three options:-

Resources Option 3 – Option 4 – New Option 5 – New requirements & Purchase Hafod Build Integrated Build Integrated Costs Hedd & Refurbish Dementia Centre Dementia & AMH Centre

Works Cost £356,000 £800,000 £890,157.26

Non-works cost £254,000 (Inc. £20,700 £45,750 Building Purchase) External Fees £32,192 £58,100 £59,100

Internal Project costs £3,560 £7,800 £7,800

Information £25,000 £25,000 £25,000 Technology costs Equipment costs £50,000 £50,000 £50,000

Contingency £17,800 £50,000 £50,000

VAT together with £76,560 £174,150 £182,181.45 assessment of recoverable VAT Total Costs £815,112 £1,185,800 £1,309,989.09

Based on the above cost and resource information, it should be noted that whilst Option 3 is achievable within the ICF capital allocation approved by WG (£812,928), options 4 and 5 both require an additional capital allocation to cover the shortfall. However Option 4 delivers poor value for money in that the overall capital cost is only slightly reduced and it does not include Adult Mental Health services so does not deliver full integration or include the rationalisation of the Cilan site.

3.4 Key Assumptions and dependencies of the Options

Option 3 (Purchase & refurbishment of Hafod Hedd site) assumes the Gwynedd local authority owned site is still available for purchase. It also assumes there are no significant issues with planning and statutory approvals. Options 4 & 5 (new build at back of Bryn Beryl site) also assume no significant issues with planning permission and statutory approvals, as well as connections to existing site infrastructure.

3.5 Options Appraisal

30 | P a g e Betsi Cadwaladr University Health Board Capital Business Case Guidance and Template

The preferred and possible options detailed in the Benefits tables in Section 3.2 have been carried forward onto the short list for further appraisal and evaluation. All the options that were discounted as impracticable have been excluded.

3.5.1 Criteria for Assessing the Options

The table and narrative below summarises the assessment of each option against the investment objectives:

Reference to: Option 3 Option 4 Option 5

Description Purchase New Build New Build Hafod Integrated Integrated Hedd & Dementia Dementia Refurbish Centre & AMH Centre

Investment Objectives

1. Expanded, fit for purpose    estate 2. Improved integration   

3. Alignment with Health    Board Strategy 4. Improve quality & efficiency    of estate

3.5.2 Selection of Preferred Option

All 3 options for consideration provide improved, expanded, fit for purpose accommodation, although Options 4 & 5 (as new builds) will be purpose built rather than refurbishment within an existing footprint (Option 3). All 3 options deliver improved integration, however Options 3 and 5 deliver full integration between Dementia and AMH services. Options 4 and 5 are in line with BCU’s LHSW Strategy delivering integrated care closer to home, however in terms of estate rationalisation, only Option 5 delivers fully in terms of providing a new Centre for both Dementia and AMH services on an existing Health Board level 1 community hospital / health & wellbeing centre site, thereby releasing the Cilan MHRC site. Option 3 also releases the Cilan site but involves the acquisition of a new site. All 3 options improve the quality of estate to varying degrees, however Option 5 remains the preferred option in terms of efficiency, as it achieves the rationalisation of poor community estate.

Overall, taking into account the option benefits in Section 3.2, the cost and resource information in Section 3.3 and an assessment against the investment objectives above, Option 5 – a new build Integrated Dementia and Adult Mental Health Services Centre on the Bryn Beryl site represents the preferred option in terms of improved patient care, integration, effectiveness, alignment with national and Health Board strategy and efficient use of resources (value for money).

31 | P a g e Betsi Cadwaladr University Health Board Capital Business Case Guidance and Template 4 The Financial Case 4.3Capital Cost of the preferred option

£ Works Cost £890,157.26 Fees - External fees £59,100 - Internal project costs £7,800 Non Works Costs £45,750 Equipment - Equipment £50,000 - Informatics £25,000 Contingency £50,000 VAT £182,181.45 Sub Total £ 1,309,989.09 Less Recoverable VAT Total £

4.4Revenue consequences

The assumption is that the revenue costs relating to this business case are all estate and facilities related. All other service staffing (OPMH and AMH) existing costs will move to the new Centre and the intention is to continue to look for efficiencies on an ongoing basis e.g. in terms of admin/reception and joint working opportunities, however this would in reality contain capacity/growth.

The annual details with regard to estates are as follows:

Site / building Annual Note running costs

Hafod Hedd (temporary site) running costs £19,597.81 BCU is not being charged full costs by Gwynedd LA at the moment but these are are the indicative annual costs. Cilan MHRC running costs £10,823.24

Savings from closure of Ala Road site £45,766.15 Most of these savings have already been realised in 18/19 however the site has not been sold yet Do Nothing / Status Quo option revenue £30,421.05 (Hafod Hedd + Cilan) costs

Preferred Option estimated revenue costs £24,440.00 New Integrated Dementia & AMH Centre extension (360m²)

Projected overall Project savings £5,981.05 Transition costs will be linked to the ultimate

32 | P a g e Betsi Cadwaladr University Health Board Capital Business Case Guidance and Template

On delivery of new Centre and closure / closure and sale of Ala disposal of Cilan (2021/22) Road & Cilan sites

4.5Expenditure Profile

Year Year Year Year Total 18/19 19/20 20/21 21/22 Works Cost 890,157 0 100,000 765,157 25,000 Non-works Cost 45,750 2,500 11,000 30,750 2,500 External Fees 59,100 32,000 20,000 12,900 2,000 Internal Project Costs 7,800 0 2,600 2,600 2,600 Information Technology 25,000 0 0 25,000 Costs Equipment Costs 50,000 0 0 50,000 Contingency 50,000 0 0 50,000 VAT (Inc payable Vat) 182,181.45 0 20,000 159,181 3,000 Total 1,309,989 34,500 151,00 1,092,988 32,500

5 Project Management 5.3Governance

The project management arrangements for capital projects are outlined in the Procedure Manual for Managing Capital Projects, which was adopted by the Health Board in May 2015.

5.4 Project Plan – Implementation Timeline

The key dates and milestones associated with the project are detailed in the table below:

Milestones Target Date WG approval of ICF capital allocation Sep 2019 BCUHB approval of Business Case Oct / Nov 2019 Commence on site January 2020 Handover / Commissioning December 2020 Project Closure December 2020

6 Critical Assumptions, Risk and Issues

The Health Board is required to undertake a comprehensive assessment of the risks associated with the Preferred Option.

The risk management strategy is based upon the following principles:

 Identifying the possible risk in advance, putting in place mechanisms to minimise the likelihood of risks occurring and their associated adverse effects

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 Having processes in place to ensure up to date, reliable information about risks is available, and establishing an ability to effectively monitor risks  Establishing the right balance of control is in place to mitigate the adverse consequences of risks, should they materialise  Setting up decision-making processes, supported by a framework of risk analysis and evaluation

The Project Board has identified and quantified the key risks associated with the preferred option. All identified risks have been apportioned to either the Health Board or SCP and mitigating strategies identified in the risk register. This will be monitored on a monthly basis by the Project Board for the life of the project. It is the project manager’s responsibility to manage the risk register.

7 Conclusions and Recommendations

It is concluded that the preferred option to develop a new build Integrated Dementia & Adult Mental Health Centre on the Ysbyty Bryn Beryl site is approved, as it delivers a full range of benefits in terms of the improvement of patient care as outlined within this case, is strategically aligned to both national and organisational strategies, and secures financial efficiencies related to estate rationalisation.

It is proposed that the development is funded from a combination of Welsh Government ICF capital and Health Board discretionary capital, as set out within the case. It is envisaged that the savings generated by closing two community sites (Ala Road savings already realised) and the Cilan savings will be offset against the running costs of the new Centre. In terms of revenue costs, Option 5 is less expensive than the Do Nothing / Status Quo option and will ultimately deliver overall annual savings of approximately £6K .

8 Project Evaluation 8.1 Monitoring of Project Progress

The project will follow the monitoring guidelines set out in the Capital Manual. A monthly project board meeting will be held and chaired by the Project Director. Cost and Highlight Reports will be prepared by the Project Manager for consideration and monitoring at the Project Board meetings. A Service User Group will be held on an ad hoc basis to include representation from key statutory services (Fire, Health & Safety, Operational Estates, Facilities etc) as well as OPMH / AMH service users to assist in agreeing the design detail and operational management of the new building.

Whilst building work / construction is in progress, there will be monthly contract progress meetings with the Contractor, Project Manager and Design Team to review progress to date and to address any issues causing concern or requiring action. Design Team meetings will be held with representatives as and when required. Any decisions required from the meetings referred to above will be escalated to the Project Board to agree the way forward.

The Project Board will report on progress and cost to the West Area Leadership Team and to the Capital Management Team meeting. The Project Manager will provide monthly cost and highlight reports for the Project to the Project Director and Assistant Director of Strategy – Capital And Planning.

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8.2 Post Project Evaluation

The Health Board is fully committed to ensuring that a thorough and robust post-project evaluation is undertaken at key stages in the process to ensure that positive lessons can be learnt from the project. The lessons learnt will be of benefit to:

 The Health Board – in using this knowledge for future projects including capital schemes  Other key local stakeholders – to inform their approaches to future major projects  The NHS more widely – to test whether the policies and procedures which have been used in this procurement effective

NHS guidance on PPE has been published and the key stages which are applicable for this project are:

 Evaluation of the project procurement stage  Evaluation of the various processes put in place during implementation  Evaluation of the project in use shortly after the new unit is opened  Evaluation of the project once the new unit is well established

35 | P a g e 1 FP19.298c EqIA screening form BB Dementia AMH Centre (003).doc

EQUALITY IMPACT ASSESSMENT FORMS PARTS A and B: SCREENING AND OUTCOME REPORT

Introduction: These forms have been designed to enable you to record, and provide evidence of how you have considered the needs of all people (including service users, their carers and our staff) who may be affected by what you are writing or proposing, whether this is:  a policy, protocol, guideline or other written control document;  a strategy or other planning document e.g. your annual operating plan;  any change to the way we deliver services e.g. a service review;  a decision that is related to any of the above e.g. commissioning a new service or decommissioning an existing service.

This is not optional: Equality Impact Assessment is a specific legal requirement on public sector organisations under equalities legislation and failure to comply could result in a legal challenge to a decision or strategy. More importantly, equality impact assessment helps to inform better decision-making and policy development leading to improved services for patients. This form should not be completed by an individual alone, but should form part of a working group approach.

The Forms: You must complete:  Part A – this is the Initial Screening that is always undertaken and consists of Forms 1 to 3; these forms are designed to enable you to make an initial assessment of the potential impact of what you are doing, and decide whether or not you will need to proceed to a Full Impact Assessment (Part C); AND  Part B – this is the Outcome Report and Action Plan (Form 4) you will need to complete whether or not you proceed to a Full Impact Assessment;

Together, these forms will help to provide evidence of your Impact Assessment and how you have shown “due regard” to the duties.

You may also need to complete Part C (see separate Form) – if parts A and B indicate you need to undertake a Full Impact Assessment. This enables you to fully consider all the evidence that is available (including engagement with the people affected by your document or proposals) to tell you whether your document or proposal will affect people differently. It also gives you the opportunity to consider what changes you may need to make to eliminate or mitigate any adverse or negative impact you have identified.

1 Remember that these forms may be subject to external scrutiny e.g. under a Freedom of Information request.

Once completed, the EqIA Forms should accompany your document or proposal when it is submitted to the appropriate body for approval.

Part A Form 1: Preparation

What are you assessing i.e. what is the title The capital business case for the development of a new integrated Dementia and Adult 1. of the document you are writing or the Mental Health Centre on the Ysbyty Bryn Beryl site. The case presents an exciting opportunity service review you are undertaking? to develop a fit for purpose combined facility that will operate as an integrated, co-located and joint (with local authority) model of different stage dementia services with adult mental health services to meet the specific needs of the local population. Provide a brief description, including the The proposal is to provide a modern, fit-for-purpose, fully compliant and accessible building to 2. aims and objectives of what you are deliver an improved therapeutic environment for local Older People’s Mental Health (OPMH) assessing. and Adult Mental Health (AMH) service users and staff on the Bryn Beryl site (previously located in very poor conditions in 3 separate buildings). The co-location of OPMH and AMH services and staff in one centre, as well as with local authority OPMH colleagues will significantly improve the integration of and communication between services, which will positively impact on the delivery of patient care.

It is proposed to use a combination of ICF capital monies and Health Board discretionary capital to fund the new integrated Dementia Centre. The total capital cost is £1,309,989.

Key Objectives

 Modern, fit for purpose accommodation – we want to provide purpose built facilities and a suitable therapeutic environment to meet the needs of our vulnerable OPMH and AMH client groups  Improved integration - Integrating dementia and AMH services in one building enables people to access the most appropriate element of the service easily and seamlessly, providing continuity of care, and a 'wraparound' approach to care – ultimately

2 increasing the number of patients cared for within their own communities with reduced need for hospital admission. Integration also significantly improves communication between community teams and agencies.  Reduced service fragmentation - OPMH and AMH services in Dwyfor are currently fragmented across previously three (and now two) sites. One centre will provide a single point of access.  Increased clinical capacity through expanded accommodation to see more dementia and AMH service users locally in line with the Mental Health Measure, the Health Board’s Care Closer to Home strategic objective and projected future demand.  Strategic alignment – Building a new integrated centre on the Bryn Beryl site is in line with BCUHB strategic direction (Living Healthier, Staying Well) in terms of Care Closer to Home - caring for people with dementia / AMH conditions for longer in their own communities, as well as the North Wales Mental Health Strategy (promoting integration and less fragmentation) and the Health Board’s Estates Strategy – investing in Bryn Beryl as a level 1 Health & Wellbeing hospital / centre.  Rationalise estate and generate efficiencies - We would like to get rid of existing, poor community estate and replace with modern, fit for purpose, efficient facilities in line with the Health Board’s Estate Rationalisation Strategy

Project Outcomes:

The project outcomes can be quantified as follows:

 Modern, expanded, fit for purpose accommodation to meet OPMH (Dementia) & AMH service user and staff needs  More integrated and improved patient care for OPMH Dementia and Adult Mental Health service users as a result of co-location - leading to improved continuity of care for service users, less duplication and better communication between services  Increased capacity by up to 10-15% to deliver both group and individual therapy as required under the Mental Health Measure and in line with increasing demographic demand  Care closer to home - supporting more accessibility in the community as set out in the national Dementia Strategy, the Mental Health Measure, the Health Board’s Living Healthier, Staying Well (LHSW) Strategy and the Estates Strategy through investment in the Ysbyty Bryn Beryl site as a Level 1 community hospital / health & wellbeing facility, 3 providing integrated dementia and AMH services as locally as possible  Estate efficiency and rationalisation - improving the quality and efficiency of the estate through the rationalisation of poor community sites, reduced backlog maintenance, reduced running costs and achievement of statutory and regulatory compliance. Who is responsible for the document/work A Dementia Centre Project Board has been established to oversee the development of the 3. you are assessing – i.e. who has the scheme since May 2019 and this Board reports to the WALT (West Area Local Team). The authority to agree/approve any changes you business case will be seeking approval from the Health Board’s Estates Improvement Group, identify are necessary? the F&P Committee and the Board. In terms of design changes, these will be discussed and agreed at Project Board level (ensuring within overall budget). Is the Policy related to, or influenced by, The business case links into multiple national and organisational strategies and legislation: 4. other Policies/areas of work? The national Dementia Strategy focuses on the need to provide high quality, person-centred care to people living with dementia and those affected by it, to support the creation of dementia-friendly communities and to listen and respond to people with dementia. The provision of facilities and a therapeutic environment that are purpose built to meet the needs of people with dementia is paramount. The model focuses on the need to ‘support people to remain self-caring avoiding admission to hospital’ - whether general or psychiatric - whenever possible and facilitate timely discharge from hospital (with the right care or support at home), as an admission to hospital can be devastating for a person with dementia.

Welsh Government’s Mental Health Measure requires health boards to provide timely assessments and interventions to significant numbers of individuals in the locality. Current estate provision is limited in terms of capacity. This provision will provide much increased capacity to deliver group therapy and individual care close to home.

The North Wales Mental Health Strategy aims to ensure there is promotion of health and well-being for everyone; prevention of mental ill-health and early intervention when needed and the delivery of joined-up and recovery-focused care. The Strategy focuses on integrating as much as possible – across disciplines, across agencies and across services, in both planning and delivering services, with a view to reducing fragmentation.

A key strand of the Health Board’s ‘Living Healthier, Staying Well Strategy’ is the delivery of Care Closer to Home. An integrated centre for OPMH and AMH services will enable service users to access the most appropriate element of the service easily and seamlessly, providing

4 continuity of care, and a 'wraparound' approach to care. People can 'step up and step down' within the services depending on their need at the time, a flexible approach within both the adult mental health service and the dementia service. Separate locations and buildings for OPMH and AMH services are currently fragmenting services for service users and their families. An integrated centre for dementia and adult mental health services will provide easier access for local people to ensure.

New Programme for Government and the NHS Plan The Welsh Government’s new Programme for Government Taking Wales Forward 2016-21 and NHS Plan set out a programme for health and wellbeing in Wales focussing on improving our healthcare services; our healthcare staff; being healthy and active; our mental health and wellbeing; the best possible start for children and care for older people.

Well-being of Future Generations (Wales) Act 2015 The Welsh Government published the Well-being of Future Generations (Wales) Act in April 2015 to improve the social, economic, environmental and cultural well-being of Wales. It aims to make public bodies think more about the long-term, work better with people and communities and each other and look to prevent problems and take a more joined-up approach. The Act sets out seven well-being goals, and five ways of working in order to support the implementation of these goals:  a prosperous Wales  a resilient Wales  a healthier Wales  a more equal Wales  a Wales of cohesive communities  a Wales of vibrant culture and thriving Welsh Language  a globally responsible Wales

Social Services and Well-being (Wales) Act 2014 A number of actions in this delivery plan have been developed to further embed the requirements of the Social Services and Well-being (Wales) Act 2014, which came into force on the 6 April 2016. The Act places a duty on health boards and local authorities to jointly undertake an assessment of the local population’s care and support needs, including the support needs of carers. The population assessment is intended to ensure that health boards and local authorities produce a clear and specific evidence base to inform various planning 5 and operational decisions, including Integrated Medium Term Plans.

Population Needs Assessment Population needs assessments are critical to the development of good long-term strategies. The Well-being of Future Generations Act makes it clear that this needs to be done in conjunction with other public service bodies, such as local authorities, education and housing. Population needs assessment underpin the local well-being plan, developed by public service boards.

Health and Social Care Inequalities Delivering the actions set out in the plan will make a positive contribution to the Welsh Government’s equality agenda objectives through a commitment to identify and meet the needs of all groups in relation to stroke, including those from disadvantaged backgrounds who are statistically more likely to be living in poverty and be at greater risk of heart disease.

Welsh Language The objectives of ‘More than just words’ the Welsh Government’s strategic framework for Welsh language services in health, social services and social care have also been embedded into the plan through actions that make it clear all organisations associated with service delivery must ensure that such services are available to those who wish to communicate in Welsh. Who are the key Stakeholders i.e. who will The key stakeholders are:- 5. be affected by your document or proposals?  The general public, including patients & carers needing to access Dementia and AMH services.  BCUHB Clinicians, Managers and Staff  Gwynedd Local Authority, Social services and elected members  Third Sector and voluntary organisations  Community Health Council  Public Health Wales  Welsh Government  Ysbyty Bryn Beryl League of Friends  Independent Contractors including GPs and Pharmacists  Welsh Ambulance Services Trust  Community Transport  Local Town and Community Councillors 6  Assembly Members and Members of Parliament  Trade union representative What might help/hinder the success of If the Health Board decides not to fund the business case capital shortfall from discretionary 6. whatever you are doing, for example capital, this will prevent the scheme progressing. It will then be necessary to review with the communication, training etc? Director of Estates the available options and the preferred way forward.

Communication on a local and regional level will be crucial to raise awareness of the new Integrated Dementia and AMH Centre. If the business case is approved, a communication campaign will be undertaken by the Health Board’s Communication Officer for the West e.g. joint press releases, promoting on various social media platforms and internal staff communications.

7 Form 2: Considering the potential impact of your document, proposals etc in relation to equality and human rights

Characteristic Potential Impact by Please detail here, for each characteristic listed on the left:- or other factor Group. Is it:- (1) any Reports, Statistics, Websites, links etc. that are relevant to your document/proposal and to be Positive (+) High have been used to inform your assessment; and/or considered Negative (-) Medium (2) any information gained during engagement with service users or staff; and/or any other Neutral (N) or information that has informed your assessment of Potential Impact. No Impact/Not Low applicable (N/a) Age Positive High It is anticipated that the impact for adults / older people will be positive and high. The new integrated Centre will provide purpose built, expanded facilities for Dementia and AMH service users. It will provide a much-improved therapeutic environment and will ensure services for these vulnerable clients are delivered closer to home.

Dementia and AMH services are available for all people over the age of 18 years. At the age of 17.5 years, there is a handover between CAMHS and AMH to ensure a smooth transition for young people.

Evidence includes:

8 Population projections, persons aged 18 years and over, by age group, Gwynedd, 2015 to 2035

2015 2020 2025 2030 2035 18 to 24 15,070 14,370 14,070 14,430 13,820 25 to 34 13,480 16,500 18,110 17,110 17,210 35 to 44 12,820 11,870 12,960 15,940 17,550 45 to 54 16,100 14,820 12,680 11,750 12,840 55 to 64 14,980 15,930 16,220 15,020 12,980 65 to 69 8,180 6,870 7,280 7,830 7,630 70 to 74 6,520 7,450 6,280 6,690 7,240 75 to 79 4,880 5,700 6,580 5,580 6,000 80 to 84 3,860 3,980 4,760 5,550 4,760 85 and over 3,870 4,420 5,030 6,150 7,560 Total population aged 18 and over 99,780 101,910 103,960 106,050 107,570 Source: Welsh Government Statistical Unit (Daffodil) Figures may not sum due to rounding. Crown copyright 2014

Disability Positive High The new Centre will positively impact those with disabilities, as it will meet all statutory and DDA regulations ensuring full accessibility. The improved therapeutic environment and signage within the new centre will also adhere to all dementia friendly requirements. Car parking for service users, carers and community transport will be an improvement on existing arrangements and will further improve with the future redevelopment of the Bryn Beryl site. Patients with a disability have the same access to Dementia and AMH services as everyone else. 9 Evidence includes:

Number of people registered as having a learning disability, by age group, Gwynedd, 2018-19

Under 16 years: 81 16-64 years: 514 65+: 71 Total: 666

10 Number & percentage of people of working age who report having a disability, Wales & Betsi Cadwaladr UHB unitary authorities, 2013

Number Percentage Wales 409,900 22.5 Isle of Anglesey 8,000 20.4 Gwynedd 12,300 17.5 Conwy 12,600 20.3 Denbighshire 13,000 24.7 Flintshire 15,700 17.3 Wrexham 14,300 17.6

Source: Office for National Statistics

Persons with learning disabilities*, by accommodation type, Betsi Cadwaladr UHB unitary authorities, 2015/16

Private or Health service Local authority voluntary Total accommodatio residential residential Other Total community n (inc. accommodation accommodation accommodation placements placements hospitals/host (staffed or (staffed or els etc.) unstaffed) unstaffed) Isle of Anglesey 274 3 6 29 0 312 Gwynedd 614 3 21 41 20 699 Conwy 540 18 2 69 27 656 Denbighshire 469 10 2 64 3 548 Flintshire 685 0 0 52 0 737 Wrexham 455 12 1 55 14 537

Source: StatsWales (WG) * The register of people with learning disabilities is a voluntary register, and therefore may be an underestimate the total number of people with learning disabilities

Gender Neutral No Reassignment Impact No anticipated differential impact

Evidence includes: Following section taken from North Wales Local Authority Summary Equality Profile Isle of Anglesey:-

Data on gender reassignment is not routinely collected. The section below is taken from a 2009 11 report from the Office of National Statistics, entitled ‘Trans Data Position Paper’, which defines transgender as an ‘umbrella term referring to individuals whose gender identity or gender expression falls outside of the stereotypical gender norms’.

Currently, there are huge inconsistencies in population estimates of both transsexual people and the less clearly defined trans community. The Home Office ’Report of the interdepartmental working group on transsexual people‘ based on research from the Netherlands and Scotland, estimates that there are between 1,300 and 2,000 male to female and between 250 and 400 female to male transsexual people in the UK. However, Press for Change estimate the figures at around 5,000 post-operative transsexual people. Further, GIRES claims there are 6,200 people who have transitioned to a new gender role via medical intervention and approximately 2,335 full Gender Recognition Certificates have been issued to February 2009.

The figures are more diverse when looking at the trans community in the UK, where estimates range from 65,000 to 300,000. To put this in context, the former figure is close to the population of Inverness, while the latter is similar to the population of Cardiff (51,000 and 305,000 respectively). The variation above demonstrates that it is important to find accurate measures of the trans population at local and national levels. The absence of official estimates makes it difficult to ascertain the level of discrimination, inequality or social exclusion faced by the trans community.

Neutral No Marriage & Civil Impact No anticipated differential impact. Partnership Evidence includes:

Census 2011 - Marital and civil partnership status, unitary authorities in North Wales – All usual residents aged 16 years and over

Single Separated Divorced or Widowed or All (never (but still formerly in In a surviving categories: married or legally a same-sex registered partner Marital and never married or civil Married same-sex from a civil registered a still legally partnership civil same-sex partnership same-sex in a same- which is partnership civil status civil sex civil now legally partnership partnership) partnership) dissolved Isle of Anglesey 57,890 17,245 28,385 90 1,210 5,694 5,266 12 Gwynedd 100,923 36,781 44,330 140 1,906 9,049 8,717 Conwy 96,102 27,729 46,379 197 2,229 10,215 9,353 Denbighshire 76,781 23,413 36,950 138 1,790 8,043 6,447 Flintshire 123,862 37,581 62,308 167 2,770 11,962 9,074 Wrexham 109,026 35,546 52,154 151 2,179 10,877 8,119

Pregnancy & Positive High Maternity It is anticipated that there will be a high positive impact for this group because there will be improved access for service users and carers, in terms of both the physical building and increased numbers of clinics. Accommodation will be available if required for those wishing to breast feed.

General fertility rate (GFR)*, Gwynedd and Wales, 2005-2014

Gwynedd Wales

Number of Number of GFR* (95% CI) GFR* (95% CI) live births live births

2005 1,263 56 (53 to 59) 32,590 56 (55 to 57) 2006 1,332 59 (56 to 62) 33,623 57 (57 to 58) 2007 1,254 56 (53 to 59) 34,392 59 (58 to 59) 2008 1,276 57 (54 to 60) 35,644 61 (60 to 61) 2009 1,338 60 (56 to 63) 34,938 60 (59 to 60) 2010 1,272 57 (54 to 60) 35,945 62 (61 to 62) 2011 1,319 60 (56 to 63) 35,604 61 (61 to 62) 2012 1,327 60 (57 to 63) 35,238 61 (61 to 62) 2013 1,229 56 (53 to 60) 33,742 59 (58 to 60) 2014 1,175 54 (51 to 58) 33,541 59 (58 to 60) Produced by Public Health Wales Observatory, using PHB & MYE (ONS) *GFR is the number of live births per 1,000 females aged 15-44 CI=Confidence Interval

Race / Neutral No No anticipated differential impact. Ethnicity Impact Evidence includes:

13 People who say Percentage of People who say they are from a population from a they are from a non-white non-white white background background background Isle of Anglesey 68,700 800 1.1 Gwynedd 115,400 5,700 4.7 Conwy 112,300 2,000 1.8 Denbighshire 91,900 2,200 2.3 Flintshire 150,000 3,900 2.6 Wrexham 131,800 4,100 3.0

Source: StatsWales (WG)

Religion or Neutral No No anticipated differential impact. Patients and carers across the religious denominations will have Belief Impact the same access to spiritual support as required.

Evidence includes:

Figure 17: Religious denominations, Betsi Cadwaladr UHB unitary authorities, 2011 All Religion Other No categories: Christian Buddhist Hindu Jewish Muslim Sikh not religion religion Religion stated Isle of Anglesey 69,751 45,400 165 45 40 250 43 257 17,797 5,754 Gwynedd 121,874 72,503 426 238 55 1,378 39 637 36,163 10,435 Conwy 115,228 74,506 347 206 62 583 17 478 30,017 9,012 Denbighshire 93,734 60,129 266 167 32 469 8 345 25,132 7,186 Flintshire 152,506 101,298 344 158 70 482 29 362 38,726 11,037 Wrexham 134,844 85,576 351 504 58 860 87 310 36,927 10,171 Source: Census 2011 (ONS) Sex Neutral No Impact No anticipated differential impact.

Evidence includes: 14 Sexual Neutral No No anticipated differential impact. Orientation Impact Evidence includes:

Sexual identity by status, UK, Wales and North Wales unitary authorities, 2014

Heterosexual/ Gay/Lesbian/ Don't No response Other Straight Bisexual know/Refusal United Kingdom 92.8 1.6 3.9 1.4 0.3 Wales 93.9 1.5 3.0 1.1 0.4 Isle of Anglesey 96.6 * 1.7 0.6 * Gwynedd 96.4 * 1.4 1.3 * Conwy and Denbighshire 90.1 1.3 7.2 1.1 * Flintshire and Wrexham 87.4 1.0 9.7 1.5 *

Source: StatsWales (WG)

Welsh Positive High Language It is anticipated that the impact on the Welsh Language will be positive and high. Most Centre staff will be bilingual speakers and patients will be receiving care in their own community closer to home. The Dementia and AMH staff will be adhering to the ‘active offer’ delivering services through the medium of Welsh in the Dwyfor locality. All signage in the new Centre will be bilingual in line with BCUHB Policy.

Evidence includes:

15 Persons aged 16 years and over who speak Welsh, 2018-19 Number % Wales 463,670 18 Betsi Cadwaladr UHB 187,960 33 Isle of Anglesey 30,690 53 Gwynedd 68,200 66 Conwy 36,320 37 Denbighshire 23,420 30 Flintshire 13,950 11 Wrexham 15,380 14

Source: StatsWales (WG) using National Survey for Wales

Human Rights Positive High It is anticipated that the impact on Human Rights will be positive and high. The Centre will provide a much improved, purpose built, therapeutic environment for Dementia and AMH service users – meeting all DDA regulations and dementia friendly requirements. It will also facilitate improved patient confidentiality through better clinic room soundproofing. The Centre will also provide a single point of access to Dementia and AMH services locally (instead of fragmented across several sites at present). Integrating these services in one building will enable people to access the most appropriate element of the service easily and seamlessly, providing continuity of care, and a 'wraparound' approach to care – ultimately increasing the number of patients cared for within their own communities with reduced need for hospital admission.

Guidance on completing Form 2: For each of the characteristics listed, and considering the aims and objectives you detailed in Q2 on Form 1, you need to consider whether your document or proposal likely to affect people differently, and if so, will this be in a positive or negative way? For example, you need to decide:  Will it affect men and women differently?  Will it affect disabled and non-disabled people differently?  Will it affect people in different age groups differently? - and so on covering all the protected characteristics.

Use your judgement to indicate the scale of any impact identified. The factors used to determine an overall assessment for each characteristic should include consideration of scale and proportionality as well as potential impact.

16 Form 3: Assessing Impact against the General Equality Duty

As a public sector organisation, we are bound by the three elements of the “General Duty”. This means that we need to consider whether (if relevant) the policy or proposal will affect our ability to:-  Eliminate unlawful discrimination, harassment and victimisation;  Advance equality of opportunity; and  Foster good relations between different groups 1. Describe here (if relevant) how you are ensuring The new Centre will significantly improve access to Dementia and AMH services in the Dwyfor locality. It is not anticipated that the proposed development will create any negative impacts upon your policy or proposal does not unlawfully protected characteristic groups or the wider community. It has anticipated a range of significant discriminate, harass or victimise positive impacts on a number of groups (outline these) as well as high impact on the Welsh Language and Human Rights.

2. Describe here how your policy or proposal could The integrated Centre will address the current issue of service fragmentation and will enable those better advance equality of opportunity (if relevant) AMH (Consultant Psychiatry etc.) services currently being delivered in Ysbyty Alltwen (as there is no capacity in the Pwllheli area) to transfer across to the new Centre ensuring more care closer to home. The staffing skill mix of the new Centre will also offer a bilingual workforce so that patients can receive care from staff speaking their first language. 3. Describe here how your policy or proposal might By co-locating Dementia and AMH health and social care professionals together, this will foster better working relationships and more streamlined transfer of patients through the different stages of be used to foster good relations between different care. The familiarity of the surroundings in one integrated Centre will benefit these vulnerable service groups (if relevant) users and carers.

17 Part B:

Form 4 (i): Outcome Report Organisation: BETSI CADWALADR UNIVERSITY HEALTH BOARD

1. What is being assessed? (Copy from Form 1) Copy form 1

2. Brief Aims and Objectives: Copy form 1 (Copy from Form 1) The project has the following main aims and objectives:

 Modern, fit for purpose accommodation – we want to provide purpose built facilities and a suitable therapeutic environment to meet the needs of our vulnerable OPMH and AMH client groups  Improved integration - Integrating dementia and AMH services in one building enables people to access the most appropriate element of the service easily and seamlessly, providing continuity of care, and a 'wraparound' approach to care – ultimately increasing the number of patients cared for within their own communities with reduced need for hospital admission. Integration also significantly improves communication between community teams and agencies.  Reduced service fragmentation - OPMH and AMH services in Dwyfor are currently fragmented across previously three (and now two) sites. One centre will provide a single point of access.  Increased clinical capacity through expanded accommodation to see more dementia and AMH service users locally in line with the Mental Health Measure, the Health Board’s Care Closer to Home strategic objective and projected future demand.  Strategic alignment – Building a new integrated centre on the Bryn Beryl site is in line with BCUHB strategic direction (Living Healthier, Staying Well) in terms of Care Closer to Home - caring for people with dementia / AMH conditions for longer in their own communities, as well as the North Wales Mental Health Strategy (promoting integration and less fragmentation) and the Health Board’s Estates Strategy – investing in Bryn Beryl as a level 1 Health & Wellbeing hospital / centre.  Rationalise estate and generate efficiencies - We would like to get rid of existing, poor community estate and replace with modern, fit for purpose, efficient facilities in line with the Health Board’s Estate Rationalisation Strategy

18 The project outcomes can be quantified as follows:

 Modern, expanded, fit for purpose accommodation to meet OPMH (Dementia) & AMH service user and staff needs  More integrated and improved patient care for OPMH Dementia and Adult Mental Health service users as a result of co-location - leading to improved continuity of care for service users, less duplication and better communication between services  Increased capacity by up to 10-15% to deliver both group and individual therapy as required under the Mental Health Measure and in line with increasing demographic demand  Care closer to home - supporting more accessibility in the community as set out in the national Dementia Strategy, the Mental Health Measure, the Health Board’s Living Healthier, Staying Well (LHSW) Strategy and the Estates Strategy through investment in the Ysbyty Bryn Beryl site as a Level 1 community hospital / health & wellbeing facility, providing integrated dementia and AMH services as locally as possible  Estate efficiency and rationalisation - improving the quality and efficiency of the estate through the rationalisation of poor community sites, reduced backlog maintenance, reduced running costs and achievement of statutory and regulatory compliance

3a. Could the impact of your decision/policy be discriminatory Yes No x under equality legislation?

3b. Could any of the protected groups be negatively affected? Yes No x 3c. Is your decision or policy of high significance? Yes No x

4. Did the decision Yes No x scoring on Form 3, coupled with your The assessment is that the development will have a range of high positive impacts on a number of protected answers to the 3 characteristic group and a neutral / no differential impact on the remaining groups. Overall, the new integrated questions above Dementia and Adult Mental Health Centre will have a significant positive impact on the delivery of these services indicate that you need locally. It will replace fragmented, extremely poor existing accommodation in the Pwllheli area with fit for purpose to proceed to a Full facilities to meet the needs of Dementia and AMH service users and staff. Ultimately, the expanded accommodation Impact Assessment? will ensure that more people can be cared for in their local communities for longer avoiding the need for admission wherever possible.

19 5. If you answered ‘no’ Yes X above, are there any issues to be addressed Record Details: There may be a small group of AMH / Dementia patients who live in the Pwllheli area who may e.g. mitigating any experience an issue with accessing the proposed Centre on the Bryn Beryl site. This will be mitigated by providing identified minor clarity on the public and community transport options available (e.g. bus routes, hospital transport and O Drws i Drws negative impact? etc). All patients / carers will be asked at the point of referral to the new Centre whether they have any transport concerns and every effort will be made to address the individual’s circumstances and identify a transport solution. Currently the means of transport available to access the service is predominantly hospital transport; this is arranged in advance either at the point of referral or within 48 hours’ notice, and is the most popular mode of transport (about 80 - 90% currently avail of this option). Around 5% -10% arrive with a carer or family member (in the car) and about 5% avail of the local O Drws i Drws service. Only one day in the last 6 years has a person looking to utilise the dementia service, used the public bus service.

Patients and carers have been travelling to the former Hafan Dementia Day Assessment Unit (on the Bryn Beryl site) for several years and are currently travelling to Hafod Hedd in Y Ffor which is further from Pwllheli than Bryn Beryl. As mentioned, the Consultant Psychiatric clinic will be transferred from Ysbyty Alltwen to the new Centre, which will improve local access and DNA rates.

Currently anyone looking to access Ysbyty Bryn Beryl can do so via the following 2 buses; (www.traveline-cymru)

 The # 12 bus (Direction: Trefor) has 18 stops departing from Bus Station, Pwllheli and ending in Maes Y Neuadd, Trefor. The 12-bus normally starts operating at 18:25 and ends at 22:40. Normal operating days weekdays.

 The # 14 bus (Direction: Pwllheli) has 32 stops departing from Smithy, Clynnog and ending in Bus Station, Pwllheli (C). The 14-bus normally starts operating at 08:55 and ends at 08:55. Normal operating days: weekdays.

20

6. Are Yes x No monitoring arrangements in How is it being monitored? The project will follow the monitoring guidelines set out in the Capital Manual. A monthly place so that project board meeting will be held and chaired by the Project Director. Cost and Highlight you can Reports will be prepared by the Project Manager for consideration and monitoring at the measure what Project Board meetings. A Service User Group will be held on an ad hoc basis to include actually representation from key statutory services (Fire, Health & Safety, Operational Estates, happens after Facilities etc.) as well as OPMH / AMH service users to assist in agreeing the design detail you implement and operational management of the new building. your document or proposal? 24 months after opening, a post project evaluation exercise will be undertaken by the Project Board to assess whether the Project’s objectives and outcomes have been met.

Who is responsible? The Project Board with regular reporting to Planning and WALT. What information is being The Dementia and AMH services will collect their own data, whilst Estates will record building related information in accordance with the Capital Manual. used? When will the EqIA be 24 months after opening reviewed? (Usually the same

21 date the policy is reviewed)

7. Where will your decision or policy be forwarded for approval? Project Board / WALT / Capital Improvement Group / Execs / F&P/ Board

8. Describe here what engagement you have Dementia and AMH staff have been involved in the planning and design of the new Centre from the project outset. A combined AEDET (achieving Excellence Design Evaluation undertaken with stakeholders including staff and Toolkit) meeting will be undertaken in due course including service users and carers to help service users to help inform the assessment inform the detailed design.

9. Names of all parties Name Title/Role involved in undertaking this Equality Impact Christine Rudgley West Area Lead Operational Improvement (Chairperson), BCUHB Assessment: Gary Prendiville Assistant Project Manager, BCUHB Daniel Eyre Estates Senior Project Manager, Planning, BCUHB Glenys Williams Team Manager, Mental Health & Learning Disabilities, BCUHB Jane Hartshorne Day Services Lead, Older Persons Mental Health, BCUHB Mark Couchman? Mental Health Services Manager Adult & Older Persons (community), Mental Health & Learning Disabilities, BCUHB Iolo Jones Deputy County Manager, Adult Mental Health & Social Care, BCUHB Please Note: The Action Plan below forms an integral part of this Outcome Report

22 Form 4 (ii): Action Plan This template details any actions that are planned following the completion of EqIA including those aimed at reducing or eliminating the effects of potential or actual negative impact identified.

Proposed Actions Who is responsible for this When will this action? be done by? None 1. If the assessment indicates significant potential negative impact such that you cannot proceed, please give reasons and any alternative action(s) agreed:

None 2. What changes are you proposing to make to your document or proposal as a result of the EqIA? With regard to public and community Gary Prendiville / Joyce Jones By January transport to and from the new Centre, the 2020 3a. Where negative impacts on certain various options available will be clarified groups have been identified, what actions are including the bus routes and timetables and you taking or are proposed to mitigate these this information will then be collated for impacts? Are these already in place? service users / carers by Reception staff to ensure that there are no issues with access for patients to the new Centre. None 3b. Where negative impacts on certain groups have been identified, and you are proceeding without mitigating them, describe here why you believe this is justified.

None 4. Provide details of any actions taken or planned to advance equality of opportunity as a result of this assessment.

23 24 8 FP19/299 Summary of Private business to be reported in public 1 FP19.299 Private session items reported in public v1.0.docx

Cyfarfod a dyddiad: Finance and Performance Committee 19.12.19 Meeting and date: Cyhoeddus neu Breifat: Public Public or Private: Teitl yr Adroddiad Summary of business considered in private Report Title: session to be reported in public

Cyfarwyddwr Cyfrifol: Sue Hill, Acting Executive Director Finance Responsible Director: Awdur yr Adroddiad Diane Davies, Corporate Governance Manager Report Author: Craffu blaenorol: None Prior Scrutiny: Atodiadau None Appendices: Argymhelliad / Recommendation:

The Committee is asked to note the report

Please tick one as appropriate (note the Chair of the meeting will review and may determine the document should be viewed under a different category) Ar gyfer Ar gyfer Ar gyfer Er penderfyniad Trafodaeth sicrwydd gwybodaeth  /cymeradwyaeth For For Assurance For For Decision/ Discussion Information Approval Sefyllfa / Situation: To report in public session on matters previously considered in private session

Cefndir / Background: 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. This principle is also applied to Committee meetings.

Asesiad / Assessment

The Finance and Performance Committee considered the following matters in private session on 4.12.19

 Proposed Interim Arrangements for Continuing Health Care (CHC) and Free Nursing Care Fee Changes for 2019/20  Medical and Dental Agency Locum monthly report  Approved the tender for the project to develop the SMS accommodation at Rowley’s Drive, Shotton.