MEETING OF THE POWYS TEACHING HEALTH BOARD BOARD MEETING WEDNESDAY 24 APRIL 2013, 1.00PM - 4.00PM, THE PAVILION, ROYAL WELSH SHOWGROUND, BUILTH WELLS
NO ITEM ENC PRESENTER
PRESENTATION: INTEGRATED COMMUNITY CARE
1 PRELIMINARY MATTERS
1.1 Welcome and Apologies for Absence
1.2 Declarations of Interest All
1.3 Minutes of meeting held on 20 February 2013 1.3 Chairman
1.4 Action Review from Previous Meetings 1.4 Chairman
1.5 Chairman’s Report Verbal Chairman
2 ITEMS FOR APPROVAL / ENDORSEMENT
2.1 Three Year Plan 2013-2016 2.1 Chief Executive
2.2 Annual Plan 2013/14 2.2 Chief Executive
2.3 Financial & Budgetary Strategy 2013/14 2.3 Director of Finance
2.4 Funded Nursing Care 2.4 Director of Nursing
2.5 SHSW: Governance and Accountability Module 2.5 Director of Therapies & HS
2.6 Stroke Delivery Plan 2.6 Director of Therapies & HS
2.7 Information & Consultation Strategy for Carers 2012-15 2.7 Director of Planning
2.8 Builth Wells Hospital Site 2.8 Director of Planning
ITEMS FOR DISCUSSION
3 STRIVING FOR EXCELLENCE
3.1 Integrated Performance Report 3.1 Chief Executive
3.2 Corporate Risk Register 3.2 Director of Therapies & HS
3.3 The Francis Report 3.3 Director of Therapies & HS
4 IMPROVING HEALTH AND WELLBEING
4.1 Measles Outbreak Update 4.1 Director of Public Health 4.2 Powys Tobacco Control Strategic Planning 4.2 Director of Public Health
4.3 Improving Quality Together 4.3 Director of Public Health
5 MAKING EVERY POUND COUNT
5.1 Financial Performance 2012/13 : Month 11 5.1 Director of Finance
6 GOVERNANCE & ASSURANCE
6.1 Board Committee Reports:- Committee Chairs Quality and Safety Committee 6.1a Audit Committee 6.1b Integrated Governance Committee 6.1c
7 OTHER MATTERS
7.1 Any Other Urgent Business Verbal Chair
7.2 Date of Next Meeting: 19 June 2013, 1:00-5:00pm, Training Room 1&2, Bronllys Hospital
KEY: Annual Plan Themes Improving Health and Wellbeing Involving the People of Powys Ensuring the Right Access Making every Pound Count Striving for Excellence Governance & Assurance
Motion to Exclude Members of the Public and the Press To approve a motion under Section 1(2) Public Bodies (Admission To Meetings) Act 1960: “Representatives of the press and other members of the public shall 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”.
FOR APPROVAL
BOARD MEETING 24 APRIL 2013
AGENDA ITEM 1.3
DRAFT MINUTES OF BOARD MEETING HELD 20 FEBRUARY 2013
Report of Chairman
Paper prepared by Corporate Governance Manager
Purpose of Paper To provide the Board with the draft minutes of the Board Meeting held on 20 February 2013 for approval.
Action/Decision required The Board is asked to APPROVE the draft minutes of the Board Meeting held on 20 February 2013.
Link to ‘Doing Well, 1. Governance and Accountability Doing Better: Standards for Health Services in Wales’:
Link to Health Board’s Improving Health & Well-Being Corporate Plan Ensuring the Right Access Striving for Excellence Involving the People of Powys Making Every Pound Count
Acronyms and N/A abbreviations
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MINUTES OF THE MEETING OF THE POWYS TEACHING HEALTH BOARD HELD AT 1.00 PM ON WEDNESDAY 20 FEBRUARY 2013, TALGARTH TOWN HALL, TALGARTH
Present: Mel Evans (ME) tHB Chair (Chair of Meeting) Jo Mussen (JM) tHB Vice Chair Andrew Cottom (AC) Chief Executive Alan Austin (AA) Associate Member (SRG Chair) Mark Baird (MB) Independent Member Joanna Davies (JD) Director of Workforce & OD Paul Dummer (PD) Independent Member Roger Eagle (RE) Independent Member Rosemarie Harris (RH) Independent Member Gareth Jones (GJ) Independent Member Gloria Jones Powell (GJP) Independent Member Andrew Leonard (AL) Independent Member Brendan Lloyd (BL) Medical Director Gyles Palmer (GP) Independent Member Dr Douglas Paton (DP) Associate Member Rebecca Richards (RR) Director of Finance Carol Shillabeer (CS) Director of Nursing Amanda Smith (AS) Director of Therapies & HS
In Attendance: Sumina Azam (SA) Interim Director of Public Health Emily Games (EG) Corporate Governance Support Officer Cynthia Jones (CJ) District Nurse Team Leader (tHB/13/06 only) Paul Labourne (PL) Assistant Nurse Director (tHB/13/06 only) Rani Mallison (RM) Corporate Governance Manager Ceri Rees (CR) District Nurse Deputy Team Leader (tHB/13/06 only) Nathalie Thomas (NT) Service Improvement Officer (tHB/13/06 only) Bruce Whitear (BW) Interim Director of Planning
Public Attendance: There were 14 members of the public present
Apologies: Jeremy Patterson (JP) Associate Member (CEO, Powys CC)
tHB/13/01 Declarations for Interest
There were no declarations of interest received for noting.
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FOR APPROVAL tHB/13/02 Minutes of the meeting held of 19 December 2012
The minutes of the previous meeting held on 19 December 2012 were agreed as a true and accurate record. tHB/13/03 Matters Arising from Previous Meetings
There were no matters arising from the previous meeting. tHB/13/04 Action Review from Previous Meetings
The Board received an Action Review Grid which provided a summary of actions arising from previous Board meetings held during 2012, as at 19 December 2012. tHB/13/05 Chairman’s Report
Following a formal welcome to Board Members:- The Chairman reported on the recommendations outlined in The Francis Report (report into Mid Staffordshire NHS Trust) and summarised the major implications for NHS in Wales and Powys tHB. The Board noted next steps regarding issues concerning standards of care afforded to patients in relation to standards, dignity, care and compassion. It was noted that there would be a need to consider scrutiny and provide assurances that quality measures were in place. In addition, the need to design an assessment to identify clear priorities was required going forward. AS advised the Board of work currently underway with significant focus on the following areas; • improved intelligence regarding incidents • inspections • review effectiveness of walkrounds and lessons learned • robust mechanisms regarding staff concerns with patient care.
DP advised the Board of mechanisms required to ensure that patients who were treated outside Powys received good quality care. BL noted to the Board that with regards the patient experience, the role of the GP was an integral part of reporting patient experience. In light of this, DP advised the Board that a structure was required for GPs to discuss and raise concerns formally, which would also provide an opportunity to review quality within the contracting process.
In light of the Francis report the Chairman confirmed that the Board Development session scheduled on 14 March 2013 would discuss the following areas;
The Chairman advised that the Board Development Session, to be held on 14 March 2013, would focus on the tHB’s approach to the recommendations arising from The Francis Report. The Chairman confirmed that it was essential that issues were acted upon swiftly and
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confirmed that the Director of Therapies and Health Sciences would take the lead on this area as the work linked heavily to business undertaken by the Quality and Safety Committee and its development regarding the SHS Governance and Accountability self- assessment.
The Board was pleased to note that a 3-year NICE fellowship had recently been awarded to the Director of Therapies and Health Sciences which assessed work specifically regarding the implementation of NICE guidelines on the Patients’ Experience. tHB/13/06 Presentation: Patient Story
A Powys patient gave a verbal account via a pre-recorded audio facility and described how care was delivered through a new primary care led alternative model of care in the South of Powys. The patient described that prior to her illness she had already undergone a hip operation and had an infection so felt relieved that care and treatment could be delivered at home. The patient outlined the benefits of being treated at home and noted that the opportunity of treatment at home enabled the recovery time to be much faster due to the fact that she was within her own surroundings which ultimately had a positive impact. In addition, it reduced cross infection to other patients which may have occurred if she had been admitted to hospital.
The patient felt that the service and care received by the Community Resource Team was excellent and advised the Board that it saved an unnecessary trip to hospital and saved money for her personally in the process. The patient noted that it was a welcomed surprise that an intravenous drip could be assembled at home and the access to such IV treatment provided an efficient and brilliant service which brought a positive benefit to the patient experience.
The Board held brief discussion regarding the Virtual Ward which aimed to provide patient centered care within the community, enabling patients to receive multi-disciplinary care at home. PL confirmed to the Board that the virtual ward was the way of working across the South of Powys and a number of sites were due to go live at the beginning of March 2013. PL noted that GPs, District Nurses and Social Workers met on a regular basis and were at the core of the virtual ward and any patients considered vulnerable in the community could be treated. PL confirmed that the Virtual Ward also included weekly multidisciplinary team meetings with a wider team and focused on patients with specific needs. The Board noted that the involvement of Social Services within the project had created a significant and positive impact.
GJP asked if there were limitations in terms of how many patients were able to be treated. PL advised the Board that there would be a limit regarding how much demand there was but Reablement was one area that could be called upon to assist with the demand. PL noted that the project was still in the early stages of implementation and a greater understanding of population need and demand would become clearer as the project developed.
The Board NOTED the patient’s story and welcomed the positive comments
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and benefits as outlined and welcomed the work underway to deliver local Integrated Care for South Powys. tHB/13/07 Stroke Services in South East Powys
BW presented the previously circulated paper, providing the Board with the outcome of the formal consultation exercise and a proposal regarding the future of the stroke service in Bronllys Hospital for consideration.
BW summarised to the Board on extensive local engagement undertaken in respect of the future of services in South East Powys. BW reported to the Board that Powys tHB had completed a formal consultation which ran from 14 September to 14 December 2012 and included an additional two week period following a request from community representatives to the Community Health Council (CHC) to extend the deadline.
BW outlined to the Board elements of the extensive programme of consultation in order to reach the widest audience in the locality. In addition, 115 questionnaires had been received by the tHB in electronic and written format from professional, elected members, voluntary and community groups as well as residents, service users and Staff. In addition, 3,144 signatures were submitted to the Welsh Government to the Petitions Committee.
BW provided a brief summary of the analysis of the responses to the consultation and outlined further comments submitted by the CHC in respect of the clarity of the consultation documents and CHC’s response to the proposals that stated their support.
BW noted to the Board that whilst concerns around the Bronllys site had been acknowledged, ultimately the main objective to improve the quality of care for Powys patients was priority. BW reported that, action would be taken to improve the public transport and parking arrangements at Brecon hospital which was noted as a big concern for residents. BW explained to the Board that the future of the Bronllys site would be addressed by the establishment of a formal project which would bring forward a long term plan for the hospital and the wider site for consideration by the Board in early 2014. This would be conducted in conjunction with the CHC and community representatives.
The Board noted that the consultation process had given Powys tHB an opportunity to learn and build into the next consultation phase improvements in relation to the engagement process.
The Chairman invited members of the public to offer comments. A community representative challenged the level of robustness and detail within the paper and stated that the contents of the paper did not demonstrate or offer a plan that would stand the test of time and questioned if there would be an action plan in place to examine the links that could be developed relating to the South Wales Programme.
David Adams, Chief Officer of the CHC, advised the Board that throughout the
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process CHC members looked at the South East Powys plans and significant analysis was carried out in relation to concerns around the Bronllys site and in supporting the favored option, the CHC requested that car parking arrangements and appointment scheduling were resolved prior to the transfer of stroke services and recommended that Powys tHB develop a clear and robust plan for the future of health services at Bronllys hospital. In addition, the CHC also requested the organisation to examine links that could be developed with the emerging South Wales Programme.
AA requested the Board to give an update regarding the impact on staff during the transfer of services from Bronllys to Brecon. AS confirmed to the Board that phase 1 of the project had been completed and the next phase of the implementation plan was underway. AS clarified to the Board that stroke services at Brecon would be delivered by the same staff at Bronllys. AS noted to the Board that significant investment regarding training staff in Brecon and Bronllys had been made to ensure delivery. In addition, continued efforts had been made to engage staff to ensure a fair process was undertaken. JD advised the Board that currently staff side and workforce were already involved in a robust process regarding potential of application but noted that in terms of suitable candidates/individuals this component had not been met.
GJP acknowledged the work undertaken from the relevant parties involved in the process. GJP noted to the Board that proposals outlined in the paper provided sustainable interest and clinical quality for Powys patients and for these reasons supported the paper. GJP queried potential bed capacity for patients at Brecon hospital due to already existing waiting times. BW advised the Board that an implementation plan was not yet fully developed but would be included in a number of workstreams going forward.
The Board held a further discussion on car parking arrangements for Brecon hospital and the lack of space for patients and visitors currently. AA noted that a lead officer should be allocated to the whole programme regarding this issue. On behalf of PCC, RH offered joint working support in light of the accommodation strategy the PCC was progressing.
Following detailed discussion, the Board:- APPROVED the proposed transfer of Stroke Services from Bronllys Hospital to Brecon Hospital; AGREED to ENSURE the caveats to the move of Stroke Services as set out by the CHC and the proposed measures to address them were delivered; AGREED TO ENSURE that planned action to improve public transport and parking arrangements at Brecon Hospital were progressed; and AGREED TO ENSURE that a project to prepare a long term plan for Bronllys Hospital and services at Talgarth and the Bronllys areas was established.
The Board also noted that further work was required to convince the public of the clinical benefits of the approved option.
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FOR APPROVAL tHB/13/08 Draft Three-Year Plan
AC presented the previously circulated paper, providing the Board with the draft framework for the Three Year Plan 2013-16.
AC outlined to the Board the approach of the Three Year Plan 2013-16 which strengthened the links between developing strategic plans for the organisation and would develop the capacity for delivery and demonstrating performance. AC advised the Board that the paper also described the principles of the proposed financial regime and how this would support the planning cycle.
The Board noted that there would be a rolling three year planning cycle which would update the plan each Autumn. An Annual Plan for 2013/14 would be derived from the Three Year Plan and furthermore, it was expected that the Three year Plan would cover all aspects of health care delivery, including public health, primary care and prescribing and also support the series of delivery plans that supported the Together for Health Programme.
The Board further noted that the overall framework for the Three Year Plan was discussed at its Board workshop in January 2013. Discussions had also taken place with the Stakeholder Reference Group and with the Local Partnership Forum. AC summarised the outcomes of the discussions held and outlined the next phase of planned actions;
• Completion of strategic narrative to inform the plan in each of the key planning areas and to ensure coverage of key Welsh Government, Together for Health priorities • Further refine the key aims, measures and priority actions • Develop the supporting strategy sections for IT, Estates and Workforce and that fall out of specific service plans • Continue with the financial planning process.
The Board held brief discussion regarding the detail of the paper and BW confirmed that the contents and format of the paper should be considered a ‘vision’ as opposed to a detailed plan. AC further advised the Board that the paper was a framework which aimed to articulate the over all direction of the organisation for 2013-16.
The Board NOTED the progress made in relation to the preparation of the tHB’s Three Year Plan and that the final Three Year Plan would be considered by the Board in April 2013. tHB/13/09 Integrated Performance Report
JD presented the previously circulated paper, providing the Board with an update in progress being made regarding the delivery of the high level objectives included in the Annual Plan and further progress made to further develop the Health Board’s integrated performance report. Discussion was held regarding the following areas;
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Waiting Times JD advised the Board that currently, some Powys patients were breaching the 36 week target at English providers. JD noted that the majority of breaches were in Trauma and Orthopedics at Robert Jones & Agnes Hunt. JD confirmed to the Board that an ongoing management plan to address breaches had been undertaken and Powys tHB would continue to monitor the situation. In addition, Powys tHB had sought assurance from Welsh Providers that patients waiting longer than 36 weeks were being managed. Welsh Providers had emphasised that patients were managed based on clinical need and length of time waiting and patient residency was not a factor.
DP noted to the Board that Powys tHB should be made aware that urgent cases were normally seen within 2 weeks and currently the waiting time for urgent cases was 12 weeks. ME asked if the situation could be resolved going forward. DP advised the Board that resolution was possible, if Powys patients were referred to English Providers. The Board noted the difficulties for the tHB’s GPs regarding the waiting time targets when a patient was not considered urgent until the point at which he/she was seen by a Consultant and that, during this time, the GP had ultimate responsibility for the patient.
Staff Appraisals JD reported an update regarding Staff appraisals and noted that the monthly trend in the percentage of staff in receipt of a review on a rolling 12 month basis reached a current percentage of only 42.87% which remained considerably short of the tHB target of 100%. JD outlined the additional actions undertaken which included tackling a Leadership issue and the KSF Lite review process which had been implemented for Managers to use with their staff. The simplified process presented data differently to help and improve performance in this area. In addition, regular progress reports were presented to the Executive Team via monthly Locality Performance reports and Quarterly Workforce Performance Information reports. The Board noted that JD felt confident the next reporting period would be an improved position.
Level of Staff Sickness Absence JD reported that monthly absence rates had continued to increase since July 2012 and the 12 month rate was 5.11% compared to the target of 4.42%. The increased levels of sickness absence was due to increasing levels of long term absence and action had been detailed in a separate report to Executive Directors with the necessary identified planned actions to address the issue. It was noted that management issues, reporting inaccuracies, Occupational Health and longstanding issues regarding ‘stress’ outside the workplace were a multitude of areas to be addressed.
The Board NOTED the progress made on the delivery of high level objectives included in the Annual Plan and progress in the development of the performance management framework. tHB/13/10 South Wales Programme
BW presented the previously circulated paper, providing the Board with a
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summary of the themes transpired from the engagement exercise in Powys on the South Wales Programme Proposals.
BW summarised the engagement process undertaken by Powys tHB and their respective partners. BW advised the Board that a series of clinical conferences regarding the future models of clinical services across the region had taken place and key messages from the process had supplied the Programme Board and were used to inform the development of the Consultation document.
BW outlined the schedule of the events throughout the engagement period and issues raised in the stakeholder meetings. The Board noted the recurrent themes from the Powys engagement events which included:
• Impact of the proposed changes - The future role of hospitals in Abergavenny and Merthyr Tydfil • Emergency Transport – the crucial role of fit for purpose emergency transport in facilitating any change in services and the need for the Welsh Ambulance Services Trust to be full partners in the Programme. Air ambulance was identified as key if patients were expected to travel further for emergency care. • Access – Concern about increased travel costs to patients, families and carers, with greatest impact on the most vulnerable, the quality of the journey and the public transport links to distant hospital. The issue of accommodation for families, or discounted hotels, close to hospitals was raised in several of the meetings • Access to services locally – issues were raised about the services that would continue to be provided locally such as MIU
The Board noted that following the results from the Opinion Research Services questionnaire from all Local Health Boards in South Wales, 94% agreed that the right characteristics had been identified to ensure health services were sustainable. In addition, there were mixed views on the relative prioritisation of treatment at a local hospital versus travelling to receive care from a specialist team.
The Board NOTED the completion of the Engagement process and key messages outlined for submission to the Programme Board. tHB/13/11 Powys LSB: Partnership Rationalisation
BW presented the previously circulated paper, providing the Board with information regarding the review and rationalisation project for partnership arrangements under the Local Service Board.
The Board noted that Welsh Government guidance “Shared Purpose Shared Delivery” placed a requirement on Local Authorities to review their partnership arrangements, in their community leadership role, with the intention of rationalising the structures and business processes that sit within the Local Service Board (LSB) infrastructure.
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The Board noted that it was necessary to build on the initial work undertaken in Powys and respond to the statutory guidance.
BW advised that through a secondment, PCC had created the role of Partnership Support Manager for 12 months from December 2012. This post would develop and lead the project which would fall in 4 phases;
1. Developing the Concept 2. Implementation of Concept 3. One Plan Development – (Concludes March 2014) 4. Business as Usual - Implementation of the One Plan
The Board NOTED the role of the LSB in supporting the tHB in delivering its statutory duties for partnership working and APPROVED its associated governance arrangements. tHB/13/12 Community Development Dietitians
SA presented the previously circulated paper, providing the Board with an update on work undertaken by Community Development Dietitians.
SA updated the Board on the development of a community dietetics capacity grant programme which had widened its scope to include the development and delivery of nutrition qualification for those working with Older People. Currently, SA reported that in Powys, there were two Community Development Dietitians who were located with the Public Health team and co-managed by the Head of Dietetics.
SA outlined a training programme which had been developed for those working with Early Years, with children and young people and with older adults. SA reported that Community Development Dietitians delivered level 2 training and identify those who are able and willing to deliver level 1 training to those they work with. Following training, SA noted that support was provided to enable appropriate nutrition messages to be incorporated in work with Client groups. The Board noted the aim of the programmes to enable those working in the community to deliver and cascade evidenced based food and nutrition messages to individuals and families they work with. In addition, the Board acknowledged the scope of work which included adults in care who were at risk of malnutrition, particularly older adults.
SA advised the Board that nine courses had been delivered in a number of locations across Powys and the course had been jointly promoted through Powys tHB training department, PCC training department the Children and Young Person’s Partnership and through PAVO. SA outlined planned next steps to develop further links with food cooperatives, Designed to Smile, CYPP, Change4Life food and fitness programme MEND and Appetite for Life. Furthermore, support of the work of the Healthy Schools and pre-schools scheme would continue.
SA reported that in conjunction with Welsh Government and Community
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Dietitians in Wales, a new weight management programme know as ‘FoodWise’ would be rolled out across Powys and this would support the implementation of the All Wales Obesity Pathway. The programme would deliver the basis knowledge and skills of nutrition to enable adults to make informed choices regarding their eating habits, to help weight loss and to improve their health.
The Board ACKNOWLEDGED the work undertaken which looked at the whole pathway regarding food, diet and priorities for people. The Board NOTED the contents of the paper and planned next steps necessary to Improve Health and Wellbeing for the people of Powys across all age groups. tHB/13/13 Financial Performance 2012/13: Month 09
The Board received the Financial Performance 2012/13: Month 09 in respect of the outturn financial performance of the tHB against the 2012/13 Financial Plan, approved by the Board in June 2012.
• The tHB had identified an overspend of £4.338M to month 09 • The tHB had reported, based on current performance, a most likely forecast overspend of £4.319M to month 12 with associated risks identified • The tHB had reported a forecast savings of 5.91%, a small deterioration from Month 08 • The tHB was on track to achieve its capital resource limit target • The tHB was on track to achieve the Public Sector Payment Policy • The tHB had participated in a range of actions with NHS Wales with a view to improve the forecast outturn position across Wales
RR summarised a number of risks and outlined how they were currently being managed. RR made reference to Welsh Contracts and the HB’s forecast contractual performance with NHS Wales providers and noted a number of issues which had not been agreed by them which included;
• The application of a 1.8% price deflator • The application of contractual requirements around prior approval and productivity/efficiency measures • The management of patients to a 36 week waiting times target
RR noted that All Wales Directors of Finance were committed to resolve the issues outlined by the end of January, but there remained a risk that these issues would continue to remain unresolved.
The Board NOTED the organisation’s financial performance at Month 09 of 2012/13 and the updates against further actions in place to limit the risks against the forecast performance.
Financial Performance 2012/13: Month 10
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The Board received the Financial Performance 2012/13: Month 10 in respect of the outturn financial performance of the tHB against the 2012/13 Financial Plan, approved by the Board in June 2012.
RR reported to the Board that the paper builds upon Month’s 09 reported position and highlighted only where there had been changes to financial performance and associated actions one month on.
• The tHB had identified an overspend of £5.206M to month 10 • The tHB had reported, based on current performance, a most likely forecast overspend of £5.161M to month 12 with associated risks identified • The tHB was on track to achieve its capital resource limit target • The tHB was on track to achieve the Public Sector Payment Policy .
RR updated the Board in relation to Welsh Providers challenges as outlined in Month 09 and confirmed that on going dialogue and correspondence had continued between the NHS Wales Health Board. In addition, for several organisations, these issues had been formally escalated to Chief Executive level and it was noted that there would be an expectation that the matter of the deflator would most likely escalate to Welsh Government for arbitration.
JM asked the Board if Powys’ HB was ready for arbitration and RR confirmed that the advice received was that Powys would need to settle as much as possible and had been formally encouraged to work through the process.
The Board NOTED the organisation’s financial performance at Month 10 of 2012/13 and the updates against further actions in place to limit the risks against the forecast performance. tHB/13/14 Wales Audit Office: Annual Audit Report
RR provided the previously circulated paper, providing the Board with the tHB’s Annual Audit Report 2012, issued by the Wales Audit Office in February 2013.
RR summarised two sections of the report and updated in respect of the following areas;
Audit of Accounts RR reported that the report concluded that the Auditor General for Wales issued an unqualified opinion on the 2011-12 financial statement and in light of this, had brought a small number of issues to relevant officers and the Audit Committee placed a substantive report alongside the audit opinion of the Health Board and concluded that:-
• The HB achieved financial balance at the end of 2011-12, but only as a result of year-end additional non-recurring funding from the Welsh Government, as a result of the Auditor General placed a substantive report alongside his audit opinion. • The Health Board’s financial statements were properly prepared and
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materially accurate; • The Health Board’s internal control environment reduced the risks of material misstatements and its significant financial systems were appropriately controlled and operated as intended although there were some areas for improvement.
Arrangements for securing economy, efficiency and effectiveness in the use of resources RR summarised the findings from a range of performance audit work, which included structured assessment, undertaken in 2012. RR noted that the detailed report concluded that progress had been made in a number of areas and noted that further progress was needed to address the increased challenges in some of those areas. RR noted that the report concluded that the Health Board was unlikely to achieve a break-even position at the end of 2012-13 and plans to achieve longer-term financial sustainability were still being developed.
The Board NOTED the contents of the paper and findings and recommendations made by the Wales Audit Office. tHB/13/15 Stakeholder Reference Group Annual Report
AA presented the previously circulated paper, providing the Board with the 2012 Annual Report of the Stakeholder Reference Group.
AA summarised the Stakeholder Reference Group Annual Report and outlined detailed work undertaken by the Group and attendances noted from January to December 2012. AA reported to the Board that the SRG had been very active on aspects such as the Corporate Plan, offered comments on consultation and engagement exercises, and helped to disseminate and cascade information from a wide range of Stakeholder Reference Networks. AA noted that despite the activity of the SRG its effectiveness in making a difference was opened to question. The Board noted that, as with other Health Board’s across Wales under increased pressure to save money welcomed the opportunity to redefine and re-launch the SRG in a more effective way.
AA reported that the similar challenges encountered by SRGs in other Health Boards and informed the Board of work currently underway to address the issues by developing guidance on good practice. AA further noted that an engagement meeting scheduled for the 25 February 2013 had been cancelled so was unsure of the current position. AA Acknowledged the support provided by Powys tHB Planning Directorate throughout this period.
The Board RECEIVED the update for information and NOTED progress made to date.
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FOR APPROVAL tHB/13/16 Board Committee Reports:-
The Board received and noted for information:-
an update from the Audit Committee Chair which outlined key developments via the Audit Committee at its meeting in February 2013; an update from the Integrated Governance Committee Chair which outlined key developments via the Integrated Governance Committee in January 2013;
No issues of concern were raised by Committee Chairs.
The Board RECEIVED the reports from the: Audit Committee Chair; Integrated Governance Committee Chair. tHB/13/17 Any Other Business
No further items for discussion were noted. tHB/13/18 Date and Time of Next Meeting
24 April 2013, 1.00pm, The Pavilion, Royal Welsh Showground, Builth Wells
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FOR DISCUSSION
BOARD MEETING 24 APRIL 2013
AGENDA ITEM 1.4
ACTION REVIEW FROM PREVIOUS MEETINGS 2012/13
Report of Chairman
Paper prepared by Corporate Governance Manager
Purpose of Paper To provide the Board with a summary of actions arising from previous Board Meetings held (2012/13), as at 20 February 2013.
Action/Decision required The Board is asked to DISCUSS progress against the actions arising from previous Board Meetings (2012/13).
Link to ‘Doing Well, 1. Governance and Accountability Doing Better: Standards for Health Services in Wales’:
Link to Health Board’s Improving Health & Well-Being Annual Plan Ensuring the Right Access Striving for Excellence Involving the People of Powys Making Every Pound Count
Acronyms and N/A abbreviations
Action Review Page 1 of 3 Board Meeting 19 December 2012 24 April 2013 Agenda Item 1.4
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BOARD MEETINGS ACTIONS ARISING OUTSTANDING
Board Minute Board Date Action Responsible Progress Completed tHB/12/39 27 June 2012 Review of effectiveness of Agreement to Director of Finance Overarching Section 33 be reported to Board in July 2013. Agreement
COMPLETED tHB/12/47 27 June 2012 Request for approval of proposal to be Corporate 05/09/12: Proposal sent to 9 Proposal for Board Associate sent to Minister for Health and Social Governance Manager Minister for Health and Social Member Services. Services for consideration.
19/12/12: Follow-up letter sent to Minister. Formal position to be reported to Board in February 2013.
20/02/13: Approval received from Minister and GP Associate Member appointed to the Board. tHB/12/64 05 Mental Health Strategy to be presented Director of Nursing 24/10/12: Strategy development 9 Mental Health Vision for Powys September to Board in December 2012, for approval. underway. 2012 19/12/12: On agenda tHB/12/44 27 June 2012 Outcome of review of Powys Chief 24/10/12: Complete. Presentation 9 Powys Public Health Strategic Partnerships to be presented at a future Executive/Corporate held 13 September 2012. Framework Board Development Session. Governance Manager 05/09/12: Board Development Session Programme to be established for 2012/13.
Action Review Page 2 of 3 Board Meeting 19 December 2012 24 April 2013 Agenda Item 1.4
FOR DISCUSSION tHB/12/19 18 April 2012 An update report in respect of Setting the Director of Strategic 05/09/12: Included on Board 9 Annual Plan 2012/13 Direction (including the maturity matrix) Planning/Director of Meeting agenda. to be presented to the Board in Therapies & Health September 2012. Sciences
Action Review Page 3 of 3 Board Meeting 19 December 2012 24 April 2013 Agenda Item 1.4
FOR APPROVAL
BOARD MEETING 24 APRIL 2013 AGENDA ITEM 2.1
THREE YEAR PLAN 2013-16
Report of Interim Director of Planning
Paper prepared by Interim Director of Planning
Purpose of Paper To receive the tHB’s Three Year Plan for 2013-16
Action/Decision required The Board is asked to APPROVE the three year plan and annual plan
Link to ‘Doing Well, This paper supports all Standards for Health Services Doing Better: Standards in Wales. for Health Services in Wales’:
Link to Health Board’s Improving Health & Well-Being Corporate Plan Striving for Excellence
Acronyms and N/A abbreviations
Three Year Plan Page 1 of 2 Board Meeting 24 April 2013 Agenda Item 2.1
FOR APPROVAL
THREE YEAR PLAN 2013-16
The Welsh Government has introduced a new NHS Wales Planning Cycle to support the delivery by Health Boards of Together for Health that requires the publication of a three year delivery plan that runs from April 2013. The Board previously received a paper outlining the approach to developing the Plan at its December 2012 meeting.
The new planning framework attempts to ensure alignment and coherence across three dimensions: • Time – linking 5-year, 3-year and annual plans • Structures – linking national, regional, LHB and local plans • Scope – linking service, workforce, finance, capital and ICT planning.
The new planning guidance requires the health board to produce a first three year plan for the three years from April 2013 to March 2016 by March 2013. There will be a rolling three year planning cycle updating the plan each autumn. An Annual Plan for 2013/14 has been derived from the Three Year Plan also presented on the agenda, which will be the basis of performance management of delivery of year 1 of the plan. The associated three year financial plan is presented as part of the document. The approach to the 2013-14 financial plan is also presented as a separate paper on the agenda.
Recommendation The Board is asked to APPROVE the three year plan 2013-16
Report prepared by: Presented By: Bruce Whitear Bruce Whitear Interim Director of Planning Interim Director of Planning
Three Year Plan Page 2 of 2 Board Meeting 24 April 2013 Agenda Item 2.1
Three Year Plan 2013/14 – 2015/16
“..truly integrated care centred on the needs of the individual..”
March 2013 Version 8:
SUMMARY
“..truly integrated care centred on the needs of the individual..”
This plan sets out the tHB’s approach to planning and delivery of services for the residents of Powys for the three year period 2013-16. The Plan is designed around the vision set out by the board to deliver “..truly integrated care centred on the needs of the individual..” through five inter- related values
• Improving health and well-being • Ensuring the right access • Striving for excellence • Involving the people of Powys • Making every pound count
Powys teaching Health Board is primarily a primary care and community services organisation, which commissions the majority of secondary care provision on both an emergency and planned basis from neighbouring Health Boards and English NHS Trusts. The tHB’s service plans are based on further harnessing the primary care strengths of the organisation to manage the demand for services, improve quality and contain costs through a number of inter-related actions.
The key to effective delivery of our plans is to continue to strengthen the capacity of local teams that work across five health systems that serve Powys in addition to the systems of care that operate for women and children, mental health and specialised services. This means delivering a programme of organisational development that will enable local teams to lead and manage change.
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Powys already works from a strong base in respect of the degree to which a primary care and community services model drives service delivery, quality and drives down cost. Key performance areas include:
• a flat pattern of emergency admissions in the face of significant demographic growth • a high proportion of births that occur within Powys at home and in birthing centres and high uptake rates of breast feeding • the lowest levels of prescribing in Wales • service modernisation leading to the closure of Builth Hospital in 2013 • engagement of primary care in leading change at local level • successful completion of service change at Bronllys Hospital • low rates of teenage pregnancy
Powys Population A full needs assessment for the population is available from the tHB linked to the Public Health Strategy. This will be refreshed during 2013 as part of work to further develop the Powys single integrated plan One Powys: Powys Un, and it is not intended to repeat that assessment here. An analysis of the overall demographic trends within Powys is discussed below to illustrate the challenges Powys faces in delivering a sustainable health care system.
The population pyramid for Powys’ resident population shows that there are substantially more people aged over 50, and substantially fewer working age adults, 20-39 than the Wales population.
Proportion of population by age and sex, Powys & Wales: 2010
Produced by the Public Health Wales Obseravtory using data from 2010 mid year population estimates, Office for National Statistics
Powys LA females Powys LA males Wales fem ales Wales m ales
85+ 80-84 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 05-09 00-04
141210864202468101214 Proportion (%) of population
The projected population pyramid for Powys’ resident population for 2033 shows substantially fewer 20-24 year olds compared to the Welsh average, and there are substantially more people aged over 65 than the Welsh average.
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Proportion of projected population by age and sex, Powys & Wales, 2033 Produced by the Public Health Wales Obseravtory, using population projections from Stats Wales (WG)
Powys LA females Powys LA males Wales fem ales Wales m ales
85+ 80-84 75-79 70-74 65-69 60-64 55-59 50-54 45-49 40-44 35-39 30-34 25-29 20-24 15-19 10-14 05-09 00-04
141210864202468101214
Projected proportion (%) of population
In the population projections for Powys until the year 2033 the over 65 age group is set to increase dramatically, with an 80% increase between 2008 and 2033. A 20% rise has already been seen in the five years since 2008 and during the life of this plan this is set to rise by a further 10%. If current trends continue, the proportion of people aged under 65 will decrease by the year 2033. Current projections predict the number of people aged over 75, to increase, dramatically from 14,000 to 28.000 in 2031.
2008-based population projections for Powys Teaching Health Board, Produced by the Public Health Wales Observatory, using data from the Welsh Assembly Government 0-15 16-24 25-44 45-64 65+ 100
80
60
40
20
0
-20 Percentage change from 2008 Percentage 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031 2032 2033
At present, older people in Powys report better health compared with the Wales average. For example, the proportion of people aged over 65 years with a limiting long term illness is 49% in Powys, compared with 56% across Wales. However, the increase in the proportion of older people living in Powys means that the number of people with long term conditions such as diabetes will increase. There will also be an increase in the number of people with dementia. It is estimated that whilst the number of people in Powys aged over 65 years with dementia was 31,700 in 2011, this is likely to rise to 50,300 in 2030.
Whilst the population of Powys experiences the highest life expectancy at birth in Wales and experiences better health outcomes e.g. lower levels of premature mortality compared with the
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Wales average, inequities in health outcomes remain. The graph below shows the difference in life expectancy, healthy life expectancy and disability free life expectancy between the most and the least deprived fifths of the Powys population (inequality gap) over two time periods. Over 2005-09 females in the least deprived fifth of the Powys population experienced a 13.6 years greater healthy life expectancy compared with most deprived fifth of the population.
Life expectancy in Powys
2001-05 2005-09 Life expectancy with 95% Inequality gap confidence interval (SII in years) Males Life expectancy 77.5 6.0 79.1 5.5
Healthy life 66.7 6.4 expectancy 67.7 5.9
Disability-free life 61.6 7.1 expectancy 62.5 6.3
Females Life expectancy 81.2 5.7 82.7 4.9
Healthy life 66.7 13.7 expectancy 67.5 13.6
Disability-free life 62.8 9.6 expectancy 63.3 9.3
Source: Public Health Wales Observatory
A Sustainable Health Service for Powys Putting in place the building blocks of a sustainable health system for Powys that will be able to cope with the forecast demographic changes for the County’s resident population is the golden thread underpinning this three-year plan. Those building blocks include:
• improving health and well-being and reducing the impact of inequalities through a targeted a public health approach and shared, neighbourhood based partnership approach through the Local Service Board • building capacity in primary care to lead and manage the local health system, with enhanced local decision making • building capacity of local primary care and community services to manage demand for healthcare, including an enhanced preventive approach • in partnership with social care further building a flexible local integrated health and social care to maximise independence, and modernise longer term care • a robust approach to prioritisation and new investment in health services
The consequences of no growth in the funding the tHB receives from Welsh Government, and no foreseeable planned growth, places considerable pressure on the tHB to maintain service quality in the face of the demographic pressures of increasing demand, introduction of new health technologies and inflationary pressures. The challenge to the tHB of achieving a sustainable service model in this financial environment is not to be under-estimated. In 2011-12 the tHB achieved financial balance through the early draw-down of £4M and for 2013-14 the tHB is forecasting an end of year deficit position of £5.1M. Substantial year on year savings in excess of 5% have been achieved in reaching this position, but this is clearly not sufficient. Looking forward the tHB has identified efficiency savings that will be achieved through service modernisation and a strengthened commissioning approach, but at this stage these do not equate to enabling a balanced financial position for 2013-14 or in subsequent years. Over a three year period of the level of savings required to support a balanced position from commissioned services across England and Wales is in the region of £21M.
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The tHB is taking a fresh approach to commissioning from 2013-14 that will make explicit the financial challenge to provider organisations and seek to negotiate a collaborative and shared approach to both maintaining health care quality and challenging the cost of services provided. Specifically within Wales there will need to be recognition within neighbouring Health Board plans of the constraints on the tHB’s budgetary capacity to commission services and for their associated income assumptions to be reflected in their plans.
Two thirds of the tHB’s resources are allocated to primary care services and to the community hospitals and community services that the tHB operates. The opportunities for the tHB to make financial savings also lie in investment and productivity in front-line services to more effectively manage the demand for out of county services. As such the role of the tHB as a commissioner is to be strengthened, both in terms of efficiently commissioning services from external providers, and ensuring that directly provided services are also commissioned efficiently. This approach is in line with public demand for more accessible services locally, and a rural model of health care as set out in Welsh Government’s Rural Health Plan.
There is much opportunity that can be achieved in all areas of Powys’ business to build on existing successes, including working to narrow gaps in performance across the different geographical areas that the tHB serves. The diagram below sets out our overall strategy to build on successes and further shift the pattern of healthcare to an increasingly local model.
Component Efficiency: Demand Management:
Effective Contracting
The diagram provides an illustration of Powys’ overall approach to service re-design and shift the focus towards prevention and early intervention and the balance of care from out of County hospital to primary and community services. Over the three year period of the Plan the tHB will continue to work systematically through the most significant care pathways as defined by the volume of activity and their associated cost across emergency and elective services, to drive improvement and efficiency.
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• Clear pathways of care that demonstrate the most appropriate care in the most appropriate setting. The intended consequence is a reduction in unnecessary steps and delays which in themselves can drive costs upwards through poor clinical outcomes. For Powys, the complexity comes with designing and implementing pathways through 5 healthcare systems and requires the will of other Health Boards in Wales and the two major providers in England to assist us in this task. • Each component of pathway to be efficiently secured. costing work has observed that there is variation in cost base where delivery is at similar scale and complexity. This is observed across a range of services and there is continued focus is to tackle these variations • Improvements in clinical systems and processes. This will reduce demand for higher cost healthcare, a more efficient right first time system and improved patient experience. Using system improvement, quality and value as key drivers will enable frontline staff to focus on reducing escalating demand, reduce reworked activity through errors/poor quality reductions and improving processes for care delivery. • Tackling inequalities in resourcing. the geographical spend profile is weighted significantly more towards the Mid/South end of the county across both general and mental health services as compared to the North. Both geographical areas cover similar sized population and our health needs assessment does not draw out any conclusions as to why spend should be disproportionate. A proportionately higher focus of cost reduction is required in the mid and south of the County, whilst maintaining the momentum of cost reduction through efficient working and pathway re-design in the North. • Economic model - Care closer to home. Generally, the preferred approach is to promote care closer to home where it is clinically appropriate and can be evidenced as providing value for money.
Making it Happen Central to the ability of the tHB to deliver a sustainable health system for the future is the maturity of the organisation in having the capacity and capability for delivery. During 2012 the tHB has undertaken a significant self-assessment diagnostic supported by technical external assessments in respect of financial management, information and the overall Wales Audit Office structured assessment. As a consequence the tHB has set in train a leadership and organisational development programme, underpinned by a strengthened Governance framework. The diagnostic demonstrated the need to transform the organisation in respect of strategic shifts in
• Clinically led and managed • Devolved decision making, supported by clear accountability • Performance driven, supported by strong information • Systematic approach to planning and driving change • Embedding a commissioning approach across the organisation
The response to this diagnostic is presented at the head of this plan: the Leadership and Organisational Development Programme is crucial to the ultimate success of the organisation in delivering improvements in quality and a sustainable healthcare system.
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Table of Contents
SUMMARY ...... 2 LEADERSHIP AND ORGANISATIONAL DEVELOPMENT ...... 9 Governance ...... 15 IMPROVING HEALTH AND WELL‐BEING ...... 17 Unscheduled Care...... 20 ENSURING THE RIGHT ACCESS ...... 20 Elective Care ...... 24 Women and Children’s Services ...... 27 Cancer Services ...... 28 Stroke Services ...... 29 Mental Health ...... 30 Learning Disabilities ...... 32 Integrated Care: Working in Partnership ...... 33 QUALITY DELIVERY PLAN ...... 35 STRIVING FOR EXCELLENCE ...... 35 Medicines use and Prescribing ...... 38 INVOLVING THE PEOPLE OF POWYS ...... 38 MAKING EVERY POUND COUNT ...... 38 INFORMATION TECHNOLOGY...... 38 CAPITAL AND ESTATE...... 38 WORKFORCE ...... 38
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LEADERSHIP AND ORGANISATIONAL DEVELOPMENT
Delivery of the vision of integrated care around the needs of the individual requires Powys tHB to develop the culture and organisational structure for delivery. Since re-organisation in 2010 the tHB has driven forward a locality and service directorate led management model that has at its heart local leadership for planning, management and delivery of the entire pathway of care, including full control of the resource around a given population. This approach has been based on an approach that
• is clinically led at a local level with GPs at the heart of the planning, commissioning and delivery of services • maximising the capacity and capability of locality and service directorate teams • a diminished corporate infrastructure which is principally responsible for enabling and supporting the locality teams, providing strategic leadership, governance, assurance and performance management frameworks • strengthened partnership working with staff and their representatives and with external stakeholders and partners to ensure staff participate in decision making at all levels and feel empowered to influence service design and delivery • strengthened local engagement and partnership working to ensure true integration
During 2012, under the leadership of the Director of Workforce and Organisational Development the Health Board has taken stock of this approach. An assessment of capacity and capability of the organisation has been undertaken through a combination of internal assessment and external reviews including Alison Lord; Chris Hurst, Wales Audit Office and Internal Audit and a commissioned review of the tHB’s information function. From this assessment a structured programme of Leadership and Organisational Development has been developed that will deliver maturity in the organisational model and underpin service, workforce and financial sustainability.
A performing organisation is one that is able to demonstrate a flexible and agile approach to managing challenges and change. These programmes will provide this level of organisational maturity that will facilitate the long term sustainability service delivery for Powys citizens. The programme is now well established and will continue to be implemented over the next three years.
A programme of change was initiated in 2012 and will be further implemented within the timeframe of this plan. The initial focus of the work was to undertake baseline assessments of the fitness for purpose of organisational structures, leadership capacity and capability including clinical leadership, information and commissioning functions, financial regime and performance management framework and the streamlining of the Board assurance and governance structures.
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Diagnostic work has been undertaken to determine the capacity and cultural aspects of the organisation’s ability to drive transformation and delivery, in partnership with our staff and with other stakeholders and partners. External support was sourced including specialist finance, information, commissioning and OD expertise to undertaken this diagnostic work. These assessments have informed the development of a programme of activity to build the maturity and capability of the organisation across the 9 core areas identified below.
•Clinical leadership •Developing a •Use of technology and management culture of learning to support access Skills development and innovation and delivery Delivery Capacity
•Strengthening •Data and •A Programme and locality and service information drving approach to and and
directorate performance and transformation capacity change and accelarated clinical change
•Performing teams Learning •Full engagement of at all levels based staff, patients and •Sustainability as a on the Aston the public core organising
Leadership approach principle Performance
1. Clinical leadership and management development Building capacity and capability among our clinical leaders and managers is critical to our Organisational Development strategy. During 2012 the tHB successfully recruited and inducted staff to key leadership vacancies in the executive team, localities, the programme office, workforce development and information functions. GP involvement in locality and at board level has been progressively strengthened. A core objective is to build on the current leadership programme and implement a coherent and strategic approach to clinical leadership and management development that reflects the purpose and direction of the organisation.
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Deliverables • A competence based Leadership and Management Framework will be developed that clearly articulates the skills and behaviours required of our managers across all professions and disciplines. • Development of a values and behaviours framework informed by the emerging issues from the Francis Review and analysis of the recently completed NHS Staff Survey • A programme of formal and informal learning interventions based on a self-assessment of skills and the appraisal process. • It is also important that teams who work together, also learn together, including across health and social care. • Our vision is that clinicians of all professions be actively engaged and undertake visible leadership roles throughout the care system in Powys. • Medical Director is Welsh regional lead for Faculty of Medical Leadership and management, CD for W&C is undertaking clinical leadership programme and GPs placed on Deanery 3D programme
2. Strengthening locality and service directorate capacity The health board is responsible for securing health services for the residents of Powys and achieves this through commissioning services across care pathways from primary care contractors, directly managed services and securing services from neighbouring LHBs and NHS Trusts and other care providers. Ensuring access through local partnership working with Powys Council is key. A primary care and clinically led approach to commissioning across the health system is central to driving improvements in the quality of care around the patient and delivering a sustainable and integrated health system. Public Health will be integral to developing a commissioning process that is based on population health needs and incorporates disease prevention in pathways of care. All staff will increasingly recognise their role in service commissioning.
As the Locality and Service Directorate approach to transformation drives service change and delivery, a programme of re-alignment of corporate functions and organisational capacity commenced in 2012 which will be complete by the end of 2013. This includes: • Management structure: complete • GP/Medical Leadership: complete • Finance Alignment: due 1 April 2013 • Commissioning Alignment: due 1 June 2013 • Planning Alignment: complete • HR Business Partner: complete • Information Manager/Analyst: due 1 May • Public Health alignment: complete • Programme Management Office: complete
As these arrangements mature the leadership role of these teams will be supported through the range of OD interventions described in this chapter, and a particular emphasis on developing the commissioning capacity of these teams.
3. Performing teams at all levels based on the Aston approach The Health Board has committed to the implementation of a systematic approach to the development of teams across the organisation. This is based on the research based Aston OD Team Based Working approach. Twenty three Team Coaches have been recruited and accredited in the first wave at all levels in the organisation. The programme is being rolled out across the organisation and monitoring arrangements will be determined to assess and report on impact, and further work planned to consider how the programme can support joint working with Powys Council.
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4. Developing a culture of learning and innovation The HB has determined that its ‘teaching’ status should evidence an aspiration to develop a learning and innovation culture driven and enabled by strong leadership. Our aim is therefore to build an organisation characterised by: • A drive for innovation, continuous improvement and learning • Empowering the workforce - allowing staff and teams to innovate and take appropriate decisions in a ‘no blame culture’. Recognise and utilise the expertise that we already have in the workforce • Improved communication at all levels to build confidence, relationships and openness • Acting on ideas both at a local level – ‘just do its’ - and corporately through more formal implementation programmes • Routinely identifying, celebrating and sharing good practice and success • Multi professional, multi disciplinary and multi-organisational learning – erosion of silos • Effective team working at all levels principally through the Aston work • Delegated decision making • Alignment of staff objectives and development activity with innovation and improvement • Developing as a centre of excellence for rural and community practice with a holistic ‘team Powys’ approach to include the HB, further education and higher education sectors, Powys CC, primary care and third sector.
Research Organisa Organisati Quality Education Knowledge and Innovati tional onal Improvem and Manageme Developme on Effective Developme ent Training nt nt ness nt Faculty Development and Leading Improvement Organisation Medical Data/Intellige Learning of People, for the Quality and School nce driven Organisation New Models Clinical delivery of Safety Placements organisation Culture of Care Processes, Rural Clinical and Healthcare Clinical Post Improving EmployerManagement led Evidence Placements Graduate Organisation Quality educationSystems Based New ways of for pre‐ Medical al Maturity Together development Practice working registration Library Initiative with HEIs Protected Optimising Partnership Learning Learning Rural Health technology to working with Appraisals through 1000 lives Time – Library support care County Technology Primary Care delivery Council Award Partnership Integrated Horizon Clinical Skills winning working with Systems and Scanning Development organisation other Health Processes Activity Boards Accelerated Essential Participation Clinical Skills in research Change Programme
Statutory and Pathway Mandatory Redesign Training
Work Team Based Experience Working
Competence Apprenticeshi Based ps Workforce Development
Accreditation Employer of for Learning Choice
Integrated Service and Workforce Redesign
Deliverables • Development of an integrated multi- professional education, innovation, research and clinical effectiveness/quality improvement function. • Build on the level of appraisal achievement that moved from 46% to 66% in 2012-13 to reach 85% • Build on the annual Research and Innovation Conference to expand research, audit and benchmarking activity to inform practice, service change and innovation • Establish a ‘Team Powys’ virtual faculty across the Health Board, County Council, Primary Care, Voluntary sector , and local educational establishments. • Establish a programme of apprenticeships • Strengthen internal staff communications through the Communications Forum
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• Maintain the in-house Excellence Awards and maximise opportunities to showcase Powys innovation and good practice externally • Develop a virtual library service to support community and rural practice. • Increase hosting of undergraduate and postgraduate development activity for the medical and dental workforce in partnership with Cardiff and Swansea medical schools and with the Deanery
5. Data and information driving performance and change During 2012 the tHB commissioned a review of its information function and the way in which it supports the core business of the organisation. The review made seven key recommendations which the tHB are taking forward through a programme approach to change, that relate to the capacity, systems, and process for change. This programme will make a strategic shift from an information function that was primarily information gathering to a team that fully supports the corporate and operational business of the organisation in respect of:
• Consistent information gathering and reporting across all operational functions of the tHB, particularly community services and consistently sourced from provider organisations • Availability of management information directly on desk-top and a customer oriented approach to meeting organisational information needs • Increased capacity for information analysis across the organisation • Agreed and consistent use of information to drive organisational performance at Board, Directorate and operational levels
The performance management focus is in developing meaningful measures and KPIs that include the Tier 1 and 2 requirements of Welsh Government but also outcome focused measures to evidence that the organisation’s strategic objectives are being met, and that link organisational delivery with financial performance. This is in line with the developing Balanced Scorecard approach to performance management being developed by Welsh Government. Progress has been made to strengthen performance reporting to the Board and further work will be undertaken align key indicators with the priorities of the Board set in this Plan.
6. Full engagement of staff, patients and the public The tHB will further strengthen engagement with staff, patients and the public through a variety of media, building on current two-way communication using a range of tools with individuals and in partnership. We want to ensure that patients feel involved and engaged in their own care and the future of the organisation. We aim to improve our evidence of patient experience consistently across all services and provide greater assurance through service evaluation forms, surveys, questionnaires and other such media. Our long term aim is to ensure that people who use our services and the services we commission have the best possible experience. Working in partnership with trade unions, the HB will build on the work commenced in 2012/13 to strengthen internal communication to ensure that the views of staff are routinely accessed and heard through simplified, effective and valued mechanisms and that staff have a genuine opportunity to shape and influence policy and practice
Deliverables • Consistent strategies of continuous engagement with all geographical communities in Powys • Strategies tailored to engage children, young people and people with a learning disability. • Development of the use of social media as a tool in engagement • A joint approach to Powys wide engagement in the context of the Local Service Board with an emphasis on providing assurance around equality
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7. Use of technology to support access and delivery The tHB’s overall IT Strategy is aligned to the national ICT strategy, the NWIS Plan and the shared platform of ICT with Powys County Council through a Section 33 Agreement. A new three year strategy for ICT for the tHB is required which will include:
Deliverables • Digital Powys – a cross-public sector project jointly led by Powys tHB and PCC to develop the wider ICT infrastructure in Powys as a driver for economic regeneration and sustainable communities in additional to supporting innovative service delivery • Continued delivery of key NWIS Programmes in Powys • Development of a shared Business case for implementation and roll-out of Telehealth and Telecare with Powys County Council • Continued roll-out of tele-presence to support rural health care delivery and reduce transport costs for staff and patients
8. A Programme approach to transformation A Transformation Board has been established in the short term to focus on the Accelerated Clinical Change Programme but in the longer term it is anticipated that it will cover all newly defined programmes of work within this Plan. The Transformation Board strengthens clinical leadership of change in the tHB through strong GP representation to prioritise, drive and communicate the clinical change programme in Powys and reports directly to the Integrated Governance Committee. To support Powys tHB to deliver service transformation, a Programme Management Office has been established and will be strengthened to provide project and programme management support to:
• Improve benefits realisation by defining quality improvement and financial outcomes at project initiation • Provide a clear and consistent methodology for implementing change • Bring an organisation wide view of change which ensures projects and programmes are strategically aligned • Increase awareness and management of programme level risks and issues • Strengthen accountability and ensuring appropriate control through governance and scrutiny processes that provides assurance on key decisions and delivery.
Current priorities have been identified that support delivery of priority delivery plans within the first year of the Three Year Plan to address the key areas in the plan relating to Unscheduled Care, Scheduled Care, Adult Mental Health and delivery of a transformed information service to ensure Powys becomes a data driven organisation strengthening evidence based decision making.
9. Sustainability as a core organising principle The tHB is an integral part of our local communities and as such it is imperative that we continue to build and strengthen our relationships and networks at local level through the core organising principle of sustainable development. In line with the Welsh Government’s ’One Wales: One Planet’ scheme for sustainable development we will continue to work toward integrating the core principles of involvement and integration into all aspects of our activities; corporate and operational. This means placing people and communities at the heart of our policies and procedures, and undertaking and connecting only those approaches which effectively integrate economic, social and environmental challenges.
The initial key challenges we aim to address will be to focus on the sustainable use of resources, reducing our Carbon footprint through proactively engaging in sustainable environment projects and schemes and achieving and maintaining a quality Environmental Management System (ISO 14001). We will use evidence based approaches to our decisions, providing local services and care reflecting the distinctive needs of the population we serve. We will strive to be at the
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forefront of efforts to promote wellbeing within our staff and communities, and we will seek ways to underpin all our activities with a commitment to a joined up approach in delivering economically, environmentally and socially sustainable services.
Deliverables • Achieve ISO140001 Environmental Management Standard by 2014 • Achieve Platinum level Corporate Health Standard by 2014 • Deliver a 7% reduction in Carbon emissions over a five year period
Governance The governance arrangements within NHS Wales and the tHB continue to be developed to ensure that there is clarity on objectives, risks and performance management arrangements from the Welsh Government through to the Health Board and then to all operational management areas. Moving forward, the basis for this will be “Safe Care, Compassionate Care – A National Governance Framework”, issued in February 2013. This document sets the vision and framework for taking forward integrated assurance and governance. This document also frames the ‘Quality Triggers’ which are key trigger questions to provide structure to triangulate information from a variety of sources which cover all dimensions of quality:-
Maturity Measures & Assessment Integrated Performance Reports
Integrated Governance Plans Structures
Values, Standards for Culture & Health Services Leadership Quality Trigger Questions Governance Wider Public Manual Sector
Internal Audit Public Domains Information & Transparency
Health Wales Audit Inspectorate Office Wales Structured Reviews Assessment
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In developing an integrated governance and assurance system within the organisation, the Board will develop its Board Assurance Framework which will set out the key strategic risks to achieving the Board’s objectives, the controls in place to prevent those risks from materialising and the assurances that the Board receives regarding the effectiveness of those controls. The following demonstrates the process that the Board will adopt:-
Annual Plan The Board reviews its performance The Board identifies the key purposes and desired achievements for towards the achievement of its purpose and desired achievements the organisation Locality/Directorate/Department/Team and individual objectives will directly link to these
OBJECTIVES The Board establishes and The Board communicates its approach to risk evaluates the – including its risk appetite effectiveness of its risk and assurance
Citizen ASSURANCE RISKS Led
The Board identifies its risks (both The Board opportunities and threats) at a receives corporate level and this process is evidence to repeated at all levels of the satisfy its CONTROLS organisation
The Board articulates its Management designs assurance needs to demonstrate and operates its controls are effective to manage system of internal risks. control
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IMPROVING HEALTH AND WELL-BEING Health
Our approach to improving health and well-being is to work with our partners, particularly through the Local Service Board, to develop the capacity in the community and across agencies to improve health now and lay the foundations for maintaining good health for the future. It recognises that all of our communities are individual; in their nature, and our response to improving health will reflect both nationally driven programmes for health improvement, while allowing room to recognise local difference, and reduce inequality in experience of health and health outcomes. A neighbourhood management approach led through the LSB will promote and enable greater ownership of health behaviours by communities. The priorities of the LSB will be underpinned by a Strategic Needs Assessment, with focus on actions that have the greatest impact on improving health and wellbeing and reducing health inequity. Every member of staff has a part to play in taking opportunities to improve the health and well-being of the population.
Key Aims 1. Improve the opportunities and life chances for children
2. Reduce preventable death and disability due to chronic disease
3. Reduce illness, death and healthcare utilisation due to flu
4. Optimise the health, well-being and public health skills of
the workforce
Public Health’s contribution to the 3 year plan encompasses the three domains of Public Health:
• Health improvement • Health protection • Health services quality
This is underpinned by health intelligence, so that the spectrum of the tHB’s plans is data led, evidence based and can demonstrate measurable improvements in health outcomes. Public Health will be integral to the thematic programmes to develop skills and capacity of the tHB. Key interdependencies between Public Health and organisational development include: • development of a workforce that is “data aware” and able to confidently use data for service planning, driving performance and change. • service evaluation, contributing to a culture of learning and innovation and resulting in service improvement • embedding Public Health in the working practice of all staff, resulting in a workforce that are able to deliver interventions to reduce unhealthy behaviours e.g. having staff skilled in Brief Intervention, Motivational Interviewing and promote health e.g. childhood vaccinations • having quality improvement embedded throughout the workforce, ensuring a common language and a common approach
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Improving health and wellbeing Health improvement priorities and actions have previously been articulated in the Powys Public Health Strategic Framework 2011-14. This framework sets out the Powys response to the ten challenges identified in Welsh Government’s public health strategy Our Healthy Future:
• stopping growth in health inequities • reducing smoking rates • increasing physical activity rates • reducing unhealthy eating • stopping growth in harm from alcohol and drugs • reducing teenage pregnancy rates • reducing accident and injury rates • improving mental well being • improving health at work • increasing vaccination rates to recommended levels
This Framework was developed with key partners and demonstrates a collective approach to the ten challenges within the context of the population outcomes to be achieved in Powys. For 2013-16, the Health and Wellbeing key aims are:
• Improve the opportunities and life chances for children • Implement Action Plans to improve childhood immunisation and flu vaccination uptake in order to achieve immunisation targets • Develop and implement strategies and action plans for reducing smoking prevalence, reducing prevalence of overweight and obesity and reducing the proportion of Powys residents drinking alcohol above national guidelines • Reduce preventable death and disability due to chronic disease by increasing the proportion of the population engaged in healthy behaviours - Reduce the prevalence of smoking - Reduce the prevalence of excess alcohol consumption - Increase the proportion of adults consuming 5 portions of fruit and vegetables per day - Increase the proportion of adults meeting physical activity guidelines • Reduce illness, death and healthcare utilisation due to flu by increasing flu vaccination uptake amongst at risk patients and healthcare staff to target levels • Optimise the health, well being and public health skills of the workforce
Measures • Breast feeding rates at birth and at 28 days. • Health assessment rates for Looked After Children and children involved with Powys Youth Offending Team. • Child immunisation uptake • Flu vaccination uptake levels in at risk patients and staff • Lifestyle measures – smoking prevalence, overweight and obesity levels, excess alcohol consumption levels, physical activity levels, 5 A Day consumption • Alcohol attributable mortality • Staff sickness absence measures and survey • GMS quality and outcome framework measures for chronic conditions • Proportion of adults reporting being treated for diabetes, heart conditions and respiratory illness
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Actions • Develop & participate in neighbourhood management approach with LSB partners • Achieve and maintain corporate health standard Platinum level • Develop and deliver integrated children's services and centres across Powys • Work with communities to develop a co-ordinated approach to increasing the proportion of Powys residents engaged in healthy behaviours e.g. through increasing health literacy, and developing a community health champions approach
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Services ENSURING THE RIGHT ACCESS
The health board is responsible for securing health services for the residents of Powys and achieves this through commissioning services across care pathways from primary care contractors, directly managed services and securing services from neighbouring LHBs and NHS Trusts and other care providers. Ensuring access through partnership working with Powys Council is key. Focussing on the tHB’s commissioning role along these pathways is key to ensuring appropriate and safe access to care. A primary care and clinically led approach to commissioning across the health system is central to driving improvements in the quality of the patient experience of care and delivering a sustainable health system. All staff will increasingly recognise their role in service commissioning.
Key Aims
5. Deliver local integrated health and social care system
6. Ensure adults and children receive timely access to scheduled care
7. Ensure people have access to clearly defined and co- ordinated pathways of care
8. Improve emotional well-being and mental health of the population
Unscheduled Care Powys already has the lowest level of Emergency Admissions in Wales and the actions taken to date to strengthen community services would seem to have stabilised the position in terms of growth. However with the fastest growing older population in the Country there is a need to further focus on the management of people with long term conditions and other unscheduled care needs to ensure a sustainable system of care for the future.
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This analysis of emergency admissions of Powys patients over time demonstrates a normal variable trend around a stable median. A step change in activity is evident around April 2011 which would seem to be due to changes in data collection in Aneurin Bevan and ABMU Health Boards, rather than a change in demand. Over the last 12 months of the analysis there appears to be a growing volatility in the trend, though this remains around a stable median.
Analysis of emergency admissions by GP practice above through a funnel plot demonstrates apparent variations in the rate of emergency admissions by GP practice and a key action to the tHB is to target variance between practices. The European age standardised rate of Emergency Admissions per 1,000 population is an indicator based on admissions of individuals. It is possible for individuals to be admitted to hospital on multiple occasions but this indicator counts individuals only once. It is designed to measure the level of morbidity in the population rather than the burden on hospitals, and Powys has the lowest rate in Wales. On this measure the following comparison can be made.
Health Board European Number of bed days for Powys Patients aged 65 and over Standardised rate admitted as an emergency
of Emergency 50000 admissions per 45000 1000 population 40000 35000 30000
Cwm Taf 80.8 25000 Aneurin Bevan 79.1 20000 ABMU 71.6 15000 10000
BCU 64.9 5000 Cardiff & Vale 61.8 0 Powys 55.3 2007/8 2008/9 2009/10 2010/11 2011/12
The second table above shows the overall pattern of bed days used for Powys residents admitted as an emergency aged over 65 across all hospitals. This shows a significant falling trend in bed utilisation and the tHB will aim to maintain this trend.
The table below highlights the levels of bed occupancy in Powys community hospital beds, and the level of bed occupancy that remains devoted to delayed transfers of care. Powys has worked to reduce the impact the delayed transfers on hospital capacity, and remains with relatively low levels overall. Pressure will be maintained on managing DToC and also a strategic approach with Powys Council to widen the available alternatives, including strengthening reablement, extra care and nursing home care capacity.
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Occupancy Without DToC Occupancy With DToC Hospital (%) (%) Builth 83% 92% Knighton 72% 72% Llandrindod 91% 96% Llanidloes 89% 92% Machynlleth 64% 94% Newtown 82% 98% Welshpool 68% 91% Brecon 69% 89% Bronllys 84% 94% Ystradgynlais 93% 94%
Bed occupancy in Powys Hospitals, including and excluding delayed transfers of care
The approach to unscheduled care for adults in Powys is one that is designed around managing the whole system of care at locality level, maximising the capacity available at local level to manage people’s needs at home or within community facilities. Maintaining pressure on avoiding out of county care requires further effort, led by local GPs and clinical teams to identify those patients most in need and seek out new ways of meeting their needs.
The Accelerated Clinical Change project for South Powys, focussed on the area of the County with the highest level of admissions and aims to reduce the number of Powys unscheduled care admissions to Nevill Hall Hospital by 20%, generating patient, staff and financial benefits. This project will form the laboratory from which a number of lessons can be drawn for application across Powys.
In parallel across Powys the following programme is outlined as part of the programme of continuous improvement in unscheduled care, which will require the delivery of local unscheduled care plans, and management of performance against this framework.
UNSCHEDULED CARE PLAN 2013- 2014- 2015- 14 15 16 Health promotion and prevention for the public Support national choose well programme √ √ √ Align GMS enhanced services to prevention √ Flu vaccination programme √ √ √ Implement “Talk to Me” the suicide and severe self-harm √ √ √ action plan Primary care access focus on appointment availability within contracted hours to improve early morning appointments, as well as appointments between 17:00 and 18:30 on weekdays. √ The second phase, from 2013-14 will relate to encouraging appointment availability from 18:30 onwards. √ The third phase will relate to exploring access provision at weekends i.e. Saturday morning and this will be the focus from 2014-15. √ build further resilience into effective care and treatment pathways √ √ √ Chronic condition management Develop further our engagement with GPs and adult social √ √ √ services in implementing the integrated health and social care model described in Setting the Direction
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Develop business case and roll-out from Pilot √ √ Communications Hub Early identification through pro-active case finding √ √ Work with practices to identify patients over 65 who have one √ or more chronic condition (perhaps 40 per practice) Sample this group to assess how they are currently accessing √ services and the patient experience Implement a risk stratification model for planning and targeting √ resources effectively Implement a multidisciplinary personalised approach to √ chronic condition management (including housing advice) Actively promote self-management (to include third sector √ opportunities) and equip with knowledge of how to access responsive services when required
Develop business case for telemedicine and telecare jointly √ with Powys Council Introduce telemedicine on a condition specific basis, e.g. √ √ cardiac, COPD Review capacity in system design for robust discharge √ planning Locality Scorecard as recommended by the Audit Commission √ (2011) to evaluate and monitor whole pathway Deliver the national programme driven High Impact Changes √ √ √ for both Chronic Conditions and Complex Care General Practice Out of Hours (GP OOH) Review of Meddygon Powys performance data and OOH √ admission by locality Consideration of OOH contract as current contract in place √ until 2013 Minor Injury Units Update MIU Guidelines √ Secure governance arrangement for MIUs. √ Regular audit of MIU at locality level. √ Partnership working with Welsh Ambulance (WAST, social √ √ √ services and 3rd Sector) to increase direct transfers to Powys services Powys community hospitals Local GP led strategies for unscheduled care including the √ number, location and function of community hospital beds Bed occupancy and management review √ Mortality & morbidity review √ Review of “Choice” policy √ Review of new Repatriation Policy √ Workforce Development Skilled and retained workforce to deliver expertise and quality √ √ √ care across all service areas
The tHB will develop a renewed commissioning relationship with the Welsh Ambulance Service that is based around a number of key outcomes relevant to Powys: • Strategic deployment of emergency vehicles around Powys based on differential analysis of demand • Efficient operation of non-emergency patient transport • Further pathway development for patient transfers within Powys reducing out of county journeys.
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Elective Care
There is evidence to suggest that the rate of age standardised elective in-patient activity in respect to Powys residents is higher than the Welsh average, and has been rising against the Welsh average. It will be challenging to demonstrate the reasons why this might be the case as there are a number of factors that influence service utilisation including for example proximity, referral and treatment thresholds and additional activity to meet progressively challenging waiting times targets.
The diagram above demonstrates that the elective admission rate for Powys residents over a ten year period has been rising and has gone from the lowest in Wales in 2001 to the highest in Wales in 2011-12, and from below to above Welsh average. Orthopaedics is a specific area where overall elective activity has been rising, and is also an area where greatest elective costs are expended by the tHB. Public Health Wales has completed an analysis on the rates of primary hip and knee replacement. In Powys age standardised rates have been consistently below the Welsh average for primary knee replacement and above the Welsh average for primary hip replacement. This variation can be accounted for based on a number of factors that warrant further evaluation.
The tHB will embark on a programme of reviewing services through implementation of the commissioning cycle. The first priority area will be orthopaedic services, based on the analysis of cost and volume that these services present. The tHB has delivered significant changes in the re-design of pathways within orthopaedics in line with the national programme over the last two years, most notably the implementation of CMATS services and podiatric surgery within Powys. There is however further work to be undertaken to complete and implement a full commissioning review of orthopaedic services to maximise the opportunities for pathway re- design including the implementation of a prioritisation exercise for some elements of current service delivery.
The planning work for this will be completed in 2013-14 and implemented from 2014. Based on this work further programmes will be identified for detailed scrutiny across Powys.
The tHB has already made significant progress in changing patient pathways and flows to deliver an improved experience for patients through the local delivery of services, and delivery of
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more cost-effective pathways. This approach will continue and be accelerated during the life of this plan. The approach is based on a number of programmes of work:
• Re-commissioning of priority elective pathways to ensure evidence based prioritised services • Demand and referral management to reduce unnecessary out of county flows including compliance with Interventions not normally undertaken (INNU) policies • Pathway re-design to increase activity provided within Powys • Efficiency and productivity within Powys provided services outpatient and day-case services • LTA investment levels and effective contract management to assure delivery against Welsh Government RTT performance targets
The tHB is working within five healthcare systems and has developed a three Locality structure, and a similar structure for children’s and midwifery services to manage the available resource across the system. The locality and service directorate teams are being strengthened to enable them to undertake an increasingly commissioning based approach to securing services for the local population.
The tHB will focus delivery of Powys Provider elective services in three locations across Powys, which differentiates them as centres that provide rural acute services across the spectrum of minor injuries, diagnostic and treatment facilities and elective care. These three centres are being developed as:
• Breconshire War Memorial Hospital as a centre for elective outpatient and day-case procedures delivered in association with strategic partners • Llandrindod Hospital as a centre for elective outpatient and day case procedures which requires capital investment to refurbish and modernise the estate infrastructure • A centre in North Powys for elective outpatients in a network arrangement centred on Newtown Hospital
These sites may not be the exclusive locations for service delivery but will form the focus for service efficiency. Alongside the development of these centres the tHB will also seek to build the use of technology in the provision of elective care, including the use of tele-presence and other forms of remote advice and support to patients and local practitioners to avoid travel for patients and reduce reliance on out of county services. A summary of the programmes are provided below for each locality, which encompass change programmes in up to 10-15 pathways in each locality.
South Powys (Aneurin Bevan and ABMU Anticipated Benefits systems) Objectives • Preventing unnecessary referrals going to • Reduction in out of county outpatient out of county DGHs at a higher cost referrals • Maximising usage of the theatre facilities at • Reduction in out of county day case Breconshire War Memorial Hospital referrals • Maximising outpatient appointments • Increased use of local Out Patient provided in Powys by securing consultant Department capacity • Increased Theatre Utilisation • Defining standard pathways for Elective • Reduced cost Procedures • Reduced travel for patients
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Mid Powys (Wye Valley Trust system) Anticipated Benefits Objectives • Preventing unnecessary referrals going to • Reduction in out of county outpatient out of county DGHs at a higher cost referrals • Maximising usage of the theatre facilities at • Reduction in out of county day case Llandrindod Wells Hospital to ensure referrals greater efficiency • Increased use of local Out Patient • Maximising outpatient appointments Department provided in Powys by securing consultant • Increased Theatre Utilisation capacity • Reduced consultant mediated • Defining standard pathways for Elective outpatients Procedures • • Increasing the use of therapists and nurses within elective pathways • Strengthen referral management processes
North Powys (Hywel Dda and SaTH Anticipated Benefits systems) Objectives • Ensuring present provider (internal and • Reduction in out of county outpatient external) services delivered are efficient referrals • Reviewing and where appropriate, • Reduction in out of county day case redesigning clinical/patient pathways from referrals GP referral across the whole system of • Increased productivity of existing care capacity • Delivering services that meet quality • Increased use of Out Patient standards and the scheduled care quality Department framework • Reduced cost • Repatriating patients to services within • Reduced travel for patients Powys • Delivering the best value for money pathways of care.
Specialised Services Powys tHB has made considerable investment into specialised services in the last two years, against the overall trend of cost reduction and service efficiency. This is not tenable over the period of this plan, and the tHB has already indicated to the WHSSC committee an indicative expenditure level in line with 2011-12 investment levels. Powys is atypical within the WHSSC arrangements in that a significant proportion of the specialised services commissioned on behalf of Powys follow pathways into the English system. The relatively low volumes of activity and high costs for some services can lead to a volatile financial position for the tHB. The tHB has proposed a programme of work with WHSSC to assist in the containment of costs as follows: • Developing the strategic relationships with WHSSC through a business partner approach, with a particular emphasis on jointly managing English contract activity. • A review WHSSC investments to ensure that Powys patients have received the anticipated benefits • Delivery of Community Intensive Therapy Team (CITT) within CAMHS to Powys residents • Review of the risk share arrangements and full contribution to overall WHSSC business process, including referral and demand management and pan-Wales savings schemes such as forensic mental health • Support for the WHSSC prioritisation exercise and associated de-commissioning process • Managing English WHSSC contracts to the same RTT as Wales
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Women and Children’s Services The tHB’s women and children’s services deliver a significant portfolio of public health services and services for children with urgent and acute health need and maternity services. The tHB’s vision for these services is to provide as much of the care pathways as possible within Powys to improve the service offer, experience for patients and manage cost. The next three years will be a dynamic period of change in Women and Children’s Services. Results of a series of consultations with children and families in Powys demonstrate they want safe responsive services delivered as locally as possible. They want integrated services for children with a disability and they want to know that when they travel for specialist NHS services that these are of good quality, and link seamlessly with local services in Powys. The Plan for Women & Children’s Services is organised into the following principle domains based on total care pathway management:
Maternity Powys currently births around 250 women per year in Powys. The aim is to birth around 500 women a year by 2016, increasing to 80% of ‘low risk’ women. Steps have already been taken since September 2012 to ensure that ‘low risk’ women are booked to Powys services as the first option to enable this target to be reached. In addition the midwifery team will work to maximise the level of ultrasound scanning and day assessment of pregnant women that is undertaken in Powys facilities.
Paediatrics Work undertaken in 2012/13 has established that it is possible to review and divert appropriate referrals into Powys services for children and this has commenced. Full management control of elective and emergency paediatric care pathways is planned to be in place during 2013/14 utilising the professional expertise within the health board, working alongside primary care. Health Visiting, School Health Nursing and Community Paediatric Nursing will change methods of working to create additional capacity in consultant community paediatrician sessions to manage the additional activity being undertaken in-house. Paediatric triage will be extended to all elective referrals with support provided to general practice to advise on child health and appropriate referral pathways. Performance management capacity will be created within the service to manage admissions to district general hospitals.
Integrated Teams Through its joint working arrangements the teaching Health Board is following a path of incremental integration of services for children in relation to services supporting Disability, Emotional Health & Wellbeing and Family Support. This includes service, management and where possible physical integration to enable the seamless delivery of services to children and their families
Child and Adolescent Mental Health The tHB’s overall approach to modernisation of mental health services across all ages, encompassing the requirements of the Mental Health (Wales) Measure are described in the mental health chapter. A specific focus for children will be in the development of Community Intensive Therapy services as a more appropriate alternative to avoiding where possible out of county placements for children.
Safeguarding Safeguarding of children, jointly with statutory partners will continue to be a focus for the health board given the complexity of in-county and cross-border arrangements for children’s services for the County. Particular proprieties over the life of this plan are to address: • compromised parenting • domestic violence • safety of looked after children (including those in out of county placements) and those in the youth justice system.
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Cancer Services Welsh Government published its Cancer Strategy, Together Against Cancer in March 2012. This placed renewed emphasis on the need for tackling cancer by delivering fast, effective and personal care. For the period 1995-2009 for Powys, there was an average of 380 new cases of cancer per year. The most commonly diagnosed cancers were breast, lung, bowel and prostate cancer. Cancer mortality in Powys is below the national trend, and the one year survival rate of cancer exceeds the all-Wales trend. An estimated 43% of cancers are avoidable. Childhood cancers are rarer, but are the commonest cause of death from disease in 1-14 year olds.
Preventing cancer The prevention agenda for cancer aligns closely with the broader public health agenda for the lifestyle issues of smoking, obesity, health eating and physical activity and alcohol mapped out elsewhere in this Plan. In addition take up of the HPV vaccine in girls is a long term programme that will in time reduce the incidence of the cervical cancer.
Detecting Cancer Quickly Eligible women aged 50-70 years are invited for breast screening every three years and women over the age of 70 years can self refer to be screened. Uptake of Breast Screening in Powys for 2010-11 was 71.7. Women aged 20 to 64 years are invited to attend for a cervical screening test every 3 years for Powys, the coverage was 79.9% against a target of 80% and was the highest in Wales. Adults aged between 60 and 74 are invited for bowel screening every two years in Powys, the uptake was 54.7% against a target of 60%.
• Continue to support screening programmes and target shortfall and inequalities in uptake • provide training for primary care practitioners in cancer awareness and diagnosis • participate in cancer symptom awareness programmes
Delivering fast, effective treatment and care Powys patients treated in English or Welsh Hospitals will be assessed against the target to receive first definitive treatment within 31 day from diagnoses when referred through the ‘Non Urgent Suspected Cancer’ route and the 62 day target from referral to treatment for patients diagnosed through the ‘Urgent Suspected Cancer’ route.
• The tHB will commission services to meet the 31 and 62 day targets • The tHB will map the common cancer pathways and activity and determining if patients are travelling to most appropriate centre for care • Plan and commission chemotherapy and radiotherapy as close to home as possible • Commission new technologies through WHSSC as appropriate
Meeting People’s Needs • Develop capacity within Powys for the delivery of cancer rehabilitation • Determine an approach to assigning a key worker for each person with cancer and preparation of care plan • Further roll-out of the Lymphoedema Service
Caring at the end of Life • Review and improve end of life care to support people to die in their place of choice • Development of Rural Palliative Suite concept in Powys facilities
Improving Information • Joint approach to information provision to people with cancer and their carers • Further develop data and information collection for Powys residents irrespective of the location for treatment • Report cancer information performance annually
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Stroke Services There are on average 200 people admitted from Powys to a District General Hospital with a stroke each year. On average 20% of these die during their acute admission, 40% are discharged direct back to their usual place of residence and 40% are transferred back to a Powys Hospital for ongoing inpatient rehabilitation and discharge planning. Powys currently commissions hyper-acute and acute stroke services from 5 main providers and has a multi- agency Stroke Steering Group which meets on a quarterly basis to oversee the delivery of the Stroke Action Plan. In-patient stroke rehabilitation services are based in Bronllys and Newtown Hospitals, with proposals agreed to transfer the Stroke services at Bronllys to Brecon during 2013-14. Emergency hospital admissions with primary diagnosis of cerebro-vascular disease (stroke), European age-standardised rate per 100,000 persons, 2008-2010 in Wales is 100 for Powys against the Wales average of 124. Based on the Stroke Delivery Plan 2013-16 the high level priorities for the 3 year period are focussed around our ambition for increasing number of stroke survivors and increasing the proportion of survivors left with minimum disability:
Preventing stroke The prevention agenda for stroke aligns closely with the broader public health agenda for the lifestyle issues of smoking, obesity, health eating and physical activity and alcohol mapped out elsewhere in this Plan. In addition • Improving the percentage of the population who have cardiovascular risk factors, atrial fibrillation and high risk TIAs appropriately managed. • Embedding secondary prevention measures into inpatient care and long term follow up reviews
Detecting stroke quickly • Supporting public health campaigns on detecting and acting on signs of stroke quickly • Working with and monitoring performance of WAST to ensure their ambulance clinicians are competent at identifying suspected stroke and responding accordingly • Ensuring all GPs are aware of the stroke pathway of their local acute stroke unit
Delivering fast, effective treatment and care • Engaging in the implementation of recommendations arising from the NHS Midlands and East Stroke review and development of South Wales Plan to ensure that Powys patients are able to access high quality hyperacute stroke units within 60 minutes of onset of symptoms. • Ensuring Powys patients are able to access high quality acute stroke and TIA services, including carotid endarterectomy, in a timely way
Supporting Life after Stroke • Increasing number of stroke survivors • who are supported to leave hospital by a skilled stroke early supported discharge team • who are reviewed by an appropriately skilled health or social care professional 6 weeks, 6 months and 12 months after leaving hospital
Improving Information • Developing service user involvement and having a focus group for stroke survivors as part of planning Life after Stroke Services. • Develop register of interest for people in Powys affected by stroke to get involved in stroke service development.
Targeting Research • Developing research capacity and registering as a research site with appropriate multicentre trials
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Mental Health
“Hearts and Minds: Together for Mental Health in Powys”, is a 3 year strategy and delivery plan to improve the mental health and emotional wellbeing of the people of Powys covering the local response to “Together for Mental Health” new legal entitlements under the Mental Health (Wales) Measure 2010 and local priorities within One Powys: Yn Un.
The vision for mental health in Powys has been developed in a number of ways since 2011 including formal public consultation on “One Powys: Yn Un”, the implementation in 2012 of new legal requirements under the Measure, engagement of users (including children and young people) and work with stakeholders and through partnership arrangements under the LSB
For the purposes of the teaching Health Board’s three year plan the following critical areas have been highlighted.
Primary Care Services and the Mental Health Measure Part 1 of the Mental Health Measure was intended to establish a Local Primary Care Mental Health Support Service from October 2012. This was already established in Powys and the tHB plans to work Mental Health providers to enhance the existing service, to include professionals such as Psychiatrists targeting time to work alongside GPs. Improving early recognition and treatment of depression will be a particular focus. • Improve the capacity and capability of primary care services to identify and support people with mental health concerns; and supporting those with mental health concerns to access good physical health advice and support • Improve access to a wide range of supportive interventions including psychological therapy that enable people to be cared for an the appropriate tier of care • Enable people to have easy access to good advocacy services that will enable greater participation of the individuals in decisions about their care and treatment • Support carers in their role whether this is with people who have mental health issues or whether as an unpaid carer generally • Ensure that people who need secondary care have a well developed care and treatment plan that focuses on the needs of the individual • Enable people who have used secondary care to access assessment on a direct return basis
Acute Mental Health Services First The early years of a psychotic disorder offer a “window of opportunity” to improve long term outcomes through rapid and sustained provision of effective interventions. Growing evidence suggests that tailored early intervention for people developing psychotic disorders can reduce admission and detention rates, reduce attempted and completed suicides and improve general and social functioning and user satisfaction. Powys tHB will work with the three service providers to ensure that services and interventions described in the draft Intelligent Targets for First Episode Psychosis are implemented.
Crisis Resolution Home Treatment Teams (CRHTs) for adults have been late in developing in Powys. The last area to benefit from this service will be North Powys, with the service due to start at the end of April 2013. As these teams bed in and become more efficient, it is expected that Powys tHB will be able to further review the adult in-patient bed provision.
Service for People with Dementia The care of people with Dementia is a major challenge for Powys. Together with Ceredigion is has the highest predicted rate of Alzheimer’s disease in Wales, 44% by 2021. There needs to be a fundamental shift in the approach to dementia care in Powys if the Health Board and Local Authority are to be able to meet people’s needs. Dementia will need to become a mainstream issue for all services with only those with complex needs being supported by mental health
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services. All care teams in community and hospital settings, who currently care for older people, will need to have the skills to address the needs of people with dementia. Communities will also need to build an understanding on how to support with dignity neighbours and friends who may be trying to fulfil their daily lives with symptoms.
Adult services 2013-14 2014-15 2015-16 All CMHT areas will have established at least one clinic √ per week based in Primary Care to include liaison with Primary Health Care Team
Review all third sector contracts to towards becoming √ providers of Wellbeing, Learning and Recovery Centres.
Identify and train dedicated staff to be able to support √ CMHTs in providing the appropriate treatment in first episode psychosis.
First episode psychosis care embedded in the normal √ practice of CMHTs
Powys tHB to appoint a dedicated Dementia lead to √ coordinate the work programme
All Intelligent Targets for Dementia to be implemented √
Two pilot sites established for Dementia Supportive √ Communities.
Review of specialist mental health Dementia services √ with the aim of shifting resources from in-patient assessment to primary and community care specialist support.
Intelligent Targets for Dementia embedded in to practice. √
Roll out of learning from Dementia Supportive √ Communities pilot sites.
Demonstrable achievements against the National √ Dementia Action plan.
Review of effectiveness of CRHTs. √
Option appraisal and implementation plan on the future √ √ √ provision of in-patient facilities
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Learning Disabilities
The plan for learning disability is delivered within the context of Welsh Government Strategies including Practice Guidance on Developing a Commissioning Strategy for People with a Learning Disability (2011), Carers Strategies (Wales) Measure (2010), Statement on Policy and Practice for Adults with a Learning Disability (2007), Learning Disability Strategy – Section 7 Guidance on Service Principles and Service Responses (2004) and Fulfilling the Promises – Proposals for a Framework for Services for People with Learning Disabilities (2001).
There are approximately 670 people registered with a Learning Disability in Powys. This includes people with a mild to moderate learning disability through to those with a high level of need. The model of care is generally recognised as a tiered system. This includes:
Tier 1 – largely primary care based with support provided to primary care teams (such as GP and Practice Nurses) to ensure the needs of people with a Learning Disability are recognised by mainstream services. Approx £1.7M is spent by the teaching Health Board in partnership with the Local Authority on services such as supported tenancy, day services, etc. Tier 2 – community based services, including some specialist in nature, supporting people with a learning disability to live fulfilled lives within their own homes and communities. The team based care is provided on a multi-disciplinary basis and approximately £1.2M is spent on this tier of service. Tier 3 and 4 in-patient care services are no longer provided in Powys as the focus on community services has resulted in fewer clients needing such care. Highly specialist services for clients who cannot safely and adequately be supported at home are procured from specialist centres. The tHB currently spends approx £1.8M on such placements.
Services must continue to evolve in order to deliver highly effective citizen focused outcomes and represent good value for money. Practitioners continue to drive forward service developments and innovations aimed at continuous improvement and the priorities identified have been influenced by those within the service.
The key priorities for Powys tHB Learning Disabilities are:
• Partnership between health services, service users and carers, social services, neighbouring health boards and mental health services • Relationships and family life • Improving community care • Ensuring seamless transition • Access to specialist in-patient care • Improving the resilience of services • Improving access to general healthcare • Improving communication • Empowering staff • Cost effective services including Continuing healthcare
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Integrated Care: Working in Partnership “Shared Purpose Shared Delivery” places a requirement on Local Authorities to review their partnership arrangements to rationalise the structures and business processes that sit within the Local Service Board (LSB) infrastructure. Powys Local Service Board pre-empted this through the development of its single delivery plan; the One Powys Plan. At the regional local government footprint level The Mid and West Wales Health and Social Care Collaborative is a developing strategic partnership between the Hywel Dda and Powys Health Boards and the four local authorities in the region and is complementary to the role of the LSB
An integrated and collaborative approach to service planning and delivery is referenced across this Plan is respect of services for children, people with mental health problems and learning disability services. This approach also extends to older people. One of the key themes of integrated partnership working through the LSB going forward will be that of Neighbourhood Management to facilitate a very local approach to integrated service leadership and delivery across Public Services to ensure that public agencies work together effectively to address issues which are identified locally and reflect the key outcomes and priorities of the One Powys Plan.
Powys County Council and Powys teaching Health Board have worked together on a new model of health and social care. Many of the component parts of the model are already in place across Powys such as strengthened community services, third sector services and joint reablement services. In Builth Wells this programme of change is taking a considerable step further as the development of a new short stay shared care facility, Glan Irfon, and closure of the community hospital will enable a step change in the way in which services are delivered. The initial phase of this change is currently underway and due for completion during 2013.
In Powys, there is now a shared understanding across the health and social care community of the strength of the case for service transformation. This context is laid out in detail in the document “Common Vision Statement for New Models of Health and Social Care” which was adopted by both the teaching Health Board and Council Board in July 2009. The rural integrated model is summarised schematically below.
Fig 1: PROPOSED INTEGRATED HEALTH & SOCIAL CARE MODEL Treatment out of Powys
Tertiary
District General Hospitals
Local Rural Hospitals Care Pathway Rural Health & Social Care Services (Community-based)
Primary Care & Home-based Health & Social Services
Care at Home
The tHB and Powys Council have and continue to take forward a number of initiatives, both separately and in partnership to deliver this transformed service model.
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In place 2013-14 2014-15 2015-16 Tier 1 Information advice and Pilot Roll-out of support comms. comms. hub hub in place Health and Wellbeing √ √ √ Services
Housing Related √ √ Support – extra care.
Telecare and Teleheath Preparation Delivery phase phase Responsive Home √ Support Service
Tier 2 Developing ‘Rapid √ √ Response’ within rural model
Integrated Community √ Equipment Service
Flexible Care Home Joint Strategy √ √ Accommodation
Integrated Reablement √ Implement Service Section 33 and refine model Community Resource √ Team
Care Transfer co- √ ordinators in each DGH
Care Coordination √
Extended Community √ Nursing Service Hospice at home service √
Communications Hub √
Improved information, √ √ √ training and support for carers (carers measure)
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Delivery STRIVING FOR EXCELLENCE
The public must have confidence in the excellence of the services provided by its NHS. The tHB will be relentlessly concerned with high quality care and believes it to be of paramount importance for patients and their carers to be treated with dignity, respect and compassion whilst in our care or in the care of services we fund. Staff need to be developed to take responsibility for improving standards and practice and to make the best use of resources. Local and devolved management has brought increasing control over local working environments, contributing to practical improvements and the satisfaction of seeing clearer benefits for patients. There is, however, more to be done. In publishing our Annual Quality Statement, the teaching Health Board will routinely assess and inform the public about how well we are doing across all of our services, including areas that need to improve. The opportunities for the tHB to lead and contribute to research and development will also be supported, giving definition and direction to the ‘teaching’ status of the Health Board.
Key Aims 9. Embed a culture of continuous improvement in safety, quality and patient experience in all settings
10. Create a culture that places the patient first in everything that is done
11. Ensure absolute compliance with fundamental standards, professional conduct and competence across all disciplines
QUALITY DELIVERY PLAN
The Board’s Quality Delivery Plan over the next three years is based simply around the following four themes.
Putting quality and safety above all else: Embed a culture of continuous improvement in safety, quality and patient experience in all settings. Ensure absolute compliance with fundamental standards, professional conduct and competence across disciplines
Patient-centred care: Create a culture that places the patient first in everything that is done. Patients and their carers to be treated with dignity, respect and compassion
Integrating improvement into everyday working and eliminating harm, variation and waste by adopting a quality improvement methodology
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Investing in our staff: through training and development, enabling them to influence decisions and providing them with the tools, systems and environment to work safely and effectively
As Healthcare Providers 2013-14 2014-15 2015-16
Develop internal quality system (to provide assurance √ √ √ on quality) • Reviewing the governance framework around quality • Routinely use relevant quality triggers as early warning system • Inspection and audit processes including external eg CHC, Children/Older People Commissioners, HIW, WAO • Enhanced approach to Quality and Safety Walk rounds Develop staff √ √ • Strong leadership across professional groups • 100% mandatory and statutory training • 100% PDR • Robust personal and professional development and career framework in place • Establish direct link between training and development for staff to identified quality concerns Use evidence √ √ √ • Systematic use of national and professional guidance, e.g. NICE Apply best / good practice √ √ √ • Readily accessible fundamental standards and means of compliance • Share and spread successful and effective developments across the tHB Engage in continuing improvement √ √ • 25% of staff trained in quality improvement skills • Staff participation in 1000 Lives Plus programme • Standards for Health Services underpin continuous self assessment and improvement actions Learn from mistakes √ • Consistent and transparent incident reporting across organisation • When things go wrong, proportionate investigation, including root cause analysis methodology, routinely used • Through Putting Things Right process, establish effective and transparent approach to staff and organisational responsiveness and learning from concerns • Regular review of local and national trends to inform quality improvement Audit √ √ √ • Use clinical audits and outcome reviews to test quality of care and drive improvement • Rolling programme of local clinical audit
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• Use internal and external audit assessment and recommendations to inform service improvement Undertake research √ √ √ • Education, research and development built into workforce planning and personal development plans • Research and innovation driving improvements in care and uptake of new interventions and technology Communicate with the public √ √ • improve the web-site and social media • patient survey and feedback • engagement in service change Transparency: publish data / information √ √ • publication scheme • better data on quality and patient safety published • Annual Quality Statement Listen and act on complaints/concerns √ • Improve analysis of complaints and take action As healthcare commissioners
Plan services √ √ • Evidence-based and patient focussed service planning and commissioning • Engage as stakeholders in service plans Set quality requirements √ √ • Review quality requirements in all contracts • Impact assessment on any change to services Monitor performance √ √ • Develop and implement effective and comprehensive quality assurance measures • Use quality trigger tool ¾ Complaints in/against providers ¾ Clinical Governance for GDS ¾ GMS QOF monitoring ¾ CHC visits feedback • Build quality monitoring into the contract review process Support improvement √ • Training and development for: ¾ Care homes ¾ GP practices Intervene √ • Swift action where needed when quality triggers or measures highlight potential for substandard care/problems
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Medicines use and Prescribing High quality prescribing is a must to aid both patient safety and financial sustainability. Annual growth in prescribing volume continues at approximately of 3.5% per annum, against a background where Powys has the lowest prescribing rate in Wales. This will remain a challenge as the population ages and older people, in general, requiring more medicines.
Cost growth is contained by increased use of medicines off patent, increased use of ‘Category M’ products, and work in practices to change prescribing to more cost effective choices. Increased emphasis will also be placed on effective use of medication and a more intensive patient centred approach at practice level. Formulary work and electronic decision support systems will help to consolidate and maintain the gains made from the collaborative work with practices. Cost savings are anticipated to continue to accrue for the next 18 months, as the impact of patent expiries work through, but costs will rise with volume towards the end of this three year period.
Major gains in medicines use in primary care over the next three years will be in:
• Supporting effective medicines taking to tackle the up to 50% who don’t take medicines as intended that result in 5-17% of hospital admissions • Identifying at risk patients where adverse effects may increase their risks of admission • Working with medication systems and medication review in care homes to reduce admission from these settings • Supporting safe and effective medicines administration by non Health Care Professional carers in patients homes, reducing the risks and need for NHS intervention or transfer to more institutional settings • Supporting effective use of prescribable nutritional supplements, to reduce the estimated £32m associated with poor nutrition and hydration, in Powys. • Work on the 1000lives+ programme to tackle avoidable harm in treatment of dementia patients • The use of Medicines Usage Reviews and Discharge Medicines Usage reviews provide a means to support the work of Community Resource Teams, and the Virtual Wards • NICE, and AWMSG approved medicines remain a significant medicines cost growth area for patients who receive out of county care. Collaboration between Medicines Management and Commissioning will help to identify and realise benefits from appropriate use of these medicines and the discount schemes that are available. • Technology advances have the potential to support more effective use of pharmacy skills and improves safety and effectiveness in medicines management, as well as give better information on use and rationale. Plans are already in place to begin the organisational development required to take advantage of the Medicines Transcribing and electronic Discharge system that will become available through the Welsh Clinical Portal in 2013. Ward Medicines Vending systems will be piloted with a view to further roll out within the next three years. Utilisation of ‘at a distance’ communication systems to reduce travelling and provide greater access to highly skilled professionals will be taken forward, in part through the ‘Digital Powys’ initiative • Utilisation of digital media and messaging techniques to support patients care for themselves in their medicines use will also be evaluated
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People INVOLVING THE PEOPLE OF POWYS
Maintaining confidence in local services and enabling service change requires the tHB to continuously engage with local communities in respect of the service, quality and financial challenges that the tHB faces. Transparency in the service delivery, quality and financial performance of the organisation will enable a greater understanding of the challenges Powys faces in meeting the needs of a rural population. In return the tHB will look to the people of Powys to use that information and those services well and appropriately, and to take more responsibility for themselves and those around them. Our staff are key local advocates for the tHB and are central to helping deliver the message of positive change, and there are many opportunities for partnership working to gain a shared public sector perspective across Powys.
Key Aims 12. Systematic, open, honest and active engagement with Powys residents in service planning and decision making
13. Improve citizen experience of care through listening and learning
People in Powys interact with the tHB, and public service providers in general, within three broad spheres. Individual – concerned with personal and family matters direct interaction with the NHS services; interest – acting alongside others with a similar concern and place – people living in the same community. The approach of the tHB will be to incrementally strengthen engagement with Powys residents through each of these spheres, through a combination of the direct approach with patients as we are in contact with them and a strategic partnership approach with the Local Service Board.
Actions: • Review and develop the role of the tHB’s stakeholder reference group in supporting the patient voice to be heard • Strengthen the use of internet and social media as a tool for engagement • Strengthen formal service user feedback mechanisms such as surveys and evaluation • Strengthen the partnership approach to engagement through the Local Service Board Participation Strategy • Develop engagement plans around local service change and delivery in each community in Powys, including a mid-Wales Planning Board and follow-up engagement to the stroke consultation in South Powys • Engage Powys residents in discussion around out of county services changes • Undertake formal public consultation on service change where specifically required by the Community Health Council • Ensure transparency on performance of services that serve Powys residents and their carers through improved provision of information • Undertake equality impact assessment on specific service plans
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Money MAKING EVERY POUND COUNT
The NHS in Wales is facing an unprecedented financial challenge in meeting the health needs of the population in an environment of zero growth funding. To meet this financial challenge, Powys tHB recognises that general year on year efficiencies will be insufficient to enable a sustainable financial footing over coming years. Under these conditions, the financial strategy has to be founded on re-engineering the way services are designed and delivered in order to reduce cost.
Key Aims
14. Achieve the statutory duty for financial balance in each financial year
15. Build an organisation with effective planning and financial
management capacity and capability
Powys tHB’s financial strategy is one of improving services and reducing cost. The tHB fervently believes that the ‘triple aims’ of improving health, enhancing quality and access and controlling costs go hand in hand in hand. This must be demonstrated across the entire patient pathway regardless of setting or organisational boundary.
The key approaches to reducing cost are set out in the tHB’s Financial Strategy as described below.
• Clear pathways of care that demonstrate the most appropriate care in the most appropriate setting. The intended consequence is a reduction in unnecessary steps and delays which in themselves can drive costs upwards through poor clinical outcomes. • Each component of the clinical pathway to be efficiently commissioned. Our costing work has observed that there is variation in our cost bases where delivery is at similar scale and complexity. This is observed across a range of services. • Improvements in clinical systems and processes. This will reduce demand for higher cost healthcare, and deliver a higher quality, more efficient right first time system with improved patient experience and outcomes. • Tackling inequalities in resourcing. We have identified that our geographical spend profile is weighted significantly more towards the Mid/South end of the county across both general and mental health services as compared to the North. • Economic model - Care closer to home. The preferred approach is to promote care at or closer to home where the evidence indicates this will provide better health outcomes for the patient and can be demonstrated to provide value for money.
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Service delivery changes planned within this three year plan which will reduce costs have been tested against these approaches to ensure and confirm that they are in line with our overall strategy.
However, the “flat cash” outlook puts an unprecedented financial pressure upon the NHS in Wales including Powys tHB. The changes planned within our service delivery model do not as yet identify that full break even will achieved over the next 3 year period.
Further actions are planned by the tHB to draw together a balanced financial plan include the following
• Secure external planning support to confirm the current position and identify further opportunities for cost reductions • Review and refresh the Financial Strategy of the organisation in view of the outcomes of the external review where required. • Develop a 3 year service and workforce plan that demonstrates the future service model that delivers recurrent financial balance within the resource allocation from Welsh Government • Strengthen the planning and commissioning functions and processes through structural change and a robust Organisational Development plan • Develop a clinical procurement strategy, based on a commissioning model that ensures value for money • Develop an improved platform of information data and analysis to inform both financial and non financial planning and performance management • Develop a financial planning and budget setting model which is based around population need
Three Year Summary Financial Plan and Financial Assumptions
The three year financial plan has been developed using known assumptions regarding the health board’s likely funding from Welsh Government, the likely cost pressures facing the organisation and implementing the service and workforce strategy which will reduce costs.
Income
Our income assumptions are that there will be zero uplift in funding for the organisation for the coming three years.
Cost Pressures
The Health Board is currently profiled to spend £22M more than Welsh Government funding across the range of its services based on existing commitments at the start of the financial year. This has arisen from, in the main, increasing costs associated with the volume of patients receiving care in health bodies beyond our borders, driven by increasing expectations / demand of patients and clinicians, plus the additional capacity required to meet the decreasing waiting times targets.
Our underlying over commitments against funding will be further exacerbated through increasing annual cost pressures for which no financial uplift will be forthcoming for the foreseeable future, plus the likelihood of year on year repayment of old year overspends.
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The cost pressure assumptions built in annually above existing over commitments are as follows;
• Commissioning / demand growth year-on year of 3%. This will be mitigated by the application of a price deflator, which is assumed to be 1.1%. • Prescribing is reflected as 3% growth year-on-year. • 3% growth in continuing care. • Pay and non-pay increases are reflected with the same assumptions as 13/14. • £5.2M income reductions in 2014/15 and 2015/16 to reflect the potential overspend currently forecast of 2013/14 being repayable in future years. This is untested with Welsh Government and therefore will be subject to further debate and amendment
The above pressures equate to an estimated annual increase in costs of £5M per year (2.5%) which will be unfunded and therefore, cost reduction or cost avoidance strategies will need to be employed to mitigate.
Savings plan
The assessed impact of service changes as set out the in the three year plan have been quantified as far as possible based on existing assumptions.
The Health Board has estimated that £20M cost reductions could be realised over the coming three year period across the range of our services and as described in Table 1 below.
Table 1 Three year savings plan over expenditure area
13-14 14-15 15-16 Cumulative Savings Savings Savings Total Continuing Healthcare (484) (50) (50) (584) Estates/Energy (133) (118) 0 (251) Externally Commissioned Services (6,862) (3,786) (1,747) (12,395) Management Costs Reductions (80) (150) (70) (300) Medicines Management (1,247) (1,090) (433) (2,770) Procurement & Other Non Pay (110) (110) (110) (330) Workforce Modernisation (1,001) (995) (2,339) (4,335) Grand Total (9,917) (6,299) (4,749) (20,965)
As can be seen, the largest targeted reduction is with our externally commissioned providers. These are the organisations outside of our geographical boundary who provide, in the main, secondary healthcare to our population.
The reduction in costs will arise from
• Redesigning services within our own delivery organisation to prevent patients travelling beyond our borders for care, for example, repatriation and implementation of the virtual ward • Better managing of flow of patients through the healthcare system i.e. avoiding multiple and duplicate attendances at hospital • Better contract management i.e. negotiating a fairer price and ensuring quality delivery from our providers
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Summary three year plan The three year plan has been set out in high level summary form below in Table 2 and identifies that having taken into account zero increase in funding, the likely increase pressures arising from demographic changes and cost of living and our plans to reduce costs through service improvement, the health board will still not be able to live within the resources allocated.
Table 2 Summary 3 year plan
Cumulative Financial Plan 13/14 14/15 15/16 £000 £000 £000
Income 225,957 225,957 225,957
Cost Pressure 27,500 32,897 37,928
Savings (9,917) (16,216) (20,965)
Remaining Financial Risk 17,583 16,681 16,961
For illustrative purposes only
Growth funding @ 2.3% 5,315 10,631 15,946
Net Risk with Growth funding 12,268 6,050 1,015
For illustrative purposes, the table 3 above also sets out the impact if funding for growth and other incremental costs were funded at 2.3% over the coming three years in line with NHS England in 2013/14. Whilst this would not resolve the underlying position of the health board in 2013/14, it demonstrates that, combined with our service transformation programme, return to breakeven could be reached over the 3 years.
The actions set out at the start of this chapter describes the further actions that the health board will take to improve its financial position.
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INFORMATION TECHNOLOGY
In 2012 Powys tHB and Powys Council agreed a Section 33 agreement that formally bought together the two organisations’ IT functions and teams into a single management structure with a single strategic and operational approach. Powys needs both organisations working together to make significant strategic change in the way that services are delivered and support integration of health and social care provision and wider public sector support services. ICT is a key enabler to these strategic changes as well as a key component of current operational delivery of services. The current Joint ICT Strategy runs to 2014 and is aligned to support both organisations strategic change plans, and aligned nationally. A series of work programmes are established within the strategy aligned to the National Public Sector ICT Strategy, NWIS Strategy and local joint priorities.
National ICT strategy for the public sector in Wales
• Desktop standardisation • Voice services • Common licensing • Data centre service rationalisation • Public Sector Broadband Aggregate • Local Land and Property Gazetteers (PSBA) deployment • Common service management • Video networking • Common back office & transaction systems
The national NWIS ICT Strategy
• Welsh Clinical Communication gateway • My health On-line (MHOL) (WCCG) • Case note tracking capability of the • Master Patient Index (MPI) Myrddin system • Welsh Clinical Portal (WCP) • Community Services, Maternity and • Individual Health Record (IHR) Theatre modules of the Myrddin system
Joint Powys local ICT Strategic Priorities
• Develop the ‘Digital Powys’ Project • Improvements in network performance to • Multi site connectivity for PCC, PtHB and rural schools (supporting child health other LA’s accessibility). • Greater use of mobile and remote working • more standardisation of ICT solutions and with all partner organisations (public and services private sector) • ICT support ‘hours’ aligned to business • Greater Integration of information systems operations (within the council, across councils, with • Rollout of the paperless office PtHB, and with other partners) • a growing demand and expectation of • Sharing of information securely (within the customer ‘self service’ council, across councils, with PtHB, and • maintain the strong emphasis on security with other partners) (physical security, backup security, and • On-line learning environments and systems free from intrusion by learning/parent portals to support schools unauthorised access) • Requirement for Video and audio • Network availability (will improve with conferencing – Point to Point and meeting PSBA) room combinations Core application availability (will improve with • Remote GP training – Web X Disaster Recovery for PCC critical systems • GP Network Bandwidths known as ‘RED’ systems by utilising the National data Centre at Blaenavon)
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CAPITAL AND ESTATE
Powys currently delivers services through ten main community sites. The tHB has a series of drivers in respect of its estate that are outlined in this plan that are being brought together in a renewed Estates Strategy by March 2014. These include: • The demand for appropriate and modern clinical space that supports a series of service modernisation agendas: - Repatriation of outpatient and day-case activity to Powys facilities - Modern facilities for delivery of integrated services to children - Integrated intermediate care, longer term care and palliative care facilities that support a care at home based health and social care model - Much of the estate utilised by mental health services requires improvement. Environments of care (not just inpatients) for people with cognitive impairment are required urgently. There is also potential benefit for co-location of mental health services with other services, including housing, enabling a greater collaboration and integration. - The growing need for accommodation to support older people with mental health problems and people with dementia • A full assessment of the current estate is underway, following a series of incidents, in respect of the key areas of statutory compliance: mechanical and electrical, water management; fire safety; asbestos • The delivery of ISO14001 Environmental Management Standards • An assessment of the estate is currently underway by the Carbon Trust , due for completion in June 2013 to identify the opportunities for capital investment to reduce Carbon Emissions that will be the subject of an Invest to Save bid • Health and safety concerns in respect of the quality of office accommodation
The tHB’s existing capital programme is in-line with the above drivers; however greater pace is required in taking this forward to the next stage given the difficulties within the existing estate. It is anticipated that the Estates Programme will therefore need to include the following:
• Full opening of new Glan Irfon facility in Builth Wells by October 2012, closure and disposal of current building • Submission of business case for Phase 1 refurbishment and re-configuration of Llandrindod Hospital by December 2013 to start April 2014 • Transfer of staff from Mansion House to Bronllys Hospital and disposal of Mansion House by March 2014 • Completion of Strategy for Bronllys Hospital by February 2014 based on a transfer of the site to a Housing Association for development during 2014-16 • Implementation of plans for further integration of health and social care in Machynlleth and Knighton in conjunction with Powys Council by 2016 • Development of case for refurbishment of Brecon Hospital in respect of estates compliance and carbon reduction by mid-2014 • Refurbishment and rationalisation of services in Ystradgynlais at Ystradgynlais Hospital • Development of joint business case with Powys County Council for two Integrated Children’s Centres for Powys • Development of women’s health centres on two locations in Powys to maximise the delivery maternity care pathway in Powys, and maximising opportunity for birthing in Powys
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WORKFORCE
The pay bill for Powys tHB accounts for approximately £47.5million or 19% of the total revenue budget, with the variable pay element being approximately £2.8M or 6%. This is significantly different from the pay costs of other NHS Wales organisations which typically account for 70- 80% of total budget and variable pay around 11 – 15%.
Workforce profile Key features of the tHB’s workforce include: • Total headcount of 1644 and FTE of 1263 • 78% of the workforce are part-time, 60% of Nursing & Midwifery registered staff work part- time affording flexibility for additional hours at plain time, supporting the low variable pay bill. • 25% of staff are over age 55, and 10% over 60. Particular concerns relate to AHPs, registered nursing, ancillary, estates and works and GPs. Over the next five years the Health Board could lose nearly 30% (330 FTE) of its workforce based on this age profile. This is both a risk and an opportunity for redesign. • Turnover has remained around 6% for the past three years which equates to 76 WTE in a full year. The workforce predominantly lives and works in Powys and given the economic context this low turnover rate is unlikely to change for the foreseeable future. If no staff were replaced, turnover alone could only deliver a maximum of 3% reduction in year • The Christmas tree below indicates the banding profile of the workforce. 57% of staff are on the top incremental point (66% of nurses). Low turnover and the constraints of national terms and conditions inhibit the capacity to re-skill mix and employ staff on lower bands or at the bottom of pay scales.
Consultant Other Medical Band 9 Band 8D Band 8C Band 8B Band 8A Band 7 Band 6 Band 5 Band 4 Band 3 Band 2 Band 1
The tHB’s workforce plan is based on the assumption that the workforce will be deployed and used efficiently and effectively to deliver a sustainable service model, particularly in respect of the growing older population and repatriation of services into Powys. Within this context, and the impact of pay inflation, the tHB assumes that the overall pay bill will remain flat or marginally reduce and is not therefore a significant part of overall savings plans.
The contribution of workforce change to financial sustainability will be largely through increased productivity linked to service plans. These are primarily concerned with managing emergency demand and modernisation of elective care, i.e. doing more in Powys with the same resource, but will require higher skill level and in some cases targeted increases in staffing (theatre capacity for example). Local modelling indicates that workforce efficiencies will deliver approximately £872,000 of savings through repatriation and avoidance of onward referral to secondary care and funding will be released to enable an increase in the workforce of approximately 26 WTE, a 2% increase.
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The tHB will also undertake progressive skill mix review across community hospital and community nursing to deliver improved quality and innovation and also support the implementation of service change programmes such as the Builth model for nursing. This will be evaluated in year one and is planned to deliver the equivalent of 3WTE reduction in workforce numbers due to the move of hospital based staff into the community in-reach service. Roll out to other health economies will require detailed planning of workforce capacity but will not deliver significant WTE reductions due to the need to build capacity in the community teams.
Workforce Priorities for 2013-14 • Continued implementation of the programme to build the capacity and capability of our locality teams with a diminished corporate infrastructure: - Conclude consultation and implementation of revised structures for Information, Commissioning, Quality and Safety, HQ administrative support and Programme Management Office. The net impact of these changes is likely to be cost neutral with increases in WTE and skill mix in information and PMO and reductions in administration roles. - Review administrative and clerical functions and staffing levels across the tHB to develop deliver economies of scale, and resilience. - Review Band 8 posts with a view to merging and skill mixing senior roles - Review role of all project officers in corporate structures - Conclude reviews of Medicines Management and Corporate Nursing structures • Implement outcome from catering and cleaning reviews which will deliver reductions • Complete review of estates and works workforce and implement change programme with an anticipated increase of 2 WTE to reduce estates related risk and improve compliance. • Completion of the new workforce profile for the Builth Wells project – release of 3 WTE • Implementation of new medical service delivery model for North • Review job plans of Consultants in SE Powys as part of service change implementation • Review Brecon clinical change pilot – roll out Community Resource Team model • Reduce sickness absence by 0.5% in each management unit/function – to use a stretch target approach based on current performance. • Develop sustainable workforce for CAMHS to address current fragility • Explore capacity to ‘cluster’ community teams and primary care. • Reduce travel costs through further extension of use of VC and pool car arrangements • Review of mobile technology usage • Review of telephony and capacity to maximize cost avoidance using web based technologies • Conclude work with staff partners to understand the additional hours worked within the context of sickness levels, headroom calculations, patterns of deployment, baseline establishments and other measures of productivity. • Introduce the Safer Nursing Care Tool in Community Hospitals and address non compliance with skill mix and WTE requirements. This would require a net investment of £730,000 and a net increase in WTE of 17. • Re-launch KSF Lite and build on recent increase in Performance and Development Reviews to achieve 85% compliance.
Exiting strategies including VERS Modelling has identified that to deliver savings in the region of £1million would require a reduction of 30 WTE (at an average cost of £33K). This level cannot be achieved through the current turnover rate even if no staff were replaced. Consideration will therefore be necessary to utilising VERS and, as a last resort, redundancy. Vacancy control mechanisms are in place and will remain. The tHB intends to use VERS on a selective basis to support specific change programmes building on the success of this approach in 2012. Both VERS and redundancy would only be available to the tHB if it is able to access invest to save monies via the WG as in previous years. Given the need to build the workforce capacity to manage increased service provision in county, the use of exit mechanisms is likely to be principally targeted at corporate and support functions.
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Key Enablers to achieve workforce change
Technology Recruitment and retention • I.T. equipment across the Health Board • Development of the status of the Teaching does not meet the e-learning specification Health Board role and function and to and for people living in some rural areas, exploit the opportunities that this status broadband access is not possible. To link in brings to attract the future workforce across with the national e-learning strategy group all professional groups. to explore solutions to maximising e- • Provision of work experience for year 11 learning opportunities where appropriate. students and NHS open days, particularly • Further roll out of E.S.R. Self Service will be targeted towards the future workforce model fully introduced and Manager Self Service and the opportunities available in Powys. further developed by 2013. E-learning and • Development of Apprenticeships/cadetships maximisation of OLM will be promoted. to support a career pathway within the Introduction of E-expenses to be completed. Health Board, with a particular focus on E-rostering to be explored for suitability in a Estates and Works roles. community setting • Develop a talent management and • Develop a competence based framework to succession planning strategy. outline the skills and competences required • Further work is required to understand the within a rural setting. impact of migration patterns for new • Use of portable technologies to support graduates in nursing and other healthcare productivity and effective deployment, e.g. professions. hand held devices for the Estates and Works team.
Working in Partnership Building Capacity • Identify opportunities to work in partnership • Complete roll out of Aston University Team with Powys County Council across the Based Working. Workforce and Organisational Development • Understand the impact for the Health Board function. on the utilisation of some of the workforce • Maximise the opportunities for shared enablers developed nationally e.g. workforce delivery offered through the Delegation Guidelines, Advanced Practice Section 33 Framework that has been Framework and Induction Standards for developed between the Health Board and Health Care Support Workers. Powys County Council. • Develop a systematic and continuous • Increase opportunities for multi-agency process for identifying and sharing good training practice • Partnership working with Powys County • Staff engagement and empowerment Council to ensure that recruitment within the through the use of existing staff forums for Health Board does not negatively impact on engagement and consultation the Council’s ability to sustain their services, • Change Management & Leadership, e.g. depletion of the domiciliary care integrating workforce redesign, service workforce. change and improvement skills with • Joint working with Third Sector/Independent communication skills and team working and Sector partners in the development of notably Band 7 posts integrated services. • Maximise support worker potential and optimise skill mix, employing the principles of safe and effective delegation and to identify any requirements for Assistant Practitioner development.
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FOR APPROVAL
BOARD MEETING 24 APRIL 2013 AGENDA ITEM 2.2
ANNUAL PLAN 2013-14
Report of Chief Executive
Paper prepared by Chief Executive
Purpose of Paper The purpose of this paper is to present the Board with the Chief Executive’s proposed Annual Plan for 2013- 14 for discussion and approval.
Action/Decision required The Board is asked to discuss and APPROVE the Annual Plan for 2013-14.
Link to ‘Doing Well, The annual plan incorporates the actions required to Doing Better: Standards make progress across the Standards for Health for Health Services in Services. Wales’:
Link to Health Board’s This paper is a summary of the Annual Plan Annual Plan
Acronyms and SHS: Standards for Health Services abbreviations
Annual Plan 2013-14 Page 1 of 9 Board Meeting 24 April 2013 Agenda Item 2.2
FOR APPROVAL
ANNUAL PLAN 2013-14
BACKGROUND The development of a plan for the Health Board on an annual basis is now well established, and for 2013-14 this plan is simply titled as the ‘Annual Plan’. It now forms part of a three year rolling planning cycle
The Executive Team engaged with senior leaders and the staff side representatives in the organisation to review the vision and values that lie behind the Three Year Plan following he extensive review last year. This is not a new approach, but rather recognises that the tHB is at a crucial point in its development at which it can build on previous success and set the challenges for the future.
The annual planning process is the key contributor to delivering organisational success. Its key function is to clearly articulate the Board’s priorities for the coming year including:
• setting the agenda for service transformation to meet the evolving needs of the population and deliver a sustainable healthcare system • the performance management and assurance framework that gives the Board a transparent view of performance against objectives • provide the basis on which accountabilities for delivery can be defined and objectives set throughout the organisation • set the tone and pace of change for the organisation • provide a vehicle for communication particularly to staff within the Health Board and also to its stakeholders.
VISION AND AMBITIONS In developing the plan the executive team have considered the changing service, policy and financial environment and developed the plan in the context of a three year planning cycle:
• the publication of further policy in support of Together for Health by the Welsh Government • the draft Tier 1 delivery targets set out in the NHS Wales Delivery Framework issued in March 2013-14 • the need to develop and strengthen a sustainable approach that improves health, enhances patient experience and controls costs in the face of growing demand and reduced income to the tHB • a longer term view that takes account of the three year planning cycle • clarity on the priorities for joint working with Powys County Council and other local partners as set out in Yn Un: One Powys plan developed by the Local Service Board • the tHB’s organisational risk and audit profile, and Standards for Health Services (SHS) self assessment and priorities • the Francis report
Annual Plan 2013-14 Page 2 of 9 Board Meeting 24 April 2013 Agenda Item 2.2
FOR APPROVAL
The tHB continues to drive forward its vision and ambition to enable
‘Truly integrated care, centred on the individual’ by
Each of these ambitions has been further developed into a delivery plan attached at Appendix 1 that comprises key aims, improvement actions and measures that where appropriate link back to national and local targets. This is supported by a programme of enabling strategies.
To ensure that the executive begin 2013-14 with renewed pace, the executive have agreed a programme of deliverables for the first 100 days of the year that are the early milestones that will demonstrate progress with delivery in jey areas and directly link to the improvement actions in the Plan. These are included in each section below including further implementation of the organisational development programme described as ‘making it happen’.
IMPROVING HEALTH AND WELL-BEING Our approach to improving health and well-being is to work with our partners, particularly through the Local Service Board to develop the capacity in the community and across agencies to improve health now and lay the foundations for maintaining good health for the future. It recognises that all of our communities are individual; in their nature, and our response to improving health can both reflect nationally driven programmes for health improvement such as through education, while allowing room to recognise local difference, and reduce inequality in experience of health. Every member of our staff has a part to play in taking opportunities to improve the health and well-being of the population
Annual Plan 2013-14 Page 3 of 9 Board Meeting 24 April 2013 Agenda Item 2.2
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Key aims
1. Improve the opportunities and life chances for children
2. Reduce preventable death and disability due to chronic disease
3. Reduce illness, death and healthcare utilisation due to flu
4. Optimise the health, well-being and public health skills of the workforce
100 Day Deliverables
• Plan agreed for 2013 flu programme • Immunisation programme complete to contain measles outbreak
ENSURING THE RIGHT ACCESS The health board is responsible for securing health services for the residents of Powys and achieves this through commissioning services across care pathways from primary care contractors, directly managed services and securing services from neighbouring LHBs and NHS Trusts and other care providers. Ensuring access through partnership working with Powys Council is key. Focussing on the tHB’s commissioning role along these pathways is key to ensuring appropriate and safe access to care. A primary care and clinically led approach to commissioning across the health system is central to driving improvements in the quality of the patient experience of care and delivering a sustainable health system. All staff will increasingly recognise their role in service commissioning.
Key aims
5. Deliver local integrated health and social care system
6. Ensure adults and children receive timely access to scheduled care
7. Ensure people have access to clearly defined and co-ordinated pathways of care
8. Improve emotional well-being and mental health of the population
100 day Deliverables
• New model for mental health developed • Project arrangements for integrated health and social care schemes agreed with Powys Council • Stroke transfer plan and timetable agreed • Transfer of community services to Glan Irfon complete and tender exercise for services complete • 2014 year end position on waiting times agreed
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STRIVING FOR EXCELLENCE The public must have confidence in the excellence of the services provided by its NHS. The tHB will be relentlessly concerned with high quality care and believes it to be of paramount importance for patients and their carers to be treated with dignity, respect and compassion whilst in our care or in the care of services we fund. Staff need to be developed to take responsibility for improving standards and practice and to make the best use of resources. Local and devolved management has brought increasing control over local working environments, contributing to practical improvements and the satisfaction of seeing clearer benefits for patients. There is, however, more to be done. In publishing our Annual Quality Statement, the teaching Health Board will routinely assess and inform the public about how well we are doing across all of our services, including areas that need to improve. The opportunities for the tHB to lead and contribute to research and development will also be supported, giving definition and direction to the ‘teaching’ status of the Health Board.
Key aims
9. Embed a culture of continuous improvement in safety, quality and patient experience in all settings
10. Create a culture that places the patient first in everything that is done
11. Ensure absolute compliance with fundamental standards, professional conduct and competence across all disciplines
100 day deliverables
• Clear approach and response to Francis Report set out and underway • 75% IPR achieved and maintained • All staff to have identified their home team and discussed their team purpose
INVOLVING THE PEOPLE OF POWYS Maintaining confidence in local services and enabling service change requires the tHB to continuously engage with local communities in respect of the service, quality and financial challenges that the tHB faces. Transparency in the service delivery, quality and financial performance of the organisation will enable a greater understanding of the challenges Powys faces in meeting the needs of a rural population. In return the tHB will look to the people of Powys to use that information and those services well and appropriately, and to take more responsibility for themselves and those around them. Our staff are key local advocates for the tHB and are central to helping deliver the message of positive change, and there are many opportunities for partnership working to gain a shared public sector perspective across Powys.
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Key Aims
12. Systematic, open, active engagement with residents and stakeholders in service planning and decision making
13. Improve citizen experience of care through listening and learning
100 day deliverables
• Consultation completed on South Wales Programme • Engagement strategy complete
MAKING EVERY POUND COUNT After a long period of significant investment the tHB has experienced two years of lower growth in its financial allocation while demands on services, new treatments and other financial pressures continue to advance. The full detail of the financial plan and strategy is presented elsewhere in the Board papers but presents a stark position for 2013-14. Whilst costs are forecast to continue to rise no further growth in funding is planned and the impact of the forecast outturn for 2012-13 adds to the financial challenge. The tHB fervently believes that the ‘triple aims’ of improving health, enhancing quality and access and controlling costs go hand in hand in hand. A significant proportion of the tHB’s budget is paid across to external providers of care. There must therefore also be a relentless quest for value for money across all providers, and through working with partners on shared approaches to commissioning and delivery. A focus on financial efficiency and effectiveness must not a distraction from the core purpose of the NHS and this overall plan seeks to provide this balance. All staff will be asked to contribute to delivery of the triple aim to contribute to a sustainable NHS. In view of our assessment of residual financial challenge, the health Board is seeking additional external support to assist in identifying further scope to reduce costs. The scope of the support will be to;
• Freshly articulate our underlying problem and what some of our system obstacles are • Evolve our plan through o A “red pen” exercise (ensure we have questioned everything) o Ensure we have the right disciplines and pace in place o Bring to us good practice that is being used elsewhere to reduce costs o Advice on how best to extract the cash (particularly around contracting) • Bring a range of expertise around Localities (inc contracting); Mental Health; Women & Children; Corporate services to identify further cost reductions
A tender exercise to seek this support is underway with a view to commencing work by the end of April 2013, and whilst this intervention is broadly reflected
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in the key aims, the intervention will be required to report within the first 100 days and is likely to influence the tHB’s priorities as the year progresses.
Key Aims
14. Achieve the statutory duty for financial balance in each financial year
15. Build an organisation with effective planning and financial management capacity and capability
100 day deliverables
• Implement the actions from the financial plan to be in place by June • Headquarters and administration budget and staffing review completed
The Annual Plan describes the aims for the organisation for 2013-14. It provides clarity on the deliverables and sets out the priorities that all staff in the tHB will be working toward. Setting clear objectives however is only one part, albeit an important one, of delivering the expectations of the Board. The focus on translating aims and objectives into practice is of absolute importance.
A Stronger Organisation
In the preamble to the 2012-13 plan a series of actions were set out to strengthen the organisation in respect of delivery as follows:
Commitment Acheivement accountabilities and performance Complete management
alignment of Executive functions Complete
recruitment of Locality General Complete Managers and other key positions
the availability and use of information Function externally reviewed and to determine areas for change and implementation underway to embed outcomes from action approach across the organisation
technical skill such as commissioning Some progress to devolve to localities and contracting across all sectors but considerable further work required including primary care and secondary care
a whole system approach to Embedded in the organisation, and improvement and cost reduction requires further review
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the ability to be proactive in shaping Active involvement in change in service changes that affect our Wales and England: population, particularly in the context • Hywel Dda and Betsi of Together for Health and working Cadwalldr across Wales and into England. • South Wales Programme • English stroke review • Cross-border protocol
Continually Improving Organisational Fitness The ability of the organisation to meet its financial duty in a very difficult economic environment and to make sufficient cost savings to achieve at least a breakeven position will require the organisation to deliver the annual plan and more. The extent of the challenge is detailed in the Financial Plan 2013- 14. The need to further improve the fitness and ability of the organisation to meet and exceed the challenges and to grasp the opportunities will requires on-going pressure to achieve the step change commitment that the tHB has already made.
•Clinical leadership •Developing a •Use of technology and management culture of learning to support access development and innovation and delivery •Strengthening •Data and •A Programme
locality and service information drving Delivery approach to
Skills
Capacity directorate capacity performance and transformation and and
and change accelarated clinical
and •Performing teams
at all levels based •Full engagement of change on the Aston staff, patients and •Sustainability as a approach the public core organising Learning principle Leadership Performance
Approach to a step change The tHB has developed thematic programmes, based on the diagnostics that were undertaken during 2012-13, to develop the overall skills and capacity within the organisation to deliver the agenda and priorities set out in this plan. A performing organisation is one that is able to demonstrate a flexible and agile approach to managing challenges and change. These programmes will provide this level of organisational maturity that will facilitate the long term sustainability service delivery for Powys citizens.
The key components of this organisational change programme are outlined below, including 100 day deliverables in support of delivery of the tHB’s overall plan:
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• Programme approach to change through the delivery of the Programme Office • The Aston approach to team development • Strengthened clinical leadership • Strengthened localities – further building on the role of localities to deliver change • Financial intervention to further inform system change and development
100 day deliverables
• Programme Management Office fully functioning • Financial intervention secured and completed • All staff aware of tHB’s top priorities • All staff identify their home team and have participated in discussion of their team purpose • Performance framework re-aligned to the new Welsh Government Framework • Commissioning, planning and information capacity and capability support to localities completed • Commissioning framework agreed and implemented
Conclusion This paper sets out the delivery of the tHB’s aims as set out in the annual plan, to achieve a step change in service and financial delivery and performance. It provides a systematic and targeted focus, through an organisational development approach, to improve services and reduce costs. Monitoring arrangements on delivery of the Plan will continue to be through the presentation of the Integrated Performance Report to the Board and service reports to Board Committees.
Recommendation
The Board is asked to APPROVE the tHB’s Annual Plan 2013-14.
Report prepared by: Presented By: Andrew Cottom Andrew Cottom Chief Executive Chief Executive
Annual Plan 2013-14 Page 9 of 9 Board Meeting 24 April 2013 Agenda Item 2.2
POWYS tHB ANNUAL PLAN 2013-14
Aim Improvement Action Measure Lead Director Standards for Health Services/Risk Register/Tier1 IMPROVING HEALTH AND WELL-BEING OF COMMUNITIES
1. Improve the Increase uptake of childhood vaccinations 95% uptake of scheduled Director of Tier 1 opportunities and to 95% target through the implementation of immunisations for children under Public Health life chances for the Powys Immunisation Action Plan. 4 years. children
2. Implement the Children’s Integrated Child and family satisfaction Nurse Director Services Plan (including co-location) measures
3. Implement the Baby Friendly Initiative Increase in breastfeeding rates Nurse Director Programme by 10% in year at both 10 days and 28 days
4. Undertake the specific Health Board actions (outcomes as indicated in the Nurse Director relating to multi-agency working for children LSB framework) (Youth Offending; Corporate Parenting; Stable Lives/Brighter Futures; Integrated Family Support Services; Child Poverty Programme; Flying Start
5. Reduce Reduce prevalence of smoking through the Year on year reduction in Director of Tier 1 preventable death implementation of the Powys Tobacco smoking prevalence from Public Health and disability due Control Action Plan and increase access o 2010/11 = 21%, to 16% by 2020. to chronic disease smoking cessation services for Powys Reduction in non-smoking adults' residents exposure to passive smoke indoors (2010/11 baseline 18%) 5% of Powys smokers to be treated by smoking cessation services (baseline 3.5%, 2012- 13)
Annual Plan Page 1 of 12 2013-14
Aim Improvement Action Measure Lead Director Standards for Health Services/Risk Register/Tier1 6. Reduce the prevalence of overweight and Year on year reduction in Director of obesity through the development and prevalence of obesity from Public Health implementation of the Healthy Weights 2010/11 24% baseline Action Plan Year on year increase in the proportion of adults who report being physically active on 5 or more days in the past week (baseline 39%, WHS 2010/11) Year on year increase in the proportion of adults who reported eating five or more portions of fruit and vegetables the previous day (baseline 40%, WHS 2010/11)
7. Support the development and delivery of Reduction in adults who reported Director of the Substance Misuse Strategy, as led by drinking above guidelines on at Public Health the Area Planning Board least one day in the past week (baseline 41%, WHS 2010/11). Adults who reported binge drinking on at least one day in the past week (baseline 25%, WHS 2010/11). Alcohol attributable mortality
8. Develop a Community Health Champion Community Health Champion Director of approach approach to be in place in 2013- Public Health 14
9. Contribute to the development of a Neighbourhood Management to Director of neighbourhood management approach with be established in 2013-14 Public Health / partners in the Local Service Board Planning
Annual Plan Page 2 of 12 2013-14
Aim Improvement Action Measure Lead Director Standards for Health Services/Risk Register/Tier1 10. Reduce illness, Increase uptake of flu vaccination amongst 75% uptake of influenza Director of Tier 1 death and at risk population to 75% and health care vaccination among Public Health healthcare workers to 50% through the implementation • Over 65s utilisation due to flu of the Powys Flu Action Plan • Under 65s in at risk groups • Pregnant women 50% uptake of influenza vaccine among Health care workers
11. Optimise the Increase the proportion of Powys tHB staff Alcohol - Baseline 2 staff Director of health, well-being who have undergone Alcohol Brief 2012/13. Public Health and public health Intervention and Smoking Brief Intervention Smoking - Baseline 22 staff skills of the training, and assess skills requirements as 2012/13 (Awaiting final figures). workforce part of training needs assessment
12. Implement the recommendations of the Recommendations implemented Nurse Director Welsh Government review of Health Visiting, strengthening the public health role of the health visiting team
13. Implement staff health and well-being Assessed against a baseline of Director of strategy and introduce reporting framework 1/4/14 achieve reduction in Workforce and based on line manager reports sickness absence of 0.5% in OD each department
Annual Plan Page 3 of 12 2013-14
Aim Improvement Action Measure Lead Director Standards for Health Services/Risk Register/Tier1 ENSURING THE RIGHT ACCESS
14. Deliver local Develop and deliver unscheduled care plan Joint indicators for maturity: Medical Tier 1 integrated health and maturity matrix in each locality area, Emergency medical admissions Director and social care and for children, and Powys wide actions Bed days utilised system including communications hub Discharges to care homes Deaths at home Delayed transfer of care
GP access: appointments after 5pm 4 hour A&E performance Ambulance response times
15. Develop and implement strengthened Improved value for money Nurse Director commissioning arrangements for complex demonstrated; care jointly with the Local Authority where Clear quality assurance process possible (Funded Nursing Care, Joint Care in place and audited Packages, and Continuing Healthcare)
16. Fully implement and assess benefits Health and social care utilisation Director of realisation of integrated health and social indicators Planning care model in Builth Wells
17. Implement year one of the carers strategy Key performance indicators Director of to deliver the carers measure within plan Planning
Annual Plan Page 4 of 12 2013-14
Aim Improvement Action Measure Lead Director Standards for Health Services/Risk Register/Tier1 18. Ensure adults and Implement year one of three year Increase level of in-county Director of children receive repatriation project for adult services and paediatric work by 20% for Year Public Health timely access to Year 2 of the Scheduled Care Repatriation 2 DGHs (Wales) and a further scheduled care Project for children’s services (paediatrics) 10% for Year 1 DGHs (England) and maternity services Increase level of in-house adult service provision by 30%
Increase to 80% of all low risk women giving birth in Powys
19. Deliver timely access to scheduled care 26 and 36 week waiting times; Director of Tier 1 services, and risk assess services for therapies waiting times Planning Risk 7 fragility and ensure business continuity plans in place
20. Develop and implement commissioning Orthopaedic waiting times Director of strategy for orthopaedics Shift in resource from secondary Planning to primary care Reduced in overall activity
21. Ensure people Deliver together for health service change 31 and 62 cancer targets Director of Tier 1 have access to plans: achieved Planning clearly defined and • implement cancer plan co-ordinated • implement stroke plan Increase in chemotherapy pathways of care Prepare plans in response to WG planning services provided in-county and delivery plan due for publication during 2013-14 Quality indicators for stroke care
22. Influence delivery of service change plans Approval of plans Director of Risk 8 in neighbouring health boards (South Wales Planning Programme; Hywel Dda and Betsi Cadwalladr) to reduce risk of fragile services to Powys residents
Annual Plan Page 5 of 12 2013-14
Aim Improvement Action Measure Lead Director Standards for Health Services/Risk Register/Tier1 23. Improve emotional Implement Year 1 of the Together for Reduction in suicide levels Nurse Director Tier 1 well-being and Mental Health Strategy, specifically: Increase in mental wellbeing, as (including mental health of the - Test current governance arrangements measured by the SF36 Mental evidence of population - Develop and implement Powys “Five Component Summary Score measurement Ways to Wellbeing (Baseline 51, WHS 2010/11) of user - Evaluate Mental Health Measure and experience in compliance Key milestones of the plan met mental health) - Develop, agree and implement the adult services modelling (including out of hours services and potential for technology in mental health care); - Implement key milestones of Suicide Prevention Action plan; - Develop, agree and implement a Community Intensive Service solution for children and young people
24. Develop and implement the Assurance Implemented Assurance Nurse Director Framework for the Mental Health Act to Framework demonstrate compliance
25. Finalise and implement the Learning Milestones in the LD Strategy Nurse Director Disabilities Joint Commissioning Plan met; Improved value for money demonstrated
26. Implement the sustainability and Improvement Plan implemented Nurse Director improvement plan for specialist Child and Adolescent Mental Health services
27. Develop and implement the Joint Dementia Key miles implemented; Nurse Director Plan with Local Authority and Third sector Intelligent targets met partners that meets intelligent targets for dementia care
Annual Plan Page 6 of 12 2013-14
Aim Improvement Action Measure Lead Director Standards for Health Services/Risk Register/Tier1 STRIVING FOR EXCELLENCE
28. Embed a culture of Implement the “Improving Quality Together” 25% of directly employed and Director of SHS 3:6 continuous programme contractor workforce trained in Public Health improvement in quality improvement safety, quality and methodology by April 2014 patient experience in all settings 29. Develop internal quality system: Identify and Reduction in healthcare acquired Director of Tier 1 Quality implement changes following review of infections, pressure damage and Therapies and triggers; governance framework and inpatient falls Health Science fundamentals reporting/assurance mechanisms around HAT; discharge letters, sepsis of care audit; quality and safety nursing dashboard and complaints 30. Develop and implement clinical audit Inspection reports and audit Medical programme focussed on learning, access reports demonstrate evidence- Director and implementation of evidence-based based practice practice across all services
31. Establish effective and transparent Evidence of improvements in Director of approach to staff and organisational place in response to incidents Therapies and learning, training and development linked to and complaints. Health Science learning from incidents and complaints, concerns, patients stories, coroners 100% mandatory and statutory ombudsman and national reports training
32. Deliver medicines management Prescribing indicators Medical improvement plan Director
33. Develop and Implement a Protecting Milestones implemented Nurse Director Corporate Risk Vulnerable People Strategy (2013 – 2015) 10
Annual Plan Page 7 of 12 2013-14
Aim Improvement Action Measure Lead Director Standards for Health Services/Risk Register/Tier1 34. Create a culture Increase transparency of patient experience Board and committee papers to Director of SHS 3.4 that places the and health outcomes and patient related include impact assessment on Therapies and patient first in quality and safety data at Board level quality of patient experience and Health Science everything that is health outcomes done Data on quality and patient safety published in Annual Quality Statement, Service Reports and Annual Report
Integrated performance report
35. Ensure absolute Implement Clinical Professions Strategies Milestones met Nurse Director SHS 2.6 compliance with (nursing, medical, therapies and health Medical re-validation and Medical Tier 1 (clinical fundamental Science) including attention to safe staffing appraisal milestones met Director engagement) standards, levels Director of professional Therapies and conduct and Health Science competence across all disciplines 36. All teams to participate in Aston Team 100% identified home team by Director of Tier 1 approach and robust personal and 1/7/13; all teams agreed purpose Workforce and SHS 1:2 professional development and career by 1/9/2013; PDR 75% OD SHS 3:9 framework in place compliance at 1/7/13 and 85% Corporate Risk by year end 2
37. Implement quality assurance framework for Evidence of intervention where Director of receiving, evaluating and taking action indicators of quality standards Therapies and where quality triggers or measures highlight not met Health Science potential for substandard care/problems 38. Support providers to improve quality of Evidence of training and Director of services development implemented for Therapies and care homes, GP practices. Health Science
Annual Plan Page 8 of 12 2013-14
Aim Improvement Action Measure Lead Director Standards for Health Services/Risk Register/Tier1 INVOLVING THE PEOPLE OF POWYS
39. Systematic, open, Strengthen engagement mechanisms Measures to be developed Director of SHS 1:1 active engagement through development and delivery of locality Planning with residents and strategies, joint Powys wide approach stakeholders in through LSB and review role of SRG and service planning develop reporting mechanisms and decision making
40. Strengthen strategic joint planning through Joint LSB performance indicators Director of SHS 1:5 a review of partnership arrangements under Planning the Local Service Board
41. Embedding values of equality and diversity Increase number of EIA’s Director of SHS 1:3 through implementation of Equality Impact undertaken Workforce and Assessment and monitoring impact on all OD stakeholders including patients and staff
42. Further develop an internal communications Improvements in staff survey Director of SHS 3:5 strategy, to systematically gain, record and indicators Workforce and act on the views of staff OD
43. Improve citizen All directly provided services to have a Consistent approach to patient Director of SHS 3:8 experience of care formal service user feedback mechanism in survey and feedback measures Therapies through listening place and develop methodologies for across services and learning gaining patient feedback on externally ‘I want great care’ survey for end provided services of life care Mental health user and carer measures
Annual Plan Page 9 of 12 2013-14
Aim Improvement Action Measure Lead Director Standards for Health Services/Risk Register/Tier1 MAKING EVERY POUND COUNT
44. Achieve the Secure external planning support to confirm Reduction in Financial Planning Finance Corporate Risk statutory duty for the current position and identify further gap identified for 2013/14 and Director 1 financial balance in opportunities for cost reductions, and review beyond Tier 1 each financial year financial strategy in light of outcomes of external review
45. Embed the 3 year service and workforce All home teams to have Director of plan that demonstrates the future service discussed and fed back on Plan Planning model that delivers recurrent financial balance within the resource allocation from Welsh Government
46. Implement year 2 of the all-Wales CHC Meet 2013-14 target cases Director of Corporate Risk retrospective claims project resolved Nursing 3
47. Build an Strengthen planning and commissioning Service specification and service Director of SHS 1:4 organisation with processes, development of a 3 year rolling level agreements to reflect Planning SHS 2:8 effective planning plan to incorporate national planning expectation of high quality SHS 3:2 and financial priorities, demonstrate the views of citizens patient experience and health Corporate Risk management considered and includes a Quality outcomes 11 capacity and Assurance Framework and performance capability monitoring process across all providers. 48. Implement the recommendations arising Recommendations completed in Finance from planning and financial reviews year Director undertaken by external support and Wales Audit Office 49. Implement an improved platform of Measured increases in range, Director of information data and analysis to inform both scope and analysis of Planning financial and non financial variance information available on desktop analysis, planning and performance management
Annual Plan Page 10 of 12 2013-14
MAKING IT HAPPEN Enabling Strategies Enabler Improvement Action Measure Lead Reference 50. Organisational Complete implementation of Programme Programme processes and tools Director of SHS 2:3 development Office to support Transformation embedded in organisation Workforce and Corporate Risk programme Programmes such as Information Services Project outcomes achieved OD 6 and the clinical change programmes
51. Conclude review and implantation of WTE and financial neutrality of Director of SHS 2:1 change programme for HQ and locality changes Workforce and functions OD Productivity improvements
52. Development of an integrated multi- Plan in place and milestones Director of SHS 3:3 professional education, innovation, research achieved Workforce and Corporate Risk and clinical effectiveness/quality OD 4 improvement function
53. Workforce Ensure that the workforce is recruited, 100% of appointments involve Director of developed and managed through the lens of service users Workforce and the user OD 50% of training courses have a user/carer component included
54. Maximise benefits of ESR through All agreed posts identified on Director of continued implementation of WfIS national ESR Workforce and and local priorities Cessation of paper systems OD capable of being managed through ESR Relevant policies to have been undated Scoping completed by 1/7/13
55. Develop and introduce multi professional Training needs assessment Director of Corporate Risk education and training strategy using best complete by 1/7/13 Workforce and 6 practice methodology based on a holistic OD training needs assessment Annual Plan Page 11 of 12 2013-14
56. Estates Develop a long term estates strategy Strategy in place approved by Director of SHS 2:2 Board Planning Corporate Risk Key estates performance 5 indicators improving
57. IM&T Define IT business requirements of the Reviewed strategy in place Medical Corporate Risk organisation to inform IT strategy from 2014 Director 9
58. Further develop and deliver ‘Digital Powys’ Number and scope of pilot Medical programme schemes in place Director
59. Implement action plans to achieve key audit Delivery of key actions Director of SHS 2:4 recommendations to be overseen by re- Therapies and established Information Governance Health Science Committee
60. Governance To adopt an integrated governance Annual Report Board SHS 2.5 approach which continuously reviews and Annual Governance Statement Secretary develops the annual governance statement, linking more closely to corporate priorities
61. Strengthen the approach for management Risk register and audit of Director of SHS 2.7 of Board level risk. process Therapies and Health Science 62. Development of a Board Assurance Approved framework Board SHS 3.1 Framework which will determine all risks of Secretary achieving the Board’s strategic objectives (which will include legal and other requirements placed upon the teaching Health Board) and outline the sources of assurance available to the Board in satisfying itself that all are delivered.
63. Implement Board Business Cycle to Approved cycle Board SHS 3:7 determine reporting requirements of the secretary Board
Annual Plan Page 12 of 12 2013-14
FOR APPROVAL
BOARD MEETING 24 APRIL 2013 AGENDA ITEM 2.3
FINANCIAL & BUDGETARY STRATEGY FOR 2013/14
Report of Director of Finance
Paper prepared by Director of Finance
Purpose of Paper To present to the Board the Financial Plan for 2013/14
Action/Decision The Board is requested to NOTE the process and progress in required establishing the financial plan for 2013/14 and the next steps being employed to secure an improved position.
The Board is being asked to APPROVE the interim plan to allow budgets to be set for the year as set out in Table 6 of the Financial and Budget Strategy.
Link to ‘Doing Well, N/A Doing Better: Standards for Health Services in Wales’
Link to Health Board’s Living within our Means. Corporate Plan
Acronyms and WHSSC – Welsh Health Specialised Services abbreviations WG – Welsh Government
Financial Plan 2013/14 Page 1 of 4 Board Meeting 24 April 2013 Agenda Item 2.3
FOR APPROVAL
FINANCIAL AND BUDGETARY STRATEGY FOR 2013/14
PURPOSE
The purpose of this report is to present to the Board the interim 2013/14 Financial Plan for approval.
The Board is being asked to approve the interim plan to allow budgets to be set for the year.
SUMMARY
The Board is required to produce a balanced financial plan for the year, setting out how it will live within the annual revenue allocation from the Welsh Government. This plan sits within the context of the 3 year plan which will be presented to Board in April 2013.
The Board has a clear strategy to reduce costs and improve quality. Whilst the Board can demonstrate that the service redesign and cost reduction programme as set out in the three year plan it is moving in the direction of the financial strategy, the plans to date are insufficient to demonstrate likely break even.
This paper proposes to set a balanced budget for the year, but the Board should note that in doing so, our assessment of likely performance against budgets identify substantial risks to delivery of break-even.
Our review of current commitments, likely additional pressures and planned cost reductions currently identify a financial risk of overspend against the delivery of budgets of £17.5M. This sum includes the assumption that the currently forecast year-end deficit in 2012/13 will be repaid in 2013/14. For the purposes of this iteration of the plan, the impact of the 2012/13 year end outturn overspend, repayable in 2013/14, has been assessed as £6.6M. Its actual impact will be determined by the actual outturn position as assessed in month 12 at the end of April 2013.
The Board is therefore being requested to approve the delegation of budgets that live within the resources available, but note that in doing so, the current assessment is that these will not be met.
The Board is taking further steps to address the risk of non-delivery of the statutory duty to break-even and as such, this should be regarded as an interim plan pending conclusion of the intervention planned in April 2013 and finalization of the 2012/13 outturn position.
Financial Plan 2013/14 Page 2 of 4 Board Meeting 24 April 2013 Agenda Item 2.3
FOR APPROVAL
MOVEMENTS BETWEEN DRAFTS
The Board received a draft financial plan at an in-committee session in February and again in presentational format at a development workshop in March.
The Board was advised that between each presentation, continuous assessment would take place on challenging both the cost pressures and savings presented by localities / directorates. The analysis of each iteration is shown in Appendix 1 to this covering report.
The main movement between iterations is the inclusion of risks assessed as “below the line” or not included in the headline figures.
For the purposes of the April 2013/14 Financial Plan presentation to the Board, these have now been included. These mostly relate to the likely repayment requirement of the 2012/13 outturn position as referred to in the section above.
It is important that this are now included ensuring the Health Board and Welsh Government can appropriately assess and plan for additional savings and resource requirements in 2013/14.
NEXT STEPS
The plan has been discussed with Welsh Government over recent weeks to provide clarity on our approach and the resulting potential financial consequences to our position. This dialogue is on-going with a view to finding acceptable solutions to meeting our statutory duty requirement.
Given the fluidity around several factors including; • uncertainty around the impact of the 2012/13 outturn position in 2013/14 • Welsh Government consideration of the plan and whether there is scope for funding to be allocated again in 2013/14 • the potential outcome and recommendations from the intervention planned in April 2013/14
the plan can only be considered as interim.
The final section of the plan makes reference to the immediate next steps and timescales for the health Board and these are set out again below for ease of reference;
The financial plan, as set out above, should be considered as interim pending a number of further issues and decisions. These include
Financial Plan 2013/14 Page 3 of 4 Board Meeting 24 April 2013 Agenda Item 2.3
FOR APPROVAL
• Final assessment of 2012/13 which will impact on the assessment of pressures leading into 2013/14 (conclusion end April 2013)
• Secure and conclude intervention work to confirm current assessment, test robustness of plans and recommend further actions to be taken by the Board (end May 2013)
• Decisions to be taken by the Board on outcome of the intervention and other potential actions to reduce expenditure in-year e.g. continuation of 36 weeks waiting times (June 2013)
It is recommended therefore, that this interim plan be approved for the first quarter of 2013/14 and that the Board consider the outcome of the steps as set out above in June 2013.
CONCLUSION
The Board has continued to pursue the financial strategy agreed in April 2012/14 in its approach to 2013/14 and beyond.
In pursuing the planned elements of this strategy for 2013/14, our assessment of cost pressures and savings identify a net risk to delivering a break even of £17.5M. This sum includes the assumed repayment of the year end overspend position in 2012/13.
A range of enhanced supporting strategies and processes have been adopted to improve arrangements to lead to improved financial performance.
The Board is securing further support through a self imposed intervention process to provide assurance to our currently reported position and recommend further actions.
RECOMMENDATION
The Board is requested to NOTE the process and progress in establishing the financial plan for 2013/14 and the next steps being employed to secure an improved position.
The Board is being asked to APPROVE the interim plan to allow budgets to be set for the year as set out in Table 6 of the Financial and Budget Strategy.
Report prepared by: Presented By: Rebecca Richards Rebecca Richards Director of Finance Director of Finance
Financial Plan 2013/14 Page 4 of 4 Board Meeting 24 April 2013 Agenda Item 2.3
FINANCIAL AND BUDGETARY STRATEGY FOR 2013/14
INTRODUCTION
The Health Board is required to prepare a financial plan which demonstrates that it is able to live within the resources provided by Welsh Government.
The Health Board’s Annual Financial Plan is based upon the agreed work programme within the Annual Plan and is set in the context of the three year service, workforce and financial plan which will be presented to Board in April 2013.
This report will cover the following
• Recap of our financial strategy • The approach to developing the plan for 2013/14 • Income from Welsh Government • Analysis of Assessed cost pressures facing the organization • Summary of Planned Savings to date • Summary of Net Financial Risks (Anticipated Overspend) • Approach to budget setting • Ensuring Delivery and Reporting • Underpinning Strategies and Processes • Seeking External Intervention • Next Steps
RECAP OF OUR FINANCIAL STRATEGY AND APPROACH TO COST REDUCTION
In April 2012, the Board approved the interim financial plan for 2012/13 and in doing so, approved the approach as set out below.
• Clear pathways of care that demonstrate the most appropriate care in the most appropriate setting. The intended consequence is a reduction in unnecessary steps and delays which in themselves can drive costs upwards through poor clinical outcomes. • Each component of the clinical pathway to be efficiently commissioned. Our costing work has observed that there is variation in our cost bases where delivery is at similar scale and complexity. This is observed across a range of services. • Improvements in clinical systems and processes. This will reduce demand for higher cost healthcare, and deliver a higher quality, more efficient right first time system with improved patient experience and outcomes. • Tackling inequalities in resourcing. We have identified that our geographical spend profile is weighted significantly more towards the Mid/South end of the county across both general and mental health services as compared to the North. • Economic model - Care closer to home. The preferred approach is to promote care at or closer to home where the evidence indicates this will provide better health outcomes for the patient and can be demonstrated to provide value for money.
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The executive team has debated whether the approach as set out above is still valid and has confirmed that this is still the approach we are pursuing. This assumption will be tested through the intervention referred to later in this report.
This sets the backdrop against which the 3 year service and financial plan has been focused. As such, this paper should be regarded as year one of the three year financial plan.
APPROACH TO 2013/14 – BUILDING A FINANCIAL PLAN THAT GIVES CONFIDENCE OF DELIVERY AND CLEAR ACCOUNTABILITY
Using the experience of 2012/13 and previous years, the Executive Team, led by the Director of Finance, have considered the approach to developing the financial plan in order to ensure ownership and clear accountability to delegated budget holders.
As a result, a refreshed process to develop the financial plan across the organization has been adopted. A subset of the Executive Team has been established as the scrutiny panel of financial plans prepared by localities and directorates. This team involves the Chief Executive and include the following members for their specific remit
Nurse Director As lead for the Accelerated Clinical Change Programme, ensure the key lessons learned and expected best practice identified during 2012/13 are evidenced within financial plans (Clear pathways of care that demonstrate the most appropriate care in the most appropriate setting)
Medical Director As lead Director of Unscheduled Care, test that the model agreed is being implemented (Clear pathways of care that demonstrate the most appropriate care in the most appropriate setting)
WOD Director Test that plans around the workforce are clear, feasible and identify any requirements or support from a capacity / capability perspective.
Finance Director Test that component efficiencies are being maximised in the plans presented. (Each component of the clinical pathway to be efficiently commissioned.) Plus overall lead for the process.
Scrutiny sessions have been held with primary budget holders during January to March with a view to securing and testing assurance that
• cost pressures have been adequately captured • measures to reduce costs are robust and sufficient to ensure budget holders are living within control totals • measures to reduce costs are in line with our strategic direction • measures to reduce costs are stretching and demonstrate we are reaching for maximum efficiency and performance
Primary budget holders are as set out in Table 1 below.
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Table 1 Primary Budget Holders and budgets held Primary Budget Holder (s) Budget Held Locality General Manager (North) North Locality Locality General Manager (South) South Locality Locality General Manager (Mid) Mid Locality Nurse Director Women and Children’s Directorate Nurse Director Mental Health Directorate Planning Director Works and Estates Planning Director WHSSC Finance Director, Workforce & OD Director, Various Corporate / Central Budgets Medical Director, Nurse Director, Planning Director, Therapies & Health Sciences, Corporate Services Manager
The Board will recall that budgets have been set as far as possible based on pathways of care. This means that the end to end expenditure for most conditions are in one place based on geography and /or condition.
For example, all costs associated with general medical conditions, including primary care, community care and secondary care are within locality budgets.
The financial plan that follows is the result of the output of the sessions held with primary budget holders across their range of budgets for which they are held to account. The process has ensured the full engagement of primary budget holders and members of the Executive Team in understanding the financial risks facing the organization and reinforced the responsibility and ownership of the actions required to reduce cost.
INCOME – 2013/14 REVENUE ALLOCATION FROM WELSH GOVERNMENT
The income received by the Health Board from Welsh Government for 2013/14 is £230.424M
The Board have previously been advised that there will be no funding to meet the increasing costs of providing NHS Healthcare and this was been confirmed in our 2013/14 Revenue Allocation received from Welsh Government on 7th February 2013.
Overall, there is relatively little change in our revenue allocation between financial years. The main highlights of changes of the allocation are as follows;
• Return of the £3.9M brokerage funding removed from the tHB’s allocation in 2012/13 (arising from the overspend position in 2011/12) • Removal of non-recurrent strategic funding (£4M) received in 2012/13 • Removal of funding for hosting the Community Health Councils for Wales £3.8M, however, interim arrangements will apply and associated funding will be allocated separately to ensure cost neutrality
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The allocation letter reaffirms our planning assumptions that there is no funding allocated for anticipated cost of living and demographic impact on costs.
Our assumptions in setting the plan include a prudent view that the year end position for 2012/13 will be a deficit position that will need to be repaid in 2013/14. We have therefore included the assumptions that income will be reduced by £5.2M as described in Table 1 below. This will create a cost pressure leading into 2013/14.
Table 2 Income Assumptions 2013/14 Income Assumptions £M Revenue Allocation Letter 230.424 Annual in-year allocations from other WG departments e.g. substance misuse 0.733 Assumed reduction in income – repayment of 2012/13 overspend (5.200) Income Assumptions for 2013/14 225.957
ANALYSIS OF ASSESSED COST PRESSURES
The scrutiny process outlined above has sought from budget holders their expectations of likely expenditure cost pressures. These have been captured at present at £22.3M for 2013/14 and are summarized as follows;
Table 3 Analysis of Cost Pressures 2013/14
Cost Pressure £M Additional 2012/13 year end outturn risk impacting on 2013/14 1.4 Old Year Recurrent impact on 2013/14 13.6 New Year Cost pressures 7.3 Total Anticipated cost pressures before savings applied 22.3
These cost pressures are further analysed below;
Additional 2012/13 year end outturn overspend risk (£1.4M)
The Health Board is currently forecasting a forecast outturn overspend of £5.2M for 2012/13 which has already been taken into account in the income section of this report (see Table 2 above)
In addition to this forecast position, there are risks that current contractual discussions with neighboring Health Boards and Trusts will impact adversely on the year end position. The planning assumptions take a prudent view on this risk and are included, at this stage as a cost pressure rather than an income risk.
Once year end discussions have concluded, the risk assessment and its classification will be adjusted accordingly.
In total therefore, the total 2012/13 year end outturn requiring repayment in 2013/14 assumed within this financial plan is £6.6M (£5.2M plus £1.4M).
Old Year Recurrent Impact on 2013/14 (£13.6M) Financial Plan 2013/14 Page 4 of 24 Board Meeting 24 April 2013 Agenda Item 2.3b
In reporting a year end position of £5.2M outturn position in 2012/13, there are a number of factors that have suppressed expenditure non recurrently.
The breakdown of the £13.6M cost pressures that lead into 2013/14 from 2012/13 are therefore as follows;
• 2012/13 Year end outturn recurrent overspend (£5.2M) arising from unachieved savings and growth, plus o Additional 2012/13 year end outturn risk impacting again in 2013/14 (£1.4M) o Non recurrent use of balance sheet and reserves in 2012/13 suppressing expenditure non recurrently (£2.8M) o Non recurrent savings delivered in 2012/13 suppressing expenditure non recurrently i.e. contract challenges(*) and waiting list extension to 36 weeks (£3.8M) o Impact of loss of Non WG income, including Community Health Councils and Provider LTAs (£0.220M) o Full year impact of 2012/13 commitments, including Joint Equipment Store, new posts approved (£0.260M)
(*) Contract challenges have been regarded as non recurrent achievement of savings, however they will feature again in the 2013/14 savings programme below as an annual non recurrent savings opportunity.
New Year Cost Pressures (£7.3M)
New year cost pressures are those we anticipate being incurred as a new additional expenditure in 2013/14 and include issues such as inflationary increases / cost of living and the expected impact of demographic growth. Further Analysis of the £7.3M is as follows
• Inflationary /cost of living (£1.4M)
• 1% pay increase to total pay costs (£0.514M) • Staff increments (£0.537M) • Non pay increases on budgets for statutory and unavoidable costs (£0.348M)
These costs have been derived through benchmarking with other NHS organisations across Wales to ensure consistent assumptions across common expenditure areas.
• Impact of demographic growth (£4M)
Quantifiying the impact of demographic growth is difficult to assess. We have taken some judgement from past experience and applied to the future and as such remain somewhat speculative.
• Commissioning Costs 3% (£2.573M) • CHC costs 1% (£0.300M) • Prescribing (£1.100M)
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• Return to 26 weeks waiting times (1.9M)
The Board will need to take a view on some whether it wishes to invest in returning to a 26 week waiting times target. The figure included is an estimate at this stage (£1.9M) and will need to be appropriately quantified once year end year-end waiting times data is available to assess the new year impact.
The overall cost pressures of £22.3M as set out above, are the Health Board’s assessment of likely expenditure risks but as will be apparent from the narrative, many are speculative and will always be subject to actual performance.
This sum represents a requirement of 10% cost avoidance and/ or cost reduction to be in place in order to reach break even.
SUMMARY OF PLANNED SAVINGS TO DATE
The savings identified for delivery in 2013/14 has been quantified to date as £9.9M which represents a 4.2% savings delivery target against our total budget.
The process outlined above in the section headed “Approach to 2013/14” sets out the mechanism for engaging the organization in developing the financial plan.
The scrutiny process adopted has to date identified a range of cost reduction initiatives that fall in line with our overall financial strategy.
These are summarized at a high level in the section below and outline the range of services which will be developed and transformed and improved, generating cost reductions for the organization.
• Clear pathways of care that demonstrate the most appropriate care in the most appropriate setting. The intended consequence is a reduction in unnecessary steps and delays which in themselves can drive costs upwards through poor clinical outcomes. Service which will be developed through pathway redesign include o Continence Services o Musculoskeletal (Orthopaedics) o Adult Mental Health o Unscheduled care, including Telehealth Health promotion and prevention strategies Introduction of Rapid Acute Response Team (ART) Rollout of Virtual Ward Neurorehabilitation services Managing Falls Managing epilepsy Managing Diabetes Extending access to Powys Urgent Response Service at Home (PURSH) Increasing Nurse & therapy Prescribers
• Each component of the clinical pathway to be efficiently commissioned. Our costing work has observed that there is variation in our cost bases where delivery is at Financial Plan 2013/14 Page 6 of 24 Board Meeting 24 April 2013 Agenda Item 2.3b
similar scale and complexity. Focus is on reducing the cost of services with a view to increasing efficiency and effectiveness.
The following describe the services which will be subject to cost reduction through improved efficiencies o Use of deflator on commissioned services o Contract challenges on commissioned service o Review of Mental Health Voluntary Sector services o Reducing CHC costs through joint working with Marie Curie o Review of all CHC packages of care (General and Mental Health) o Income generation through sale of theatre capacity o Income generation for Pain management services o Income generation – ensuring we are collecting data and charging for all services provided to other bodies o Catering and cleaning efficiencies o Prescribing efficiencies o Efficient Learning Disability services o Efficient community paediatric services o Reviews of Administration and patient services functions o Introduction of Builth model in Builth o Review of Bronllys site / service o Evaluate the cost benefit of reablement
• Improvements in clinical systems and processes. This will reduce demand for higher cost healthcare, and deliver more efficient right first time system and improved patient experience. These systems in themselves are unlikely to reduce substantial costs but will support the overall system of care to deliver improved and more efficient services in the right setting o Implementation of referral management o Rollout out of the care co-ordination centre
• Tackling inequalities in resourcing. We have identified that our geographical spend profile is weighted significantly more towards the Mid/South end of the county across both general and mental health services as compared to the North. Further work will need to be undertaken by the Board in addressing inequalities in access and resourcing but an example of differential cost reductions being applied is with prescribed drugs which has differential cost reduction targets to further address the in-county variation in spend.
• Economic model - Care closer to home. Generally, the preferred approach is to promote care closer to home where it is clinically appropriate and can be evidenced as providing value for money. A range of schedules care services are currently and prospectively being remodelled to repatriate and redesign services These include, but are not limited to, the following specialties o Ophthalmology o Orthopaedics o General Surgery o ENT o Dermatology o Urology Financial Plan 2013/14 Page 7 of 24 Board Meeting 24 April 2013 Agenda Item 2.3b
o Rheumatology o General Medicine o Paediatric o Maternity services
To date, the impact identified in taking forward the above proposals for 2013/14 is £9.9M. This includes both the full year impact of schemes commencing in 2012/13 and new schemes commencing in 2013/14.
A full schedule and expected impact by primary budget holder is shown in Appendix 1.
To give a sense of scale and stretch, the percentage reductions across organization expenditure areas are described in Table 4 below.
Table 4 Analysis of planned savings to budget allocation by expenditure type Budget Savings % planned Allocation Programme reduction £000's £000's
Commissioning (Localities excl WHSSC,W&C,MH) 57,749 (4,934) ‐8.54% WHSSC 26,916 (1,000) ‐3.72% Provider (Localities excl W&C, MH) 34,612 (1,302) ‐3.76% Primary Care 31,087 0 0.00% Prescribing 26,375 (1,247) ‐4.73% Continuing Care (Localities excl W&C, MH) 4,123 (50) ‐1.21% Joint Financing (Localities excl W&C, MH) 895 0 0.00% Voluntary Sector 1,668 0 0.00% Women & Children 11,640 (484) ‐4.15% Mental Health 19,552 (901) ‐4.61% Central/HQ 13,036 0 0.00% Reserves 3,504 0 0.00% Grand Total 231,157 (9,917) -4.29%
As can be seen in the table above, the Health Board is again targeting its most significant savings at commissioned services. This is because the impact of redesign work and efficiencies is mostly targeted at those services beyond our borders.
Services currently without a savings target include • Ringfenced primary care services • General Joint Financing, although reviews are planned which may reduce costs • Voluntary Sector, although reviews are planned which may reduce costs • Corporate / HQ Functions – work is still on-going in this area. There is an expectation of cost reductions to apply
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SUMMARY OF NET RISKS (ANTICIPATED OVERSPEND)
Taking into account our income, cost pressure and savings assumptions as set out above, the anticipated overspend that has been assessed for 2013/14 is £17.5M and is set out below. This includes the assumed repayment of the forecast year end position from 2012/13.
£M Assumed Income reduction arising from 2012/13 outturn 5.2 Old year and new year cost pressures 22.3 Savings identified (9.9) Anticipated overspend 17.5
This has been assessed by primary budget holder in Appendix 2 for further details of where cost pressures and savings plans are attributed.
Risk Assessment – upside and downside risks
The above sections assess the current likely risks facing the organization for 2013/14. There are however, many variables in what may or may not occur during the course of the year.
We have undertaken a further analysis of other upside and downside risks which may affect the position but not included in the above analysis. This is set out in table 5 below.
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Table 5 Overview of upside and downside risks
Financial Challenge 2013/14
Worse Most Best Case Likely Case £'000 £'000 £'000
Anticipated Overspend 17,583 17,583 17,583
WHSSC savings – plans are in development stage 1,000 0
Deflator assumptions within NHS Wales – no agreement secured 500 0 Repatriation savings on elective inpatients within South Locality - outline plan only 250 0 Tariff rebasing with South Locality providers – no agreement secured 250 0 Elective Care remodelling North Locality –plan are in formative stage 500 0
Reductions in costs within Mental Health (formative stage only) 300 0
Women & Children’s proposals around establishment of CITT team 200 Success in challenges around deflator and other contract discussion in 2012/13 (2,800)
Non reversal of 36 weeks target to 26 weeks (1,900)
3,000 (4,300)
Total Risk Analysis 20,583 17,583 12,883
In the main, the worst case scenario reflects those savings plans which have yet to be fully developed or where required, have yet to be agreed with providers putting at risk their achievement in year.
The best case scenario reflects the potential that year end issues in 2012/13, if proven successful would have a positive impact on 2013/14. In addition, the Board will need to consider again its stance on waiting times, a decision to continue with the 36 week wait could reduce the cost pressures identified for 2013/14.
APPROACH TO BUDGET SETTING
Budget setting is an important part of the annual financial and performance cycle. It provides budget holders with clear limits of expenditure to be contained.
Consideration has been made to the right approach to budget setting for 2013/14 given the scale of the challenge. The Executive Team considered that the balanced budget must be
Financial Plan 2013/14 Page 10 of 24 Board Meeting 24 April 2013 Agenda Item 2.3b maintained but also that meaningful budgets to individual budget holders also need to be established in order to engender commitment and allow appropriate holding to account.
Agreement with the Primary Budget holders is that realistic budgets will be set using our known commitments. The residual financial challenge by budget holder will remain with them as “negative budgets” to ensure the level of residual challenge remains in sight.
Therefore, budget setting process for 2013/14 will ensure that whilst the overall budget of the organization will be balanced as set out in Table 6, there is transparency and recognition in each primary budget holders position of the residual financial challenge (assessed level of likely overspend) that needs to be addressed.
The balanced budget, taking into account the revenue allocation letter is summarized below by primary budget holder and set out in further detail including service areas in Appendix 3.
Table 6 Summary Budget Plan 2013/14 and assessed level of overspend
13‐14 Annual 13‐14 13‐14 Directorate/Locality Recurrent Assessed Overspend Budget Forecast Mid Locality 30,865 33,797 2,932 North Locality 65,758 70,464 4,706 South Locality 53,140 58,444 5,304 Corporate Services 1,411 1,732 321 Finance 1,305 2,430 1,125 HR (WOD) 1,057 1,120 62 PH and Planning 33,986 33,891 (95) Nursing 2,736 2,835 99 Mental Health 19,552 19,776 224 Women and Children 11,640 12,057 418 Medical 5,501 5,121 (380) Therapies and Health Sciences 703 663 (40) Reserves 3,504 1,212 (2,292) Revenue Resource Limit (Income from WG) (231,157) (225,957) 5,200
Grand Total 0 17,584 17,584
The profile of gross expenditure, savings and net expenditure across the year is set out in Graph 1 below.
This demonstrates that without our savings programme we would be spending on average £2.3M more than we are funded per month.
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Our savings programme is profiled to increase in savings per month during the course of the year from £0.4M to £1.1M per month, gradually reducing our net monthly overspend per month during the course of the year from £1.9M to £1.2M.
Graph 1 Profile of Gross expenditure, savings plan and net expenditure through the year 0 Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar
‐500
Monthly profile of net ‐1000 overspend before savings Monthly savings profile
‐1500 Net Monthly profile (Overspend)
‐2000
‐2500
ENSURING DELIVERY AND REPORTING
Individual savings schemes range from simple management actions i.e. a switch in window cleaning supplier or removal of vacant posts from the establishment, to major transformation programmes i.e. implementation of the virtual ward or redesign of mental health services.
The approach to performance management around the savings programme will therefore vary from scheme to scheme. Management action implementation will continue to be scrutinized through the monthly financial performance route with the finance director.
For all schemes which require a planned approach, the expectation made of primary budget holders is that they have in place prior to the start of the year, clear and explicit plans which will
• demonstrate cost reduction, • include clear milestones to their achievement • establish the non financial metrics that will be used to determine achievement • provide a monthly profile of expenditure against which financial performance will be monitored
As it currently stands, plans which meet the above requirements have been developed in various stages of completeness. The Transformation Board, supported by the programme office will be overseeing and supporting the major components of the savings programme. The programme office will assist in ensuring the robust planning and delivery of programmes that fall within the remit of Financial Plan 2013/14 Page 12 of 24 Board Meeting 24 April 2013 Agenda Item 2.3b
• Scheduled Care • Unscheduled Care • Mental Health
The remainder of the programme will be overseen by the Finance Director as part of the existing performance framework.
Regular updates on the impact of delivery of the overall programme will continue to be reported as part of the existing financial reporting processes within the organization.
UNDERPINNING STRATEGIES AND PROCESSES
As part of ensuring delivery, there are number of supporting strategies and processes that are critical to success. The Executive Team has considered the main areas where specific additional focus and action is required to support the organization in its delivery.
Access to Robust Information
The organization has established the principle of being a data driven organization. As part of improving access and analysis of information for decision making, the Executive Team have agreed that the Information department will be the primary source for all patient information held within the organization.
Crucially, this also necessitates an information function that has the capacity and capability to analyse and present information to the required format for management use. Following the NWIS review and recommendations on Information Services, the Executive Team has also approved a revised structure for the information function including the appointment of a full time information manager who is now in post.
A forum to establish the information requirements of budget holders has been established by the Planning Director with a clear programme of work to improve access and use of information. This will significantly support the work of the Finance Directorate in analyzing costs and financial trends for the organization.
A robust contracting approach
The tHB is taking a fresh approach to commissioning from 2013-14 that will make explicit the financial challenge to provider organisations and seek to negotiate a collaborative and shared approach to both maintaining health care quality and challenging the cost of services provided. Specifically within Wales there will need to be recognition within neighbouring Health Board plans of the constraints on the tHB’s budgetary capacity to commission services and for their associated income assumptions to be reflected in their plans.
From an English perspective, the PbR Contracting mechanism can be a complex set of arrangements that require expertise to navigate and ensure confidence that we are being charged appropriately. To give assurance, the Health Board has secured the expertise of on external consultant to review the charges made by English providers to give confidence of current payments or offer a platform of challenges. This work is in-hand and is built into the year end arrangements for 2012/13 and for the start if 2013/14. Financial Plan 2013/14 Page 13 of 24 Board Meeting 24 April 2013 Agenda Item 2.3b
As with any contract, our Long Term Agreements will need to be supported by a clear service strategy and implementation plans which identify how planned volume shifts to enable cost reductions will be managed. This has been an explicit requirement of Localities to quantify as part of their delivery model and is already being brought into the contract discussion with providers as part of the 2013/14 contract negotiations.
Discussions and correspondence with providers has already taken place, making clear our expectations of them for 2013/14. The aim is to conclude by June 2013 or ensure early escalation for resolution.
Developing Strategic Partnerships
We have previously been explicit about our key partnerships are in terms of secondary care providers. This set out that our strategic partnerships were with Welsh NHS providers whilst maintaining our contractual relationships with NHS England.
Interestingly, it is our English NHS providers who have been more forthcoming in assisting us taking forward our strategic direction to repatriate activity into county. The financial impact on them being part of the drive to work this us, but is also a factor in the slow response to date.
The Executive Team has been debating whether we should be aiming for a contestable or collaborative approach with providers. The consensus is that we need to aim for both. We make clear with providers that they are our provider of choice and demonstrate this through a long term commitment. However, built into the long term commitment must be a robust contractual challenge process that ensures the health Board is continuously receiving value for money.
We will do this with both English and Welsh providers where the benefit of doing so is mutually beneficial.
Approach to WHSSC
The Health Board has invested additional funding into Welsh Health Specialist Services Committee (WHSSC) secured services in 2012/13, a resource which will need to be diverted away from mainstream services in order to ensure affordability.
Given the significant proportion of expenditure with Welsh Health Specialist Services Committee secured services, a specific approach will be pursued which will make clear with WHSSC the requirement of a plan that lives within a budget £1M less than planned for 2012/13. To facilitate this, our expectations to secure the cost reduction will be as follows
• A price deflator to be applied to all providers • Ensure WHSSC are applying the same contract compliance requirements on specialist service providers as we would expect from our own local service providers • A review of the risk sharing agreement which to our view isn’t really a risk share but a cost apportionment methodology • Specific actions to review and consider alternative approaches to the 4 main English providers with whom Powys accesses the greatest proportion of care.
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Workforce strategy and approach
Planned cost reductions within the workforce have not been fully achieved in 2012/13. This is due to a range of factors.
During 2012/13 the Health Board introduced a vacancy control panel (Finance Director and WOD Director with a Union Member) to review and challenge all applications to fill vacancies. Posts have been turned down where robust justification has not been provided, indicating that there are some weaknesses in exerting control over workforce expenditure by budget holders.
For 2013/14 the approach will be as follows
• Budget holders have been advised to pursue workforce reductions without being held back by concerns regarding displacement – this will be handled corporately • Voluntary Early Release funding has again been applied for and is likely to gain success (£0.4M). The process will be commenced earlier in the year to gain maximum in-year benefit. • Increased staff requirements as a result of pathway improvement will only be approved with an accompanying business case that demonstrates how the net financial benefit to the organisation will be achieved.
The organisational development programme will continue help build capacity and capability where required to assist in delivery of our objectives, including financial balance. To this end, the team-work approach is in the process of being rolled out across the organisation.
Improving Financial Management
During 2012/13 and external review of financial management was commissioned. The review made recommendations for improvement including the “cultural” aspects around financial management within the organization.
In addition, Wales Audit Office was invited by the Audit Committee to conduct a view of financial management and budgetary control within the organisation.
The recommendations within these reviews have been responded to including
• Mandatory finance training for budget holders • Preparation of a 3 year financial plan • An inclusive approach to financial planning and budget setting with primary budget holders to ensure ownership • Augmenting senior finance support to localities and directorates
Further recommendations made from these reviews are in hand and will be reported through Integrated Governance and Audit Committee during the year.
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SEEKING EXTERNAL INTERVENTION
In view of our assessment of residual financial challenge, the health Board is seeking additional external support to assist in identifying further scope to reduce costs. The scope of the support will be to;
• Freshly articulate our underlying problem and what some of our system obstacles are • Evolve our plan through • A “red pen” exercise (ensure we have questioned everything) • Ensure we have the right disciplines and pace in place • Bring to us good practice that is being used elsewhere to reduce costs • Advice on how best to extract the cash (particularly around contracting) • Bring a range of expertise around Localities (inc contracting); Mental Health; Women & Children; Corporate services to identify further cost reductions
A tender exercise to seek this support is underway with a view to commencing work by the end of April 2013.
The Board will be further appraised on progress in this respect at the Board meeting.
NEXT STEPS
The financial plan, as set out above, should be considered as interim pending a number of further issues and decisions. These include
• Final assessment of 2012/13 which will impact on the assessment of pressures leading into 2013/14 (conclusion end April 2013)
• Secure and conclude intervention work to confirm current assessment, test robustness of plans and recommend further actions to be taken by the Board (end May 2013)
• Decisions to be taken by the Board on outcome of the intervention and other potential actions to reduce expenditure in-year e.g. continuation of 36 weeks waiting times (June 2013)
It is recommended therefore, that this interim plan be approved for the first quarter of 2013/14 and that the Board consider the outcome of the steps as set out above in June 2013.
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Appendix 1 – Detailed Savings Programme by Primary Budget Holder 2013/14
Savings Locality/ Category Description Plan Directorate £000's
A ‐ Mid Locality Externally Commissioned Services Commissioning Price Deflator (161) Reduced cost of Day Case theatre activity delivered out of county. (200) Reduced cost of non‐elective admissions to out‐of‐county hospitals. (50) Reduced cost of Outpatient activity delivered out of County (100) Externally Commissioned Services Total (511) Medicines Management (Primary & Secondary Care) Medicine Management ‐ Removal of Pharmacist from Practice (38) Prescribing savings (309) Medicines Management (Primary & Secondary Care) Total (347) Procurement & Other Non Pay (excl. energy) Income from selling theatre space (10) Procurement & Other Non Pay (excl. energy) Total (10) Workforce Modernisation Reduced cost of service in the Builth Wells area (100) Re‐organisation of catering / domestic / portering supervision. (2) Revised catering arrangements at Knighton Hospital (15) Workforce Modernisation Total (117) A ‐ Mid Locality Total (985) B ‐ North Locality Estates/Energy Estates Utilisation (3) Non Clinical (130) Estates/Energy Total (133) Externally Commissioned Services Commissioning Price Deflator (378) Contract Challenges (1,780) Maximisation of Income (182) New Service Models ‐ Urgent Care redesign (230) Pathway Redesign (828) Externally Commissioned Services Total (3,398) Medicines Management (Primary & Secondary Care) Prescribing ‐ North (500) Medicines Management (Primary & Secondary Care) Total (500) Workforce Modernisation Medical Model (200) Sickness and Vacancy Management (315) Financial Plan 2013/14 Page 17 of 24 Board Meeting 24 April 2013 Agenda Item 2.3b
Workforce Modernisation Total (515) B ‐ North Locality Total (4,546) C ‐ South Locality CHC (excl. DTOC) South ‐ Reduction in CHC spend (50) CHC (excl. DTOC) Total (50) Externally Commissioned Services Commissioning Price Deflator ‐ ABHB (116) Commissioning Price Deflator ‐ ABMU (80) Commissioning Price Deflator ‐ C&V (14) Commissioning Price Deflator ‐ CT (10) Commissioning Price Deflator ‐ NCA's/LTA Exc & Velindre (17) Elective Care ‐ ABHB (268) Elective Care ‐ ABMU (91) Elective Care ‐ WVT (110) Unscheduled Care (CRT/VW) ‐ ABHB (316) Unscheduled Care (CRT/VW) ‐ ABMU (186) Externally Commissioned Services Total (1,207) Management Costs Reductions Locality Support Workforce changes (80) Management Costs Reductions Total (80) Medicines Management (Primary & Secondary Care) Prescribing savings (400) Medicines Management (Primary & Secondary Care) Total (400) Procurement & Other Non Pay (excl. energy) Income (Theatre and Pain Management) (100) Procurement & Other Non Pay (excl. energy) Total (100) Workforce Modernisation Provider Efficiencies (165) Workforce Modernisation Total (165) C ‐ South Locality Total (2,002) D ‐ PH and Planning Externally Commissioned Services WHSCC (1,000) Externally Commissioned Services Total (1,000) D ‐ PH and Planning Total (1,000) F ‐ Mental Health CHC (excl. DTOC) CHC Reviews (400) CHC (excl. DTOC) Total (400) Externally Commissioned Services Powys CC s28 Review (150) LTA ‐ABMU (242) LTA ‐ABHB (65) LTA ‐Betsi (31) LTA ‐South Staffs (13)
Financial Plan 2013/14 Page 18 of 24 Board Meeting 24 April 2013 Agenda Item 2.3b
Externally Commissioned Services Total (501) F ‐ Mental Health Total (901) G ‐ Women and Children CHC (excl. DTOC) CHC Childrens (34) CHC (excl. DTOC) Total (34) Externally Commissioned Services Management of paediatric & maternity care pathways ABMU (191) Management of paediatric & maternity care pathway ABHB (16) Management of paediatric & maternity care pathways Cardiff (1) Management of paediatric & maternity care pathways Wye Valley (0) Management of paediatric & maternity care pathways SATH (7) Commissioning Price Deflator WVT (0) Commissioning Price Deflator SaTH (23) Children's CHC Reviews & Assessment Process (6) Externally Commissioned Services Total (244) Workforce Modernisation W&C Provider (2) W&C Provider ‐CAMHS (204) Workforce Modernisation Total (206) G ‐ Women and Children Total (484)
Grand Total (9,917)
Financial Plan 2013/14 Page 19 of 24 Board Meeting 24 April 2013 Agenda Item 2.3b
APPENDIX 2 SUMMARY OF RISKS AND SAVINGS BY PRIMARY BUDGET HOLDER
Assumed Old year and new Directorate/Locality Service Area Income Savings plans. Total 13‐14 year cost pressures. reduction.
A ‐ Mid Locality 01.Commissioning 0 3,358 (511) 2,847 11. Provider 0 348 (127) 221 21. Primary Care 0 (51) 0 (51) 31. Prescribing 0 144 (347) (203) 41. Continuing Care 0 90 0 90 91. Income 0 28 0 28 A ‐ Mid Locality Total 0 3,917 (985) 2,932 B ‐ North Locality 01.Commissioning 0 7,754 (3,216) 4,538 11. Provider 0 1,285 (830) 455 21. Primary Care 0 (253) 0 (253) 31. Prescribing 0 172 (500) (328) 41. Continuing Care 0 64 0 64 51. Joint Financing 0 35 0 35 91. Income 0 196 0 196 B ‐ North Locality Total 0 9,252 (4,546) 4,706 C ‐ South Locality 01.Commissioning 0 5,679 (1,207) 4,472 11. Provider 0 1,102 (345) 757 21. Primary Care 0 (130) 0 (130) 31. Prescribing 0 247 (400) (153) 41. Continuing Care 0 84 (50) 34 91. Income 0 323 0 323 C ‐ South Locality Total 0 7,305 (2,002) 5,304 D ‐ Corporate Services 11. Provider 0 321 0 321 D ‐ Corporate Services Total 0 321 0 321 Financial Plan 2013/14 Page 20 of 24 Board Meeting 24 April 2013 Agenda Item 2.3b
D ‐ Finance 01.Commissioning 0 11 0 11 11. Provider 0 1,130 0 1,130 91. Income 0 (16) 0 (16) D ‐ Finance Total 0 1,125 0 1,125 D ‐ HR (WOD) 11. Provider 0 62 0 62 D ‐ HR (WOD) Total 0 62 0 62 D ‐ PH and Planning 01.Commissioning 0 783 (1,000) (217) 11. Provider 0 122 0 122 51. Joint Financing 0 0 0 0 D ‐ PH and Planning Total 0 905 (1,000) (95) E ‐ Nursing 11. Provider 0 (11) 0 (11) 21. Primary Care 0 0 0 0 41. Continuing Care 0 0 0 0 42. Funded Nursing Care 0 110 0 110 E ‐ Nursing Total 0 99 0 99 F ‐ Mental Health 01.Commissioning 0 1,011 (351) 660 11. Provider 0 (195) 0 (195) 41. Continuing Care 0 159 (400) (241) 51. Joint Financing 0 150 (150) 0 F ‐ Mental Health Total 0 1,125 (901) 224 G ‐ Women and Children 01.Commissioning 0 699 (246) 453 11. Provider 0 159 (204) (45) 41. Continuing Care 0 44 (34) 10 G ‐ Women and Children Total 0 901 (484) 418 M ‐ Medical 01.Commissioning 0 (113) 0 (113) 11. Provider 0 (159) 0 (159) 21. Primary Care 0 (106) 0 (106) 31. Prescribing 0 (2) 0 (2) M ‐ Medical Total 0 (380) 0 (380)
Financial Plan 2013/14 Page 21 of 24 Board Meeting 24 April 2013 Agenda Item 2.3b
T ‐ Therapies and Health Sciences 11. Provider 0 (40) 0 (40) T ‐ Therapies and Health Sciences Total 0 (40) 0 (40) Y ‐ Reserves 94. Reserves 0 (2,292) 0 (2,292) 95. Balance Sheet 0 0 0 0 Y ‐ Reserves Total 0 (2,292) 0 (2,292) Z ‐ RRL 99. RRL 5,200 0 0 5,200 Z ‐ RRL Total 5,200 0 0 5,200 Grand Total 5,200 22,301 (9,917) 17,584
Financial Plan 2013/14 Page 22 of 24 Board Meeting 24 April 2013 Agenda Item 2.3b
APPENDIX 3 BUDGET PLAN 2013/14
13‐14 13‐14 assessed Directorate/Locality Service Area Annual 13‐14 Risk forecast Budget costs A ‐ Mid Locality Commissioning 11,691 14,538 2,847 Provider 7,980 8,201 221 Primary Care 7,098 7,047 (51) Prescribing 4,055 3,852 (203) Continuing Care 231 321 90 Income (190) (162) 28 A ‐ Mid Locality Total 30,865 33,797 2,932 B ‐ North Locality Commissioning 27,132 31,670 4,538 Provider 12,742 13,197 455 Primary Care 20,314 20,061 (253) Prescribing 5,009 4,682 (328) Continuing Care 823 887 64 Joint Financing 588 623 35 Income (851) (655) 196 B ‐ North Locality Total 65,758 70,464 4,706 C ‐ South Locality Commissioning 17,530 22,002 4,472 Provider 16,458 17,215 757 Primary Care 13,120 12,990 (130) Prescribing 6,276 6,123 (153) Continuing Care 1,283 1,317 34 Income (1,526) (1,203) 323 C ‐ South Locality Total 53,140 58,444 5,304 D ‐ Corporate Services Provider 1,411 1,732 321 D ‐ Corporate Services Total 1,411 1,732 321 D ‐ Finance Commissioning 229 240 11 Provider 1,302 2,431 1,130 Income (225) (241) (16) D ‐ Finance Total 1,305 2,430 1,125 D ‐ HR (WOD) Provider 1,057 1,120 62 D ‐ HR (WOD) Total 1,057 1,120 62 D ‐ PH and Planning Commissioning 28,584 28,367 (217) Provider 5,095 5,217 122 Joint Financing 307 307 0 D ‐ PH and Planning Total 33,986 33,891 (95) E ‐ Nursing Provider 814 803 (11) Primary Care 133 133 0
Financial Plan 2013/14 Page 23 of 24 Board Meeting 24 April 2013 Agenda Item 2.3b
Continuing Care 0 0 0 Funded Nursing Care 1,789 1,899 110 E ‐ Nursing Total 2,736 2,835 99 F ‐ Mental Health Commissioning 10,613 11,273 660 Provider 364 169 (195) Continuing Care 7,265 7,024 (241) Joint Financing 1,310 1,310 0 F ‐ Mental Health Total 19,552 19,776 224 G ‐ Women and Children Commissioning 4,526 4,979 453 Provider 6,900 6,855 (45) Continuing Care 214 224 10 G ‐ Women and Children Total 11,640 12,057 418 M ‐ Medical Commissioning 1,166 1,054 (113) Provider 2,878 2,720 (159) Primary Care 911 804 (106) Prescribing 545 543 (2) M ‐ Medical Total 5,501 5,121 (380) T ‐ Therapies and Health Sciences Provider 703 663 (40) T ‐ Therapies and Health Sciences Total 703 663 (40) Y ‐ Reserves 94. Reserves 3,504 1,212 (2,292) Y ‐ Reserves Total 3,504 1,212 (2,292) Z ‐ RRL 99. RRL (231,157) (225,957) 5,200 Z ‐ RRL Total (231,157) (225,957) 5,200
Grand Total 0 17,584 17,584
Financial Plan 2013/14 Page 24 of 24 Board Meeting 24 April 2013 Agenda Item 2.3b
FOR APPROVAL
BOARD MEETING 24 APRIL 2013 AGENDA ITEM 2.4
FUNDED NURSING CARE REVIEW – UPDATE REPORT
Report of Director of Nursing
Paper prepared by Director of Nursing
Purpose of Paper The purpose of this report is to provide an update on progress with the Funded Nursing Care (FNC) Review
Action/Decision required The Board is asked to: • Note the progress made in respect of the Funded Nursing Care Review • Confirm its agreement to the recommendation of the Chief Executives
Link to ‘Doing Well, 1. Governance & Accountability Doing Better: Standards for Health Services in Wales’:
Link to Health Board’s Striving for Excellence Corporate Plan Acronyms and N/A abbreviations
Funded Nursing Care Review Page 1 of 3 Board Meeting 24 April 2013 Agenda Item 2.4
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FUNDED NURSING CARE REVIEW – UPDATE REPORT
Introduction
The Board considered a report in December 2012 regarding the work proposed to take place to determine future Funded Nursing Care arrangements. The proposal, to contribute to an All Wales process of review, was agreed by the Board. The report provides a briefing to Board members on the progress of this work and consideration of the advice given by Chief Executives in this matter.
Background
In summary: - Chief Executives considered a report at their September 2012 meeting setting out progress in undertaking a review of FNC arrangements. This work is required in response to a series of judicial reviews against Local Authorities in Wales during 2010 and 2011. These reviews indicated a requirement to be able to demonstrate due process in reaching decisions regarding care sector fees. - Following these judicial reviews, pre judicial review correspondence was subsequently issued against one Health Board by lawyers acting on behalf of providers. Given the co-ordinated basis that Health Boards have adopted to provide a consistent weekly FNC rate across Wales, a challenge against one Health Board would have had implications across Wales. - The key requirement is for Health Boards to be able to demonstrate a robust methodology in calculating FNC rates. Statute does allow NHS bodies to exercise some discretion as to how they allocate resources, but a proper and demonstrable methodology must be in place to support reaching such a decision. - Whilst a review is taking place, Health Boards determined not to agree uplift in Funded Nursing Care Fees; and not to back date any award resulting from a wider sampling study.
Progress
The Review work has been successfully tendered and has commenced. In the meantime however Care Forum Wales have written to Health Boards challenging on the following issues:
- Equality Impact Assessments; - Use of ‘readily available data’ (upon which to determine the setting of care home fees)
The Review Group as a result has undertaken a screening assessment of Equality Impact and reviewed the previous decision on the ‘readily available information’ issue.
Funded Nursing Care Review Page 2 of 3 Board Meeting 24 April 2013 Agenda Item 2.4
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Further consideration has been given to this matter by the Chief Executives Peer Group based on the work undertaken by the Funded Nursing Care Review Group and the challenges presented by Care Forum Wales. The recommendation from CEOs is to:
1. Not award an interim uplift – in line with previous decision; and 2. Not to agree any backdating.
The reasons given for recommendation 1 include: 1. The data available was not collected to consider the process for setting the rates of Funded Nursing care; 2. The data sample showed significant inconsistencies 3. The CEOs do not wish to prejudge the wider sampling work.
The reason given for recommendation 2 include: 4. Health Boards would be committing to an entirely unknown financial settlement and therefore would not be able to demonstrate due diligence
Conclusion
The previously agreed All Wales work is underway to review the Funded Nursing Care arrangements, including fees. Further challenges to Health Boards from Care Forum Wales have resulted in a reconsideration of the previous decisions regarding changes in fee levels. The recommendations from the Chief Executives Peer Group at this stage suggest that no interim uplift is awarded, and furthermore that no agreement be made to backdating.
Recommendations
The Board is asked to: • NOTE the progress made in respect of the Funded Nursing Care Review • CONFIRM support for the recommendations of the Chief Executives: o No interim uplift is awarded o No agreement is made regarding backdating.
Report prepared by: Presented By: Carol Shillabeer Carol Shillabeer Director of Nursing Director of Nursing
Financial Assessment The decision does not at this stage incur a financial cost.
Funded Nursing Care Review Page 3 of 3 Board Meeting 24 April 2013 Agenda Item 2.4
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BOARD MEETING 24 APRIL 2013 AGENDA ITEM 2.5
STANDARDS FOR HEALTH SERVICES IN WALES GOVERNANCE AND ACCOUNTABILITY MODULE 2012/13
Report of Executive Director of Therapies and Health Science
Paper prepared by Service Improvement Officer
Purpose of Paper To provide the Board with the outcomes of the Governance and Accountability Module 2012/13
Action/Decision required The Board is asked to NOTE the process for undertaking the improvement priorities and APPROVE the Governance and Accountability Module for submission.
Link to ‘Doing Well, All Standards, specifically Standard 1- Governance & Doing Better: Standards Accountability Framework for Health Services in Wales’:
Link to Health Board’s Striving for Excellence Corporate Plan
Acronyms and SHS - Standards for Health Services abbreviations HIW- Health Inspectorate Wales
Governance and Accountability Module Page 1 of 47 Board Meeting 24 April 2013 Agenda Item 2.5
FOR APPROVAL
STANDARDS FOR HEALTH SERVICES IN WALES GOVERNANCE AND ACCOUNTABILITY MODULE 2012/13
Background Standards for Health Services in Wales (SHS) were launched by Welsh Government in 2010 as a means of setting out what citizens have a right to expect of all health organisations across Wales. The standards provide a framework upon which all teams are able to assess and develop their services in relation to governance, quality, safety and effectiveness. A specific assessment, the Governance and Accountability Module, was created for use by the Board to assess: itself, the organisation’s governance arrangements and performance against Standards for Health Services in Wales.
Introduction The Governance and Accountability Module contains three themes against which the Board has completed a self assessment: 1. Setting the Direction 2. Enabling Delivery 3. Delivering Results, Achieving Excellence
The Governance and Accountability Module was undertaken using the guidelines issued by Health Inspectorate Wales (HIW) in February 2012. If the requirements of HIW change for 2012/13, the completed Module will be updated accordingly. Completion of the module has identified a number of priorities for improvement to be addressed by the teaching Health Board.
Process A structured approach to completing the Module was undertaken, although improvements to the process for self assessment were identified and the process revised. Key stages in the process undertaken included: • Board Development Session on SHS and the role of the Board • Completion of the supporting narrative by the Executive Team • Initial discussion of narrative at Board Development Session – identified the need for more in depth narrative, and a scrutiny of the narrative for assessment • Narrative updated and circulated to Independent Members • Final scrutiny panel held by Board members (Executive Team and Independent Members)
Assessment The completed module can be found as Appendix 1. The following table summarises the outcome of the self assessment for each theme, including the level of agreement rated as a score on a scale from 1-5, with 5 being the highest.:
Theme Score Assessment of Theme 1.Setting the 4 We have well developed plans and processes and can Direction demonstrate sustainable improvement throughout the organisation 2.Enabling 3 We are developing plans and processes and can demonstrate Delivery progress with some of our key areas for improvement 3.Delivering 3 We are developing plans and processes and can demonstrate Results, Achieving progress with some of our key areas for improvement Excellence
Governance and Accountability Module Page 2 of 47 Board Meeting 24 April 2013 Agenda Item 2.5
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For a comparison against the assessment undertaken in 2011/12, see Appendix 2.
Priorities for Improvement Priorities for improvement have been identified for each of the three key themes of the Module. Each priority will be addressed via objectives set in the organisation’s Annual Plan – this document should be considered the organisation’s SHS Improvement Plan. The overarching aims identified in the Annual Plan under which these improvement priorities will be addressed can be found in the table below:
Improvement priorities identified in Module 1 Link to Annual Plan overarching aims Theme 1- Setting the Direction
1. A full strategic approach to engagement is to be Involving the people of developed, identifying areas where the voice of the Powys people should be stronger and sustaining high levels where this exists 2. Developing and implementing and organisational Enabling strategy behaviour framework as part of the team coaching work 3. Embedding values of equality and diversity through Involving the People of strengthening the implementation of Equality Impact Powys Assessment and monitoring impact on patients 4. Strengthen the planning and commissioning Making Every Pound processes through development of a 3 year rolling Count plan that incorporates national planning priorities and demonstrates that the views of the citizens have been considered 5. Strengthen strategic joint planning through a review of Involving the People of partnership arrangements under the Local Service Powys Board Theme 2 – Enabling Delivery
1. Executive Directors working to fully delegate Enabling strategy appropriate accountability to Teams and Locality and Directorate Managers, ensuring cohesion between teams (Supported by Team Based Working) 2. Develop a forward estates strategy Enabling strategy 3. Ensure that the Programme Office is fully functioning Enabling strategy to support Transformation Programmes such as Information Services and the clinical change programmes 4. Action plans to achieve key audit recommendations to Enabling strategy be overseen by re-established Information Governance Committee 5. To adopt an ongoing approach which links the annual Enabling strategy governance statement more closely to corporate priorities 6. Fully participate in development and application of Enabling strategy new Workforce Tools to ensure vigour is applied to determining safe staffing levels
Governance and Accountability Module Page 3 of 47 Board Meeting 24 April 2013 Agenda Item 2.5
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7. Continue to strengthen the approach for management Enabling strategy of Board level risk. 8. Further work will be undertaken to build capacity for Enabling strategy integrated planning across service, finance and workforce Theme 3 – Delivering Results, Achieving Excellence
1. Development of an Assurance Framework which will Enabling strategy determine all legal and other requirements placed upon the teaching Health Board and outline the sources of assurance available to the Board in satisfying itself that all are delivered. 2. Development of a Quality Assurance Framework to Striving for Excellence provide greater robustness in the reporting of information relating to quality of service provision required from external providers. This will inform the Locality based contract review process and will be included in the Annual Quality Statement to be published from September 2013 3. Establish a consistent and systematic approach to Striving for Excellence reporting and learning from clinical audit across all services 4. Further develop the Integrated Performance Report Striving for Excellence and supporting infrastructure to ensure focus and information have direct alignment with the Annual Plan 5. Further develop an internal communications strategy, Enabling strategy to systematically gain, record and act on the views of staff 6. Participating in the national programme of work to Striving for Excellence build the skills of the workforce in quality improvement methodology 7. Development of a Board Business Cycle to determine Enabling strategy reporting requirements of the Board 8. Surveying the reactions of users of external services Involving the People of Powys 9. In light of the Francis Review, national work on Striving for Excellence professionalism to be considered and applied where appropriate
Conclusion Completion of the Governance and Accountability Module has identified key priorities for improvement across the organisation, which will be addressed via the organisation’s Annual Plan. The improvement in the process of completing the Module will inform designing the process for next year.
Recommendation The Board is asked to NOTE the process for undertaking the improvement priorities and APPROVE the Governance and Accountability Module for submission.
Governance and Accountability Module Page 4 of 47 Board Meeting 24 April 2013 Agenda Item 2.5
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Report prepared by: Presented By: Nathalie Thomas Dr Amanda Smith Service Improvement Officer Executive Director of Therapies and Health Science
Background Papers Doing Well, Doing Better: Standards for Health Services in Wales (Welsh Government, 2010)
Doing Well, Doing Better: Standards for Health Services in Wales – Driving Improvement through Self Assessment, the Governance and Accountability Module
Financial Consequences None
Other Resource Implications As determined by the report
Consultees Board Members
Governance and Accountability Module Page 5 of 47 Board Meeting 24 April 2013 Agenda Item 2.5
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Appendix 1 APRIL 2013
DOING WELL, DOING BETTER: STANDARDS FOR HEALTH SERVICES IN WALES GOVERNANCE & ACCOUNTABILITY MODULE THE SELF ASSESSMENT
Note: In establishing your level of agreement in relation to each of the statements made, you must be able to demonstrate through your supporting narrative not only what your organisation or business is doing, but how well it is working and the resulting impact on organisation performance.
1 2 3 4 5 We do not yet have a clear, We are aware of the We are developing We have well We can demonstrate agreed understanding of improvements that need plans and processes developed plans and sustained good where we are (or how we are to be made and have and can demonstrate processes and can practice and doing) and what / where we prioritised them, but are progress with some of demonstrate innovation that is need to improve. not yet able to our key areas for sustainable shared throughout demonstrate meaningful improvement. improvement the organisation/ action. throughout the business, and which organisation/ others can learn from. business.
THEME 1 – SETTING THE DIRECTION
Desired Outcomes:
We place the people who use our services at the heart of our work We make sure our purpose is clear and know how to develop and deliver our services to improve overall health and well being We are a value based organisation/business and carry out our work openly, honestly, ethically and with integrity
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We can demonstrate that:
strongly disagree...... ….strongly agree 1 2 3 4 5 Supporting Narrative We make an effective 9 The teaching Health Board contributes to the delivery of the strategic vision for health contribution to the services in Wales at both national and local levels. achievement of the strategic vision for All Executive Directors lead on or participate in a range of national programmes and health services in project boards established to deliver the NHS Wales agenda. Specifically, the Chief Wales Executive is the lead CEO for Primary & Community Services which is likely to include the next iteration of strategy and has led to discussion before the Bevan Commission.
The Chief Executive and Executive Team have participated in and presented at the Team Wales events, which further support the teaching Health Board in delivering the strategic vision for health services in Wales.
All Executives actively participate in their peer group fora, meeting with their counterparts from other organisations in Wales on a regular basis, with the aim of sharing approaches to achieving the strategic vision for health in Wales. Several are also in engaged in specific national programmes of work either on behalf of their professional groups/functions or as representatives of Powys teaching Health Board.
The teaching Health Board is developing services at locality level in line with Welsh Government Strategy ‘Setting the Direction’ and has developed and agreed a joint maturity matrix with Powys County Council to monitor delivery of this model. The teaching Health Board has been actively involved in engagement with the public on plans for service change that respond to Together for Health in Hywel Dda and has participated in the consultation on service change in Hywel Dda and Betsi Cadwalladr. The teaching Health Board is also a member of the South Wales Programme Board that is developing plans for service change across the South Wales area. Governance and Accountability Module Page 7 of 47 Board Meeting 24 April 2013 Agenda Item 2.5
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strongly disagree...... ….strongly agree 1 2 3 4 5 Supporting Narrative
At a local level, the geographical Locality Teams and Service Directorates provide co- ordination and support to the Executive Team and Senior Managers in achieving the strategic vision for health services in Wales. Senior managers and clinical leads participate in all Wales task and finish groups to contribute, for example, to the development of service specific delivery plans and outcome measures.
Increasingly, the emphasis is on public services integration. The teaching Health Board has increased its influence and achievement of multi-agency strategy through working as effective partners with social services, education, police and voluntary sector. Examples include locally the review and revision of the Local Service Board and the influence of the Social Services and Wellbeing Bill. The teaching Health Board is also engaged in the mid and west Wales public services collaborative.
We have a clear 9 The Board is able to demonstrate its purpose, vision and strategic direction through the purpose, vision and Annual Plan. The Annual Plan specifically shows how it relates to government strategy, overall strategic including Together for Health, Setting the Direction and the Rural Health Plan and direction that supporting strategies such as the Quality Improvement Framework, Working Together, effectively aligns our Working Differently and local need through the One Plan as described below. local needs with the national strategy for Underpinning strategies which are aligned to the Annual Plan are in place supported by health services in delivery plans with progress reported to the Board, These include, for example the Wales Maternity Strategy, Learning Disabilities Strategy, Therapy and Health Sciences Strategy and Delivery Plan, Nursing and Midwifery Strategy Public Health Strategic Framework and Mental Health Strategy, as well as enabling strategies and frameworks such as organisational development, information, IT, strategic Equality and Human Rights and Welsh Language frameworks.
The teaching Health Board published its annual report on cancer services in line with Governance and Accountability Module Page 8 of 47 Board Meeting 24 April 2013 Agenda Item 2.5
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strongly disagree...... ….strongly agree 1 2 3 4 5 Supporting Narrative national requirements. The Three Year Stroke Delivery Plan has been developed in line with the National Strategic vision set out in Together for Health, Stroke Delivery Plan for the NHS up to 2016.
Powys teaching Health Board’s commitment to meeting local needs in collaboration with its partners can be demonstrated through Powys’ strong Local Service Board partnership. The Board’s continued commitment to the ongoing development and delivery of the Powys One Plan is a mechanism for aligning local needs to national strategy.
Localities are key in understanding local needs for their population and securing services that both meet needs as well as achieving the organisation’s strategic direction. Public Health are working to provide support to localities to enhance understanding of population health needs.
Our citizens, staff and 9 The teaching Health Board has undertaken a number of engagements and other stakeholders consultations with the public, staff and other key stakeholders as demonstrated below. inform and influence The Health Board’s Stakeholder Reference Group has established a work programme our based on scrutiny and involvement in key aspects of the teaching Health Board’s organisation/business’s Annual Plan. purpose, strategic vision and direction Consultation Events The teaching Health Board has undertaken the following engagement and consultation events in respect of Service Change Plans that respond to Together for Health and, in doing so, the teaching Health Board has been fully compliant with Welsh Government consultation guidance:-
The Health Board has held engagement events in respect of consultation proposals put forward by Hywel Dda and Betsi Cadwaladr Health Boards which informed the Board’s Governance and Accountability Module Page 9 of 47 Board Meeting 24 April 2013 Agenda Item 2.5
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strongly disagree...... ….strongly agree 1 2 3 4 5 Supporting Narrative response to those proposals.
The Health Board has undertaken a consultation exercise, following an engagement programme in respect of stroke services in South East Powys.
The Health Board has undertaken an engagement process in respect of the early proposals for paediatric, neonatal; obstetric and A&E services in South Wales.
In addition, each of the three geographical locality teams in Powys regularly engage with stakeholders in the formulation and delivery of local service change; for example, the midwifery liaison committee and local Community Health Council forums.
The teaching Health Board held a joint consultation event with older people as part of the preparation of the older people’s strategy.
The teaching Health Board has undertaken an engagement exercise in the development of the Carers Measure.
The teaching Health Board has undertaken an engagement process in the development of the mental health services strategy.
Patient Experience and Feedback Patient experience of our services and systems of health and social care influence the strategic direction and the priority of certain aspects of work.
All concerns are dealt with via the Concerns Team. The priority for 2011/12 has been to design, implement and embed new processes for the management of concerns (patient safety incidents, complaints and claims). During 2011/12 the teaching Health Board received 114 formal concerns. During 2011/12 the teaching Health Board achieved Governance and Accountability Module Page 10 of 47 Board Meeting 24 April 2013 Agenda Item 2.5
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strongly disagree...... ….strongly agree 1 2 3 4 5 Supporting Narrative 68% compliance with the target response time of 30 days. A 100% response was achieved against a maximum target of 6 months completed by 31 March 2012.
The Improving Patient Involvement and Experience (IPIE) Committee receives multi- agency, including Community Health Council and Third Sector, feedback on patient experience across provided, contracted and commissioned services and work has commenced to develop a thematic approach to ensure learning leads to service improvement.
A proactive approach to inclusion of patient stories at Board meetings and Board Development Sessions has been progressed. Since October 2012 there have been three patient stories at Board Meetings, reflecting diverse clinical and geographical areas.
The teaching Health Board is represented on the All Wales User Experience Groups to take forward the development of a framework to capture service user experience using a consistent and equitable approach. Currently more local approaches are undertaken by individual services, such as by Maternity services, who have engaged over 100 women in feedback regarding both their experience of care and their views on development of services which is informing service planning. Furthermore, the use of COOS (Comment on our Services cards) has been embedded throughout the last year in relation to maternity services. This includes the review of the experiences of women and families both within Powys and the District General Hospital as appropriate. This has led to changes in the way services are delivered.
Strategy Development The teaching Health Board has worked with Powys County Council, voluntary organisations and carers in the development of the Information and Consultation
Governance and Accountability Module Page 11 of 47 Board Meeting 24 April 2013 Agenda Item 2.5
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strongly disagree...... ….strongly agree 1 2 3 4 5 Supporting Narrative Strategy for Carers under the Carers (Wales) Measure 2010.
The teaching Health Board worked in partnership with Powys County Council to engage with the public, services users and staff in the development of its strategic equality objectives which were published in April2012
In relation to the development of the vision and strategy for Mental Health, significant citizen, staff and stakeholder involvement directly influenced the final vision and direction, including: • Over 200 adults participated in engagement discussions • 91 children were surveyed about their views on CAHMS • Multiagency workshops included police, fire, leisure, children’s social services, adult’s social services, Public Health and the Voluntary Sector In relation to children’s and young people’s services, the teaching Health Board has further developed during the year its engagement mechanisms on a partnership basis through the Children and Young People’s Partnership, demonstrating commitment to the Children’s participation rights. Two examples include the engagement with the Youth Forum across Powys, understanding their views on School Health Nursing, for example, and the engagement with the Eat Carrots Stay Safe from Elephants Junior Local Safeguarding Children’s Board.
Staff Engagement Communication and engagement with staff across the organisation and at every level takes place through a range of approaches. Staff and their representatives were involved in the development of the 2012/13 Annual Plan through a series of workshop sessions and a consultation period.
At the most senior level, the CEO has redesigned monthly Key Brief to engage in dialogue with staff and to enable discussion around the business of the Board of Governance and Accountability Module Page 12 of 47 Board Meeting 24 April 2013 Agenda Item 2.5
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strongly disagree...... ….strongly agree 1 2 3 4 5 Supporting Narrative Directors. |From February 2013 this will be supplemented with a monthly roadshow by the CEO to meet staff at all localities on a programmed basis.
We have also established a regular staff newsletter which is developed with staff and their representatives to share news and developments and seek the views of our workforce.
The HB has robust arrangements in place to meet with staff representatives on a regular basis with both an organisational Partnership Forum and local partnership forums in the localities. During the year work has been undertaken to strengthen the partnership working arrangements including a jointly commissioned workshop facilitated by Uniglam, a review of facilities and time off arrangements, joint training and development via inclusion in the management seminar programme and the Aston team coaching skill programme.
Work is underway jointly to improve communication mechanisms across the organisation and also to strengthen and improve the capacity of the trade unions to participate in partnership work. This has included reintroducing a session by the TUs in the corporate induction programme to promote the TU role.
Roadshows are currently underway jointly facilitated by the assistant Director of workforce and OD and the Staff side Secretary. The LPF has recently undertaken a workshop session to explore how we can improve communication mechanisms to ensure staff are engaged and consulted with effectively.
There is further work to be undertaken to further strengthen partnership working and ensure that staff are appropriately engaged in decision making.
All therapy and health science professions and teams were engaged in and contributed Governance and Accountability Module Page 13 of 47 Board Meeting 24 April 2013 Agenda Item 2.5
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strongly disagree...... ….strongly agree 1 2 3 4 5 Supporting Narrative to developing the Three Year Therapy and Health Science Strategy and Delivery Plan. They were also invited to submit achievements for inclusion in the teaching Health Board Annual Report.
As part of the Quality & Safety Unit, the Concerns Team manages any concern raised to the teaching Health Board. Lessons learned are shared Powys-wide and published quarterly in the Quality & Safety Newsletter which is available to all staff.
Staff involvement in the health & safety agenda includes staff partner Health & Safety Representatives actively involved as members of the Corporate Health & Safety Committee and other supporting groups.
The Health Board achieved Corporate Health Standard Gold Award this year through an active partnership based well being at work programme. Work is underway to achieve the Platinum Award. This is primarily focused on public & corporate responsibility and concerned with the sustainability agenda. It will involve strategic planning and further engagement with stakeholders and the wider public across Powys. More recently a number of jointly facilitated action learning sessions with managers, staff and TUs have been conducted to consider addressing specific issues such as sickness absence in partnership
Staff and their representatives are engaged in service change plans across the organisation under formal project arrangements including the Builth Hospital project, South East Powys and stroke services plans and have been involved in supporting changes to structures in radiography, workforce and OD, information and commissioning. The teaching Health Board recognises that whilst there is strong engagement across the organisation and that this has developed over the last 12 months, a fully strategic
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strongly disagree...... ….strongly agree 1 2 3 4 5 Supporting Narrative and systematic approach across the organisation is still to be developed.
We carry out our work 9 The Board has adopted the NHS Citizen Centred principles and these are included instilled with a strong within its Governance Framework; Additionally it has developed strategic equality and sense of values, human rights objectives through a consultation and engagement process. supported by clear standards of ethical Professionally registered staff are required to adhere to a code of ethical standards as behaviour well as professional standards laid down by their respective professional and regulatory bodies, such as the General Medical Council, Nursing and Midwifery Council and the Health and Care Professions Council. Codes of Conduct are actively used both to guide health care professionals and as a core part of professional regulation. The Code of Conduct for Health Care Support Workers sets out the standards expected for non professionally-qualified staff.
As an example of how promoting a sense of values is being developed, Nursing and Midwifery leaders within the organisation have been actively involved in a national project on professionalism. This work was commissioned by the Chief Nursing Officer for Wales with local discussions on the draft recommendations now being led by Nurse Directors.
Progress has been made on the twelve recommendations of the Older Persons Dignified Care Action Plan. For example, dementia care interventions work has been piloted at Machynlleth and Brecon and is being rolled out across all general wards; WRVS funding has been secured for Volunteer schemes in all community hospitals to support mealtime experience and activity for dementia patients; all carers are offered a Carer’s Assessment with every admission, in line with the Carers Strategy.
All clinical and non-clinical teams in localities, central services and directorates across
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strongly disagree...... ….strongly agree 1 2 3 4 5 Supporting Narrative Powys are now fully engaged in self assessment against the All Wales Standards for Health Services. This is routinely reported and assessed at monthly performance meetings as well as through the Standards Steering Group, and demonstrates significant development in staff awareness of the standards and a recognition of the value in participating in patient-centred service improvement at all levels. Individuals and teams have been sharing examples of good practice and demonstrating improvements in systematic review of effectiveness of service delivery.
Physiotherapists, for example, have led in the development of a model of clinical supervision to provide a framework for peer support for professional staff; it has been adopted for use by all eight therapy and health science services and successfully adapted further to include nursing. It is based on enabling clinicians to respond ethically and with integrity to challenging situations and to maintaining high professional standards. It is now being considered for adoption by the All Wales professional committees.
Staff demonstrate a commitment to reporting concerns, through the incident and risk reporting systems, as well as through professional management routes; these concerns may relate to access to the right care at the right time, when this does not go as well as it should for patients. Patient complaints that are received mirror these concerns to an extent, for example identifying delays in transport, difficulty in accessing GP or podiatry appointments.
The recently reviewed staff induction places a focus on the need for all staff to treat each other, patients and the public with dignity and respect, valuing diversity and promoting equality of opportunity.
The organisation is committed to further develop and implement an organisational behaviour framework; this will be undertaken as part of the team coaching programme Governance and Accountability Module Page 16 of 47 Board Meeting 24 April 2013 Agenda Item 2.5
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strongly disagree...... ….strongly agree 1 2 3 4 5 Supporting Narrative which is now underway, with the first cohort of executive and senior managers having completed the five day Aston Team Coaching module in November. The cascade from this has already begun to take place. We promote equality 9 Work has continued during the year on the promotion of equality and diversity across and recognise diversity all areas of the teaching Health Board’s activity. The Board has developed and across all our services published its Strategic Equality Objectives and a corporate Strategic Equality and and activities Welsh Language Steering Group. has been established, with independent member input, to oversee the implementation of the Strategic Equalities Action Plan and Welsh Language Strategy The Strategic Equality and Welsh Language Steering Group held its inaugural meeting on 6 December 2012. The purpose of the group will be to develop, promote and review the teaching Health Board’s equality and human rights policy and strategy with a view to eliminating discrimination and promoting equality of opportunity.
Equality impact assessments are undertaken as part of the policy development process although there is further work to be undertaken to embed EQIA as a routine part of decision making processes.
The organisation has well established employment policy and practice which reflect a strong management of equality & diversity. However, the organisation has further work to do in embedding values of equality & diversity in service delivery and monitoring the impact on patients and service users and this is a core priority within the Strategic Equality Objectives.
As part of the Mental Health Strategy, a significant emphasis has been placed on equality and reducing the stigma associated with the service. The engagement of over 200 people/service users and 91 children has helped to inform this priority.
Further demonstration of the organisation’s commitment to equality includes the focus Governance and Accountability Module Page 17 of 47 Board Meeting 24 April 2013 Agenda Item 2.5
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strongly disagree...... ….strongly agree 1 2 3 4 5 Supporting Narrative on older people and focus on children. The implementation of action plan in response to the Older People’s Commissioner Report on Dignified Care has resulted in improvements in care.
We apply and embed 9 During the course of the year, the teaching Health Board has made progress in this professional standards area, though as outlined below there is more work to do to ensure that this is in place and equality across the whole organisation. requirements in a way that meets the needs The teaching Health Board continues to ensure that all services are developed and and expectations of delivered to embed professional standards, codes of conduct, NICE guidance and best patients, service users, practice through the professional governance structures. citizens and other stakeholders Stroke teams have developed new ways of engaging patients and providing improved access to training and information for all people and carers living with stroke, despite physical and communication disabilities. The quality of clinical leadership and application of professional standards has been evidenced from the positive feedback from service users in South Powys during the recent engagement and consultation events.
In relation to standards of care, increasing use of evidence based care as demonstrated by the developments within the 1000 Lives Plus Programme is resulting in improvements to patient care. These ‘new’ and emerging standards demonstrate the progression of healthcare practice with an emphasis on increasingly being patient/citizen centred.
Plans to embed equality thinking into the organisation include a “train the trainer” initiative. All trainers delivering essential training to staff are required to design their course content to subtly include consideration of dignity, diversity and human rights. The first of these “train the trainer” sessions took place in March 2012 and are on- Governance and Accountability Module Page 18 of 47 Board Meeting 24 April 2013 Agenda Item 2.5
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strongly disagree...... ….strongly agree 1 2 3 4 5 Supporting Narrative going.
The development of the Mental Health Strategy has embedded the principles of equality from the start. An equality impact assessment demonstrates this both to the Board (in terms of assurance) and to the public generally.
The Older People: Dignified Care Action Plan is based on the UN Principles for Older People. These principles are starting to be adopted more commonly in our work, however it is recognised that there is more to do.
The UN Rights of the Child are embedded in the way we work, both in partnership and as a single organisation. Clear and effective advocacy arrangements are in place supporting children to participate in decisions about their own care and influencing the development of services for children.
THEME 1 – SETTING THE DIRECTION Your Overall Assessment
In relation to this particular theme, what is your overall assessment of where and how you: 1. Are governing well • The Board is able to demonstrate its purpose, vision and strategic direction through the Annual Plan. The Annual Plan specifically shows how it relates to government strategy, including Together for Health, Setting the Direction and the Rural Health Plan and supporting strategies such as the Quality Improvement Framework, Working Together, Working Differently and local need through the One Plan as described below. • Work has been underway in partnership to improve communication mechanisms across the organisation and also to strengthen and improve the capacity of the trade unions to participate in partnership work.
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2. Need to strengthen your arrangements • The organisation has a well established employment policy and practice which reflect strong management of equality & diversity. However, the organisation has further work to do in embedding values of equality & diversity in service delivery and monitoring the impact on patients and service users and this is a core priority within the Strategic Equality Objectives. • The organisation recognises the need to strengthen planning and commissioning processes to incorporate national planning priorities and demonstrate that the views of the citizens have been considered.
3. Have noteworthy practice which you may wish to share • The organisation is demonstrating commitment to develop and implement an organisational behaviour framework; this is being undertaken as part of the team coaching programme which is now underway, with the first cohort of executive and senior managers having completed the five day Aston Team Coaching module. • The organisation has successfully engaged teams in all services and directorates across Powys in regular and ongoing self assessment, service improvement and sharing good practice using the Standards for Health Services.
What maturity level have you demonstrated you have reached for this overall:
• We have well developed plans and processes and can demonstrate sustainable improvement throughout the organisation.
In relation to this particular theme, what are your priorities for improvement, what action are you going to take (and when) and how will you measure your success?
Actions arising from this module will be included within the teaching Health Board’s Standards for Health Services Improvement Plan, the tHB Annual Plan, and so both documents should be read in unison. Particular actions arising from this theme are as follows:- 1. A full strategic approach to engagement is to be developed, identifying areas where the voice of the people should be stronger and sustaining high levels where this exists 2. Developing and implementing and organisational behaviour framework as part of the team coaching work 3. Embedding values of equality and diversity through strengthening the implementation of Equality Impact Assessment and monitoring impact on patients 4. Strengthen the planning and commissioning processes through development of a 3 year rolling plan that incorporates Governance and Accountability Module Page 20 of 47 Board Meeting 24 April 2013 Agenda Item 2.5
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national planning priorities and demonstrates that the views of the citizens have been considered 5. Strengthen strategic joint planning through a review of partnership arrangements under the Local Service Board
THEME 2 – ENABLING DELIVERY
Desired Outcomes:
We make sure that everyone involved in delivering health services understands each others contribution, and how together we can deliver a better service We work constructively in partnership with others to improve the quality and safety of services for our patients, services users and the wider community We foster innovation and make the best use of all the resources available to us, including our people, facilities and finances
We can demonstrate that:
strongly disagree...... ….strongly agree 1 2 3 4 5 Supporting Narrative We have the: 9 Since the establishment of the substantive Executive Team, the Board’s Scheme of • Right people Delegation has been reviewed and re-aligned to ensure greater clarity of Executive • With the right Director responsibilities. The teaching Health Board has created the locality skills management arrangements to strengthen delivery and executive directors are now • Doing the right working to fully delegate appropriate accountability and capacity to Locality General things Managers. • In the right place • And at the right In our role as a commissioner of services, the Executive Team provide support for Locality Management teams in securing and reviewing high quality accessible services Governance and Accountability Module Page 21 of 47 Board Meeting 24 April 2013 Agenda Item 2.5
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strongly disagree...... ….strongly agree 1 2 3 4 5 Supporting Narrative time to meet our from our providers where this is necessary and appropriate to meet the health needs of responsibilities our population. Engagement in commissioning and influencing the quality and access for the provision of service delivery has included our involvement in, for example, the East and Midlands of safe, high Stroke Review. Ongoing engagement in this review has been essential to secure quality care continued access for patients in North, Mid and South Powys to hyper-acute services that can be reached within an hour by ambulance.
Locality Management Teams have been successfully working with Primary Care Teams to achieve the redesign of a number of referral pathways for patients with specific clinical conditions to create improved access to appropriate intervention and quality of care closer to home. For example, the orthopaedic pathway has been implemented across locations in all three localities this year to enable patients to receive specialist physiotherapy assessment prior to consultant referral and early outcomes have indicated that this has prevented a number of unnecessary orthopaedic interventions and admissions for surgery.
Powys teaching Health Board developed an integrated workforce plan in May 2012. It outlines the workforce changes that need to take place to provide safe, high quality care. This year’s workforce planning demonstrates significant improvements, having matured from a corporate level analysis to a more localised plan, with better anticipation of future service workforce needs. This has been commended by NLIAH and the progress also noted by the Wales Audit Office.
As clarity is developed in line with future service models, more detailed workforce development plans will emerge for each of the clinical service areas. In addition, workforce change is occurring in corporate service areas to support the changes across the teaching Health Board. Central and corporate teams are reviewing and realigning working relationships to provide focussed support at locality and directorate level, while still providing the coordination and assurance mechanisms required for strategic Governance and Accountability Module Page 22 of 47 Board Meeting 24 April 2013 Agenda Item 2.5
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strongly disagree...... ….strongly agree 1 2 3 4 5 Supporting Narrative planning and reporting to the Board. The Public Health team is strengthening its relationships with Locality Teams in order to support the focus on addressing local health needs of the population.
A range of organisational development activity has been underway since January 2012 to increase the capacity and capability of the organisation particularly in terms of recruiting two high calibre locality general managers and establishing a programme management office. External expertise has been sourced to support the sustainable development of the teaching Health Board’s information and commissioning, finance, project management and workforce planning functions.
A new Learning and Development Framework is currently being developed which will enable the skills and competences of the whole workforce to be ascertained and to identify any skills and competences gaps and to ensure that current levels of skill is maintained.
Previous challenges regarding capacity and capability of middle managers have been addressed through the introduction of the management seminars and through development programmes with NLIAH for example. This will be strengthened with the introduction of Aston Team Based Coaching across the teaching Health Board.
There are also plans, in line with other NHS Wales organisations, to up-skill 25% of the workforce in Quality Improvement methodology at all levels of the organisation.
Nursing and midwifery staffing levels and skill mix are informed by benchmarking where this is available, using tools such as the Safer Nursing Care tool and the Skills for Health competency frameworks. There is however further work to do in other parts of the nursing workforce where such tools do not currently exist.
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strongly disagree...... ….strongly agree 1 2 3 4 5 Supporting Narrative Further work will be undertaken to build capacity for integrated planning across service, finance and workforce.
The different services 9 There is a good level of clarity at the Executive and Senior manager level of the and parts of our organisation, and within direct clinical services this clarity is also good. organisations/business work well together, and Executive portfolios have been realigned to strengthen role clarity. There is a strong everyone understands ethos of team meetings at the senior level and Executive and Locality general managers who does what and regularly meet as one team ensuring the link between strategic planning and the why operational delivery is strong. This has been further strengthened by the development of monthly performance management meetings between the Executive team and the Locality Senior Team, accompanied by an improved performance reporting framework which all parts of the organisation are now working to. This arrangement has supported effective communication and problem solving and has strengthened the focus on the key deliverable objectives of the organisation.
Significant work has taken place following restructuring, which has delivered positive results. There remains good infrastructure to support Executive Team working. However the Executive Team will continue to work to create better distinction between its strategic, collective Executive team responsibilities and health professional responsibilities, where there is a health professional role for some executive directors; clarity is also required regarding executive directors’ roles in supporting locality and directorate managers to deliver their programmes of change. This will be supported by the recent introduction of Team Based Working.
Improvements have been made in key services/functions that support delivery, most notably the Information function following the commissioning of an external review with NWIS support. The recommendations of the review were adopted by the Information Governance Review in September and are under implementation with improvements in Governance and Accountability Module Page 24 of 47 Board Meeting 24 April 2013 Agenda Item 2.5
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strongly disagree...... ….strongly agree 1 2 3 4 5 Supporting Narrative the availability and quality of information already evident.
The commissioning function is also being realigned to enable greater ownership and leadership through the localities and directorates.
The Quality and Safety Unit is working to embed functions previously managed centrally into Locality Team and Service Directorate systems and processes, such as effective approaches to risk management.
There has also been work undertaken to build the capacity of the localities and directorates, realigning resources from corporate functions. The teaching Health Board has also established a Programme Office to support the delivery of transformational change programmes and key annual plan objectives within a programme framework to ensure separation of business as usual and programme activity for governance and assurance processes.
Further dialogue and work is required to ensure cohesion between parts of the organisation, particularly geographical Locality Teams and Women & Children’s and Mental Health Directorates.
We properly safeguard 9 There continues to be strong performance in relation to safeguarding, including mature all those who work in and well functioning mechanisms such as: or access our health • MAPPA(multi-agency) services (including • LSCB (multi-agency) those who may • Child Protection Forum (teaching Health Board) accompany patients or • Youth Justice (multi-agency) services users), paying • Adult Protection Committee (multi-agency) particular attention to • Safe and Secure: children in the looked-after system (multi-agency) the needs of children Governance and Accountability Module Page 25 of 47 Board Meeting 24 April 2013 Agenda Item 2.5
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strongly disagree...... ….strongly agree 1 2 3 4 5 Supporting Narrative and vulnerable adults • Adult Protection Forum • Mental Health Act
Good progress has been made in focusing on the very causes of vulnerability, including development and implementation of the IFSS Service aiming to support families in difficulty due to substance misuse, protecting children and promoting family wellbeing. Recognition and inclusion of specific actions relating to vulnerability in the Mental Health Strategy, with mental health; ill-health being a significant factor for compromised parenting and personal vulnerability.
Further work is required to strengthen the links between the different parts of the safeguarding agenda and to embed this into both central and locality/services function. The development of a single Strategic Safeguarding Forum is proposed, reflecting the national direction of travel and will be implemented in April 2014.
The teaching Health Board also actively encourages Staff involvement in the health & safety agenda with staff partner Health & Safety Representatives as members of the Corporate Health & Safety Committee and other supporting groups.
The Health Board achieved Corporate Health Standard Gold Award this year through an active partnership based well being at work programme. We have well established Occupational health support services including a self referral counselling service for staff who may wish to access support. Employment policies to support staff to report bullying and harassment and staff concerns have been in operation for some years and are promoted at induction to ensure staff are aware of the support mechanisms in place.
We have the right 9 The Health Board has identified that there are significant problems with the estate facilities (equipment infrastructure that had not previously been assessed, fully recorded and risk assessed. and environment) to The organisation received three Health and Safety Executive improvement notices Governance and Accountability Module Page 26 of 47 Board Meeting 24 April 2013 Agenda Item 2.5
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strongly disagree...... ….strongly agree 1 2 3 4 5 Supporting Narrative enable us to during the year as evidence of some of these problems. An initial mapping exercise has consistently deliver been undertaken to assess the extent of the work required and a risk assessment and safe, high quality management plan put in place across the key estate compliance areas. A systematic services across all the assessment of each site by external consultants has been commissioned to assess the communities we serve works and actions required and an estates strategy is being prepared that will address the requirements arising. This issue extends to areas that include water infrastructure, asbestos, electrical infrastructure, medical gases, energy management and fire.
Strategic investments have been made in facilities, specifically to upgrade Llandrindod Theatres, and Brecon Theatres, which have enhanced the services for patients and will enable a wider range of services to be provided. Preparatory work on improving the quality of facilities in Builth Wells is nearing completion and a new facility with open in 2013. A business case for the improvement of the patient environment in Llandrindod Wells hospital was approved by the Board and Welsh Government and will be progressed to the next stage in 2013. A business case for improvements to accommodation in Bronllys Hospital was approved by the Board and initial funding secured to undertake anti-ligature works on the site and improve the IT facilities.
The Health Board’s health & safety procedures have been updated to ensure that guidance for dealing with Legionella is included. A Legionella policy and management plan has been produced and issued for consultation. Initial approval will be through the Infection Prevention & Control Committee (IP&CC) on the 27 February 2013. Refresher training on water temperature training for Estates staff has been provided; a review of water systems Powys-wide is being undertaken; a programme of regular water samples is in place and actions taken reflecting results, e.g. water temperature audits, flushing logs, disinfection regimes, use of filters and signs.
Water Consultants are currently providing professional support. Guidance is issued to Localities/ Service Directorates on confirmation of positive results to aid operational Governance and Accountability Module Page 27 of 47 Board Meeting 24 April 2013 Agenda Item 2.5
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strongly disagree...... ….strongly agree 1 2 3 4 5 Supporting Narrative management. Further action is being taken on each main site to establish flushing regimes and agree communication routes in the event of any elevated samples. These meetings involve site staff, estates staff and Heads of Departments.
Environmental workplace assessments are undertaken by the Health and Safety Team, together with staff partners, and the team is also involved in monitoring of medical devices and ergonomic assessment of equipment in the workplace for staff. This assessment and advice extends to development projects at an early stage to ensure safety by design principles, for example in the development of the stroke rehabilitation wards and in the Mansion House decant project.
There are many areas where facilities require significant improvement and where the teaching Health Board will need to develop a forward estates strategy that meets the requirements for improvement across compliance, patient environment and service development. This work is currently underway.
We support the 9 Quality and safety remains key to the organisation’s financial strategy. In order to build development and upon the progress made over the past two years, the teaching Health Board’s focus delivery of high quality, continues to be on:- safe and accessible services through • Pathway Development and Management to enable a greater proportion of care strong, effective (where safe to do so ) being provided closer to home, thus reducing the numbers of financial planning and patients to both English and Welsh providers (system change) management • A programme of repatriation to bring services back in Powys and into Wales (supplier change) • Maximising operational efficiency of preferred providers including Our own local services Primary Care provided services including GMS and prescribed drugs Challenging the price charged by English and Welsh providers. Governance and Accountability Module Page 28 of 47 Board Meeting 24 April 2013 Agenda Item 2.5
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strongly disagree...... ….strongly agree 1 2 3 4 5 Supporting Narrative Developing an efficient platform of back office functions with NHS Wales and with Powys County Council.
Our financial strategy in 2012/13 aims to achieve cost reduction of £17.252M (7.5%) through the implementation of our service, workforce and financial strategy. The targeted sums have been based on a range of benchmarked data, to ensure we are targeting appropriately.
Whilst a range of improvement actions had already been planned for the year in respect of supporting the organisation with good financial management support, we supplemented this with an internal review to assess our current financial management performance and from it designed an improvement programme. Actions and achievements include
• Becoming an accredited body for an Accounting Professional Body • Rolling out the HFMA Financial Management training programme to budget holders • Approving the recruitment of additional financial support to budget holders
In delivering our service and financial strategy we have been able to evidence that, for example, we have been able to bring services into the Powys geographical boundary that were previously only accessible to patients through travelling beyond our borders. This improvement has been achieved at reduced cost. We have also succeeded in keeping our emergency admission rate relatively flat within a context of rising demand.
Continuous improvement is being made to financial planning and management including review by external Consultant of Financial Planning, greater efficiency in use of resources resulting in 75% cost reduction, improved financial support to service directorates and localities and the exploration of financial incentives relating to quality of Governance and Accountability Module Page 29 of 47 Board Meeting 24 April 2013 Agenda Item 2.5
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strongly disagree...... ….strongly agree 1 2 3 4 5 Supporting Narrative care.
Our workforce at all 9 The teaching Health Board commissioned an independent review of its information levels in the services which was received in August with seven key recommendations. Clear and organisation/business immediate improvements are being taken forward including the appointment of a Head are equipped with the of Information. A Programme Office has been established as a consequence of one of information they need the recommendations. One of the Transformation Programmes for the Health Board will to help them carry out be to take forward the information review. Significant work has taken place to assess their work effectively, the potential for improvement in information services. Clear and immediate and this information is improvements have been made but further work is required. An action plan is in place to shared appropriately achieve this. and securely held Work is on-going to continuously improve communications with staff and the Local Partnership Forum is undertaking a review of the effectiveness of the various communications methods currently being used. The Corporate Health Standard assessment in February 2012 concluded that communications in the organisation were good with some exemplar examples. The staff intranet is a rich resource of information, including policies, news and useful links. This is reinforced by monthly staff briefings, targeted e-mailings etc. A staff magazine has also been introduced this year, which carries corporate news stories.
The development of a ward-based reporting tool is enabling staff to track and report patient safety incidents, such as pressure ulcers and falls. This is informing ward-based clinical improvements in care processes and outcomes.
Information Governance has been realigned as part of the executive portfolio review and is under the remit of the Quality & Safety Unit. This restructure has provided the opportunity to proactively progress the Information Governance agenda, including learning from incidents relating to information security that have occurred within the Governance and Accountability Module Page 30 of 47 Board Meeting 24 April 2013 Agenda Item 2.5
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strongly disagree...... ….strongly agree 1 2 3 4 5 Supporting Narrative organisation and across Wales and the UK. The newly formed Information governance Team is led by the Head of Information Governance, a new additional post established on an interim basis to accelerate progress in this area over the next 12 months.
An action plan is in place to achieve key audit recommendations which will be overseen by the re-established Information Governance Committee, a sub-committee of the Quality and Safety Committee. The Committee held its first meeting in January 2013.
Developments already underway include data protection and clinical records management training for all teams and included in staff induction, the launch of the patient records tracking project, the uploading and population of the publication scheme onto the Internet.
We are an innovative 9 As the organisation’s approach to risk management continues to mature, the key organisation/business organisational risks form a key part of the development of the Three Year and Annual that takes proper Plans and respective service objectives. The teaching Health Board plans to adopt and account of the risks ongoing approach which links its annual governance statement more closely to (both opportunities corporate priorities and the risks and barriers that present a threat to their achievement, and threats) to the as part of the Board Assurance Framework. achievement of our aims and objectives The Risk Management Strategy and Policy is in place and improvements to strategic risk management include clearer lines of accountability of the Risk Management Committee, which now reports to the Board of Directors, improvements in risk ownership, better processes for risk management and mitigation and a more succinct Board level risk register that helps the Board focus on key risk areas.
Active management of risks has been promoted across the geographical Locality Teams and Service Directorates. All risks are recorded via Datix and 6 monthly reports are received by the Board. Locality Teams and Service Directorates report risks Governance and Accountability Module Page 31 of 47 Board Meeting 24 April 2013 Agenda Item 2.5
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strongly disagree...... ….strongly agree 1 2 3 4 5 Supporting Narrative assessed as greater than 15 to the Risk Management Committee. High level risks are escalated to the Executive Team for consideration to go onto the Board’s corporate risk register.
Risk Assessment Training is included in Statutory & Mandatory Training Programmes and at Corporate Induction. Support in risk assessment and management is given by the Quality & Safety Unit to all teams at all levels within the organisation.
In relation to risk taking to promote innovation, the teaching Health Board is developing a number of programme areas that will transform the way in which services are delivered. One example is the development of a virtual ward and community resource team in South Powys, changing the pathways of care for in particular older people. This project has required appropriate risk taking in relation both to investment and the new ways of working.
Other areas such as elective care for children have been subject to review and increasingly more services are being provided in Powys. This has been well received so far indicating that the risk associated with changing pathways has been both considered and well managed.
The teaching Health Board is committed to promoting research and innovation, and holds an annual Research and Innovation Conference to showcase the work of its staff and partner organisations. We have strong, 9 The Board has established its Partnership Forum which is the formal partnership effective relationships mechanism where the Health Board’s Managers and Trade Unions work together to with our workforce, improve health services for the citizens of Powys. It is the forum where key stakeholders partners, citizens and will engage with each other to inform thinking around national and local priorities on other stakeholders health issues.
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strongly disagree...... ….strongly agree 1 2 3 4 5 Supporting Narrative Partnership working has been enhanced with the development of Locality Partnership Meetings, enabling locality managers and staff representatives to engage at a local level on service and operational matters. In October 2012, there was a successful partnership workshop, which explored techniques to improve engagement and partnership working.
The Stakeholder Reference Group continues to provide an important function in support of engagement with the teaching Health Board’s key stakeholders. The work programme for the group is established and provides opportunities to inform the strategic direction of the Board.
The teaching Health Board developed the Bridging the Gap Action Plan in Partnership with Powys Association of Voluntary Organisation to drive improvements in the development of effective working relationships with the voluntary sector. Progress is being made against the action plan, which is reviewed regularly in partnership with PAVO.
The Integrated Care Pathways for Older People Committee provides a mechanism for shared decision making and relationship building with Powys County Council Adult Social Services. Attended by members of the teaching Health Board executive team and senior managers in Adult Social Services it enables engagement and discussion around integrated service delivery initiatives such as the Joint Maturity Matrix, reablement services and planning around pooled budgets and shared services.
The CYPP remains strong with a high level of maturity. This results in consistent delivery of partnership plans.
The Local Safeguarding Children’s Board continues to develop with the teaching Health Board taking a key role in its success. Self assessment of the partnership working Governance and Accountability Module Page 33 of 47 Board Meeting 24 April 2013 Agenda Item 2.5
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strongly disagree...... ….strongly agree 1 2 3 4 5 Supporting Narrative arrangements and the effectiveness of dealing with the business takes place and a further self assessment exercise is due imminently.
Rapid and significant progress has been made during the year in achieving a partnership for Mental Health. The partnership includes the teaching Health Board, and the Local Authority (Social Services, Children’s Services, Education, Leisure) and has developed the Hearts and Minds Mental Health Strategy.
In terms of staff engagement, the teaching Health Board provides opportunities for Board members to meet and talk with ward-based staff. Executive and Non Officer Member of the Board conduct joint “Leadership Walkrounds” of hospital sites in order to better engage with staff and learn about good practice and staff concerns related to patient safety. Further work is underway to ensure issues raised by staff are taken forward through a learning and service improvement process and plans are in place to extend the walkrounds to include non-hospital based sites.
The teaching Health Board is a key committed member of the Local Service Board and through this forum is strengthening its partnership working. The work of the Local Service Board is underpinned by a Thematic Partnership Network, with representation from all key partners, with the aim of ensuring effectiveness of partnership arrangements.
Decisions taken 9 The Board has developed and agreed its Scheme of Delegation ensuring that all throughout our Executive Directors have appropriate decision making authority. organisation are made by those best placed to Further work is underway to enable decision making by teams as close to the patient as do so, are well possible. This is based on Aston Team Based Working methodology. informed, timely and are effectively Clear arrangements exist for partnership working, with sovereign bodies having this key Governance and Accountability Module Page 34 of 47 Board Meeting 24 April 2013 Agenda Item 2.5
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strongly disagree...... ….strongly agree 1 2 3 4 5 Supporting Narrative communicated decision making authority.
THEME 2 – ENABLING DELIVERY: Your overall assessment
In relation to this particular theme, what is your overall assessment of where and how you: 1. Are governing well • The Risk Management Strategy and Policy is in place and improvements to strategic risk management include clearer lines of accountability of the Risk Management Committee, which now reports to the Board of Directors, improvements in risk ownership, better processes for risk management and mitigation and a more succinct Board level risk register that helps the Board focus on key risk areas. • Rapid and significant progress has been made during the year in achieving a partnership for Mental Health. The partnership includes the teaching Health Board, and the Local Authority (Social Services, Children’s Services, Education, Leisure) and has developed the Hearts and Minds Mental Health Strategy.
2. Need to strengthen your arrangements • The establishment of a Programme Office to support the delivery of transformational change programmes and key annual plan objectives within a programme framework will ensure separation of routine business and programme activity for governance and assurance processes. • Further dialogue and work is required to ensure cohesion between parts of the organisation, particularly geographical Locality Teams and Women & Children’s and Mental Health Directorates. • Further work is required to strengthen the links between the different parts of the safeguarding agenda and to embed this into both central and locality/services function. • The Health Board has identified the need to develop and implement an estates strategy to address outstanding problems with the estate infrastructure.
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3. Have noteworthy practice you may wish to share
• Powys teaching Health Board developed an integrated workforce plan in May 2012. It demonstrates significant improvements, having matured from a corporate level analysis to a more localised plan, with better anticipation of future service workforce needs. This has been commended by NLIAH and the progress also noted by the Wales Audit Office. • In relation to risk taking to promote innovation, the teaching Health Board is developing a number of programme areas that will transform the way in which services are delivered. One example is the development of a virtual ward and community resource team in South Powys, changing the pathways of care for in particular older people. This project has required appropriate risk taking in relation both to investment and the new ways of working.
What maturity level have you demonstrated you have reached for this theme overall:
• We are developing plans and processes and can demonstrate progress with some of our key areas for improvement
In relation to this particular theme, what are your priorities for improvement, what action are you going to take (and when) and how will you measure your success?
Actions arising from this module will be included within the teaching Health Board’s Standards for Health Services Improvement Plan, tHB Annual Plan, and so both documents should be read in unison. Particular actions arising from this theme are as follows:-
1. Executive Directors working to fully delegate appropriate accountability to Teams and Locality and Directorate Managers, ensuring cohesion between parts of the organisation, e.g. Locality Teams and Directorates 2. Develop a forward estates strategy 3. Ensure that the Programme Office is fully functioning to support Transformation Programmes such as Information Services and the clinical change programmes 4. Action plans to achieve key audit recommendations to be overseen by re-established Information Governance Committee 5. To adopt an ongoing approach which links the annual governance statement more closely to corporate priorities 6. Fully participate in development and application of new Workforce Tools to ensure vigour is applied to determining safe staffing levels 7. Continue to strengthen the approach for management of Board level risk. 8. Further work will be undertaken to build capacity for integrated planning across service, finance and workforce
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THEME 3 – DELIVERING RESULTS, ACHIEVING EXCELLENCE Desired outcomes:
We provide high quality and accessible health services in a manner that ensures equity of access and minimises waste, harm and variation We build on our strengths and take early, decisive action to improve services where we need to We learn from our own and others experience to continuously improve the provision of health services We contribute to the overall improvement of health services in Wales by sharing our learning with others
We can demonstrate that:
Strongly disagree…………………………..strongly agree 1 2 3 4 5 Supporting Narrative We have a clear 9 The Board regularly receives an Integrated Performance report which provides a holistic understanding of view of performance against the WG tier 1 and 2 targets and the core priorities identified in how well we are the Annual Plan. The Integrated Performance Report has been redeveloped to enable the performing overall, teaching Health Board to measure and report on a broader range of performance indicators what services are and will continue to develop supported by improved information capacity. The information doing well, and function has developed a suite of information available on desktop for locality managers to what services need access and report. improving (including those A Quality Assurance Framework is under development to provide greater robustness in the services that are reporting of information relating to quality of service provision required from external carried out by providers. This will inform the locality based contract review process and will be included in others on our the Annual Quality Statement to be published from September 2013. behalf). We respond quickly The Quality and Safety Committee maintains oversight of clinical incident management and and effectively to identifies where it needs further improvements in clinical assurance. The Quality and Safety address areas of Unit oversees processes around concerns raised regarding contracted and externally concern, including provided services, such as those relating to Primary Care, and provides assurance to the Governance and Accountability Module Page 37 of 47 Board Meeting 24 April 2013 Agenda Item 2.5
FOR APPROVAL those relating to Board that appropriate processes are followed. individuals’ performance Locality Teams and Service Directorates actively participate in the performance review and management arrangements put in place by the Executive Team to discuss all performance related issues including staff performance. Improved quality and timeliness of information is making this more effective, and this will be further enhanced following the completion of the Information Review and associated work.
Performance appraisal processes are embedded in the teaching Health Board with requirement for all staff to participate in both an annual objective setting meeting and performance review and to have a personal development plan. The rate of appraisals has remained at around 50% despite concerted action to increase the incidence. Further work is underway to target underperforming areas and more is required to improve the rate of participation
The HB has in place a well established employment policy for the management of capability and the Workforce function provides advice and support to line mangers in its application.
As a result of the need to develop a new Mental Health strategy the engagement phase with citizens, service users and carers has resulted in a rich and comprehensive source of feedback. This has been instrumental in developing the strategy and then re-testing with citizens and other stakeholders.
In relation to standards of care in community hospitals, the Fundamentals of Care Patient Experience tool has been reviewed and redesigned and is now being used for every patient who is discharged from hospital. This tells us on a more ‘real time’ basis than previously the feelings of patients toward the care they received and their care givers. In Maternity COOS cards (Comment on our service) are being used and changes made as a result.
Further work is required to ensure that the teaching Health Board is able to effectively collate and report on the findings from such surveys; and that areas not yet using a routine and established patient feedback mechanism are supported in implementing one as soon
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as possible.
We operate in 9 The Board has developed and agreed its Scheme of Delegation ensuring that all Executive accordance with all Directors have delegated authority and responsibility for ensuring that all requirements legal and other placed upon the teaching Health Board are delivered. The Board has established its requirements committee structure and all committees play a role in providing the Board with assurance placed on us that the organisation is compliant with requirements.
Moving forward, the Board will agree its Assurance Framework which will determine all legal and other requirements placed upon the teaching Health Board and outline the sources of assurance available to the Board in satisfying itself that all are delivered.
New Measures have been introduced during this year including the Mental Health measure. Our Part 1 Mental Health measure Scheme for Local Primary Mental Health Support services met legislative requirements through its design and is currently being implemented. A full review of progress in meeting the requirements in practice will be undertaken during March and April. Other examples of inclusion in new legislation include the Child and Families measure which the teaching Health Board is taking forward jointly with the Local Authority.
The teaching Health Board was served with three improvement notices during the year from the Health and Safety Executive. These related to requirements for a management plan for Asbestos which was discharged following approval of a Plan by the Board of Directors, the requirements for a water management plan for Llandrindod Hospital which was discharged following the agreement of a Plan, and a requirement for a training programme for all staff on asbestos which remains extant and work in progress to meet this requirement.
We know what our 9 The teaching Health Board has structured engagement processes in place for staff citizens and others including a Corporate Partnership Forum, Locality Partnership Meetings, electronic based (including our communication such as Ask the Chief Executive and further work is required on an internal workforce) think of communications strategy, to systematically gain, record and act on the views of staff. The us, and this teaching Health Board will also be participating in the all Wales staff survey in January Governance and Accountability Module Page 39 of 47 Board Meeting 24 April 2013 Agenda Item 2.5
FOR APPROVAL influences what we 2013. do and how we do it The teaching Health Board has introduced a system to actively monitor the print and social media in respect of Powys teaching Health Board, and to respond as appropriate.
As a result of the need to develop a new Mental Health strategy the engagement phase with citizens, service users and carers has resulted in a rich and comprehensive source of feedback. This has been instrumental in developing the strategy and then re-testing with citizens and other stakeholders.
In relation to standards of care in community hospitals, the Fundamentals of Care Patient Experience tool has been reviewed and redesigned and is now being used for every patient who is discharged from hospital. This tells us on a more ‘real time’ basis than previously the feelings of patients toward the care they received and their care givers. In Maternity COOS cards (Comment on our service) are being used and changes made as a result.
Further work is required to ensure that the teaching Health Board is able to effectively collate and report on the findings from such surveys; and that areas not yet using a routine and established patient feedback mechanism are supported in implementing one as soon as possible.
We measure our 9 The Executive team and professional leads within the organisation are fully appraised, performance through peer and professional networks, of National, UK-wide and international research against “best findings and publications which provide evidence of best practice in planning and provision practice” and other of clinical services. Recommendations and guidance from National clinical programmes standards set for and research bodies such as NICE, together with National Delivery Frameworks, inform the services we appraisal and review of current practice. All professional staff are expected to actively provide and we use engage in continuous professional development, and to implement learning into practice the results to drive from a variety of sources, including informal and formal research findings. improvement in the provision of high Through regular engagement in audit, both clinical and non-clinical, teams are able to quality, safe and demonstrate effectiveness in service delivery and assess the impact of change in service Governance and Accountability Module Page 40 of 47 Board Meeting 24 April 2013 Agenda Item 2.5
FOR APPROVAL accessible design. However there is a need to ensure that there is greater consistency in the services approach to clinical audit across and between teams. The teaching Health Board has recently introduced a new system for monitoring and reporting on clinical audit, both nationally and locally driven, to support the development of a more coordinated and systematic approach. Plans in place to build on the skills of the workforce in quality improvement methodology will support this development.
The 1000 Lives Plus Quality Improvement Programme continues to deliver good results. There is however some inconsistency in achievement and further work is underway both the understand the needs of the different parts of the organisation in relation to QI and the more systematic reporting of outcomes from programme areas.
As part of the development of our Mental Health Strategy, understanding best practice elsewhere will continue to be fundamental. Making links with organisations across the U.K. and beyond will continue to be essential. There is further work to do if we are to compare ourselves against other similar organisations in terms of comparability.
We learn from our 9 Staff at every level in the organisation are actively encouraged to engage in learning own and others networks across Wales. This ranges from condition-specific fora, such as Cancer and experiences, and in Stroke networks and alliances to broader-based networks, such as the Patient Experience turn share our and Carers Networks. Learning lessons from adverse incidents has been a key focus this learning with year and learning across Wales has been facilitated through participation in Risk and others Concerns networks.
A Standards for Health Services Good Practice Exchange has been established to support sharing and learning between teams, clinical and non-clinical, across the organisation. Innovative approaches to engaging staff and teams have been adopted across Wales this year – these include posters developed in Powys, now adapted for use by other HBs. The Third Sector Toolkit developed with PAVO has been adapted and shared across Wales through the National Quality and Safety Forum.
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Within the teaching Health Board lessons learned from adverse incidents and from patient and staff feedback are shared internally via newsletters, face-to-face feedback, via committees and local meetings. The alerts process has been reviewed and an updated alerts policy and process is currently being put in place.
The teaching Health Board hosted a conference in October with a range of internal and external representatives to explore how it could develop a learning culture to promote innovation, sharing good practice and learning. An agreed range of actions is being taken forward including developing the ‘faculty’ to share good practice and learning; a programme of management seminars with external and internal experts; promoting good practice and lessons through all core communications forums such as newsletters, Key Brief; training and education events etc.
75 staff have attended programmes of improvement and modernisation with plans to extend this more widely across the organisation as part of the national programme to train 25% of the workforce in improvement methodology.
Professional Learning The first Therapy and Health Science Conference, “The Best Kept Secret” was held in October. The conference was well attended by all eight professions with a strong focus on learning from national examples from fitness to practice hearings, responsibilities for safer practice, effective multi-disciplinary team-based working and innovations in research and development.
An annual programme of sharing across nursing and midwifery on the organisation has been implemented. This has included the Nursing and Midwifery Conference held in December, “Inspiring Excellence”, showcased practice developments and at which the Chief Nursing Officer for Wales provided a key note address. Other events have included a ‘Question Time’ style open questions and answers session for nurses and midwives across the organisation. A programme of learning and sharing sessions have been held throughout the year for facilitators and implementers of Transforming Care. This has enabled a broader view of improvement including maternity, hospital, theatres and community care. Governance and Accountability Module Page 42 of 47 Board Meeting 24 April 2013 Agenda Item 2.5
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The teaching Health Board continues to be an enthusiastic supporter of the 1000 Lives Plus programme recently beginning work in new programme areas including Primary Care and inpatient Oral Health provision, with Life After Stroke commencing in February 2013. The existing work areas continue to attract national and international interest with learning shared throughout Wales on the community midwifery “Are you feeling well” assessment method and on the combined inpatient/community care approach taken to reduce the incidence of catheter associated infections. Interest in the teaching Health Board’s work in adapting the critical care NEWS observation system has been shown by other Welsh health Boards, Irish and Australian Health care bodies and the Welsh prison service. Experience gained as part of our pressure area damage reduction programme has also been shared with residential and nursing homes throughout the county.
Research and Development The Powys teaching Health Board Research and Development team has been successful in attracting the first commercial clinical trial into the Powys area in a new agreement with the pharmaceutical company Novo Nordisk.
Powys teaching Health Board has been successfully recruited as a clinical trial centre taking part in a multicentre research study based at Leeds University investigating the effect of dopamine on learning and recovery after stroke. It is hoped 10 patients will be recruited and that it is an opportunity for staff involved to improve their understanding of research and also of specific outcome measures.
THEME 3 – DELIVERING RESULTS, ACHIEVING EXCELLENCE: Your overall assessment
In relation to this particular theme, what is your overall assessment of where and how you: 1. Are governing well
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• Locality Teams and Service Directorates actively participate in performance review and management arrangements put in place by the Executive Team to discuss all performance related issues including staff performance. Improved quality and timeliness of information is making this more effective, • In relation to standards of care in community hospitals, the Fundamentals of Care Patient Experience tool has been reviewed and redesigned and is now being used for every patient who is discharged from hospital. This tells us on a more ‘real time’ basis than previously the feelings of patients toward the care they received and their care givers.
2. Need to strengthen your arrangements
• A Quality Assurance Framework relating to the reporting of information relating to quality of service provision required from external providers will inform the locality based contract review process and will be included in the tHB Annual Quality Statement • The organisation needs to develop a consistent approach to quality improvement, through regular engagement in audit, both clinical and non-clinical. • Performance appraisal processes are embedded across the teaching Health Board with requirement for all staff to participate in both an annual objective setting meeting and performance review and to have a personal development plan. The rate of appraisals has remained at around 50% despite concerted action to increase the incidence. Further work is underway to target underperforming areas and to improve the rate of participation.
3. Have noteworthy practice you may wish to share
• Interest in the teaching Health Board’s work in adapting the critical care NEWS observation system has been shown by other Welsh health Boards, Irish and Australian Health care bodies and the Welsh prison service. • The Powys teaching Health Board Research and Development team has been successful in attracting the first commercial clinical trial into the Powys area
What maturity level have you demonstrated you have reached for this them overall:
• We are developing plans and processes and can demonstrate progress with some of our key areas for improvement
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In relation to this particular theme, what are your priorities for improvement, what action are you going to take (and when) and how will you measure your success?
Actions arising from this module will be included within the teaching Health Board’s Standards for Health Services Improvement Plan, the tHB Annual Plan, and so both documents should be read in unison. Particular actions arising from this theme are as follows:-
1. Develop an Assurance Framework which will determine all legal and other requirements placed upon the teaching Health Board and outline the sources of assurance available to the Board in satisfying itself that all are delivered. 2. Develop a Quality Assurance Framework to provide greater robustness in the reporting of information relating to quality of service provision required from external providers. This will inform the Locality based contract review process and will be included in the Annual Quality Statement to be published from September 2013 3. Establish a consistent and systematic approach to reporting and learning from clinical audit across all services 4. Further develop the Integrated Performance Report and supporting infrastructure to ensure focus and information have direct alignment with the Annual Plan 5. Further develop an internal communications strategy, to systematically gain, record and act on the views of staff 6. Participate in the national programme of work to build the skills of the workforce in quality improvement methodology 7. Develop a Board Business Cycle to determine reporting requirements of the Board 8. Survey the experience of users of external services 9. In light of the Francis Review, national work on professionalism to be considered and applied where appropriate
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APPENDIX 2: SUMMARY AND COMPARISON TO 2011/12 Rating 2011/12 Rating 2012/13 Scale Scale
Theme 1- Setting the Direction 1 2 3 4 5 1 2 3 4 5
We make an effective contribution to the achievement of 1.1 the strategic vision for health services in Wales = We have a clear purpose, vision and overall strategic 1.2 direction that effectively aligns our local needs with the national strategy for health services in Wales: = Our citizens, staff and other stakeholders inform and 1.3 influence our organisation/business’s purpose, strategic vision and direction: =
We carry out our work instilled with a strong sense of 1.4 values, supported by clear standards of ethical behaviour ↑
We promote equality and recognise diversity across all our 1.5 services and activities = We apply and embed professional standards and equality requirements in a way that meets the needs and 1.6 expectations of patients, service users, citizens and other stakeholders = Theme 2 – Enabling Delivery
We have the right people with the right skills doing the right 2.1 things n the right place and at the right time to meet our responsibilities for the provision of safe, high quality care = The different services and parts of our 2.2 organisations/business work well together, and everyone understands who does what and why = We properly safeguard all those who work in or access our health services (including those who may accompany 2.3 patients or services users), paying particular attention to the needs of children and vulnerable adults = We have the right facilities (equipment and environment) to 2.4 enable us to consistently deliver safe, high quality services across all the communities we serve ↓ We support the development and delivery of high quality, 2.5 safe and accessible services through strong, effective financial planning and management ↓ Our workforce at all levels in the organisation/business are equipped with the information they need to help them carry 2.6 out their work effectively, and this information is shared appropriately and securely held = We are an innovative organisation/business that takes 2.7 proper account of the risks (both opportunities and threats) to the achievement of our aims and objective =
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We have strong, effective relationships with our workforce, 2.8 partners, citizens and other stakeholders ↑ Decisions taken throughout our organisation are made by 2.9 those best placed to do so, are well informed, timely and are effectively communicated = Theme 3 – Delivering Results, Achieving Excellence
We have a clear understanding of how well we are performing overall, what services are doing well, and what services need improving (including those services that are 3.1 carried out by others on our behalf). We respond quickly and effectively to address areas of concern, including those relating to individuals’ performance =
We operate in accordance with all legal and other 3.2 requirements placed on us = We know what our citizens and others (including our 3.3 workforce) think of us, and this influences what we do and how we do it = We measure our performance against “best practice” and other standards set for the services we provide and we use 3.4 the results to drive improvement in the provision of high quality, safe and accessible services. =
We learn from our own and others experiences, and in turn 3.5 share our learning with others ↑
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BOARD MEETING 24 APRIL 2013 AGENDA ITEM 2.6
POWYS TEACHING HEALTH BOARD STROKE DELIVERY PLAN 2013-16
Report of Director of Therapies and Health Science
Paper prepared by Consultant Therapist for Stroke and Neurorehabilitation
Purpose of Paper To present to the Board the Powys tHB Stroke Delivery Plan 2013-16
Action/Decision required The Board is asked to APPROVE the Powys tHB Stroke Delivery Plan 2013-16
Link to ‘Doing Well, This paper supports Standards: Doing Better: Standards 3. Health Promotion, Protection and Improvement for Health Services in 5. Citizen Engagement and Feedback Wales’: 7. Safe and Clinically Effective Care 8. Care Planning and Provision 21. Research, Development and Innovation 26. Workforce Training and Organisational Development
Link to Health Board’s Improving health and well-being Corporate Plan Ensuring the right access Striving for excellence Involving the people of Powys Making every pound count Acronyms and WG – Welsh Government abbreviations PtHB - Powys teaching Health Board NICE – National Institute of Clinical Excellence RCP – Royal College of Physicians
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POWYS TEACHING HEALTH BOARD STROKE DELIVERY PLAN 2013-16
Purpose
The purpose of this paper is to present to the Board the Powys tHB Stroke Delivery Plan 2013-16.
Background
“Together for Health – Stroke Delivery Plan” was published in December 2012 and provides a framework for action by Local Health Boards and NHS Trusts working together with their partners. It sets out the Welsh Government’s expectations of the NHS in Wales to tackle stroke in people of all ages, wherever they live in Wales and whatever their circumstances. The Plan is designed to enable the NHS to meet the needs of people at risk of a stroke or affected by a stroke. It sets out expectations with regard to:
population outcomes outcomes from treatment and support to return to health and independence how success will be measured and the level of performance themes for action by the NHS, together with its partners
In response to this Plan, Health Boards are required, together with their partners, to produce and publish a detailed local service delivery plan to identify, monitor and evaluate action needed within timescales. The LHB Executive Lead for Stroke is required to report progress formally to the Board against milestones in the delivery plan and publish these reports on the Health Board website quarterly.
Aim of the Delivery Plan
For our population we want: People of all ages to have a minimised risk of having a stroke and, where it does occur, an excellent chance of surviving and returning to independence as quickly as possible. Powys to have stroke incidence and mortality rates comparable with the best in Europe.
We will use the following overarching indicators to measure success: Stroke incidence rates Cerebrovascular mortality rates (European Age Standardized Rates) Level of disability Stroke survival rates (30 days)
Powys teaching Health Board will continue to commission and deliver high quality services that meet the needs of those individuals in Powys affected by stroke, in partnership with the local authority and third sector. Patient and carer experience and outcomes will be central to planning and commissioning of stroke services and service user feedback and engagement will be used to drive improvements in quality of care.
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Drivers
The Welsh Government Stroke Delivery Plan sets out clear reasons why stroke remains a top priority for the NHS in Wales:
It is one of the top three causes of death It is estimated there are around 11,000 stroke events, including 6,000 new strokes, per year in Wales1. Childhood stroke affects around five out of every 100,000 children a year in the UK.2 25 per cent of strokes occur in people who are under the age of 65 It is a leading cause of adult disability3 It has a higher risk for certain ethnic minorities 20–30 per cent of people who have a stroke die within a month Circulatory disease (includes stroke and cardiac disease) accounts for 8.7% of all NHS Expenditure in Wales. In 2010 -11 this amounted to £464.4 million – the second highest area of expenditure for the NHS.
What do we want to achieve?
Each year in Powys approximately 200 people experience an acute stroke. The evidence indicates that early recognition of the symptoms and fast access to appropriate treatment after a stroke has a direct impact on the outcome in terms of survival and level of long term disability. Furthermore, access to intensive and longer term rehabilitation in the appropriate setting supports recovery and the adjustment of a person affected by stroke to living with any residual disability. Emotional and social support is crucial for patients and their families/carers to adjust to a change in lifestyle after a stroke (NICE 2012, 2013; RCP 2012).
The Powys teaching Health Board Stroke Delivery Plan sets out actions to improve outcomes in the following key areas between now and 2016:
1. Preventing stroke- People live a healthy lifestyle, make healthy choices and minimise risk of stroke 2. Detecting stroke quickly- Stroke is detected quickly where it does occur or recur 3. Delivering fast, effective care - People receive fast, effective treatment and care so they have the best chance of living a long and healthy life 4. Supporting life after stroke - People are placed at the centre of stroke care with their individual needs identified and met so they feel well supported and informed, able to manage the effects of stroke 5. Improving Information
1 Estimated figures based on the Welsh population and incident rate. 2 Royal College of Physicians. (2004) Care after stroke in childhood. Information for parents and families of children affected by stroke. Lavenham Press Ltd; Suffolk. Pg. 5 3 National Audit Office, 2005, Reducing Brain Damage: Faster access to better stroke care, London, NAO – Figures relate to England and Wales. Stroke Delivery Plan Page 3 of 4 Board Meeting 24 April 2013 Agenda Item 2.6
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6. Targeting research
Recommendation
The Board is asked to consider and APPROVE the Powys tHB Stroke Delivery Plan for 2013-16
Report prepared by: Presented By: Michelle Price Dr Amanda Smith Consultant Therapist for Stroke and Director of Therapies and Health Neurorehabilitation Science Dr Amanda Smith Director of Therapies and Health Science
Background Papers NICE Technical Appraisal 264, National Institute for Health and Clinical Excellence, 2012
Stroke Pathway, National Institute for Health and Clinical Excellence, 2013
Intercollegiate Stroke Working Party. National clinical guideline for stroke, 4th edition. London: Royal College of Physicians, 2012. Financial Consequences As determined by the report
Other Resource Implications As determined by the report
Consultees Powys tHB Stroke Steering Group
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Powys teaching Health Board Stroke Delivery Plan 20132016
BACKGROUND AND CONTEXT
“Together for Health – Stroke Delivery Plan” was published in December 2012 and provides a framework for action by Local Health Boards and NHS Trusts working together with their partners. It sets out the Welsh Government’s expectations of the NHS in Wales to tackle stroke in people of all ages, wherever they live in Wales and whatever their circumstances. The Plan is designed to enable the NHS to meet the needs of people at risk of a stroke or affected by a stroke. It sets out expectations with regard to:
population outcomes outcomes from treatment and support to return to health and independence how success will be measured and the level of performance themes for action by the NHS, together with its partners
The vision:
For our population we want:
People of all ages to have a minimised risk of having a stroke and, where it does occur, an excellent chance of surviving and returning to independence as quickly as possible. Powys to have stroke incidence and mortality rates comparable with the best in Europe.
We will use the following indicators to measure success:
Stroke incidence rates Cerebrovascular mortality rates (European Age Standardized Rates) Improved level of disability Stroke survival rates (30 days)
Powys teaching Health Board will commission and deliver high quality services in partnership with local authority and third sector services that meet the needs of the individuals in Powys affected by stroke.
The Drivers:
There are clear reasons why stroke remains a top priority for the Welsh Government:
It is one of the top three causes of death
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It is estimated there are around 11,000 stroke events, including 6,000 new strokes, per year in Wales1. Childhood stroke affects around five out of every 100,000 children a year in the UK.2 25 per cent of strokes occur in people who are under the age of 65 It is a leading cause of adult disability3 It has a higher risk for certain ethnic minorities 20–30 per cent of people who have a stroke die within a month Circulatory disease (includes stroke and cardiac disease) accounts for 8.7% of all NHS Expenditure in Wales. In 2010 -11 this amounted to £464.4 million – the second highest area of expenditure for the NHS.
What do we want to achieve?
Each year in Powys approximately 200 people are admitted to hospital with an acute stroke. The evidence indicates that early recognition of the symptoms and fast access to appropriate treatment after a stroke has a direct impact on the outcome in terms of survival and level of long term disability. Furthermore, access to intensive and longer term rehabilitation in the appropriate setting supports recovery and the adjustment of a person affected by stroke to living with any residual disability. Emotional and social support is crucial for patients and their families/carers to adjust to a change in lifestyle after experiencing the often devastating effect of a stroke.
The Powys tHB Delivery Plan sets out actions to improve outcomes in the following key areas between now and 2016:
1. Preventing stroke- People live a healthy lifestyle, make healthy choices and minimise risk of stroke
2. Detecting stroke quickly- Stroke is detected quickly where it does occur or recur
3. Delivering fast, effective care - People receive fast, effective treatment and care so they have the best chance of living a long and healthy life
4. Supporting life after stroke - People are placed at the centre of stroke care with their individual needs identified and met so they feel well supported and informed, able to manage the effects of stroke
5. Improving Information
6. Targeting research
1 Estimated figures based on the Welsh population and incident rate. 2 Royal College of Physicians. (2004) Care after stroke in childhood. Information for parents and families of children affected by stroke. Lavenham Press Ltd; Suffolk. Pg. 5 3 National Audit Office, 2005, Reducing Brain Damage: Faster access to better stroke care, London, NAO – Figures relate to England and Wales.
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ORGANISATIONAL PROFILE
Organisational Overview
Powys teaching Health Board is characterised as a primary care and community services organisation, that commissions the majority of secondary care provision on both an emergency and planned basis from neighbouring Health Boards and English NHS Trusts. There are approximately 200 new acute strokes per year. Acute stroke services are provided by 5 main acute hospitals: Royal Shrewsbury, Nevill Hall, Hereford, Morriston and Bronglais.
Approximately 40% of people who have been admitted to a stroke unit are discharged straight home from the acute stroke units while 40% are transferred back to Powys community stroke units for ongoing rehabilitation.
Although there are nine community hospitals in Powys, stroke rehabilitation has been focused on two sites, Newtown and Bronllys, to facilitate the development of multi-disciplinary team working in line with National Stroke Guidelines. These two sites have both been fully engaged with the Stroke Rehabilitation Collaborative through the 1000 Lives Programme for the past four years.
Overview of Local Health Need and Stroke Challenge
Risk of stroke increases with age. Powys, as other health Boards across Wales, has an aging population, which means there is going to be an increase in demand on stroke services over the next 30 years as shown in Figure 1 below.
Fig 1. Application of current Stroke rates to population projections (stacked)
Application of current level of hospital activity to population projections, spells with a primary diagnosis of stroke (ICD10 I60 - I69) in any episode, Powys resident population, all persons Produced by Public Health Wales Observatory, using PEDW(NWIS), MYE (ONS) & Population Projections (WG)
1,000 85+ 75-84 65-74 15-64 900 800 700 600 500 400 300 Number of of Number spells 200 100 0 Baseline 2013201620192022202520282031 (average of 2008-10)
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Powys tHB is responsible for providing and commissioning stroke services for approximately 125,000 people over a geographical area of 5,179 km², which equates to 4% of the population of Wales in 25% of the total landmass of Wales. It has the lowest population density in Wales. The mountainous terrain makes travel by road slow. The low population density and long travel times, often on minor roads, are a challenge to ensuring timely access to acute services and potential life-saving treatment, such as thrombolysis. The rurality presents a further challenge in maintaining a skilled workforce to provide high quality rehabilitation for patients in the community after discharge and access to long term stroke support services and groups. Development of these services will require a flexible and innovative approach and close working relationships with social care and third sector partners.
Recommendations from a recent review of stroke services across the Midlands and East of England are expected to lead to the redesign of provision of hyper acute and acute stroke services in the two English trusts that currently provide acute and hyper-acute stroke care for approximately half of Powys residents. These are Wye Valley NHS Trust, in the Hereford and Worcester Cardiac and Stroke Network, and Shrewsbury and Telford Hospitals Trust, part of the Shropshire and Staffordshire Network. The focus of the review has been on improving the quality and sustainability of stroke services; however, changes to location in provision of hyper-acute services in the two networks has the potential to impact on timely access to high quality stroke care, specifically to thrombolysis, for Powys residents.
The development of the South Wales Plan presents similar challenges for Powys residents as services are reconfigured, with the potential to impact on travel times for patients accessing services from within Wales. Medical retrieval by air ambulance is a factor that will need to be considered as part of the solution to ensuring timely access to acute services.
DEVELOPMENT OF POWYS TEACHING HEALTH BOARD LOCAL DELIVERY PLAN for STROKE
In response to the “Together for Health – Stroke Delivery Plan” (2012), Health Boards are required, together with their partners, to produce and publish a detailed local service delivery plan to identify, monitor and evaluate action needed within timescales. The LHB Executive Lead for Stroke is required to report progress formally to the Board against milestones in the delivery plan and publish these reports on the Health Board website quarterly.
In Powys, planning and oversight of the implementation of the local stroke delivery plan is the delegated responsibility of the Director of Therapies and Health Science and discharged through the Stroke Steering Group. This is a multi-agency group which is accountable to the Powys tHB Board of Directors and provides regular progress reports to the Board through the Quality and Safety Committee. Membership includes representatives from the teaching Health Board executive, the clinical teams, primary care, third sector, including the Stroke Association, social services, Welsh Ambulance Service
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Trust (WAST), the Community Health Council and the Delivery and Support Unit arm of Welsh Government. Representatives from acute stroke service providers are also invited to attend.
The Powys tHB Stroke Delivery Plan has been developed to reflect the organisational priorities for securing and delivering high quality and safe care for the population of Powys, as set out in the overarching Powys teaching Health Board Three Year Plan.
SUMMARY OF THE PLAN - THE PRIORITIES FOR 2013 - 14
The key actions from “Together for Health - Stroke Delivery Plan” (2012) have been incorporated into the Powys teaching Health Board Local Delivery Plan for stroke services. Powys tHB Stroke Steering group has agreed the following priorities for improving stroke services in Powys for the first year of the plan, 2013-14. These priorities will be further developed over the duration of the three year plan.
1. Preventing stroke
The priorities for 2013 – 14 are: • Engaging in the Health, Social Care and Wellbeing agenda with partner organisations • Improving the percentage of the population who have cardiovascular risk factors, atrial fibrillation and high risk TIAs appropriately managed. • Embedding secondary prevention measures into inpatient care and long term follow up reviews
2. Detecting stroke quickly
The priorities for 2013 – 14 are: • Supporting public health campaigns on detecting and acting on signs of stroke quickly • Working with and monitoring performance of WAST to ensure their ambulance clinicians are competent at identifying suspected stroke and responding accordingly • Ensuring all GPs are aware of the stroke pathway of their local acute stroke unit
3. Delivering fast, effective treatment and care
The priorities for 2013 – 14 are: • Engaging in the evaluation and implementation of recommendations from the NHS Midlands and East Stroke review and the commissioning of services from our English providers to ensure that Powys patients are able to access high quality hyperacute stroke units within 60 minutes of onset of symptoms. • Engaging in the development of the South Wales Plan to ensure the same level of quality and access is available for patients requiring services from within Wales.
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• Ensuring timely access to TIA services for all Powys patients
4. Supporting life after stroke
The priorities for 2013 – 14 are: • Developing skills and capacity in community teams, specifically reablement, to ensure timely access to appropriate support for patients returning home after discharge • Ensuring patients’ ongoing needs are reviewed by an appropriately skilled health or social care professional 6 weeks, 6 months and 12 months after leaving hospital
5. Improving Information
The priorities for 2013 – 14 are: • Developing service user involvement and having a focus group for stroke survivors as part of planning Life after Stroke Services. • Develop register of interest for people in Powys affected by stroke to get involved in stroke service development. The target is to have 100 people on this register by March 2014.
6. Targeting Research
The priorities for 2013 – 14 are: • Developing research capacity and registering as a research site with one appropriate multicentre trial
PERFORMANCE MEASURES/MANAGEMENT
The Welsh Government’s Delivery Plan for Stroke (2012) contains an outline description of the national metrics that LHBs and other organisations will publish to demonstrate performance against the Local Delivery Plan. This will include information relating to the achievement of improvement in the effectiveness of stroke services as demonstrated by the overarching outcome indicators: • Stroke Incidence rates • Stroke mortality rates (Cerebrovascular) • Stroke survival rates (30 days)
Performance measures will include information from providers of commissioned services as well as relating to services provided by the teaching Health Board and be monitored and reviewed over the three year period 2013-16:
1. Public Awareness and Health Prevention
Overarching Indicator • Stroke Incidence Rates
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Performance Measures • % of adults who smoke • % of adults who are obese • % of adults who report drinking above recommended guidelines • % of adults who are physically active • Take-up of annual health check
2. Preventing and Detecting Stroke
Overarching Indicator • Stroke incidence rates Performance Measures • % of population with cardiovascular risk conditions managed appropriately • % Atrial Fibrillation patients managed appropriately • % number of higher risk TIA patients Managed appropriately (medical access within 24 hours / surgically treated within 14 days
3. Delivering fast, effective care
Overarching Indicator • 30 day survival rates Performance Measures • % of patients who have had an acute stroke who receive thrombolysis • % of patients admitted with a diagnosis of stroke admitted to a stroke unit within 4 hours of arrival at hospital • Mortality within 30 days of hospital admission for stroke
4. Supported Living with Stroke
Overarching Indicator • Stroke mortality Performance Measures • % of stroke population left with minimum disability (Rankin) • People with care plans • People with stroke who are supported to leave hospital by a skilled stroke rehabilitation team (e.g.reablement) • People with stroke who are reviewed on discharge, 6 weeks, 6 months and 12 months after leaving hospital
5. Improving Information
Performance Measures • Compliance with stroke clinical indicators, audits and bundles • Patient experience and satisfaction data
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6. Targeting Research
Performance Measures • Participation in clinical trials • Staff actively involved in research
Progress with these performance measures and indicators will form the basis of the teaching Health Board’s annual report on stroke. They will be calculated annually at both a national and LHB population level. The teaching Health Board will produce its first annual report in September 2013.
The tHB will also report progress against the Local Delivery Plan milestones to the Board, via the Quality and Safety Committee on a quarterly basis and to the public via the tHB website. The Local Delivery Plan and milestones will be reviewed and updated annually from April 2013.
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Powys teaching Health Board Stroke Delivery Plan 2013-16 Preventing Stroke
Objectives Actions Expected outcome Risks to delivery Lead Timescales
This is challenging target. Reducing smoking prevalence will require Implement All Wales Year on year reduction in strong partnership working. Mar-15 Tobacco Action Plan % in Powys of reported To reduce smoking current smokers rate in prevalence, actions include Powys of 21% (Wales Reduce the incidence of having strong leadership, 23%) to nationally set smoking preventing people from target of 16% by 2020 starting smoking, Increase in uptake of Develop and Implement increasing the number of smoking cessation Powys Tobacco Action people who quit smoking Mar-15 schemes Plan and reducing the number of people exposed to second hand tobacco smoke . The Substance Misuse Local Public Health Action Plan is being Team Year on year reduction in replaced by a Substance % of Powys adults Misuse Commissioning Reduce alcohol Implement Substance reported drinking above Strategy, which is currently consumption in general Mar-15 Misuse Action Plan the guidelines from being finalised. This work is population current rate of 41% being taken forward (Wales 45%) through the Area Planning Board, with Public Health input. Year on year reduction in The prevalence has the proportion of adults remained persistently high, Reduce Incidence of Implement All Wales that are classified as with 54% of Powys Obesity in general Mar-15 Obesity Pathway overweight or obese from residents classified as population current rate or 54%. either overweight or obese. Obesity prevalence can
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only be reduced by co- ordinated actions by all relevant partners. A recent Year on year increase in mapping of the Obesity the proportion of adults Pathway has revealed that Improve Activity Levels in Implement Food and who report being active Powys has limited Tier 3 Mar-15 general population Fitness Action Plan on 5 or more days in the and 4 weight management past week from 39% services, thereby limiting the support that is currently available to the Powys population, This work is being taken forward through a Joint Improve health and well Implement Healthy Aging Older People’s being of older people in Mar-15 Plan Commissioning Strategy for Wales Powys – Transforming Lives. Ongoing participation of All pharmacies in Powys community pharmacists. Local pharmacies to do one to have partaken in Improve public awareness Uncertainty of how effective health promotion campaign national stroke and Medicines in Powys of risks and this campaign will be in Sep-12 each year on stroke risk diabetes public Management Team management of stroke raising public awareness. reduction awareness campaigns in September 2012
Ensure that all GP Monitoring of best use of practices have most up to referral forms will require date referral forms and audit by external provider Sep-13 Ensure timely access to information leaflets for the All high risk TIAs to be unit. TIA services for all Powys services they refer to assessed and treated Primary Care patients within 24 hours of onset Audit required by provider Monitor performance of all unit. May have difficulty Sep-13 providers against this target identifying Powys residents within audit.
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Demonstrate continual QOF is voluntary, although Be involved in national Improve detection and improvement in currently all Powys initiatives to improve quality management of AF in compliance with QOF practices participate in this Sep-14 of AF services in primary Primary Care targets for AF including process. care new one for CHADS2 Capacity of team Primary Care undertaking practice visits Ensure GP practices Monitor QOF returns and Use QOF data to inform to review QOF achieve QOF targets for Jul-13 discuss at annual visits service planning achievement in sufficient BP, Diabetes, TIA and AF detail to inform service planning.
Detecting Stroke Quickly Objectives Actions Expected outcome Risks to delivery Lead Timescales
Requires data from Public awareness provider to audit figures. Ensure all Powys Improved thrombolysis rate Primary Care and campaigns in GP practices, Thrombolysis rate will residents know to dial 999 for Powys residents in line Medicines Mar-15 pharmacies and local be dependent on other if they suspect a stroke with Wales average Management facilities factors, not just patient awareness. Ensure all GPs are aware Provide written information Capacity to follow up of the stroke pathway of to each GP practice on All GPs to be aware of their information to ensure Consultant Therapist Mar-14 their local acute stroke their local acute stroke acute stroke pathway GPs maintain unit pathway awareness
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Delivering fast, effective treatment and care Objectives Actions Expected outcome Risks to delivery Lead Timescales
Ensure that people with The Welsh Ambulance Improve Pre Hospital Bundle Dependant on training suspected stroke receive Services NHS Trust to compliance from baseline of and compliance by pre hospital bundle ensure their ambulance 60% ambulance clinicians clinicians are competent at identifying suspected stroke and responding accordingly including a clear direct admission pre-hospital WAST Mar-14 pathway to acute stroke unit following rapid assessment of appropriate patients which will help support the “door to thrombolysis” within 60 minutes Ensure that all Powys Work with neighbouring Year on year improvement in Dependant on outcome of residents have access to HBs and Trusts and SDG thrombolysis rates in line with current service reviews 24/7 thrombolysis within a to ensure that other HB in Wales across England and Director of 60 minute travel time from reconfiguration of hyper Wales which may impact Mar-15 Therapies & HS their homes acute stroke units (HASU) on access to HASU does not disadvantage Powys residents
Supporting life after stroke
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Objectives Actions Expected outcome Risks to delivery Lead Timescales
During transition period of Provide MDT specialist Maintain 100% compliance transfer of stroke service Continue to work to stroke care in patient with bundles 2 and 4. Improve to Brecon will require improve compliance with Consultant rehabilitation in Newtown compliance with Bundle 1, additional training for Mar-14 early rehabilitation stroke Therapist and Bronllys (or Brecon) Achieve 50% compliance with nursing staff. Medical bundles Hospitals Bundle 3 workforce vulnerable to recruitment issues. Continue to improve the As above quality of care within Collect bundle data for all Have bundle data for all stroke resources of MDT strokes admitted and work patients transferred back to Consultant rehabilitation for those July-13 with MDT to improve Powys regardless of hospital Therapist patients who are not compliance with bundles site admitted to one of the 2 stroke wards Provide education and Deliver monthly Stroke Access to transport for training on stroke and Information sessions on the patients and carers 80% of patients to have stroke prevention to two stroke units in Consultant attended SiS while in a Powys July-13 patients and their carers, additional to general Therapist hospital in line with Carers information for patients and Strategy carers Ensure that all staff Complete audit against Capacity to complete delivering stroke services relevant professional Reporting to SSG on results of audit. Stroke Clinical across Powys are working standards and identify and audit and improvement actions Dec-13 Leads to recognised professional take forward improvement developed as required standards actions Reduce length of stay for Increase in number of Capacity to deliver Develop skills and less disabled stroke reablement staff who have training. Consultant competencies of Sept-13 patients by providing completed relevant stroke Therapist Reablement Teams ongoing co-ordinated training and competencies
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MDT rehabilitation in their Improve communication Capacity of reablement own home between stroke wards and team to deliver timely Have clear communication reablement teams across rehabilitation plan in place between inpatient Mar-14 the county to improve the and reablement teams with transfer of care from hospital Work with Reablement Dependant on wider Agreed criteria for stroke teams and Social service to review of reablement rehabilitation from reablement Mar-14 review criteria for stroke service specification and teams. patients for reablement funding arangements Review and develop Capacity of stroke support effectiveness of Stroke worker Support Worker role in Increase in number of stroke July-13 survivors who have 6 week, 6 Improve support for stroke liaison with Stroke month and 12 month reviews Consultant survivors when they are Association by appropriate health or social Therapist discharged from hospital Capacity of stroke support Develop system for 6 week, care professional worker 6 month and 12 month Mar-14 reviews for stroke survivors
Develop MDT Neuro rehab Access to transport for Improve access to Clinics in 3 localities to patients and carers 20% of stroke survivors to be ongoing rehabilitation and have capacity to complete Consultant reviewed in MDT Neuro Rehab Dec-13 therapy for those who 6 and 12 month reviews for Therapist clinics need it all strokes who require MDT input Ensure that stroke Capacity to provide Signposting to DMR by survivors are educated Year on year increase in % of medicine management Stroke Support worker to Medicines and are taking the stroke survivors discharged reviews for all patients. ensure they are aware of Management Mar-15 appropriate medications home from hospital who have what medication they Team to reduce their risk of a DMR should be taking and why further stroke
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Campaign led by Public Encourage patients who Improve flu vaccination Year on year improvement Health. Uptake dependent have had stroke to have a Primary Care Mar-15 rates in over 65s from 66% for the over 65s on informed patient flu vaccination choice. Develop a process and Access to stroke survivors Ensure that stroke All stroke survivors leaving a proforma for educating going directly home from survivors and carers are Powys hospital should have an Staff Grade patients/carers on DGH July-13 aware of their risk factors individualised secondary Doctors secondary prevention and how to manage them prevention plan issues Embed secondary Access to stroke survivors Reinforce secondary prevention questions into 6 Secondary prevention issues going directly home from Consultant prevention issues Mar-14 week, 6 month and 12 included in stroke passport DGH Therapist following discharge month reviews Capacity of Consultant Maintain register of interest Over 100 service users on therapist Dec-13 of service users register Involve service users in Consultant the development of future Have a stakeholder event Capacity of Consultant Therapist services to gain service users 20 service users to have therapist priorities for developments attended event(s) by Dec-13 of Living with Stroke December 2013 services Availability of NERS Work with local NERS Access to travel 20% of stroke survivors to groups and community Improve access to enrol in NERS schemes in transport schemes to National Exercise on areas with schemes Physio Clinical Referral Schemes (NERS) increase enrolment Lead North Sep-13 or similar exercise groups Locality across Powys Develop exercise groups Availability of appropriate Stroke exercise group for those stroke survivors exercise groups available in mid locality unable to access NERS Access to travel
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Capacity of Consultant Map patient pathways for Therapist accessing spasticity Sep-12 services in each locality
Capacity of Consultant Liaise with commissioning Therapist Improve spasticity team and service providers July-13 management locally and to ensure pathway is cost develop more robust and clinically effective Have clear spasticity pathways Consultant pathways for accessing in place for 3 localities Therapist specialist assessment and Develop opportunities for Capacity of Consultant interventions out of county using VC to improve Therapist Sep-13 access to specialist spasticity services Evaluate demand and cost Capacity of Consultant effectiveness of developing Therapist Mar-14 a local therapy led injection service Capacity of Consultant Develop list of charitable Improve timeliness of Therapist funds and protocols and Consultant access to specialist Register of charitable funds Aug-13 documentation to support Therapist equipment applications Capacity of Consultant Improve appropriate Develop cost and clinically Therapist access to Functional effective pathway for Electrical Stimulation assessment, local provision Consultant Agreed FES pathway in place Dec-13 (FES) Services and and referral on to specialist Therapist ensure equity across service for FES with related county education framework
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Improving information Objectives Actions Expected outcome Risks to delivery Lead Timescales
Ensure that, when DGHs Requires timely All patients admitted to a Improved information from are notifying PtHB of communication between DGH and carers to have DGH patients admitted with a DGH and Powys stroke Dec-13 written information on Improved information for stroke that information on team Stroke Services in Powys patient/carer Powys services is provided. All patients with stroke Capacity of stroke team admitted to a Powys Hospital to have access to Run SIS at least monthly 80% of stroke survivors to Dec-13 Stroke Information either on site or by VC have attended SIS Session during their admission Consultant All patients with stroke Improve links with 3rd Capacity of stroke team Therapist discharged from a Powys sector to ensure that written and third sector hospital or DGH to be information on local Up to date information in Sep-13 given written information sources of support are stroke passport on local services and comprehensive and up to sources of support date Keep stakeholders and Capacity of Consultant others involved in stroke Therapist Continue to produce services up to date with Bimonthly newsletter published bimonthly stroke newsletter Mar-15 local and national on intranet and post on intranet developments and new research
Targeting research
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Objectives Actions Expected outcome Risks to delivery Lead Timescales
Foster a strong research Opportunity for trial Identify opportunities for To have submitted 2 culture in Stroke Services appropriate to Consultant enrolling in multicentre applications for trials or be July-13 in Powys rehabilitation services Therapist trials accepted into one
Identify and support Capacity of stroke team Consultant clinicians interested in Register of interest in place Mar-14 Therapist partaking in research Capacity of stroke team Strengthen links with HEI, Have a Powys clinician Consultant Dec-13 IRH and OPAN involved with at least one RDG Therapist
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FOR APPROVAL
BOARD MEETING 24 APRIL 2013 AGENDA ITEM 2.7
INFORMATION AND CONSULTATION STRATEGY FOR CARERS 2012 - 2015
Report of Bruce Whitear, Interim Director of Planning
Paper prepared by Wendy Morgan, Head of Quality & Safety
Purpose of Paper To provide the Board with the redrafted Information and Consultation Strategy for Carers 2012 -2015
Action/Decision required The Board is asked to APPROVE the redrafted Information and Consultation Strategy for Carers 2012 -2015.
Link to ‘Doing Well, This paper supports: Doing Better: Standards for Health Services in Standard 1: Governance and accountability framework Wales’: Standard 2: Equality, diversity and human rights Standard 3: Health promotion, protection and improvement Standard 5: Citizen Engagement and feedback Standard 8: Care planning and provision Standard 9: Patient information and consent Standard 10: Dignity and respect Standard 11: Safeguarding children and vulnerable adults Standard 18: Communicating effectively
Link to Health Board’s Striving for Excellence Corporate Plan
Acronyms and tHB Teaching Local Health Board abbreviations
Information & Consultation Strategy for Page 1 of 3 Board Meeting Carers 24 April 2013 Agenda Item 2.7
FOR APPROVAL
INFORMATION AND CONSULTATION STRATEGY FOR CARERS 2012 - 2015
Purpose
The purpose of this paper is to request the Board to APPROVE the redrafted Information and Consultation Strategy for Carers 2012 -2015 (Appendix 1).
Background
The Carers Strategies (Wales) Measure 2010 (the ‘Measure’) placed a requirement on the National Health Service (NHS) and Local Authorities in Wales (the ‘Organisations’) to work in partnership to prepare, publish and implement an ‘Information and Consultation Strategy for Carers’ (the ‘strategy’).
Rationale for Redrafting the Information and Consultation Strategy for Carers
The draft strategy was approved by Powys County Council and Powys Health Board ‘Board’ in October pre-submission to Welsh Government 31 October 2012.
The Strategy was assessed against the requirements of the Carers Strategies (Wales) Measure 2010 Guidance by a panel consisting of officials from the Disability and Carers Branch within Welsh Government, and representatives from Carers Wales, Carers Trust and Children in Wales. The strategy was not approved on the basis of:
• it showed little real understanding of what the Carers Measure was trying to achieve; • further emphasis was needed to address the issues of caring in such a large and predominantly rural area; • other organisations working with carers in Powys other than Powys Carers Service appear to have had little input to the development of the Strategy; and • the actions were vague with no indication of how they will be taken forward and how.
Powys tHB and Powys County Council met with representatives of Welsh Government on the 7 February to discuss the feedback. It was identified that the strategy had been developed using a template document Welsh Government had issued; it appears this did not have to be used. The meeting concluded in agreement that the information was within the strategy, but it needed to be reconfigured with the analysis clearly highlighted. A draft strategy was resubmitted to Welsh Government on 11 March for their consideration and advice and was accepted for approval on the 13 March. Correspondence has subsequently been received from the Deputy Minister for Social Services confirming she is now content with the re-drafted strategy.
Funding The second allocation of monies for 2012/2013 was withheld until the redrafted strategy was approved. Correspondence on 15 March confirmed the release of the final payment for this year; these monies have been used to provide Carers training.
Information & Consultation Strategy for Page 2 of 3 Board Meeting Carers 24 April 2013 Agenda Item 2.7
FOR APPROVAL
Welsh Government have previously indicated further significant additional funding for implementation of strategies to LHBs. Confirmation of this funding has not been received for 2013-14. The level of available funding will impact on the scope and pace of implementation of the strategy.
Welsh Translation Once approved by both Powys tHB and Powys County Council, the strategy will be translated into Welsh. Arrangements have been made with Powys County Council for this to take place. The strategy will be made available on both organisation’s intranet and internet.
Carers Measure, Strategy and Related Work The Carers Measure, Strategy and related work moved from the portfolio of the Director of Therapies and Health Science to the Interim Director of Planning portfolio in January 2013. Steps are being taken to ensure that the appropriate joint governance and delivery mechanisms are in place for the strategy across the two organisations. Within the tHB progress on delivery will be reported through the Quality and Safety Committee on an annual basis.
Recommendations The Board is asked to APPROVE the redrafted Information and Consultation Strategy for Carers 2012 -2015.
Report prepared by: Presented By: Wendy Morgan Bruce Whitear
Head of Quality & Safety Interim Director of Planning
Background Papers Welsh Government (2010) The Carers Strategies (Wales) Measure 2010
Welsh Government (21) National Health Service, Wales: Social Care, Wales: The Carers Strategies (Wales) Regulations 2011
Financial Consequences None at present
Other Resource Implications None at present
Consultees Adult and Young Carers throughout Powys Powys Teaching Health Board Powys County Council Powys Association of Voluntary Organisations Members of the Public
Information & Consultation Strategy for Page 3 of 3 Board Meeting Carers 24 April 2013 Agenda Item 2.7
Carers Strategies (Wales) Measure 2010
Information and Consultation Strategy for Carers 2012-2015
Information and Consultation Strategy for Carers Page 1
TABLE OF CONTENTS
PAGE(S)
FOREWORD 4
EXECUTIVE SUMMARY 5
SECTION 1: BACKGROUND
1.1 INTRODUCTION 10
1.2 WHAT IS A CARER? 10
1.3 WHY CARERS IN POWYS NEED SUPPORT 10
1.4 SETTING THE STRATEGY IN CONTEXT WITH OTHER POLICIES 12
1.5 POWYS LOCAL SERVICE BOARD – SINGLE DELIVERY PLAN 15
SECTION 2: THE POWYS CONTEXT
2.1 GEOGRAPHY 18
2.2 DEMOGRAPHICS 19
SECTION 3: CONSULTATION
3.1 ENGAGEMENT AND CONSULTATION 30
SECTION 4: KEY MESSAGES
4.1 KEY MESSAGES FROM ANALAYSIS OF OUR CARERS POPULATION 34
4.2 KEY MESSAGES FROM CONSULTATION 35
SECTION 5: CARERS INFORMATION AND CONSULTATON STRATEGY
5.1 KEY OBJECTIVES 37
5.2 YOUNG CARERS 44
5.3 MONITORING OUR STRATEGY 46
Information and Consultation Strategy for Carers Page 2
APPENDICES
APPENDIX 1: CARERS INFORMATION AND CONSULTATION 47 STRATEGY PROJECT PLAN
APPENDIX 2: PARTICIPANTS IN CONSULTATION EVENTS 49
APPENDIX 3: INFORMATION SERVICE GAP ANALYSIS 50
APPENDIX 4: CONSULTATION EVENT – CARERS FORUM, 60 NEWTOWN 19TH APRIL 2012
APPENDIX 5: CONSULTATION EVENT – BRECON, 11 63 SEPTEMBER 2012
APPENDIX 6: ADULT CARERS SERVICE 67
Information and Consultation Strategy for Carers Page 3
Foreword
The purpose of this strategy is to ensure that Carers receive appropriate information, systematically throughout the journey of being a Carer. The processes identified must become embedded within Powys Teaching Health Board, local authority and the voluntary sector organisations to enable Carers to become recognised and acknowledged as key partners.
We have to recognise that the people who use our services are the ones driving it forward and to this end, Carers and the people they care for have to be involved in order to get it right. These principles apply to the preparation and publication of this strategy.
There is no such thing as a typical Carer and hence our challenge is to develop a strategy that identifies and responds to Carers’ specific individual needs and one that remains relevant and reacts to change.
This strategy serves to demonstrate our commitment to supporting Carers and providing them with information and advice. We endorse this strategy and commit to its implementation.
LHB Chief Executive Director of Social Services
Date of Submission:
Date of Annual Reviews: June 2014; 2015 and 2016
Planned process for Review after 18 months: The review will take place through the Carers Partnership Board and reported to Powys Teaching Health Board ‘Board of Directors’ and Powys County Council ‘Cabinet’.
Review scheduled for June 2014 and reported in September 2014.
Information and Consultation Strategy for Carers Page 4
Executive Summary
The purpose of this Strategy is to make sure that we continue to improve the support we provide to carers in Powys. It responds to the requirements of the Welsh Government’s “Carers Strategies (Wales) Measure 2010” which places a duty on the NHS and Local Authorities in Wales to work in partnership to prepare, publish and implement a joint strategy for carers. This Strategy is designed to sit alongside and complement existing Carers Strategies developed by the Local Authority and it focuses on Information and Consultation in relation to Carers as opposed to wider issues affecting Carers.
The Carers Strategies (Wales) Measure 2010 defines a carer as:
“An individual, whether an adult or a child, who provides, or intends to provide a substantial amount of care on a regular basis for: • A child who is disabled within the meaning of Part 3 of the Children Act 1989 or • An individual aged 18 or older.”
Carers usually provide care and support to a family member, friend or neighbour who is disabled, physically or mentally ill or who is affected by substance misuse. The care they provide is unpaid. Carers under the age of 18 are referred to as Young Carers.
There are a number of key national policies that provide the context for the development of this strategy. In particular: • The Carers Strategy for Wales (2000) and Action Plan (2007). This is currently being refreshed and a final version will be published later in 2013. • The Strategy for Older People in Wales (2003) and the National Service Framework for Older People (2006). The third phase of the Older People’s Strategy, covering the years 2013-2023, will be published in April 2013. • The Carers Strategies (Wales) Measure 2010. • The Mental Health (Wales) Measure 2010, the National Dementia Vision for Wales (2011), and the mental health strategy ‘Together for Mental Health’ (2012).
These key policies support Carers in their roles and underpin and promote improvement to the quality, quantity and responsiveness of services available. All reinforce the need to ensure that Carers have access to information, relevant flexible services and support at a local level, particularly where they live in a rural community such as Powys where they often face difficulties.
When developing this strategy, we have looked carefully at the particular needs of people and carers in Powys. We live in a large, sparsely populated and rural county. This presents us with unique challenges in terms of access, transport and “critical mass”.
Information and Consultation Strategy for Carers Page 5
We have looked at the information we have about our population and how it is changing, and about carers in particular. From this information we have taken some key messages which shape our future plans. These are: • In our most deprived areas (Welshpool, Newtown and Ystradgynlais) we expect that there will be a higher proportion of people who need the support of informal carers. However the information demonstrates that only 10% of carers in the County are receiving support. • We must: o Focus our activity in specific areas of deprivation o Increase the proportion of carers that receive support • The rate of increase in referrals to Powys Carers (Powys Carers Service, 2011) appeared to be levelling off in the first quarter of 2011but remain at a new and higher rate than previous years data. Referrals in July 2012 increased by 60% compared to the previous quarter. Self referrals (31%) were the most common source with health referring approximately 6% and social services 29%. • Powys Carers (2012) report nearly half of the carers registered with them as caring for somebody with a substance misuse problem are under 16. 65% (9) of these live in one of the three most deprived areas of Powys. • A significant proportion of those that care for people with a learning disability are under the age of 18. • We have good information on the employment status of carers that we are in contact with. However we do not know enough about those who have had to leave employment to provide unpaid care. We know from national research that this is an issue and we need to continue to support people back into employment. • The perceived health of carers in Powys is significantly poorer than the average for all people in Wales. • There are no significant concentrations of BME populations in Powys, however in the context of our rural economy, we can expect a changing ethnic profile, particularly a growing proportion of people from eastern Europe. Our information strategy will need to consider and be aware of their needs. • We think the majority of carers in Powys live with the person they care for. However, for those that do not live with the person they care for, rurality and our relatively poor transport network pose extra problems. • There is under-reporting/diagnosis of those with dementia in Powys. Partly as a result of this, we are not in contact with, or providing support for, enough people who are caring for someone with dementia.
We have consulted widely in the development of this Strategy as described in Section 3: “Engagement and Consultation”. The key messages that we will take through into our strategy are Carers need: • To be identified and referred for a Carers assessment; • Access to timely and relevant information on the condition of the cared for and services available; • Training for Carers in how to look after someone who has dementia, mental health problems, administering medicines safely, first aid, safe lifting and handling, cooking, etc; • Carer Awareness training for staff and professionals
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• Support to provide care for the cared for, particularly Young Carers caring for adults; and • Support to continue in education and employment; • Sustainable services.
Having considered our national policy drivers and their implications, the particular needs of our local population (and its rural nature in particular), and having consulted widely with carers themselves, we have developed six key objectives. For each of these objectives, we have agreed our key priorities as follows:
1. We will ensure that our support for carers is provided by organisations working jointly and in partnership.
Our priorities: • Ensure a clear structure for planning, commissioning and monitoring carers’ services • Develop an action plan which is linked to this Information and Consultation Strategy and the forthcoming Joint Commissioning Strategy for Carers • Ensure carers are involved in planning and evaluating the development of carers services
2. We will be able to indentify people in Powys who are acting in a caring role
Our priorities: • Work with GPs to ensure that they are “carer aware” and feel able to offer support and informed signposting. • Ensure our staff involved with hospital discharge are “carer aware” and feel able to offer informed signposting and referral. • Work with our community nursing and care management staff to increase the quality and quantity of carers assessments.
3. We will ensure that carers have access to good information to support them in their role.
Our priorities: • Review our existing information provision • Develop an effective information resource for carers on the Powys teaching Health Board website • Ensure key information is available to carers in their first language
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4. We will make available training to carers to support them in their role.
Our priorities: • Ensure carers can access training which helps them in their role • Ensure that, through respite and other arrangements, carers who wish to take part in training can take the time out to do so. • Provide support to transport carers to training events where appropriate
5. We will make sure that our staff are trained to be aware and responsive to the needs of carers.
Our priorities: • Ensure carers awareness training is made available to all key staff at induction. Ongoing awareness and training will be provided to all staff, in all sections of the Health Board in line with their training needs assessment. • Implement the e-learning package and monitor its uptake • Ensure staff are suitably trained to undertake meaningful carers assessments
6. We will make sure that we develop our services in consultation with carers.
Our priorities: • Through the continued development of our Carers Partnership Board, ensure that carers continue to be involved meaningfully in the development of services • Ensure that carers are involved and well informed at all stages in the treatment and care for the person to whom they are providing support.
For each of these key objectives and priorities, we have identified specific action that we will take. These actions are laid out in Section 5: “Carers Information and Consultation Strategy”.
We recognise that Powys has a significant and under represented population of young carers and we commit to working collaboratively with them to ensure they have access to information, support, training and development to meet their needs as referenced by specific actions within our Action Plan.
Monitoring arrangements will be through the multiagency Carers Partnership Board and report into individual organisational relevant committees. An annual report on the implementation, evaluation and progress of the strategy will be submitted to Welsh Ministers, year on year. The strategy will be reviewed after 18 months to ensure it remains ‘fit for purpose’.
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Section 1:
Background
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1.1. Introduction
The Welsh Government’s “Carers Strategies (Wales) Measure 2010” places a duty on the NHS and Local Authorities in Wales to work in partnership to prepare, publish and implement a joint strategy for carers.
The purpose of this Strategy is to make sure that we continue to improve the support we provide to carers in Powys. In particular we want to make sure that good quality information is easily accessible to carers to support them in their role and to help them to be fully involved in decisions about the person they care for. We also want to make sure that carers are consulted effectively and are fully involved in guiding the way that we develop our support services. This Strategy is designed to sit alongside and complement existing Carers Strategies developed by the Local Authority and it focuses on Information and Consultation in relation to Carers as opposed to wider issues affecting Carers.
The two key organisations that are involved in leading the delivery of this Strategy are Powys teaching Health Board (PtHB) and Powys County Council (PCC). We will make sure that we have effective arrangements in place to make sure that those organisations; whether in the statutory, voluntary or private sectors that have a role in supporting carers are able to carry it out in a framework of partnership.
1.2 What is a carer?
The Carers Strategies (Wales) Measure 2010 defines a carer as:
“An individual, whether an adult or a child, who provides, or intends to provide a substantial amount of care on a regular basis for: • A child who is disabled within the meaning of Part 3 of the Children Act 1989 or • An individual aged 18 or older.”
Carers usually provide care and support to a family member, friend or neighbour who is disabled, physically or mentally ill or who is affected by substance misuse. The care they provide is unpaid. Carers under the age of 18 are referred to as Young Carers.
1.3 Why Carers in Powys Need Support?
The Carers Trust report that “Carers are the largest source of care and support in each area of the UK. It is in everyone’s interest that they are supported.
• Taking on a caring role can mean facing a life of poverty, isolation, frustration, ill health and depression.
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• Many carers give up an income, future employment prospects and pension rights to become a carer. • Many carers also work outside the home and are trying to juggle jobs with their responsibilities as carers. • The majority of carers struggle alone and do not know that help is available to them. • Carers say that access to information, financial support and breaks in caring are vital in helping them manage the impact of caring on their lives.”
An Ipsos MORI report reveals for the first time ever the number and profile of the 1.1 million people currently caring for someone with cancer in the UK. It was found that only 5% have received a local authority Carer’s assessment which enables them to access practical, emotional and financial support in their caring role.
Carers Wales (2011) state that local authorities should be mindful that they are obliged to provide carers needs assessments under the Carers and Disabled Children Act 2000 and The Carers (Equal Opportunities) Act 2004. Currently Powys Carers Service is using nominated and trained staff to work in partnership with Powys local authority to perform “Carer’s assessments”.
Carer friendly employment policies are essential to maintain a work-life balance to enable Carers to remain in work or return to work whilst caring for the person they support. Without proper support some Carers have no choice but to resign from their employment so that they can continue to care for the person they support.
Respite care, planned and emergency, needs to be available so that Carers can gain maximum benefit from the breaks that this affords them, particularly at times of crisis and that those they care for are supported should the Carer need to go into hospital.
Carers need information and to be involved in decision making about treatment for the person they care for. Carers need to be aware of the expected outcome of treatments and medication, and in the latter to know the side effects and adverse reactions. Information must be provided in a format that is developed and provided specifically aimed at patients, Carers and their families. An example is hospital discharge advice (Welsh Assembly Government, 2005) which is patient-centred and involves the Carer and whereby the provision of a documented discharge date (agreed with the Carer) enables them to plan the discharge for the person they care for.
It must be acknowledged that the Multi-agency Reference Group for Carers ‘Carers Strategy in Powys’ (2010) is already promoting greater recognition and support for Carers in Powys. This Information and Consultation strategy now provides an opportunity to further progress this work. Working with Carers, Powys Teaching Health Board, local authority and third sector organisations have identified:
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• the information that Carers need; • how it will be provided; and • by which lead agency.
1.4 Setting the Strategy in Context with Other Policies
The key policies that influence and sit alongside this strategy are:
• The Carers Strategy for Wales (2000) and Action Plan (2007). This is currently being refreshed and a final version will be published later in 2013. • The Strategy for Older People in Wales (2003) and the National Service Framework for Older People (2006). The third phase of the Older People’s Strategy, covering the years 2013-2023, will be published in April 2013. • The Carers Strategies (Wales) Measure 2010. • The Mental Health (Wales) Measure 2010, the National Dementia Vision for Wales (2011), and the mental health strategy ‘Together for Mental Health’ (2012).
These key policies support Carers in their roles and underpin and promote improvement to the quality, quantity and responsiveness of services available. All reinforce the need to ensure that Carers have access to information, relevant flexible services and support at a local level, particularly where they live in a rural community such as Powys where they often face difficulties. In resetting the direction for Carers, the Carers Strategy for Wales (2000) set out to ensure that Carers were not disadvantaged, were listened to and treated with respect and that they received recognition for the important role they play in supporting people to sustain independence alongside leading a normal life as much as possible outside of their caring role.
Building upon the Multi-agency Reference Group for Carers ‘Carers Strategy in Powys’ (2010) this information and consultation strategy compliments the actions already being taken forward, such as:
Information and choice; Carer’s assessments; Range and quality of services; Having a voice/ Carer participation; Flexible employment / work opportunities; Service monitoring/ resource allocation; and Young Carers.
The need for information and advice for Carers has been echoed throughout other policies, more recently Part 1 of the Mental Health Measure (2010) which requires information and advice to be provided to Carers about treatment and
Information and Consultation Strategy for Carers Page 12 care, including the options available to them and signposting Carers to other means of support, such as the third sector. The importance of the third sector in supporting Carers is further advocated in Together for Health (Welsh Government, 2011) which recognises that they can help people to live more independently and speak up for those in need.
It is estimated (National Dementia Vision for Wales, 2011) that family Carers of people with dementia save the UK over £6 billion a year. The number of people across Wales affected by dementia is expected to increase by 31% by 2021 and in rural areas such as Powys the increase will reach 44%. To support this increase this policy demands a good quality of life for Carers that reflects the approaches within the Measure, again community support, information and training packages for Carers.
Powys Teaching Health Board will continue to work with its partner organisations in implementing improved information and support to Carers as outlined in the Intelligent Targets for Dementia (Annual Quality Framework, 2011).
It is important to involve Carers in service monitoring and evaluation to obtain feedback that can be integrated into future planning and performance management of services in order to support Carers effectively.
Where NHS staff identify a Young Carer to be at risk or a ‘child in need’, they can make a referral under the Framework for Assessment of Children in Need (this is a statutory framework in place across agencies including the NHS). There is an agreed multiagency referral process in place, of which Social Services are the lead agency for carrying out an assessment. Other agencies then contribute to the assessment.
In Powys, there is also an early intervention process agreed under the Children and Young People’s Partnership (CYPP). A referral can be made to a Local Resource Solution Panel by any agency, using the Common Assessment Framework (CAF). Local solutions can be put in place for emerging needs. Through the CYPP Emotional Health and Wellbeing Group Powys Teaching Health Board provide funding to Powys Carers Service to help address the needs of Young Carers.
Consent is an important issue. In order to give the Carer the help and information they need at the right time it may necessitate passing their personal details, such name, address and contact number, to other partner agencies. Consent must be sought from the Carer before their personal data is shared, ensuring the Carer understands where information can be accessed, how it can help them as a Carer, what personal details are being passed on to another agency and what they can expect from the contact.
Within Powys Teaching Health Board where it is identified a patient has a Carer, patient consent is always sought before sharing information. This extends to providing information about medication, treatment, available advocacy services and advice about practical issues such as when care is provided in the home. A common example of this is the sharing of information for moving and handling
Information and Consultation Strategy for Carers Page 13 patients in their own home, this enables the Carer to ensure the correct approach is taken to reduce the risk of harm to both the patient and the Carer. Where the patient lacks capacity to consent staff adhere to Powys Teaching Health Board guidance on consent to treatment. During a Carer and multiagency combined workshop held in May 2012, one Carer stated:
“Parent Carers cannot step away from the child but can give consent to treatment. Adult Carers can step away but cannot give consent (this can leave the Carer feeling disempowered).”
All organisations are committed to the principles of equality and diversity. The key legislation that requires local authorities to carry out certain functions on behalf of Carers includes: • The Carers (Recognition and Services) Act 1995; • The Carers and Disabled Children Act of 2000; • The Carers (Equal Opportunities) Act 2004; and • Equality Act 2010.
Powys Teaching Health Board, local authority and third sector organisations are committed to their role in implementing Race Equality Schemes. They recognise and treat Carers as key partners in the provision of care, ensuring that information and support is available and accessible to all. This extends to Carers of all ages and sections of the community, particularly Young Carers who assume responsibility for parents and siblings and Carers from Black and Minority Ethnic (BME) communities.
Key to supporting young carers is the Rights of Children and Young Persons (Wales) Measure 2011, aimed at embedding the principles of the United Nations Convention on the Rights of the Child, it sets out the child’s inherent right to life and how the child’s best interests must be the primary consideration. Within Powys, these principles will underpin the work we take forward with our young carers, young adult carers (18-25) and any caring situation where there is a child or young person in the family.
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1.5 Powys Local Service Board – Single Delivery Plan
In Powys, the Local Service Board have agreed to work together to take forward a new approach to planning and delivering public services called – One Powys.
This approach is about making sure public bodies work together to achieve the best possible outcomes for the people of Powys. Our priorities will be guided by, and linked specifically to these outcomes. The fundamental approach will be to focus on early intervention and prevention and making sure we safeguard the most vulnerable children, young people, adults and elderly people within Powys. By optimising co ordination, addressing gaps and removing duplication, it will be possible to ensure people receive the best possible services and best value is secured for “the Powys pound”.
The Single Delivery Plan will bring together and replace a range of existing strategies, plans and agendas, to provide a single focus for the individual organisation’s plans in Powys.
Figure 1: One Powys Plan
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As part of this new approach, members of the Local Service Board have agreed to focus their activity and resources towards achieving ten outcomes for the people of Powys.
1. People in Powys live in supportive, sharing and self-reliant communities. 2. People in Powys benefit from a thriving, diverse economy. 3. People in Powys have the skills to pursue their ambitions. 4. Powys families are safe and supportive places in which to live. 5. People in Powys are healthy and independent. 6. People in Powys live in good quality affordable homes. 7. People in Powys enjoy a clean, safe and green environment. 8. People in Powys feel and are safe and confident. 9. People in Powys are supported to get out of poverty. 10. People in Powys can easily access the services they need.
This Carers Information and Consultation Strategy will “sit under” the One Powys Plan, and the aspirations and actions set out in this document will contribute to the achievement of these outcomes for all carers and those they care for. This Strategy will also sit alongside the Powys Public Health Framework.
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Section 2:
The Powys Context
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2.1 Geography
Powys covers a quarter of the area of Wales, with a North-South axis similar to the distance between Bristol and London. The county covers the historic counties of Montgomeryshire, Radnorshire, most of Brecknockshire and a small part of Denbighshire – an area of 5,179km, making it the largest county in Wales by land area. It is bounded to the north by Gwynedd, Denbighshire and Wrexham, to the west by Ceredigion and Carmarthenshire, to the east by Shropshire and Herefordshire and to the south by Rhondda Cynon Taf, Merthyr Tydfil, Caerphilly, Blaenau Gwent, Monmouthshire and Neath Port Talbot.
Many of the natural catchment areas and travel routes flow east-west and it is the most sparsely populated county in England and Wales, with 26 people per square kilometre. It is an essentially rural population, which can be described as “diffuse rurality” i.e. the population is spread thinly across the area with a few market towns and relatively bigger conurbations. Consequently, where facilities require a critical mass of people to be economically or socially sustainable, they will of necessity be spread out, making factors of accessibility and transport critically important. Figure 1 illustrates this.
Figure 1: Map showing major roads and location of District General Hospitals
Although many other counties are rural, their populations are more clustered, and nearer larger towns where district general hospitals (DGHs) are located. In Powys, even the ‘densely’ populated areas are too sparse to
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ensure services would see enough patients or clients to justify a full time presence, and if there were such services staff would see too few patients to maintain their skills or avoid professional isolation.
2.2 Demographics
The 2011 Census First Release (Powys County Council, 2011) reported the population of Powys as an estimated 133,000 people. The Welsh Government (June, 2010) reported an estimated population of approximately 131,313 people with 99.3% white ethnicity and 30.1% known Welsh speakers. Overall, Powys makes up over 25% of the area of Wales but has only 4.3% of its population (Powys County Council, 2011). Of this population 16,154 are carers showing a rise of 14% (2,036) on the previous census data. This overall number of carers is likely to be under-reported, as many people (especially older people) with caring responsibilities do not identify themselves as carers.
Powys Carers Service (2011) reported there are an estimated 350,000 adult Carers in Wales and this figure does not include a breakdown of the total number of Young Carers. Of the 1,869 registered Carers in Powys (Powys Carers, December 2012), a total of 329 are reported Young Carers under 18 years of age.
The strategy for older people in Wales (2003) vision is that a higher profile is given to older people’s issues throughout Wales in all aspects of life. The population in Powys in the age groups 60–69 is 20,000, 70-79 is 12,800 and 80-89 is 6,900, a total of 39,700 equating to 29.85% of the total population (Powys County Council, 2011). It is predicted that over the next 20 years the number of people of current retirement age in Wales will increase. If we reflect upon research quoted a high percentage of those retired people will become Carers.
Future strategies, policies and programmes must reflect the needs of an ageing society in Powys. Powys Carers Strategy (2010) reiterates the objective “to improve the health and wellbeing of Carers and those they care for” as articulated by the Welsh Government in the Carers Strategy for Wales.
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2.3 Carers in Powys
Numbers of Carers
Powys Carers (2012) reports a total number of 1,869 Carers registered as at December 2012, 5% up from 1,776 in September 2012.
North Powys 796 (743) Mid Powys 425 (412) South Powys 648 (621)
180 No of Carers registered by SMOA and Age unknown
160 65+
140 55‐64
120 50‐54
100 26‐49
80 19‐25
60 16‐18
11‐15 40
< 11 20
Unknown 0 12345678910111213141516171819
Figure 1: Carers Registered by Powys Carers
Middle Super Output Area’s (SMOA’s) (most deprived areas highlighted in grey)
01 Llanfyllin, Llansantffraid, Llanrhaeadr-ym-Mochnant, Llansillin, Meifod and Llanfihangel 02 Guilsfield, Llandrinio and Llandysilio 03 Welshpool 04 Machynlleth, Glantwymyn, Banwy and Llanbrynmair
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05 Montgomery, Berriew, Forden and Trewern 06 Llanfair Caereinion, Caersws and Rhiwcynon 07 Churchstoke, Kerry and Dolforwyn 08 Newtown East, North and Llanllwchaiarn West 09 Newtown Central and South 10 Llanidloes, Llandinam and Blaen Hafren 11 Knighton, Presteigne, Beguildy, Llangunllo and Old Radnor 12 Rhayader, Nantmel, Llanbadarnfawr, Llanyre, Disserth and Trecoed 13 Llandrindod 14 Builth, Llanwrtyd, Llanafanfawr and Llanelwedd 15 Hay, Talgarth, Glasbury, Gwernyfed and Bronllys 16 Talybont-on-Usk, Felin-Fach, Yscir, Maescar and Llywel 17 Brecon 18 Crickhowell, Llangynidr, Talgarth, Llangors and Bwlch 19 Ystradgynlais, Ynescedwyn, Cwm-twrch, Aber-craf and Tawe-uchaf
Analysis: In our most deprived areas (Welshpool, Newtown and Ystradgynlais) we expect that there will be a higher proportion of people who need the support of informal carers. However the information demonstrates that only 10% of carers in the County are receiving support.
We must: • Focus our activity in specific areas of deprivation • Increase the proportion of carers that receive support
Carers’ Role
Reason for Caring and age of Carers referred Jan-March 2012 (figure 2 below):
Total One third of new referrals are Physical Under 18 15 of Carers over 65 and caring 18-34 10 for somebody with a physical 35-65 15 disability or illness and nearly 65+ 33 20% are over 65 and care for Mental Health Under 18 5 somebody with Dementia. 18-34 5 35-65 14 65+ 3 There are a larger number of Dementia Under 18 0 referrals of carers aged under 18-34 0 18 caring for somebody with a 35-65 0 physical disability or illness. 65+ 19
Learning Disability Under 18 7
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18-34 0 35-65 5 65+ 0
EOL/Palliative Under 18 0 18-34 0 35-65 0 65+ 2
ASD Under 18 7 18-34 2 35-65 1 65+ 0
Substance Misuse Under 18 0 18-34 0 35-65 2 65+ 1
Referrals
` 8/9 9/10 10/11 11/12 12/13 Adult Carers April-June 49 67 70 68 121 July-Sept 55 74 40 89 107 Oct – Dec 39 49 67 61 102 Jan-March 37 44 69 78 YAC's (16-24) April-June Included in YC 2 4 6 July-Sept and AC 3 3 10 Oct – Dec 3 3 10 Jan-March 11 3 Young Carers April-June 25 11 17 19 21 July-Sept 19 16 19 16 30 Oct – Dec 5 15 17 8 25 Jan-March 20 18 26 27 Total 249 294 344 379 432 (for 3 quarters) Annual Increase in referrals 18% 17% 10% 62% * Cumulative increase 18% 38% 52% NB: Annual increase for 12/13 based on first three quarters of each year
Figure 3: Referrals to Powys Carers (Powys Carers, 2012)
Analysis: The high rate of increase in referrals to Powys Carers continues (Powys Carers Service, 2012). More referrals were received in the first 9 months of 2012-13 than for the whole of the previous year. Referral rates have increased by 62% since the same period last year. Self referrals (29%) were the most common source with health referring approximately 7% and social services 28%.
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Carers of People with Substance Misuse Problems
Carers of people with Substance Misuse problems registered with Powys Carers Service.
Under 16 YAC 26‐49 50+ TOTAL 1 2 1 3 2 0 3 1 1 4 0 5 0 6 0 7 0 8 1 1 9 3 1 4 10 1 1 11 1 1 12 1 1 13 2 1 1 4 14 0 15 1 1 2 16 0 17 2 1 3 18 1 1 19 4 2 2 3 11 Tot 14 6 5 8 33 al
Figure 4: Carers of people with Substance Misuse problems (Powys Carers, 2012)
Analysis: Powys Carers (2012) report nearly half of the carers registered with them as caring for somebody with a substance misuse problem are under 16. 65% (9) of these live in one of the three most deprived areas of Powys.
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Carers of People with Learning Disabilities
Carers of people with Learning Disabilities registered with Powys Carers Service
Under 11 11-15 16-18 19-25 26-49 50-64 65+ AC age TOTAL unknown Carers of 3 7 2 8 42 49 23 6 140 > 14's Carers of 4 13 4 3 26 4 0 3 57 < 14's
Figure 5: Carers of people with Learning Disabilities (Powys Carers, 2012)
Analysis: A significant proportion of those that care for people with a learning disability are under the age of 18.
Carers in Paid Employment
Many Carers face barriers to remaining in employment, the main barrier being the difficulty Carer’s face in obtaining support and services for the person they care for (National Institute for Health Research [NIHR] School for Social Care Research, 2011). The NIHR (2012) reported approximately 315,000 Carers aged 16 to 64 in England left employment to provide unpaid care and were currently out of employment, of which 120,000 are men and 195,000 are women. Of Carers in employment, NIHR suggest approximately 66% of Carers of working age are in part time of full time employment. There is no reason to suggest that the situation in Wales is any different.
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500 450 400 350 300 250 200 <16 150 16‐25 100 25‐64 50 65+ 0 Adult Carers DoB unknown
Figure 6: Age of Carer and employment status (Powys Carers, 2012)
The figures (Powys Carers, 2012) provided for Carers in employment in Powys must be treated with caution because employment status changes. Carers do not always report their changed employment status and for 28% of Carers their economic status is not recorded.
Full Time Carer
Full Time Employment Full Time carer 22% Not recorded Part Time Employment 28% 2% FT Emp 8% 1% Full Time Education & Part time Employment 0% PT Emp 8% 0% Full Time Education 11% FT Ed 17% 1% 1% Part Time Education 0% 1%
Figure 7: Employment and/ or Education Status (Powys Carers, 2012)
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A 19% response rate to the Adult Carers survey undertaken as part of the consultation identified 56% of Carers were of working age and 41% were over the age of 65, of which only 45% of the total had a Social Services Carers Assessment in the last three years. However, we do not know whether the people of working age identified had to leave employment to provide unpaid care.
Analysis: We have good information on the employment status of carers that
we are in contact with. However we do not know enough about those who
have had to leave employment to provide unpaid care.
We know from national research that this is an issue and we need to continue
to support people back into employment.
We need to review our existing employment policies and practice to ‘impact
assess’ the consequences for carers to ensure that we support staff who have
caring responsibilities.
We need to work in partnership to try and get carers into employment through
flexible ways of working, finding ways to widen access to employment to meet
carers’ needs and by learning from existing best practice.
Carers’ Health
A survey1 (Powys Carers, 2011) comparing the health of Carers in Powys to the Welsh Health Survey of all citizens (2009) identified that the health of Carers suffered as a result of their caring responsibilities.
40% 35% 30% Welsh Health 25% Survey 2009 20% 15% Powys carers 10% 5% 0% Good or Very Good Good Up & Down Poor excellent
Figure 8: Comparing health of Carers against all citizens (Powys Carer, 2012)
Analysis: The perceived health of carers in Powys is significantly poorer than the average for all people in Wales.
1 10% of carers responded in Powys
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Ethnicity of Carers
Statistics currently available demonstrates ethnic background of Carers in Powys (Crossroads August 2012) as:
• British including English, Welsh, Scottish and Northern Irish = 264
• White & black African (mixed) = 2
• Any other white = 2
• Not asked = 1
• Not disclosed = 10
• Not Set = 82
Analysis: There are no significant concentrations of BME populations in Powys; however in the context of our rural economy, we can expect a changing ethnic profile, particularly a growing proportion of people from
Eastern Europe. Our information strategy will need to consider and be aware of their needs.
Where Carers Live
Data on the number of Carers who are not co-resident but look after someone from a distance, for example, living near or living in a Welsh county or other country has been difficult to source. Crossroads (August 2012) were able to compare 350 records by postcode for client and their Carer on behalf of Powys Teaching Health Board. The results indicate: • In County but not close = 5
• Near Neighbour = 13
• Out of County = 2
• Same Postcode = 330
This confirms the majority of Carers are co-located. It is recognised that better information on both ethnicity and location of Carers needs to be captured.
Analysis: We think the majority of carers in Powys live with the person they care for. However, for those that do not live with the person they care for, rurality and our relatively poor transport network pose extra problems.
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Carers of People with Dementia
Information on Carers of people with dementia has proven difficult to collect as demonstrated by figures quoted by Alzheimer's Society (August 2012). In Powys they currently only hold information on those supported, which is considered a small number of those the Alzheimer’s Society estimate are Carers of people with dementia.
The figures quoted by Alzheimer's Society (August 2012) are based on the fact that there are an estimated 2,319 people living with dementia in Powys based on demographics and prevalence of dementia within the age groups as indicated below. The diagnosis rate in Powys Teaching Health Board area is 35.4% and so, only 820 will have a diagnosis. This equates to, at best, only 820 Carers knowing they are Carers and officially recognised as such and in receipt of appropriate support both in terms of information but also in terms of finance, benefits, etc. This is one of the major implications of diagnosis as it impacts on funding, Continuing Health Care and even entitlement to a blue badge for the car.
From the prevalence of .009% of 30-34 yr olds there would be 1 in Powys .0077 of 35-39 1 in Powys .014 of 40-44 1 in Powys .030 of 45-49 3 in Powys .058 of 50-54 5 in Powys .13 of 55-59 13 in Powys .155 of 60-64 17 in Powys
The majority 2,278 people are 65 and over Source: Alzheimer’s Society August 2012
Analysis: There is under-reporting/diagnosis of those with dementia in Powys. Partly as a result of this, we are not in contact with, or providing support for, enough people who are caring for someone with dementia.
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Section 3:
Consultation
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3.1 Engagement and Consultation
In actively engaging Carers in the development of the strategy, Powys teaching Health Board put in place a project plan, which outlined planned consultation events (see Appendix 1). The consultation process set out to gain information and an understanding from Carers, the cared for, wider public, professionals and stakeholders (see Appendix 2) about what appropriate information and advice was needed. The information gained provides the baseline against which the Information and Consultation Strategy implementation plan will be assessed.
An information service gap analysis was undertaken in March 2012 (see Appendix 3) and was contributed to by Powys Association of Voluntary Organisations (PAVO), Crossroads, Citizens Advice Bureau and the Alzheimers Society. This identified existing information and areas where information could be improved or put in place. The outcome of this work was used to inform future events and gain additional information. Summary of the key points identified included:
• Information packs for Carers from Community and District General Hospitals • A Carers Resource pack needed at the strategy implementation stage • Information centring on the collection and administration of medicines • Timely information and guidance on accessing services • Information available at Housing offices and through all public facing venues • More consistent information from and signposting by frontline health and social care staff • Information on access and entitlement to day services • Information on access and entitlement to respite/short breaks while the Carer attends physical exercise facilities, e.g. gym or swimming pool • General and specific advice when needed on nutrition and dealing with behavioural issues of the person cared for • Information on safe lifting, moving and handling
The outcome of two consultation events supported by Powys Carers Service in Newtown and Brecon highlighted a range of general comments about poor services and support for Carers, comments on information in the first event (see Appendix 4) included:
• Not aware of certain information, did not know how to access some information and information was not available in some areas, e.g. health and wellbeing and training for Carers • The lack of information on discharge from hospital and from professionals • Carers having to source information for themselves
Building on information captured through previous consultation events, the second event (see Appendix 5) provided Carers the opportunity to talk about their experiences and highlight areas for improvement and development of information and services for Carers. The majority of Carers were caring for persons with various mental health illnesses and they raised concerns about:
• Funds being available for Carers awareness training
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• Systems for reporting problems need to be made easier and accessible • No information for Carers from Powys in out of county hospitals • Involving Carers in discharge planning and providing them with information to enable them to care for the cared for
A multi-professional workshop involving Carers, held in May 2012 discussed availability of information on a range of topics, namely capacity and mental health issues, young carers and support in school, signposting carers to other organisations, what information would help to improve Carers access to support and the right media for communicating information to Carers. The key messages were:
• Professionals need to be more aware and responsive to Carers needs and listen to Carers • Improve and simplify access to information • Single point of contact for Carers – a one stop shop • Integrated services across disciplines and age groups • People as carers need additional care – needs to be recognised and conveyed by professionals • Information needs to be in digestible chunks, no jargon and in different formats • Education services need to be a provider of and a route for information for young carers.
A workshop in July 2012 saw professionals and Carers come together to share views on how the strategy for Powys should reflect local need. The key information related suggestions included:
• Availability of information • Open forum for ideas or website/ information engine to signpost services • Awareness raising sessions for Carers • Need to support young carers in education? Increase awareness in schools • More information in GP surgeries • Provide support for Young Carers outside of lesson time
The Adult Carers survey (Appendix 6) undertaken as part of the consultation identified Carers gathered their information from a wide variety of sources. The top five were Powys Carers Service, Social worker and Social Services, internet and online, General Practitioner Surgery and via the post, the majority indicating their preferred media as the post. Evidence highlighted 82% of carers needed information about services for the person they cared for and they considered all types of information to be important. Financial and benefits information and information on their rights as Carers featured in the top three.
Analysis: Throughout the consultation events Carers have highlighted the same key issues about information, it has to be:
• Timely (before a crisis occurs) • Easily accessed • Understandable Information and Consultation Strategy for Carers Page 31 • Proportionate
• Relevant
Analysis: Further, the evidence supports information is needed:
• At the point of discharge from hospital • For Carers about services for the person they care for, particularly access and entitlement to services and sustainable services • Through education services for young carers • On a range of topics, for example, medicines management including safe administration, nutrition, Mental Capacity, crisis management – who to contact.
Throughout engagement and consultation training for carers was highlighted and centred on specific illnesses in order to offer ongoing support to the cared for, plus other suggestions on safer handling and moving, first aid and Dementia Support.
Areas identified for further work included transport, carers of war veterans, out of county services, transition process for Carers – advice and support when a cared for child becomes a cared for adult. This will be considered as part of the wider ranging needs of Carers by the Powys Partnership Board for Carers.
A key question asked during consultation focused on ‘How do we know that what we are doing through the strategy has actually made a difference?’ The expectation of consultees is:
• Less re-admissions – home based service for minor problems and more referrals to Third Sector organisations who provide Carers with support • Increase in number of Carer’s assessments • Identifying Carers when patients admitted to hospital • Quick and easy access to services • Reduction in need for secondary healthcare services • Improvement in school attendance and achievement for young carers
Powys has already taken steps towards making a difference, to date these are:
• Since September 2012, care plan documentation has included details of the main carer and any other caring responsibilities and “Is a Carers Assessment required?”
• Support provided to provide training/awareness raising sessions for Carers
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Section 4:
Key Messages
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4.1 Key messages from our analysis of our carers population
We have conducted a careful analysis of our carers’ population which can be seen in detail in Section 2: “The Powys Context”. The key messages that we will take through into our strategy are:
• In our most deprived areas (Welshpool, Newtown and Ystradgynlais) we expect that there will be a higher proportion of people who need the support of informal carers. However the information demonstrates that only 10% of carers in the County are receiving support.
• We must: o Focus our activity in specific areas of deprivation o Increase the proportion of carers that receive support
• The rate of increase in referrals to Powys Carers (Powys Carers Service, 2011) appeared to be levelling off in the first quarter of 2011 but remain at a new and higher rate than previous years data. Referrals the period October – December 2012 increased by 62% compared to the previous quarter. Self referrals (29%) were the most common source with health referring approximately 7% and social services 28%.
• Powys Carers (2012) report nearly half of the carers registered with them as caring for somebody with a substance misuse problem are under 16. 65% (9) of these live in one of the three most deprived areas of Powys.
• A significant proportion of those that care for people with a learning disability are under the age of 18.
• We have good information on the employment status of carers that we are in contact with. However we do not know enough about those who have had to leave employment to provide unpaid care. We know from national research that this is an issue and we need to continue to support people back into employment.
• The perceived health of carers in Powys is significantly poorer than the average for all people in Wales.
• There are no significant concentrations of BME populations in Powys, however in the context of our rural economy, we can expect a changing ethnic profile, particularly a growing proportion of people from eastern Europe. Our information strategy will need to consider and be aware of their needs.
• We think the majority of carers in Powys live with the person they care for. However, for those that do not live with the person they care for, rurality and our relatively poor transport network pose extra problems.
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• There is under-reporting/diagnosis of those with dementia in Powys. Partly as a result of this, we are not in contact with, or providing support for, enough people who are caring for someone with dementia.
4.2 Key messages from consultation
Throughout the development and consultation on the strategy, Carers have been informed:
• that the knowledge they have about caring for the cared for person will be used appropriately; • about their right to have their needs identified; • they can feel confident of continued support in their caring role and know how to get support before it becomes a problem; • they will have the right information and advice on which to understand the decisions being made and are able to input to them, and • they will understand the information being provided and consulted on, what will happen and who to contact. We have consulted widely in the development of this Strategy as described in Section 3: “Engagement and Consultation”. The key messages that we will take through into our strategy are Carers need:
• To be identified and referred for a Carers assessment;
• Access to timely and relevant information on the condition of the cared for and services available;
• Training for Carers in how to look after someone who has dementia, mental health problems, administering medicines safely, first aid, safe lifting and handling, cooking, etc;
• Carer Awareness training for staff and professionals;
• Support to provide care for the cared for, particularly Young Carers caring for adults; and
• Support to continue in education and employment;
• Sustainable services.
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Section 5:
Carers’ Information and Consultation Strategy
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5.1 Key Objectives
The key aim of this strategy is the provision of information to Carers at every point of their journey through the patient/Carer journey. To achieve this principle our key objectives are:
• We will ensure that our support for carers is provided by organisations working jointly and in partnership. • We will be able to indentify people in Powys who are acting in a caring role • We will ensure that carers have access to good information to support them in their role. • We will make available training to carers to support them in their role. • We will make sure that our staff are trained to be aware and responsive to the needs of carers. • We will make sure that we develop our services in consultation with carers.
For each of these key objectives we have developed our priorities and a set of simple, achievable actions that will ensure we achieve or objectives.
1. We will ensure that our support for carers is provided by organisations working jointly and in partnership.
Our priorities: • Ensure a clear structure for planning, commissioning and monitoring carers’ services • Develop an action plan which is linked to this Information and Consultation Strategy and the forthcoming Joint Commissioning Strategy for Carers • Ensure carers are involved in planning and evaluating the development of carers services
Our analysis of locally available statistics reveals that we are not making contact with enough people who are acting in a caring role. We need to make sure that our organisations work together, adopting a “whole system approach” so that we are able to identify carers, make information available to them and offer support as easily as possible.
We already have established arrangements for jointly planning and commissioning services to support carers. A multi agency commissioning group oversees the way we allocate our resources and monitors performance. We are producing a Joint Commissioning Strategy for carers. This will guide the future development of services. It will reflect and extend the main themes, objectives and priorities of this strategy.
We have also recently replaced our previous Multi Agency Reference Group (Carers) with a Carers Partnership Board. This group has strong representation from carers and also other organisations involved in providing support.
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We need to consolidate these arrangements and ensure that appropriate reporting, monitoring and, above all, decision making processes are in place.
In order to focus on our priorities, we will:
Year 1 • Complete an action plan for the delivery of this Strategy • Develop performance indicators and baseline data • Consult and publish our Joint Commissioning Strategy for Carers • Develop and agree a clear joint planning and commissioning framework
Years 2 and 3 • Review the implementation of our strategy and action plan with carers • Collect performance information and review progress
2. We will be able to indentify people in Powys who are acting in a caring role
Our priorities: • Work with GPs to ensure that they are “carer aware” and feel able to offer support and informed signposting. • Ensure that staff who are involved with hospital discharge are “carer aware” and feel able to offer informed signposting and referral. • Work with our community nursing and care management staff to increase the quality and quantity of carers assessments.
Our analysis of population and carer statistics shows that we are still only in touch with a small proportion (11%) of carers in Powys. We are also aware that our staff have not always been able to undertake useful carers’ assessments when first in touch with a new client.
As a teaching Health Board, we know that our primary health care services are an important gateway to ensuring that carers are identified and helped to receive any support they may need. General Practitioners will be key colleagues in improving our accessibility to carers a since they are in touch with our whole population and also will be centrally involved when situations occur that may mean a friend relative or otherwise may need to start providing care. We need to make sure that our GPs are working with us to deliver this strategy.
Carers are often involved in booking and supporting the people they care for in accessing emergency and non-emergency transport to and from hospital. We need to make sure that we work with Welsh Ambulance Services in identifying and supporting Carers to enable them to contribute to the delivery high quality services for the cared for. We need to ensure our hospital staff involved in hospital discharge arrangements are “carer aware” and proactively ensure carers are identified and offered access to information and support.
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We need to make sure that our staff working in the community understand their role in relation to carers and are able to undertake meaningful carers’ assessments which result in appreciable support.
Powys is a very sparsely populated rural county. However we know that certain communities have higher than average levels of deprivation. In these areas, our analysis of our statistics indicates that levels of ill health will be higher and we can expect a greater number of people acting in an informal caring role. These areas are Welshpool, Newtown and Ystradgynlais. We need to consider concentrating our activities in these areas where appropriate.
In order to focus on our priorities, we will:
Year 1 • Present this Strategy and our action plan to the Powys Local Medical Committee • Develop a Programme Plan around the delivery of the “Supporting Carers in General Practice” Programme. • Consider the appropriateness of including carers issues in the forthcoming Local Service Board pilot of Neighbourhood Management in Newtown. • Pilot engagement with GPs including the identification of carers champions in each practice. • Place promotional information in all GP surgeries and hospitals. • Undertake carer awareness training for health and social care staff. • Review our Hospital Discharge policy to ensure appropriate procedures for the identification of carers and assessment of their needs.
Years 2 and 3 • Roll out our General Practice Programme • Indentify “Carers Champions” in all GP surgeries and hospital wards. • Develop performance framework to ensure we can monitor how well we are doing at identifying new carers • Undertake training with community nursing and care management staff on carers’ assessments.
3. We will ensure that carers have access to good information to support them in their role.
Our priorities: • Review our existing information provision • Develop an effective information resource for carers on the Powys teaching Health Board website • Ensure key information is available to carers in their first language
We have consulted widely with carers in the development of this strategy. Clear themes have emerged in this consultation that information to support carers needs to be: • Timely (before a crisis occurs)
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• Easily accessed • Understandable • Proportionate • Relevant
We need to review the information that is currently available to carers and ensure it is effective. We also need to ensure that there is good information available to inform colleagues in primary health care about how they can support and where they can signpost.
On the basis of this analysis, we will be able to review not only the content of the information we provide, but the way in which we make it available. We need to ensure that carer awareness information is available in key places such as GP surgeries and hospitals.
In addition we recognise that the rural nature of Powys places particular challenges on us in terms of distributing information. Increasingly, the internet must be seen as a key vehicle for the contact that we hope to develop with carers. To embark on this development, we must develop the Powys teaching Health Board website to have a specific section which provides information support for carers.
Our research on the population in Powys shows that we do not have any significant proportions of BME populations. However perhaps especially in relation to our rural, agricultural economy, we are aware that there are increasing numbers of people from Eastern Europe living in Powys and we need to make sure that our information and support is available to these people.
In order to focus on our priorities, we will:
Year 1 • Review our existing information in consultation with carers • Develop and start a Project Plan for the development of the PtHB website to meet carers needs • Consider and further research the requirement for the provision of information for carers in languages other than English and Welsh.
Years 2 and 3 • Continue with the implementation of website development • Act on the review of information provision • Consider publication of carers information in additional languages.
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4. We will make available training to carers to support them in their role.
Our priorities: • Ensure carers can access training which helps them in their role • Ensure that, through respite and other arrangements, carers who wish to take part in training can take the time out to do so. • Provide support to transport carers to training events where appropriate
Better supported Carers will enable the cared for to be supported longer. The approach to training for Carers will build on existing training and take account of what Carers need to enable them to fulfil their caring roles. The training will cover a range of subjects:
• physical and emotional wellbeing • safe lifting, moving and handling techniques • the use of aids and adaptations • stress management • advice on medicines management including its safe administration • advice on specific conditions such as caring for someone with dementia, mental health problems, physical disabilities, sensory disabilities, learning disabilities, etc.
Provision of training for Carers is reported as currently ad hoc, although a range of training for Carers, such as, stress management, adult protection and facilitating and signposting Carers to other training, e.g. Alzheimer’s, is available. Powys County Council provides training which Carers can attend but the courses can be difficult to access for a variety of reasons (content, venue, timing etc). Due to the geographical nature of Powys, Carers also find it hard to travel to training and 50% of Carers do not want to leave the person they care for.
In order to focus on our priorities, we will:
Year 1 • Work with carers representatives to develop a clear carers training plan • Consider the use of e-learning linked to the PtHB, PCC and Powys Carers websites. • Ensure respite and transport are available for carers who with to undergo training.
Years 2 and 3 • Continue to implement the agreed carers training plan and monitor its take- up.
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5. We will make sure that our staff are trained to be aware and responsive to the needs of carers.
Our priorities: • Ensure carers awareness training is made available to all key staff • Implement the e-learning package and monitor its uptake • Ensure staff are suitably trained to undertake meaningful carers assessments
Organisations have a responsibility to ensure all staff are trained in Carer awareness issues to support their understanding and ability to meet the needs of Carers. Currently, staff within Powys Teaching Health Board and local authority and voluntary sector access existing training on Carer awareness issues through the local authority and voluntary organisations training sessions. Key learning outcomes of the training include;
• The impact caring has on an individual’s life & family; • Being able to define the issues faced by Adult & Young Carers; • Carers Legislation & Carers funding; • Carers rights and services available to them; • The importance of the Carers Needs Assessment and Young Carers self assessment; and • How easy is it for Carers to be able to think and therefore plan ahead for things such as social activities, education, work, hospital discharge?
Primary Care practitioners, namely General Practitioners are provided training in Carers awareness, some of them through trained Carer trainers via Powys Carers Service.
E-learning training has been procured as part of a consortium with the local authority and other Health Boards across Wales. This is accessible to all staff and will be made accessible to Carers via the internet.
In order to focus on our priorities, we will:
Year 1 • Undertake a training needs analysis for PtHB and PCC staff • Develop a training plan based on the above • Pilot the e-learning package amongst a key target group of PtHB and PCC staff • Identify carers champions in appropriate PtHB and PCC teams.
Years 2 and 3 • Implement the training plan as above. • Roll out the e-learning programme • Monitor the uptake of, and outcomes from the implementation of the staff training programme.
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6. We will make sure that we develop our services in consultation with carers.
Our priorities: • Through the continued development of our Carers Partnership Board, ensure that carers continue to be involved meaningfully in the development of services • Ensure that carers are involved and well informed at all stages in the treatment and care for the person to whom they are providing support.
Powys teaching Heath Board, local authority and voluntary organisations will ensure the participation of Carers before making any decisions regarding the provision of services to, or for Carers and the persons they care for. This extends to Carers of all ages and sections of the community, particularly Young Carers who assume responsibility for parents and siblings and Carers from Black and Minority Ethnic (BME) communities. It must never be assumed that Carers can or will provide care. Carers have a right to choose whether or not they will care and the level of support they are prepared to offer. It is important that practitioners and their partners negotiate with the Carer what care they can and are willing to provide.
As a minimum Powys Teaching Health Board, local authority and voluntary organisations will:
• Engage individuals (such as family members, advocates, individuals granted Enduring or Lasting Power of Attorney under the Mental Capacity Act and court appointed deputies) as early as possible; • Ask Carers what is important to them and how they wish to be involved; • Provide feedback to those involved, explaining what action has or has not been taken and why; • Act on information received; • Recognise that Carers may need someone to explain and revisit options perhaps on several occasions; • Allow Carers sufficient time to respond and staff will ensure that adequate time is given dependent on the issue Carers need to make a decision about; and • Ensure services are culturally appropriate, age appropriate and available through a variety of methods, including both written information and information in other media, such as stakeholder meetings. This will extend to engaging with more hard-to-reach carers and those who are not traditionally engaged or involved in consultation.
In order to focus on our priorities, we will:
Year 1 • Consolidate the role of the Carers Partnership Board and its relationship with the Carers Commissioning Group • Continue to consult with carers in the development of the Carers Commissioning Strategy. • Develop an approach that ensures that the perspective of young carers is well represented in our plans and strategies.
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• Ensure our training needs analysis and training for staff includes approaches to involving carers in treatment and care planning.
Years 2 and 3 • Ensure carers are involved in the review and monitoring of our strategies and plans through the Carers Partnership Board and workshops and other engagement mechanisms as necessary
5.2 Young Carers
Young Carers are defined (Becker, 2000) as ‘children and Young Persons under 18 who provide or intend to provide care, assistance or support to another family member. They carry out, often on a regular basis, significant or substantial caring tasks and assume a level of responsibility which would usually be associated with an adult’.
Within Powys, we know that about 30% of Young Carers registered with Powys Carers Service care for a single parent with mental health difficulties. The impact for Young Carers of looking after one or both of their parents and/ or siblings can have a detrimental impact on their education and health, and their social exclusion should not be underestimated as they can be particularly disadvantaged through their caring responsibilities. They can feel isolated from other children because they do not have enough time to spend with friends. This can affect their emotional development and impact on their future life experience and relationships.
Young Carers may face problems at school with attendance and in completing course work. Young Carers (Challenging their Own, 2003) schools need to recognise the effect caring has on Young Carers. Teachers and staff must take time to work with them. It is recognised (ADASS/ADCS (2009) that in order to support Young Carers and families effectively that a whole family approach must be adopted to support the individual needs within the family and to support the needs of the family as a whole.
Powys Teaching Health Board, local authority and third sector organisations have to consider the best interests of the child and support their right to life, survival and development, taking account of their views on being a Carer and ensuring they are not discriminated against. Consideration has been given to the type of information and support that Young Carers in Powys will find useful, suggestions include:
• dealing with domestic tasks; • personal care; • emotional care; • financial support; • life experience and relationships; • educational support;
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• accessing social activities; • counselling services; • advocacy; and • transport.
The Carer and multiagency workshops highlighted that the sources of information for Young Carers needed to include: • School Nurse; • School Champion; • Community Nurse; • Carers Champions (GP Surgeries); • Youth Service; • Information Leaflets; • Powys Young Carers; • Leisure Centres; • Libraries; • Social Media; • Drop-in sessions; • Shops/Community notices; • Peers, Apps for mobile phones, School Assemblies; • Lack of insight in key professional service, only as good as good as the deliverers; and • Joining up adult & children social services re substance abuse/mental.
Some of the practical issues the Young Carers identified in accessing information were identified as:
• Who to contact (Contact Details ); • Team around the Family (TAF); • Acknowledgement of right of Young Carer to be involved (and not involved); • Communication & Multi-Agency working; • Working relationships between agencies; • Need help to identify themselves as a Carer; • Time-out from their caring role – information on how this can happen; • Use of common assessment framework; and the • Local Resource Solution Panel needs to be used. It is recognised that education have a role to play in the provision of information to Young Carers and in response to what schools can do, Young Carers suggested:
• “Be open to involvement from Powys Carers Service” • “Awareness raising (School Resource Park)” • “Development of e-learning package” • “Notices” • “Link to Young Carers website via school website” • “Flexibility/Understanding” • “Facilitating communication with home”
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• “Sensitivity/Discretion” • “Transition Arrangements 14+, 16+” • “Identify and refer Young Carers” • “Pyramid Scheme in schools – Screen for children with problems, for example, withdrawn.”
We will work collaboratively with Young Carers to ensure they have access to information,5.3 Monitoring support, Our training Strategy and development to meet their needs as referenced by specific actions within our Action Plan.
5.3 Monitoring Our Strategy
Monitoring arrangements will be through the multiagency Carers Partnership Board and report into individual organisational relevant committees. Mechanisms for monitoring implementation of the strategy will consist of:
• A results based accountability score card has been developed, of which the performance measures identified to measure success are:
o % of Carers identified by the partnership o % of staff within the partnership area who have undertaken training o % of Carers who have been referred for an assessment o % of Carers who take up an assessment
• Additional local measures identified to meet indicated outcomes will be reported and monitored through the Carers Partnership Board.
o O1 - % of Carers who have access to timely and relevant information on the condition of the cared for; o O2 – % of Carers provided training in how to look after someone who has dementia, mental health problems, administering medicines safely, first aid, safe lifting and handling, cooking, etc; o O3 - % of staff and professionals who have accessed Carer Awareness training; o O4 - % of Young Carers caring for adults who have been provided support to care; and o O5 - % of Carers, young and adult, who have been provided support to continue in education and employment; and
• An annual report on the implementation, evaluation and progress of the strategy will be submitted to Welsh Ministers, year on year.
• The strategy will be reviewed after 18 months to ensure it remains ‘fit for purpose’.
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Appendix 1
Carers Information and Consultation Strategy Project Plan
Task Name Duration Start Finish
INITIAL DRAFTING OF CARERS STRATEGY 10 days Mon 19/03/12 Fri 30/03/12 Research Background 43 days Wed 01/02/12 Fri 30/03/12 Use WG Template 22 days Thu 01/03/12 Fri 30/03/12 PARTNERSHIP INPUT TO STRATEGY 17 days Wed 18/04/12 Thu 10/05/12 Update strategy 1 day Tue 17/04/12 Tue 17/04/12 2nd draft strategy 1 day Mon 11/06/12 Mon 11/06/12 ENGAGEMENT EVENTS 115 days Thu 19/04/12 Wed 26/09/12 19 April ‐ Powys Carers 0 days Thu 19/04/12 Thu 19/04/12 Analyse Feedback 10 days Mon 23/04/12 Fri 04/05/12 Update strategy 5 days Mon 07/05/12 Fri 11/05/12 23 May ‐ Powys tHB 18 days Wed 23/05/12 Fri 15/06/12 Preparation for session 9 days Tue 01/05/12 Fri 11/05/12 Analyse Feedback 7 days Thu 24/05/12 Fri 01/06/12 Update Strategy 10 days Mon 04/06/12 Fri 15/06/12 9 July ‐ Joint event 1 day Mon 09/07/12 Mon 09/07/12 Pre‐meeting to agree questions 10 days Tue 01/05/12 Mon 14/05/12 Meeting with Dominique 1 day Wed 30/05/12 Wed 30/05/12 Workshop 1 day Mon 09/07/12 Mon 09/07/12 Analyse Feedback 11 days Mon 16/07/12 Mon 30/07/12 Update Strategy 5 days Tue 31/07/12 Mon 06/08/12 13 September ‐ Brecon Carers 10 days Thu 13/09/12 Wed 26/09/12 Preparation for session 23 days Wed 01/08/12 Fri 31/08/12 Analyse Feedback 2 days Fri 14/09/12 Mon 17/09/12 Update Strategy 2 days Tue 18/09/12 Wed 19/09/12 SURVEY ACTIVITY 100 days Mon 23/04/12 Fri 07/09/12 Young Carers (to complete) 65 days Mon 23/04/12 Fri 20/07/12 HP to liaise with 15 days Mon 23/04/12 Fri 11/05/12 Draft survey 10 days Mon 07/05/12 Fri 18/05/12 Seek partner views on survey 45 days Mon 07/05/12 Fri 06/07/12 Organise IT Platform 49 days Tue 01/05/12 Fri 06/07/12 Contact with Schools, etc 49 days Tue 01/05/12 Fri 06/07/12 Organise and agree evaluation approach 49 days Tue 01/05/12 Fri 06/07/12 'Go Live' Survey 37 days Thu 31/05/12 Fri 20/07/12 Adult Carers 59 days Tue 01/05/12 Fri 20/07/12 Core group meeting 14 days Tue 01/05/12 Fri 18/05/12 Draft survey 24 days Tue 01/05/12 Fri 01/06/12 Seek partner views on survey 24 days Tue 01/05/12 Fri 01/06/12 Organise IT platform 49 days Tue 01/05/12 Fri 06/07/12 Organise postage arrangements 49 days Tue 01/05/12 Fri 06/07/12 Upload survey to web 30 days Mon 04/06/12 Fri 13/07/12 Organise and agree evaluation approach 54 days Tue 01/05/12 Fri 13/07/12 'Go Live' Survey 16 days Fri 29/06/12 Fri 20/07/12 Survey Evaluations 72 days Thu 31/05/12 Fri 07/09/12
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Analyse survey responses 66 days Fri 01/06/12 Fri 31/08/12 Update strategy 5 days Mon 03/09/12 Fri 07/09/12 FINAL DRAFT STRATEGY 20 days Mon 03/09/12 Fri 28/09/12 Update strategy 13 days Mon 03/09/12 Wed 19/09/12 Partnership input to strategy 13 days Mon 03/09/12 Wed 19/09/12 Sign‐off Directors Powys tHB and Powys 2 days Thu 27/09/12 Fri 28/09/12 CC SUBMIT STRATEGY TO MINISTER 1 day Mon 29/10/12 Mon 29/10/12 TRANSLATION STRATEGY 43 days Mon 02/07/12 Fri 15/03/13 Procure translation team 20 days Mon 02/07/12 Fri 27/07/12 Complete translation 22 days Wed 02/01/13 Thu 31/01/13 Final translation 1 day Fri 1/02/13 Fri 1/02/13 EASY READ VERSIONS 40 days Fri 01/02/13 Fri 29/03/13 Procure Easy Read specialists 10 days Fri 01/02/13 Fri 15/02/13 Complete Easy Read 4 days Mon 18/02/13 Fri 15/03/13 Translation Easy Read 18 days Mon 18/03/13 Fri 29/03/13
Information and Consultation Strategy for Carers Page 48
Appendix 2 Participants in Consultation Events
Age Concern Powys Alzheimers Society CAIS – Drug and Alcohol Agency Carers (as part of individual events and in response to the Adult Carer survey) Carer’s Champions (General Practitioner Practices) Care and Repair Carers Wales Careers Wales Citizens Advice Bureau Counsellors Crossroads Department for Work & Pensions – Job Centre Directorate Down Syndrome Association Fire Service Hafal Older People’s Commission for Wales Powys Advocacy Service Powys Association of Voluntary Organisations Powys Carers Service Powys Children and Young People’s Partnership Powys County Council (various representative areas) Powys Domestic Abuse Forum Powys Mental Health Information Service Powys Teaching Health Board (various representative areas) SNAP Cymru Youth Intervention Service
Information and Consultation Strategy for Carers Page 49
Appendix 3
CARERS STRATEGIES (WALES) MEASURE 2010
INFORMATION SERVICE GAP ANALYSIS
Information Service Delivered Information Service Required
Information about Carers rights Currently Powys Carers Service, Crossroads, Access to Advocacy 1. Information packs for Carers from Community and District General Service, Alzheimers Association, Age Concern, Care and Repair, Hospitals. Community Support Organisations, Social Services and PAVO 2. A Carers Resource pack needed at the implementation stage. Information Engine (a database of organizations that give information 3. Carers identified at an early stage – as part of MDT Meetings – and and support). offered support (in other parts of Wales this is achieved through the attendance of a Carers Liaison worker at all MDT Meeting)
Information about Carers rights when the needs of the person being cared for relate to their mental health Currently Powys Carers Service, Crossroads, Hafal, Access to 1. Information packs for Carers from Community and District General Advocacy Service, Alzheimers Association, Age Concern, Care and Hospitals. Repair, Community Support Organisations, Social Services and 2. A Carers Resource pack needed at the implementation stage. PAVO Information Engine (a database of organizations that give 3. Carers should be identified and offered support as soon as possible. information and support). Information about medication and its potential side effects including medication changes and combinations of medication Community pharmacists 1. Pharmacists to be involved in multi-disciplinary meetings. Pharmacy champions 2. Training for young Carers who are collecting and administering GP champions medication. 3. Training for volunteers collecting medicine 4. System required which ensures information about medication stays with the patient and is accessible by the Carer (e.g. to avoid problems when patient transferred to DGH or back)
Information and Consultation Strategy for Carers Page 50
Information Service Delivered Information Service Required
Information on the medical condition and course of treatment of persons cared for Multi-disciplinary team meetings. Patient can sign a consent form that enables information to be The Carer to be involved during the patient discharge process from the shared with Carer. District General Hospitals. See comment about a Carers Support Worker being present at all MDT’s – possibly work with other Carers Services to facilitate at DGH’s Default position in GP surgeries that Carer should be informed – or that GP practices implement permission forms already provided to practices by PCS to use. Ensure that all GP Surgeries are required to exhibit information for Carers in Surgeries.
Information to assist children and young people who have a caring role Young Carers workers in some (but not all) schools providing information and advice to individuals, through PSE sessions and Consistency across Powys as there are recorded gaps in schools and surgeries but this is ad hoc as it depends on capacity of Young colleges of further education Carers service and attitude of school. Identify, sustain and maintain Carers Champions in every school Information provided to Young Carers 1:1, by text & telephone, email, Introduce Carers Awareness in PSE sessions in each school. through groups and activities Provide Carers Awareness training for teachers in schools Via website Ideally a presence by a Young Carers worker in every school Via presence on Kooth Identification of those children who are primary carers, i.e. not siblings ESTYN (School Inspections) do consider the extra needs of the of children with a disability and information on entitlement and how to Young Carer. access respite/short break services
Information and Consultation Strategy for Carers Page 51
Information Service Delivered Information Service Required
Information on the availability, entitlement to and sources of local and national support 1. Short breaks and respite care are provided by Crossroad Services. 1. Standardised service with assessment of priority needs. 2. Social Services/Carers Assessment. 3. Information reference the Court of Protection is provided via Age 2. Consistency in delivering the Carers Assessment across Powys. Concern, Powys Carers Service and PAVO. 4 General Information on rights, entitlement, eligibility and sources of 3. Powys Carers Service to be authorised to deliver this service. support from Powys Carers Service via 1:1’s Telephone, text, email, website, newsletter diaries and events. 4. More financially sustainable respite services for Young and Young Signposting to other local and national support. adult carers (groups & activities) Respite care provided to Young Carers through groups and activities (currently dependent, to a great extent, on external funding)
Information on short breaks and respite care See above Services need to be more sustainable
Information on carer’s needs assessment Provided by: Powys Carers Service Need a far wider understanding of the right to and benefits of a Carers Social Services Assessment throughout the voluntary and statutory sector
This includes other voluntary sector organizations, Adult and, especially children’s, services, mental health, primary care (e.g. GP’s District Nurses) and within DGH’s
Information and Consultation Strategy for Carers Page 52
Information Service Delivered Information Service Required
Information on the Court of Protection Via Powys Carers Service who signpost to other organizations when necessary Information should be included in the carers’ pack
Information on Direct Payments Powys Carers Service, Citizens Advice Bureau, Powys Association of Mental Health, PAVO DEWI
Information on housing support Powys Carers Service Outreach Workers Information available at Housing offices and through all public facing Care and Repair venues. Powys Council Housing Department gWALIA
Information on independent advocacy Powys Carers Service (Independent Advocacy provided by PCS – dependent on charitable funding) More sustainable advocacy services Powys Mental Health Alliance Age Concern Powys Powys Carers Service provides low level advocacy for Young Carers and Independent advocacy for Young Adult Carers (dependent on charitable funding) Tros Gynnal
Information on counseling including bereavement support. Powys Carers Service provides counselling (dependent on charitable funding) across Powys. More sustainable services
Information and Consultation Strategy for Carers Page 53
Information Service Delivered Information Service Required
Information on guardianship Powys Carers Service provides general information and signposts to more specialist organisations where necessary
Information on age appropriate support groups Provided by Powys Carers Service – Young Carer groups (<11-14) Young Adult Carer groups (15 – 25) Adult and older adult support groups
A range of other support groups are provided by a variety of local and national voluntary sector organizations e.g. mental health (MIND), MANGO, Alzheimers, etc
Information on culturally appropriate support groups
Powys Carers Service signposts to a support groups where available e.g. church but there is not much available for different cultures in Powys
Information on financial advice and support including advice on welfare benefits Powys Carers Service provides support in relation to benefits associated with Carers and signposts to DWP and PCC Benefits advisor for more complex cases
Information and Consultation Strategy for Carers Page 54
Information Service Delivered Information Service Required
Information on managing the financial and administrative affairs of persons who are cared for Powys Carers Service provides general information and advice and All carers should be made aware of lasting power of attorney before it is signposts to more specialist services (e.g. CAB) when necessary needed.
All carers should be made aware of problems with mental capacity issues
Information and advice on employment provisions, including flexible working Powys Carers Service provides information and advice about rights and signposts to more specialist services (e.g. ACAS) when necessary
Information on the duties of local authorities to assess the needs of those who may be eligible for community care services and to access the needs of carers, and, in both cases, provide services Powys Carers Service through Outreach Workers, Web Site, Email, Text, Telephone, Newsletter, Diaries of events and through the press More awareness required in statutory services especially amongst when possible. frontline Social and primary care staff.
Information about the availability of concessionary transport schemes and other patient transport arrangements to enable carers to attend NHS appointments with the person cared for Through Powys Carers Service From some Community Transport projects Provision of information through Local Hospitals and DGH’s
Information and Consultation Strategy for Carers Page 55
Information Service Delivered Information Service Required
Information and advice on physical aids, and housing adaptations By Powys Carers Services Care & Repair More coherent and more easily accessible information required at the Via social workers right time Via Housing departments
Information on the regulation and inspection of health and care services by the Healthcare Inspectorate Wales and the Care and Social Services Inspectorate Wales Information and guidance on how to access CSSIW reports on registered domiciliary care agencies used by Carers
Information on local carer support agencies and appropriate national organisations supporting patients, users and carers Powys Carers Service provides information, advice And support and signposts to more specialist national organisations More consistent information from and signposting by frontline health and social care staff
Information on how to avoid hospital admission Not sure how to answer this – better informed, supported carers will 1. Respite/short breaks to reduce the potential for Carers to suffer ill reduce unscheduled care – the problems usually arise when health and require hospitalisation statutory services are unable to respond quickly, creatively and 2. Care at home for people with health care needs during Carer’s proactively incapacity/absence from the home
Information and Consultation Strategy for Carers Page 56
Information Service Delivered Information Service Required
Information on the availability of crisis support and how to access it Information on Availability of crisis support is provided by Powys Carers Service as well as an Emergency Card but the actual Connect Carers Emergency Card to service offered by PURSH availability of Crisis support is often (but not always) dependent on the ability of statutory services to respond in a timely way.
Information on the availability of re-ablement and intermediate care for the person cared for Provided by Powys Carers Service Primary health care services Voluntary Sector organisations
Information that helps promote health and well-being, including information and training on stress management techniques, healthy diet and physical exercise 1. Information on access and entitlement to day services 2. Information on access and entitlement to respite/short breaks while the Carer attends physical exercise facilities, e.g. gym or swimming pool
Information on the complaints procedures of the Local Health Board and the Local Authority Provided by LtHB, PCC, Powys Carers Service
Information on programmes to assist carers to carry out their caring role safely and effectively PCS provides information on what services are available but there are not many programmes available Programmes to assist carers to carry out their caring roles safely and effectively Carers Training, as provided by Crossroads in Hywel Dda Health Board area
Information and Consultation Strategy for Carers Page 57
Information Service Delivered Information Service Required
Information on safe lifting, moving and handling
Service Delivered Service Required See above Safe Lifting and handling techniques relevant to Carers Accessible to Carers in remote geographical locations Carers Training, as provided by Crossroads in Hywel Dda Health Board area
Information on medicines management including the safe administration of medication to the carer or person cared for
See above
Information on relevant nursing skills
See above Should be delivered by district nurses as necessary
Information on use of aids and adaptations Signposting by PCS
Information on continence care Signposting by PCS
Information and Consultation Strategy for Carers Page 58
Information Service Delivered Information Service Required
Information on stress management Courses and advice provided by Powys Carers Service as and when More sustainable service funding available
Information on assistance with eating and drinking 1 General advice to carers 2 Specific advice when needed
Information on dealing with behavioural issues of the person cared for 1 General advice to carers 2 Specific advice when needed
Information on helping carers to look after themselves Provided by Powys Carers Services e.g. Nutrition Respite De-stressing Pampering All dependent on ad hoc funding
Information and Consultation Strategy for Carers Page 59
Appendix 4
Consultation Event – Carers Forum, Newtown 19th April 2012
Information and advice on employment provisions, including flexible working
Benefits very complicated. Information and Advice through Job Centre Plus, PCs, Disability Advisers. Gave up work.
Information on the duties of local authorities to assess the needs of those who may be eligible for community care services and to assess the needs of carers, and in both cases, provide services (Community care services are defined in s.46(3) of the NHS and Community Care Act 1990 c19)
Welshpool Team very good, MH & SSD older and disabled people team everywhere else in Powys very problematic
Information about the availability of concessionary transport schemes and other transport arrangements to enable carers to attend NHS appointments with the person cared for
Community Transport Scheme – but has run out of funding. Most won’t take young carers. One “cared for” has free bus pass (but can’t use buses). Full price for Community transport.
Information and advice on physical aids, and housing adaptations
Brilliant but long waiting list for OT’s for assessments 6-12 weeks (however small the need is). Use Red Cross in Newtown.
Information on the complaints procedures of the Local Health Board and the local authorities
Through local (MH) service. Patient Managers through GP’s
Information on how to avoid hospital admission
GP – Specialist. Not aware of information. MH Team accredited accommodation. Not easy to access into although some services exist though. PCS posters in GP Surgeries
Information on local carer support agencies and appropriate national organisations supporting patients, users and carers
Internet PCS Services. Accessed through SW, Libraries, Dentists, Pharmacies offers (Emergency Card + icare card)
Information on the availability of crisis support and how to access it
Too busy dealing with it. PCC training. Ring PCS OW, 999, NHS Direct, Shropdoc.
Information on the re-ablement and intermediate care for the person cared for
Information and Consultation Strategy for Carers Page 60
Didn’t know reablement existed – “They were too keen to get her out of hospital
Information that helps to promote health and well-being (including information and training on stress management techniques, healthy diet and physical exercise)
No information available. Carers need support to identify own Health & Wellbeing. Health & Wellbeing through Local Voluntary Sector Groups, Powys Carers Services and Peer Support
Information on programmes to assist carers to carry out their caring role safely and effectively, to include but not limited to:
• Safe lifting and handling
Need carer relevant training. Was not able to access training. Not aware of any training available (There isn’t any) Lack of training for Carers in moving and handling
• Medicines management including safe administration of medication to the carer or person cared for
Doctors service closed down, don’t drive. Had to read the leaflets and Google into Carers do not get adequate information. Information does not exist.
Not aware additional information needs to be given to Carers. Felt isolated once discharged home following stay in hospital. “Nobody here for me/us”
• Relevant nursing skills
Not provided – have to use common service Lack of counselling sections for carer needed to source privately
• Continence care
Not sure – in theory information available through GP. Came out of hospital with catheter but not needed Information – Signposted to continence service had not been assessed was not able to receive products: Gap while waiting for assessment.
• Assistance with eating and drinking
Anecdotal evidence that it is available :Experience of Domiciliary Care Providers – One would assist with eating and drinking another would not- caused distress for family.
Other comments
Eligibility criteria for MH services too high
Priorities: Respite – little or nonexistent need widen range (MH etc)
Organisations need to work together.
Information and Consultation Strategy for Carers Page 61
Need information from hospitals on Powys Carers service.
No referral from hospitals to “Powys Carers”
Reluctant to Complain
Crisis Management poor – there is no practical help – lack of information on who to contact!!
Lack of training in specific illness to offer ongoing support
Lack of training for Carers. Need understanding of illness to give ongoing support, confidence and HOPE.
Emotional side of carers need to be acknowledged & respect by professionals.
Attitude from nursing staff on discharge in respect of lack of care of access for diabetic information
Not everyone has internet access!!
Lack of General Hospital in Powys
Lack of information from professionals
Information on discharge
Great time delay of diagnosis of illness
Personal experience need to source information independently for services.
Information and Consultation Strategy for Carers Page 62
Appendix 5
Consultation Event – Brecon, 11 September 2012
In Attendance: Director, Powys Carers Service Adult Carers Team Leader, Powys Carers Service Head of Quality and Safety Unit, Powys teaching Health Board Policy and Development Officer for Carers, Powys County Council Representative 1 - Older People’s Commission for Wales Representative 2 - Older People’s Commission for Wales Carers Champion, Llandrindod Health Centre. 8 x Carers
The Adult Carers Team Leader opened the meeting, welcomed everyone and introduced Wendy, Gyles, Rebecca and Anna.
Wendy spoke on the Carers Measure and the LHB work on the measure. The NHS have responsibility to put in place the Carers Strategy working with the County Council and voluntary organisations.
The work already undertaken was outlined. A Carers Forum (with Powys Carers Service) in April in Newtown, here the LHB began to understand better the information and advice Carers in Powys need, and what was already in place.
Multi agency workshop in May in Llandrindod with some Carers attending. Also the County Council, Education and Voluntary Organisations, including Powys Carers. Carers workshop in July in Llandrindod. Multi agency reps and Young Carers. An Adult Carers Survey was undertaken with Powys Carers Service. Sent out to 1200 households and on through an on-line survey on the PCS website. There was a 25% response rate and the results are being published.
A Gap analysis was undertaken – The regulations state what should be in place and all discussions fed into a report on what was available and what the gaps were.
A four week consultation ran on the LHB website. I response was received.
Wendy then began a workshop sharing the findings of the consultation processes above.
5 papers were set out: A. The information needed on a range of topics B Training Needed C. Areas requiring further work D. Young Carers E. How do we know we are making a difference?
Those attending were asked to add to the papers.
What the LHB had set in place so far and the process was explained: The Information Strategy must be submitted to the Welsh Government by the end of October 2012. The LHB will have identified targets for the next 3 year. These are to be approved by the Minister, then implemented and reviewed in 18 months.
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From September 2012 the LHB will ask if you are a Carer, if you have had a Carers Assessment and if not will refer the Carer to the appropriate agencies, and other agencies for support.
A paper has been submitted and approved for a Carers Champion in the Health Board. Terms of the role have to be approved.
By November there will be a training programme for LHB staff – Who Carers are, what they need and their rights.
The LHB will have an action plan, monitored by Multi agency group who will report back.
A Carer queried the finances for the strategy etc: Response – It comes from the Welsh Government. Each Health Board gets funding to engage with Carers and for training. Each must get approval for their strategy. There was no set funding to implement the strategy.
Wendy pointed out that by consulting with Carers even if there were not funds for everything Carers will be involved in prioritising the issues and where the money should be spent first.
A Carer asked for the money to be ring fenced for (Carers Awareness) training and delivery of service.
Response: By using a consortium to deliver the training the LHB has cut costs as much as they can.
Heather reported that the council does fund training for Carers.
A Carer raised the need for Carers on each board, selecting Carers at random. Also asked how do the LHB and PCC feed back to Carers.
Response: Gyles reported that Carers are represented on the Multi Agency Reference Group. Powys Carers Service regularly advertises for Carers to represent Carers on such boards in PCS newsletters, diaries, website and local press. Also that PCS does gather information and has recently done some work to highlight problems around discharge from Hospital.
Jenni said that PCS also represents all Carers in a variety of meetings and takes comments, issues and queries from Carers to them and then publishing the outcome.
Heather said that the Multi Agency Reference group will now be called Partnership Boards and the reports of meetings will be published on the Council’s website, and on the PCS website. The Partnership Board will be joint Chaired by a Carer. PCS website already carries Multi Agency Reference Group and Stake Holder Reference Group pages with reports where possible.
The problems associated with Carers actually reporting problems was discussed. Carers are often too busy caring and dealing with the problems that arise to be able to send in a complaint at the time and when the “issue” is over their time is again taken up caring and reporting what was a problem seems less important. The system for reporting needs to be very easy and accessible to enable Carers to feedback.
Wendy reported that the LHB website is holding much more information about who to contact and how, and the information should be readily available so that Carers do not have
Information and Consultation Strategy for Carers Page 64 to hunt for it. There are patient experience pages on the website for people to feed their stories into. These will be fed into the Patient Experience Groups.
Powys Carers service will always collect “narrative” data or take up complaints/ compliments on behalf of Carers.
A Carer raised the point that not all Carers have internet access.
Wendy confirmed that the LHB are thinking of how to get the information out in as many ways as possible and that they needed to be creative. She welcomed ideas. Gyles commented that Powys Carers was also thinking of different ways to support Carers. There are far too many Carers in Powys for PCS to be able to support them all by face to face Outreach Worker alone. Telephone and Text messaging support was being investigated.
A Carer asked how the measure applies to Carers of people with mental health issues. From experience several issues were raised – Senior members of staff being on long term sick without replacement apart from occasional locums – different ones each time, so there is no consistency of approach.
This left CPNs dealing with medicine management and decisions that may be beyond them as regards changing medicines. Both these problems led to little confidence in care.
Lack of funding for meaningful activities, eg Felindre Ward – the hospital has a good gym but not enough staff to allow patients to use it. The atmosphere on wards was very sterile, there was little encouragement to progress towards moving out of hospital – little learning how to live in the community again.
Wendy acknowledged the problems, spoke to the Carer alone to get further details and promised to feedback.
A Carer raised the issues around care and support provided in the community. His son with schizophrenia had received 6 hours a week of support, but it was cut back and when he was at his worst he was receiving on 1 hour a week , it has now (after much fighting from his parents) been raised to 4 hours a week. This is supplied by a charity. The Carer stated that he had been told his son’s care was worth £3500pa but for “ forensic psychiatric” patients (those who could be a danger to the public or themselves) the care budget is £104,000pa.
All Carers agreed with one who said – if you improve things for the cared for, life improves for the Carer.
The issue of there being no information for Carers from Powys in out of county hospitals was raised. A carers Information and advice strategy in Powys may improve the experience for Carers when dealing with services in Powys but how will they measure the impact on Carers who are using hospitals out of county?
Response: Wendy stressed that each health board must engage with the measure and all are part of a network to share the work done. Wendy will take all concerns to both Hereford and Shrewsbury as she liaises regularly with them. She receives information about what happens to Powys residents and the measure will strengthen the links.
Gyles reported that Powys does have a contract to provide services with out of county hospitals and is getting stronger at driving a good contract and fulfilment of services promised, the multi agency groups are working on this at present.
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A Carer raised the issues of his daughter taken into Bronllys 10 years previously then discharged. Then taken back to Bronllys and discharged again. Because his daughter does not A Carer raised the issues of his daughter taken into Bronllys 10 years previously then discharged. Then taken back to Bronllys and discharged again. Because his daughter does not acknowledge her problem the CPNs will not discuss her situation even informally with the parents. They do not want private details just a discussion and advice , it seems the LHB are prepared to let parents pick up the pieces after discharge but will not even answer or return a call.
Wendy acknowledged the problem, and said the LHB were working on how to involve Carers, but there was no easy solution. All comments would be fed back and would drive the work forward.
Gyles commented that professionals tended to hide behind “confidentiality” and this was acknowledged. The point was raised that if you are caring for someone with mental health issues and the only way to get things done is to make it a “fight” then it brings the Carer into conflict with those providing services and when it impacts on their own health, If they need counselling the people they have to go to are the very ones they are in conflict with.
Jenni mentioned that counselling is available through Powys Carers and explained that new funding just won was going to mean counselling could be offered throughout Powys. Powys Carers counselling did not end after 6 appointments, it went on as the Carer needed it.
Wendy offered to speak to the new head of Mental Health services for the LHB regarding a Mental Health Focus Group although a Carer stated it was difficult with mental health issues to share with a group. Also that he had met a lot of Carers encountering the same problems.
A Carer raised the problems surrounding discharge. An elderly man with dementia was told to get a taxi home on New Years Eve. There was no planning around if he could care for himself, if he had a Carer could they cope. Another time he was left alone for a long time while other patients were settle on a ward but he thought he had been “ abandoned “ – his word. Several years later he is still distressed at being left and this creates great difficulty for his Carer. Seemingly no extra care is taken on explaining things or his care to accommodate his memory problems.
Wendy and Jenni spoke to all the Carers separately so that they had time to give more private information and to make sure details of feedback was correct. The officers from the Older People’s Commission spoke to all Carers more informally. Wendy broke up the meeting thanking all for attending and reiterating that feedback was an ongoing process; it was always welcome and would always be sent to the appropriate department. A report from this meeting will be published on the Powys Carers website.
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Appendix 6 Adult Carers Survey
There were 294 responses to the paper and online survey. The paper survey was delivered to carers in the Powys Carers Service Newsletter and the online survey via PCS website. The link to the survey was publicised widely through the voluntary sector networks
Total sent: 1201 Total responses: 294 By post 229 Online 65
There was a 19% response rate to the postal survey.
Age of responding carers
56% of Carers were of working age 42% were over 65
Information and Consultation Strategy for Carers Page 67
Carer gender
70% of respondents were female
Level of caring provided by respondees
97% of carers said that the person they cared for would not be able to manage without their help
Over three quarters of Carers felt themselves to be ‘on duty’ for more than 50 hours per week.
How many people do you Care for?
16% of carers (1 in 6) care for two or more people
Information and Consultation Strategy for Carers Page 68
Number of carers who had had a Carers Assessment
45% of carers had had a Social Services Carers Assessment in the last three years, 55% had not.
Involvement of Carers
Over three quarters of Carers felt that they were involved in decisions about the care of the person they cared for. 23% of Carers were not always involved, weren’t involved or were not sure.
Where do Carers get information from?
Carers gathered information from a wide variety of sources
What information do Carers need?
Information and Consultation Strategy for Carers Page 69
Carers require a wide range of information and consider all types of information to be important. 82% of carers needed information about services for the person they cared for.
How would carers like to get information?
Two thirds of Carers would like to get their information through the post. Over half value Powys Carers Newsletter. Over a third would use email and a quarter would like a Carers telephone helpline.
When would carers like help?
Nearly three quarters of carers would like information before any crisis occurs and one fifth at the time of crisis.
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FOR APPROVAL
BOARD MEETING 24 APRIL 2013 AGENDA ITEM 2.8
BUILTH WELLS HOSPITAL: DECLARATION OF SITE AS SURPLUS TO REQUIREMENTS
Report of Interim Director of Planning
Paper prepared by Interim Director of Planning
Purpose of Paper To present the case that Builth Wells Hospital Site will no longer be required for NHS purposes.
Action/Decision required The Board is asked to APPROVE the declaration of the Builth Wells Hospital site as surplus to requirements.
Link to ‘Doing Well, 1. Governance & Accountability Doing Better: Standards for Health Services in Wales’:
Link to Health Board’s Striving for Excellence Corporate Plan
Acronyms and N/A abbreviations
Builth Wells Hospital Site Page 1 of 3 Board Meeting 24 April 2013 Agenda Item 2.8
FOR APPROVAL
BUILTH WELLS HOSPITAL: DECLARATION OF SITE AS SURPLUS TO REQUIREMENTS
BACKGROUND Plans for the future of service delivery to the population of Builth Wells are advancing. A new service model has been agreed between the two organisations and construction of a new facility, Glan Irfon, by Powys County Council, to support delivery of the model is due for completion during April 2013. In-patient services at Builth Wells Hospital transferred to Llandrindod Wells Hospital during January 2013 on a temporary basis pending the implementation of the new model from the new facility. It is anticipated that all remaining clinical activity at the hospital, provided on an out-patient basis, will transfer to the new facility from June 2013. A small number of staff are based at Builth Wells Hospital for expediency and will be re-located to alternative accommodation within the tHB’s remaining estate, or in rented accommodation. The combination of these actions will render the site unoccupied.
A high level assessment of the accommodation within the Builth Wells Hospital site has been undertaken and it is viewed that the level of works required to bring the building into use as office accommodation exceeds that which would be practically viable for the tHB.
The mortuary on the site has remained open, as it is also utilised by local undertakers for the purposes of a chapel of rest. Discussion has taken place to retain the use of this part of the site for the purposes of a chapel of rest as part of the disposal strategy.
INTRODUCTION Disposal of property by the tHB is governed by Health Building note 00-08 Estate code Welsh Edition.
Under this guidance disposal of surplus NHS property requires a number of steps to be taken as follows:
1. Declaration of the site as surplus to requirements by the Health Board 2. Notification to, and approval by, Welsh Ministers of the intention to dispose of the site 3. Marketing of the site via the Welsh Government Affordable Housing Protocol 4. If 3 not successful, marketing of the site via the open market
Separate disposal of the chapel of rest part of the site will need to be considered in line with estate code to ensure transparency and achieve best value for the site overall.
FINANCE The tHB is able to retain the net receipts associated with the disposal of its assets up to the value of £500K. It is not anticipated that the receipt from disposal of the site will exceed this value. This receipt can be re-invested in the tHB’s estate.
Builth Wells Hospital Site Page 2 of 3 Board Meeting 24 April 2013 Agenda Item 2.8
FOR APPROVAL
The site is valued at £2M within the tHB’s accounts, and as a consequence there will be a need to apply to WG for capital impairment funding to cover this cost.
For revenue disposal of the site will reduce the revenue commitments of the tHB in respect of utilities and routine maintenance. Elements of these costs will be transferred to the new facility, Glan Irfon.
CONCLUSION The development and implementation of a new service model for health and social care in Builth Wells will mean that the current hospital will no longer be used for NHS services as all staff and services will be re-located elsewhere. The Board is therefore able to declare the site surplus to requirements for use by the NHS and initiate the processes to dispose of the site.
Recommendation The Board is asked to APPROVE the declaration of the Builth Wells Hospital site surplus to requirements.
Report prepared by: Presented By: Bruce Whitear Bruce Whitear Interim Director of Planning Interim Director of Planning
Builth Wells Hospital Site Page 3 of 3 Board Meeting 24 April 2013 Agenda Item 2.8
FOR DISCUSSION
BOARD MEETING 24 APRIL 2013 AGENDA ITEM 3.1
INTEGRATED PERFORMANCE REPORT
Report of Chief Executive
Paper prepared by Director of Workforce & OD
Purpose of Paper The purpose of this paper is to:- provide the Board with an update and assurance on the progress being made on the delivery of the high level objectives included in the Annual Plan, and
Action/Decision required The Board is asked to:- NOTE To progress being made on the delivery of the high level objectives included in the Annual Plan, and NOTE the ongoing development of the performance management framework. Link to ‘Doing Well, 1. Governance & Accountability Doing Better: Standards for Health Services in Wales’:
Link to Health Board’s Improving Health & Well-Being Corporate Plan Ensuring the Right Access Striving for Excellence Involving the People of Powys Making Every Pound Count
Acronyms and N/A abbreviations
Integrated Performance Report Page 1 of 37 Board Meeting 24 April 2013 Agenda Item 3.1
FOR DISCUSSION
INTEGRATED PERFORMANCE REPORT
Introduction
This report serves to present the Board with the latest available performance information across the existing Tier 1 and Tier 2 priorities to provide the necessary assurance that the tHB is meeting its targets.
As discussed in previous reports there is continuing work underway to refine and develop the Integrated Performance Report and also to better resource the Information Department. This ongoing work will need to incorporate the requirements of the work underway by WG on the national performance framework.
Information is currently presented under the five delivery areas contained within the HB’s Annual Plan and also incorporates the RAG rated assessment against the 46 aims within the Annual Plan. As part of its ongoing development, consideration will need to be taken of the HB’s 2013/14.
Welsh Government is developing a new Performance Framework which, when published, will be reflected in the on-going development of this Report.
The information required to support the delivery of the Integrated Performance Report is collected from a range of providers and external sources, normally monthly or quarterly in arrears. For the purposes of this report, there are reporting timeframes for targets and service areas which may differ.
This report does not include information on the tHB’s performance against its financial targets which is the subject of a separate report from the Director of Finance.
Integrated Performance Report Page 2 of 37 Board Meeting 24 April 2013 Agenda Item 3.1
FOR DISCUSSION 1 ANNUAL PLAN AMBITION 1: IMPROVING HEALTH AND WELLBEING
Proposed Key aims: 1.1 Improve opportunity and life chances for children 1.2 Decrease the risk of premature death
ANNUAL PLAN 2012/13 - EXECUTIVE TEAM OBJECTIVES Improve the opportunities and life chances Assumes Immunistation moving in right direction and at a level that doesn't for children compromise popualtion health; ?? Teenage pregnancy & low birth-weight Reduce the impact of alcohol on Action in hand; measurement not available for period individuals, families and communities Decrease the risk of death and disability Action in hand; measurement not available for period due to vascular and respiratory disease
Increase self-responsibility and self-care Action in hand;
Increase the public health skills of the Reprted to Board workforce
Optimise the health and wellbeing of the Sickness absence figures in excess of 4% and heading in wrong direction workforce
Contribute to Widening access to Action in hand; employment and training for population of Powys
1.1 Improve opportunity and life chances for children
Key Performance Indicators • 1.1.1 Rate of immunisations and vaccinations against target
1.1.1 Rate of immunisations and vaccinations against target
Information on vaccine uptake in children in Wales is published on a quarterly basis. The latest report was published in February 2013 (COVER 105).
Integrated Performance Report Page 3 of 37 Board Meeting 24 April 2013 Agenda Item 3.1
FOR DISCUSSION Comparison with national uptake rates The chart and table below show that Powys is above the 95% target for all vaccinations for 1 year olds. Powys’ uptake is similar to national rates for 2 and 5 year olds, although is some way behind Welsh targets for MMR1 and MMR2 in 16 year olds. Powys rates for 3 in 1 in 16 year olds is similar to Welsh figure. Whilst we are still falling short of the Wales average, the trend for all childhood immunisations is improving.
PtHB trends in routine childhood immunisations Source: Public Health Wales quarterly COVER reports (COVER 105)
Age Vaccination Powys Wales Age Vaccination Powys Wales 2 MMR1 91.9% 94.3% 1 5 in 1 95.1% 96.5% 5 MMR2 89.3% 89.9% 2 PCV 94.3% 94.9% 16 MMR1 84.1% 91.0% 2 Hib/Menc 93.1% 94.1% 16 MMR2 74.3% 82.4% 5 4 in 1 91.2% 91.5% 16 3 in 1 76.3% 76.8%
Uptake of immunisations for resident children reaching 1st, 2nd, 5th and 16th birthday between 01/10/12 and 31/12/12 and resident on 31/12/12. Source: Public Health Wales quarterly COVER reports (COVER 105)
Action • A separate report will be presented by the Director of Public Health on the actions associated with the current Measles outbreak.
Integrated Performance Report Page 4 of 37 Board Meeting 24 April 2013 Agenda Item 3.1
FOR DISCUSSION HPV vaccination
The table below compares HPV vaccine uptake rates between Powys and Wales for the period 01/10/12 and 31/12/12. This shows that HPV uptake in Powys is similar to, and for some age groups lower than, Welsh national rates.
Powys Wales ResidentImmunised Resident Immunised Age Children No % Age Children No % 13 640 n/a n/a 13 15807 n/a n/a 14 690 565 81.9% 14 16384 14051 85.8% 15 690 564 81.7% 15 16921 14621 86.4% 16 735 583 79.3% 16 17497 14650 83.7% 17 687 593 86.3% 17 17011 14832 87.2% Uptake of HPV vaccine (3 doses) in girls reaching 13 to 17 years of age between 01/09/12 and 31/08/13 and resident on 31/12/12. Source: Public Health Wales quarterly COVER reports (COVER 105)
Action • An audit of current HPV uptake by schools is being undertaken to better understand reasons for low uptake. The audit has concluded and the results are currently being disseminated.
Staff uptake of flu immunisation
The table below compares uptake of immunisation across Wales. This shows that whilst short of the 50% WG in year target, uptake in Powys is ahead of other Welsh Health Boards.
Total Staff Staff with direct patient contact* Immunised Denominator Uptake Immunised Denominator Uptake Health Board (n ) (n ) (%) (n ) (n ) (%) Abertawe Bro Morgannwg 5671 15949 35.6 3933 11382 34.6 Aneurin Bevan 4783 13141 36.4 3147 8868 35.5 Bets i Cadwaladr 6024 17307 34.8 4312 12582 34.3 Cardiff and Vale 5113 14385 35.5 3769 10299 36.6 Cwm Taf 2820 8078 34.9 1961 5363 36.6 Hywel Dda 2829 9859 28.7 2073 6964 29.8 Powys 612 1675 36.5 402 1029 39.1 Wales 27852 80394 34.6 19597 56487 34.7
*combined figures for: Additional Prof Scientific and Technical, Additional Clinical Services, Allied Health Professionals, Medical and Dental, Nursing
Integrated Performance Report Page 5 of 37 Board Meeting 24 April 2013 Agenda Item 3.1
FOR DISCUSSION
1.2 Decrease the risk of premature death
Key Performance Indicators • 1.2.1 Uptake of flu vaccination amongst at-risk patients • 1.2.2 measures to indicate that the correct levels of statins have been provided
1.2.1 Uptake of flu vaccination amongst at-risk patients in Powys 2012/13
Regular Influenza Vaccination uptake reports for Health Boards are available. In addition, there are monthly vaccination uptake reports available for GP Practices.
Patients aged 65 years and over
Immunised Denominator Powys Wales Date (n )(n ) Uptake (%) Uptake (%) 19/02/2013 17125 25282 67.7% 67.6%
Latest figures for GP Practice uptake from 29/01/13 show that uptake varies from 56.9% (Llanfyllin Medical Practice) to 77.6% (Presteigne Medical Practice). Three practices have experienced data submission problems and one practice is unable to submit data electronically and these are therefore not included in the current analysis.
Patients aged less than 65 years who are at risk
Immunised Denominator Powys Wales Date (n )(n ) Uptake (%) Uptake (%) 19/02/2013 5225 10508 49.7% 49.9%
Latest figures for GP Practice uptake from 29/01/13 show that uptake varies from 36.9% (Llanfyllin Medical Practice) to 60.0% (Presteigne Medical Practice).
Action • A “flu group” is in place to further develop the flu vaccination action plan and to provide a co-ordinated approach to the flu vaccination programme. • It is also within the objectives of each Locality to increase uptake of the flu vaccination, both amongst patients and staff. The focus of current work is to review lessons learned from the 2012-13 vaccination campaign and use this to begin planning for 2013-14.
Integrated Performance Report Page 6 of 37 Board Meeting 24 April 2013 Agenda Item 3.1
FOR DISCUSSION
2 ANNUAL PLAN AMBITION 2: ENSURING THE RIGHT ACCESS
Proposed Key aims: 2.1 Maintain waiting time targets 2.2 Increase the proportion of appropriate care delivered in Powys 2.3 Maximise Theatre and Outpatient Clinic utilisation 2.4 Reduce of the number of unscheduled admissions 2.5 Increase the % of people on an appropriate pathway 2.6 Increase access to GPs
ANNUAL PLAN 2012/13 - EXECUTIVE TEAM OBJECTIVES Ensure older frail people are enabled to live Emergency admissions not reducing in line with target safely in the most appropriate setting through access to local services
Ensure that people with a chronic condition Emergency admissions not reducing in line with target are able to access the services they need to manage their condition
Ensure early treatment and prompt Compliant with bundles rehabilitation people experiencing stroke
Ensure people receive a timely, co- Emergency admissions not reducing in line with target ordinated clinically appropriate response to their need through access to appropriate evidence based unscheduled care pathways Ensure people receive a timely, co- Tier 1 targets on-line but may deteriorate due to financial position; small ordinated clinically appropriate response to increase in % provided locally their need through access to appropriate evidence based scheduled care pathways
Ensure people with cancer have access to Concerns around 62 day target - 955 of confirmed cancers with treatment plan clearly defined and co-ordinated pathways in place of care People with learning disabilities live fulfilled Action in hand; healthy lives supported by the appropriate tier of care Improve emotional wellbeing and mental Action in hand; size and complexity of task may cause delay on initial timing health of the population, supporting people with appropriate tier of care
Maximise the proportion of care for children Action in hand; but information needed to confirm actions provided within Powys where safe to do so
Maximise the uptake of the Powys midwife Action in hand; but information needed to confirm actions led service where clinically appropriate and to support highly effective obstetric led care as appropriate Improve capacity and capability of the Action in hand; organisation and its partners to undertake integrated workforce planning to ensure that the right staff deliver the right care at the right place and time Improved partnership working to secure Action in hand; involvement of staff and their representatives in the design and delivery of service change
Ensure that the tHB has the capacity to Action in hand; size and complexity of task may cause delay on initial timing effectively commission healthcare for the population of Powys from all providers Develop effective multi-disciplinary working Action in hand; to provide integrated care internally and across organisational and sector boundaries
Integrated Performance Report Page 7 of 37 Board Meeting 24 April 2013 Agenda Item 3.1
FOR DISCUSSION 2.1 Maintain waiting time targets
Key Performance Indicators • 2.1.1 RTT by speciality and locality • 2.1.2 A&E waiting time • 2.1.3 WAST performance • 2.1.4 Cancer performance • 2.1.5 Mental Health
2.1.1 Referral to Treatment (RTT) • 95% of patients to be treated within 26 weeks, and • 100% patients to be treated within 36 weeks.
The information below provides a summary of the waiting time position for Powys tHB patients using the latest available information which is up to February 2013 for Welsh providers and up to January 2013 for English providers.
Open pathway RTT – sources NWIS Open pathway RTT information gives a ‘snapshot’ of the Powys patients who are currently on an open pathway awaiting treatment.
Welsh Providers Under 26 Weeks 26 to 35 Weeks 36 Weeks and Over Feb 2013 Feb 2013 Feb 2013 (n )(%)(n )(%)(n )(%) ABM ULHB 1,176 93.2% 77 6.1% 9 0.7% Aneurin Bevan LHB 1,124 90.6% 110 8.9% 7 0.6% Betsi Cadwaladr ULHB 206 91.6% 15 6.7% * * Cardiff & Vale ULHB 271 78.3% 56 16.2% 19 5.5% Cwm Taf LHB 147 78.2% 34 18.1% * * Hywel Dda LHB 468 92.3% 29 5.7% 10 2.0% Powys Teaching LHB 5,035 98.4% 82 1.6% 0 0.0% Total Welsh Trusts 8,427 94.8% 403 4.5% 56 0.6%
English Providers Under 26 Weeks 26 to 35 Weeks 36 Weeks and Over Jan 2013 Jan 2013 Jan 2013 (n )(%)(n )(%)(n )(%) RJAH 994 76.8% 195 15.1% 106 8.2% SATH 1,916 92.0% 146 7.0% 20 1.0% Wye Valley NHS Trust 64499.4%**** English Other 9797.0%**** Total English Trusts 3,651 88.5% 346 8.4% 128 3.1%
All Providers Under 26 Weeks 26 to 35 Weeks 36 Weeks and Over Jan 2013 Jan 2013 Jan 2013 (n) (%) (n) (%) (n) (%) All Providers 11,781 92.5% 763 6.0% 191 1.5%
Integrated Performance Report Page 8 of 37 Board Meeting 24 April 2013 Agenda Item 3.1
FOR DISCUSSION
Due to rules around small numbers and the potential to identify individual patients an ‘*’ has been used where numbers are less than 5. N.B. Diagnostic and Therapy RTT patients are excluded from the tables as this information is not available for all providers.
36 week target
English providers As at January 2013, at the aggregate level there are 128 Powys patients who are breaching the 36 week target at English providers. The majority, 99 (77%), of the breaches are in Trauma & Orthopaedics at Robert Jones & Agnes Hunt. Further breakdown cannot be shown due to the possible identification of patients due to small numbers.
Welsh providers As at February 2013, at the aggregate level there are 56 Powys patients who are breaching the 36 week target at Welsh Providers. Further breakdown cannot be shown due to the possible identification of patients due to small numbers.
Action • PtHB has sought assurance from Welsh providers that Powys patients who are waiting longer than 36 weeks are being managed. The general response is that providers are aware of the long waiters and are working to treat them. They point out that patients are managed with consideration given to clinical need and length of time waiting; place of residence is not a consideration. • A number of more specific responses demonstrate that a number of the patients already have their ‘to come in’ date for treatment or have been escalated to ‘urgent’. • At ABMU there have been issues with Plastic Surgery and ABMU agreed a business case with WHSSC which introduced capacity to remove the over 36 week waiting patients by 31st March 2013.
Closed Pathway RTT – sources NWIS
Closed pathway RTT information gives an indication of the performance to date for patients whose pathway is now closed. The table below gives information for the financial year to February 2013 for Welsh providers and to January 2013 for English providers.
Integrated Performance Report Page 9 of 37 Board Meeting 24 April 2013 Agenda Item 3.1
FOR DISCUSSION Location Under 26 Weeks 26 to 35 Weeks 36 Weeks and Over Grand Total Under 26 Weeks 26 to 35 Weeks 36 Weeks and Over No. No. No. No. % % % ABM ULHB 3,173 489 117 3,779 84.0% 12.9% 3.1% Aneurin Bevan LHB 3,098 663 126 3,887 79.7% 17.1% 3.2% Betsi Cadwaladr ULHB 500 70 23 593 84.3% 11.8% 3.9% Cardiff & Vale ULHB 456 92 83 631 72.3% 14.6% 13.2% Cwm Taf LHB 358 55 36 449 79.7% 12.2% 8.0% Hywel Dda LHB 2,009 168 34 2,211 90.9% 7.6% 1.5% Powys Teaching LHB 9,979 644 10,623 93.9% 6.1% 0.0% Welsh total 19,573 2,181 419 22,173 88.3% 9.8% 1.9%
English Other 406 * * 412 98.5% * * Robert Jones 2,164 203 171 2,538 85.3% 8.0% 6.7% Shrewsbury and Telford 5,599 159 52 5,810 96.4% 2.7% 0.9% Wye Valley NHS Trust 5,215 33 5 5,253 99.3% 0.6% 0.1% English total 13,384 399 230 14,013 95.5% 2.8% 1.6%
Grand Total 65,914 5,160 1,298 72,372 91.1% 7.1% 1.8%
Powys is meeting the 36 week as a provider
26 week target At the aggregate level the 26 week, 95%, target is not being met for Powys patients treated in Wales (88.3%) but it is in England (95.5%) with an overall performance level of 91.1%.
2.1.2 Unscheduled Care - Accident & Emergency performance • 95% of all patients should spend no longer than 4 hours in a major A&E department from arrival until admission, transfer or discharge.
In the table below is a breakdown of Powys residents who attended A&E by site of attendance (Welsh sites only). There were 9 sites where the 95% target was not met. For patients attending Powys tHB sites 99.6% spent no longer than 4 hours in A&E. For patients attending non-Powys sites the performance was 79.6%.
Powys patients (Feb 2013) All patients (Feb 2013)
Attending Seen within 4 hrs Attending Seen within 4 hrs Hospital Site (n )(% )(n )(% ) Bronglais General Hospital 178 82.02% 1806 87.76% Morriston Hospital 172 73.84% 6276 75.96% Nevill Hall Hospital 263 80.23% 3364 87.69% Prince Charles Hospital 10 90.00% 3968 75.05% Princess Of Wales Hospital 8 87.50% 4270 86.51% Royal Gwent Hospital * 100.00% 6123 90.36% The Royal Glamorgan Hospital * 100.00% 4661 79.96% University Hospital Of Wales 10 90.00% 10056 83.31% West Wales General Hospital 12 83.33% 2898 84.51% Withybush General Hospital * 50.00% 2781 83.46% Wrexham Maelor Hospital 15 93.33% 5102 88.51% Ysbyty Glan Clwyd * 100.00% 4074 82.20% Ysbyty Gwynedd * 100.00% 3354 82.80% Total All Sites 678 79.61% 58733 83.21%
Breconshire War Memorial Hospital 331 99.70% 355 99.72% Llandrindod Wells Hospital 335 99.40% 348 99.43% Victoria Memorial Hospital 258 99.61% 279 99.64% Ystradgynlais Community Hospital 35 100.00% 62 100.00% Total Powys MIU 959 99.58% 1044 99.62% * Numbers cannot be shown as they are too small and may allow patient identification. Integrated Performance Report Page 10 of 37 Board Meeting 24 April 2013 Agenda Item 3.1
FOR DISCUSSION Latest performance for Powys residents attending major A & E departments in Welsh hospitals
The performance levels for the percentage of Powys patients being seen within 4 hours vary considerably. Some of this variation is due to the fact that the numbers attending are small which can skew the percentages disproportionately as can the influence of Powys MIUs on the case mix in neighbouring A&Es
Action • The DSU continues to work with Health Boards to improve A&E performance and system flow. Powys participates on a daily basis in the executive capacity call. Powys was awarded £370k earlier in the year to support unscheduled care perfomance.
Information is not available for Powys residents attending major A & E departments in English hospitals. However both Shrewsbury (SaTH) and Hereford (WVT) have consistently met the 95% A&E target.
2.1.3 WAST performance for Powys • Target - 60% of Category A calls are attended within 8 minutes.
Winter rising demand and ambulance handover issues at major A&E departments result in ambulances being delayed at the respective DGHs leaving resources in Powys stretched. The performance of WAST will remain a collective focus of WAST and HBs and WG/WAST will formally review handover and compliance processes.
Integrated Performance Report Page 11 of 37 Board Meeting 24 April 2013 Agenda Item 3.1
FOR DISCUSSION 2.1.4 Cancer
31 day target (98%) • patients not referred as urgent suspected cancer, but subsequently diagnosed with cancer, start definitive treatment within 31 days of diagnosis regardless of the referral route.
All Wales performance Across Wales compliance with the 98% target has been consistently maintained. Over the nine months to December four out of six Health Boards are achieving the 98% target individually while the other two have averaged 97% and 95%.
62 day target (95%) • patients referred by their GP with urgent suspected cancer, and subsequently diagnosed as such by a cancer specialist, start definitive treatment within 62 days of receipt of referral.
All Wales performance Over the nine months to December performance across Wales averaged 87% against the 95% target. One out of six Health Boards consistently met the target. In part this performance is reflective of the backlog of patients whose treatments were postponed in December/January and the fluctuation in capacity. The DSU are working with organisations, which have failed to achieve the target, to ensure a focussed improvement in performance.
English providers – 31 day target For the latest available information (January 2013) the performance against the 31 day target was 100%. A chart showing performance over the financial year is below. Over the financial year from April 2012 to January 2013 the average performance was 97.6%.
English providers – 62 day target
For the latest available information (January 2013) the performance against the 62 day target was 85.7%. A chart showing performance over the financial year is below. Over the financial year from April 2012 to January 2013 the average performance was 86.8%.
Integrated Performance Report Page 12 of 37 Board Meeting 24 April 2013 Agenda Item 3.1
FOR DISCUSSION
The data for English providers is based on small numbers across a number of Trusts where a single breach can mean a target is not met. This is new data to Powys and further work is underway to consider how best to use the data to monitor and drive performance improvement.
2.1.5 Mental Health
Project to review and develop the adult services model for mental health
A “Hearts and Minds” – Strategy for Mental Health in Powys was developed through the latter part of 2012 and approved by Powys County Council and Powys teaching Health Board as the legal partners in December 2012/January 2013. A key part of delivering the strategy includes the review of the adult services model, followed by a revision of the models of care and delivery where appropriate and then implementation. To describe what a “Good Mental Health Service for Powys looks like” a wide range of views and opinion from the following sources has been considered:
• Themes from service users and carers taken during the engagement process in developing the “Hearts and Minds” strategy and delivery plan. • Engagement from a wide range of stakeholders who attended the “Hearts and Minds” workshop(s) in July of 2012 and March 2013 • Responses to an on-line survey, March 2013 • Expert opinion from Dr Stephen Hunter, Consultant Psychiatrist • Lessons from service developments in Dumfries and Galloway and Crisis House options from Gofal (3rd Sector Mental Health service) • A literature review on rural adult mental health services.
Over 330 people, including service experts, were engaged in providing opinion for this project. A good mental health service for Powys is described through themes that emerged during the engagement process. Many suggestions were made to develop a high quality, coherent and equitable Mental Health service for the people of Powys. It is clear there are examples of outstanding clinical practice already in Powys, but there is inconsistency across the county in Integrated Performance Report Page 13 of 37 Board Meeting 24 April 2013 Agenda Item 3.1
FOR DISCUSSION terms of staff resource and patient experience. The next stage is to clearly define the best model to develop services to become an “exemplar of outstanding rural mental health care”. This is already underway and should be in a position to report at the end of June 2013.
In relation to answering the specific issue of ‘What a good Mental Health service for Powys should look like’, there were some fundamental principles that came through strongly from different sources.
• Powys needs to be considered as a unitary entity • An integrated service where staff/stakeholders can identify and feel a sense of belonging • Flexible services that are able to respond to client’s needs, that are quality assured and cost effective.
The three phases are:
Phase Outline Timescale 1 To describe what a “Good Mental Health Reporting to Service for Powys looks like” Transformation Board – April 2013 2 To establish what the best model of End June 2013 service is to meet this vision.
3 To implement the service model July onward
Further detail on the key outcomes and core elements is available in an Executive Summary documents and within a full report for this phase of the project.
Access to crisis resolution services
Target • 95% of services users who are admitted to a psychiatric hospital between 9am and 9pm to have received a gate-keeping assessment by the Crisis Resolution Home Treatment prior to admission. • 100% of service users who are admitted to a psychiatric hospital, who did not receive a gate-keeping assessment by the CRHTs, to have received a follow up assessment by the CRHTs within 24 hours of admission.
Whilst Powys is currently achieving 60% against this target there is currently no service provision in the north. Services in Ystradgynlais and Mid and South Powys maintain a100% compliance level.
Action A project group has been established with the support of the DSU with a timetable for the delivery of CRHT in north Powys by April 2013. Powys Local Authority is an enthusiastic partner in this development and has committed a resource through STaR workers and management support for Social Work members of the team. This integrated team should have significant benefits over a Health only service. Funding for the team has been identified through a reduced in-patient contract in Shelton Hospital making conservative assumptions on reduced activity achieved through CR/HTs.
Integrated Performance Report Page 14 of 37 Board Meeting 24 April 2013 Agenda Item 3.1
FOR DISCUSSION
2.2 Increase the proportion of appropriate care delivered in Powys Further work has been undertaken to look at the proportion of Daycase activity delivered in Powys. Below are a number of charts and tables looking at total activity together with the 3 specialities of T&O, ENT and Ophthalmology.
NB – to facilitate comparison the information below is based on the first 9 months of each financial year (latest available information is for month 9 of 2012/13).
All Specialties 2009-2010 2010-2011 2011-2012 2012-2013 In County - Powys 1339 1445 1382 1475 Out of County - English 6258 5855 6039 6248 Out of County - Welsh 2523 2417 2568 2126 All Providers 10120 9717 9989 9849 % Treated in County 13% 15% 14% 15%
T&O 2009-2010 2010-2011 2011-2012 2012-2013 In County - Powys 112 116 114 139 Out of County - English 498 550 658 684 Out of County - Welsh 276 292 313 217 All Providers 886 958 1085 1040 % Treated in County 13% 12% 11% 13%
ENT 2009-2010 2010-2011 2011-2012 2012-2013 In County - Powys 9 11 12 5 Out of County - English 250 122 177 121 Out of County - Welsh64787366 All Providers 323 211 262 192 % Treated in County 3% 5% 5% 3%
Opthalmology 2009-2010 2010-2011 2011-2012 2012-2013 In County - Powys 317 346 285 365 Out of County - English 692 601 397 385 Out of County - Welsh 303 310 267 120 All Providers 1312 1257 949 870 % Treated in County 24% 28% 30% 42%
(NB: This analysis is of procedures recorded in the National Admitted Patient Care (APC) dataset using full Standard Definitions.)
Integrated Performance Report Page 15 of 37 Board Meeting 24 April 2013 Agenda Item 3.1
FOR DISCUSSION 2.3 Maximise Theatre and Outpatient Clinic utilisation
Key performance indicators • 2.3.1 % Theatre sessions utilised – in development • 2.3.2 Number of patients per Theatre session – in development • 2.3.3 % Outpatient appointments utilised – in development
There are a number of on-going streams of work within PtHB that will provide much information for this section, but robust information will not be available until Q1 of 2013/14.
2.4 Reduce the number of unscheduled admissions
Key Performance Indicators: • 2.4.1 Emergency/Unplanned admissions
Below is a chart showing the number of emergency admissions of Powys patients. More detailed information is available with respect to site of admission, practice of registration and diagnosis on admission. Unscheduled care is a focus of detailed work by each Locality.
Emergency admissions of Powys patients to Welsh and English providers together with the relative 12 month averages.
Action • This is currently being addressed as one of the three core projects under the accelerated clinical change programme.
Integrated Performance Report Page 16 of 37 Board Meeting 24 April 2013 Agenda Item 3.1
FOR DISCUSSION 2.5 Increase the % of people on an appropriate pathway
Key Performance Indicators • 2.5.1 Decrease in Delayed Transfers of Care (DToC) • 2.5.2 Bed occupancy levels • 2.5.3 Average Length of Stay (ALoS) • 2.5.4 Integrated Care Pathway for Older People (ICPOP) indicators 2.5.4.1 Emergency admissions to hospital for people aged 65 and over; 2.5.4.2 Emergency bed days for Powys residents aged 65 and over; 2.5.4.3 Admissions to residential or nursing care; 2.5.4.4 Admissions to residential or nursing care direct from hospital; 2.5.4.5 Number of Powys residents aged over 65 dying at home.
2.5.1 Delayed Transfers of Care (DToC)
The four graphs below show the number of patients delayed and the total number of days that the patients have been delayed within Powys tHB Hospitals for the period from April 2010 to February 2013.
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FOR DISCUSSION
Non-Mental Health
Analysis • There has been a significant drop in the number of days patients are delayed in total for the month of February 2013. • There has been a small decrease in the numbers of patients (non-mental) health being delayed during February. • The reasons for delay are varied, however in the main patients are awaiting a suitable care home placement to become available; there has been some delay in starting or restarting home care packages and in some instances complex patient and family decision regarding discharge. • The February position in relation to DToC is improved upon the January position. This is important in relation to the additional winter pressures that have been evident in the system.
Action • The Delayed Transfer of care process and scrutiny has been escalated to the Nurse Director and Head of Adult Services (Powys County Council) for a period of 3 months in the first instance. The current view is that senior clinical and professional managers are working well to escalate where delays are occurring. Furthermore, there is probably only marginal gain to be achieved in improving delay rates without an increase in the capacity of the nursing home sector. • Welsh Government are currently exploring the issue of delayed patients across Wales and Powys tHB will be contributing to that work. • Furthermore an Internal Audit review of the Continuing NHS Healthcare process has commenced to understand whether there are significant delays in managing this process as a result either of the Framework or as a result of practice.
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FOR DISCUSSION
NB –for a number of months the chart is blank as information cannot be shown as numbers are too small and may lead to patient identifiable information being given Mental Health Analysis • There remain some process issues in relation to the collection of the delayed transfers of care data for the time period above. Some caution therefore should be used as it is felt that there may be some over-reporting. This will be resolved in readiness for the next reporting period. • For the period of January and February fewer mental health patients were delayed in comparison to the 4 month preceding period. • Delayed days however has increased indicating that fewer patients are delayed but they are delayed for longer. • The main reasons for delay are the availability of residential or nursing care homes that can appropriately care for people with complex needs as a result of a dementia type illness.
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FOR DISCUSSION Action • The process for the collection of the DToC data is being reviewed – specifically with Betsi Cadwaladr UHB as a result of some anomalies being identified. • Nationally a review by CSSIW has indicated that a broader approach to care home registration/classification is required to enable people to move appropriately into a care home environment. This is likely to require additional support to be put in place both from the teaching Health Board and the County Council. • The provision of community support services for people with dementia is a priority within the Hearts and Minds Strategy. Providing a range of responsive community based services should enable more people to be cared for at home. Given the demographics however the need for bed based accommodation will need to be carefully planned.
Powys Hospitals Efficiency & Capacity
2.5.2 Bed occupancy levels
The indicative target of optimum efficiency is a minimum of 85% bed occupancy level. The tables below provide information relating to the bed occupancy levels at Powys Hospitals for February 2013. Occupancy Without DTOC Occupancy With DTOC Hospital (% )(% ) Knighton 84% 86% Llandrindod 80% 93% Llanidloes 79% 91% Machynlleth 75% 96% Newtown 72% 97% Welshpool 82% 98% Brecon 85% 95% Bronllys 88% 97%
Ystradgynlais 96% 96% Bed Occupancy levels at Powys Hospitals with and without DtoC patients February 2013
The information in the table indicates that the level of DToC patients has a significant impact on the operational bed management within Powys Community Hospitals. As above, the reduction of DToC remains a key priority for the teaching Health Board as the release of a proportion of these beds could present a significant resource and opportunity for the tHB to repatriate patients from DGHs.
2.5.3 Average Length of Stay (ALOS)
The All Wales target for ALOS for Combined Medicine is 9.3 days. However, this target does not capture the different and varied patient groups within Powys Hospitals and PtHB is working with WG to develop a different and more appropriate set of metrics to capture the correct data for Powys residents against the specific ALOS target.
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FOR DISCUSSION
2.5.4 Integrated Care Pathway for Older People (ICPOP) indicators The Integrated Care Pathway for Older People (ICPOP) Programme Board have identified a number of indicators that measure the benefits of working together. The most significant savings and improvement in the quality of care for individuals can be achieved by jointly providing better prevention and provision of care in community settings. This avoids unnecessary and expensive hospital and residential care admissions. For health and social care partnerships this means focusing on:
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FOR DISCUSSION
• Reducing unplanned hospital admissions. • Reducing admissions to residential and nursing care from the community. • Improving hospital discharge arrangements, particularly to residential and nursing home care. • Enabling people to die at home rather than in hospital if that is what they prefer.
There are no updates for these indicators. The latest available information was published in the December report to Board. The next update is due around June 2013.
2.6.1 GP appointment times
100% of Powys practices are open within the contractual hours specified within the GMS regulations with no practices closing for a half day or at lunchtime.
The table below highlights where appointments are available outside of contractual hours.
GP Appointment times Summary as at November 2012
Offering Offering Offering appointments appointments appointments before between between Practice 08:30 17:00 and 18:30 18:00 to 18:30 Ystradgynlais Yes Yes No Brecon No No No Crickhowell No Yes No Haygarth No Yes No Knighton No Yes No Rhayader No Yes No Builth Wells No Yes No Llandrindod Wells No Yes No Presteigne No Yes No Montgomery No Yes No Llanidloes No Yes No Llanfair Caereinion No Yes No Welshpool No Yes No Cemmaes Road Yes No No Llanfyllin No Yes No Machynlleth Yes No No Newtown No Yes No
Integrated Performance Report Page 22 of 37 Board Meeting 24 April 2013 Agenda Item 3.1
FOR DISCUSSION 3 ANNUAL PLAN AMBITION 3: STRIVING FOR EXCELLENCE
Proposed Key aims: 3.1 Continually improve safety, quality and experience. 3.2 Workforce: Ensure Staff are appropriately skilled to undertake their roles and develop to full potential.
ANNUAL PLAN 2012/13 - EXECUTIVE TEAM OBJECTIVES Continuously improve safety, quality and Care home governance experience of care in all settings Improve citizen experience of care through Action in hand; listening and learning
Create an organisational culture in which it Action in hand; treats all its service users, staff and partners with dignity and respect at all times Ensure all medicines are prescribed, Action in hand; administered and monitored appropriately Develop and promote a culture of Action in hand; continuous quality improvement Improve strategic risk management and Compliance with Risk management audit; estates strategy inc asbestos risk compliance with key legislation key area of concern Ensuring that the tHB has the capacity and Action in hand; capability to delivery its vision and objectives Ensure all staff are appropriately skilled to Action in hand; undertake their roles and able to develop to full potential Ensure the organisation has developed Action in hand; effective integrated information management and ICT systems to support service planning, commissioning and performance management processes
Continue to implement the Workforce Action in hand; Information system (wfis) Develop effective and efficient work Action in hand; structures and deployment of staff resources Continually improve professionalism Action in hand; (standards, conduct, competence) in nursing and midwifery and medicine
3.1 Continually improve Safety, Quality and Experience
Key Performance Indicators (to include number of falls and pressure sores and Hospital Acquired Infections): 3.1.1 Primary Care Prescribing Performance – cost effectiveness 3.1.2 Community Hospitals Incident Reports – medication incidents 3.1.3 Hospital acquired infections (Norovirus/D&V Outbreaks) 3.1.4 Pressure damage incidents originating in Powys 3.1.5 Number of ‘incidents’ 3.1.6 Number of ‘investigations’ that identified an error 3.1.7 Percentage of complaints responded to within 30 days 3.1.8 General Practice Clinical Governance Toolkit
Mortality rates – proposed new indicator for 2013/14.
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FOR DISCUSSION All deaths in Powys community hospitals are reviewed at the mortality meetings and any unexpected deaths, which are extremely rare, are subject to investigation overseen by the lead clinician and medical Director.
Routine reporting on mortality rates is currently through the locality MMR meetings to the Clinical Effectiveness Group which is a sub-committee of the Quality and Safety Committee. This group is currently working on proposals for the future presentation of data to be contained within the Integrated Performance Report. The work will be informed by the outcome of the Welsh Government negotiations on the re-tender of the national contract currently provided by CHKS.
3.1.1 Primary Care Prescribing Performance – cost effectiveness
• Is comparatively cost effective and continues to improve; • continues to be the lowest LHB cost per Prescribing Unit (PUs = all patients under 65=1 PU, over 65=3PU) of the 7 LHBs.
Overall, the qualitative aspects of Primary Care prescribing within Powys compare favourably to the rest of Wales, although there is variation between practices. Powys tHB is continuing to work with GP leads to identify areas within prescribing and other aspects of medicines use that may be effective in reducing overall costs to the health economy, while supporting, or improving, the safety and quality of care provided.
3.1.2 Community Hospitals Incident reports – medication incidents
There were 96 medication incidents that occurred during the time frame specified of March 2012 to February 2013. A breakdown by type of incident is included but, due to the possibility of identifying individual patients, a number of categories have been grouped together under ‘Other’.
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FOR DISCUSSION Those under ‘Other Groups’ include: Adverse reaction when drug used as intended, wrong quantity, failure to follow up, frequency for taking of medication was wrong, Patient information leaflet wrong or omitted, Medication incorrectly stored. Other medication incidents’ is used for unusual errors or incidents and for uncategorized incidents.
The medication incidents shown are reported on an all Powys tHB basis and include incidents within the patient home, GP services and community pharmacy services as well as incidents within Powys tHB premises.
Medication Incidents
Mar 2012 - Feb 2013 Mar 2011 - Feb 2012 Incident type (n )(n ) Other Groups 34 29 Other Medication incident 33 33 Only one staff member giving controlled drugs 20 Wrong drug / medicine 9 6 Total 96 68
Source: Datix Risk Management System
*The category “Only one staff member giving controlled drugs” was added in January 2012.
Work is underway to agree the Controlled Drugs policy that will address both administration issues (single practitioner) and drug security issues. It is envisaged that this policy will be completed and agreed before the end of May 2013.
Integrated Performance Report Page 25 of 37 Board Meeting 24 April 2013 Agenda Item 3.1
FOR DISCUSSION
3.1.3 Hospital acquired infections (Norovirus/D&V Outbreaks)
The information in the table below covers from April 2012 to February 2013. Please note the figures represent the reported number of cases by staff in the outbreaks identified. Due to the numbers being small and hence the potential to identify patients, the number of patients and staff affected are combined:
Hospital Acquired Infections by Ward - Apr 2012 to Feb 2013
Number of Number of Date Ward Date Ward Patients/Staff Days Ward Hospital Ward Closed Opened Affected Closed Brecon Epynt 10/12/2012 20/12/2012 13 10 Bronllys Llewellyn 10/12/2012 17/12/2012 9 7 Builth Wells Kite 02/04/2012 10/04/2012 6 8 Builth Wells Kite 14/11/2012 22/11/2012 7 9 Llandrindod Wells Claerwen 27/04/2012 08/05/2012 11 12 Llandrindod Wells Claerwen 13/11/2012 22/11/2012 16 10 Llandrindod Wells Claerwen 14/02/2013 21/02/2012 13 8 Llanidloes Graham Davies 14/06/2012 26/06/2012 15 12 Llanidloes Graham Davies 31/10/2012 08/11/2012 28 8 Newtown Brynheulog 12/04/2012 18/04/2012 17 7 Newtown Brynheulog 11/12/2012 23/12/2012 8 12 Ystradgynlais Adelina Patti 19/12/2012 31/12/2012 13 12 Totals 156 115
Action • The Diarrhoea and/or Vomiting (Norovirus) Outbreak Toolkit was adapted from the Diarrhoea and/or Vomiting Advice Pack/Care Bundle (2009) and from current recommendations: Norovirus Working Party (2011) Guidelines for the Management of Norovirus Outbreaks in Acute and Community Health and Social Care Settings; Health Protection Scotland (2011) Norovirus Outbreak Preparedness: Control Measures & Practical Considerations for Optimal Patient Safety and Service Continuation in Hospitals
The toolkit was circulated for comment in December 2012 and finalised in January 2013 and aims to assist staff in effectively managing and reporting suspected or confirmed outbreaks of Norovirus or other cases of infectious diarrhoea and vomiting.
Integrated Performance Report Page 26 of 37 Board Meeting 24 April 2013 Agenda Item 3.1
FOR DISCUSSION 3.1.4 Pressure damage incidents originating in Powys
Pressure Damage
Mar 2012 - Feb 2013 Mar 2011 - Feb 2012 Type (n) (n) Grade 1 Ulcer 34 41 Grade 2 Ulcer 57 103 Grade 3 Ulcer 8 10 Grade 4 Ulcer 7 7 Moisture Lesions 38 2 Total 144 163
Source: Datix Risk Management System *The category “Moisture lesions” was added in December 2011
Improvements put in place in 2012 leading to increased awareness and reporting of certain types of incidents mean that comparison between 11/12 and 12/13 data should be made with caution. Further, a new category ‘moisture lesions’ was added for 2012/2013 which has contributed to more accurate reporting of pressure damage. Figures differ from previous report due to improved reviewing of incident reports and the time frame has changed from 9 months to a rolling 12 month year.
Action • Further roll out of the skin care bundle has taken place over the last 6 months. This is improving nursing practice, specifically in relation to the knowledge of nurses and healthcare support workers. As part of Transforming Care areas are now using the safety crosses which give a visual display of the incident of pressure ulcers. The Nursing Conference held in December 2012 demonstrated the significant improvement that Ystradgynlais Hospital has made in reducing pressure ulcers, leading to improved patient experience and reduced cost of treating pressure ulcers. This work generated significant interest across other service sites. The verbal report from the Ystradgynlais site on number of weeks without pressure damage differs to information contained in report submissions. This difference has been tracked to an input error on origin of pressure damage; this is due to be changed by site staff.
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FOR DISCUSSION 3.1.5 Number of ‘Incidents’*
Number and Type of 'Incidents'
Mar 2012 to Feb 2013 Mar 2011 to Feb 2012 Type (n )(n ) Incidents Involving Patients 1927 1830 Incidents Involving Staff 267 269 Child Protection Issues 44 65 POVA - Protection of Vulnerable Adults 8 13 Any Other Type of Incident 423 492 Informal Complaint 24 39 Totals 2693 2708
Source: Datix Risk Management System
3.1.6 Number of ‘investigations’ that identified an error.
Number and Type of Investigations
Apr 2012 - Feb 2013 Apr 2012 - Dec 2012 Type (n )(n ) Number of Moderate Harm, patient related incidents that have 70 60 come through for review. Number of Moderate Harm Incidents/Complaints that have been 22 22 presented to the Redress Panel. Number of those presented to Redress Panel identified as having 77 a Breach of Duty which caused harm to the patient; Number of those presented to Redress Panel identified as having 88 a Duty of Care but No Breach of Duty; Number of those presented to Redress Panel which identified a Duty of Care and a Breach of Duty but the panel concluded that 11 this Breach did not cause the harm to the patient. Number of those presented to Redress Panel identified as having a Duty of Care where the Breach of Duty &/or Causation is still to 66 be determined or Further information required before the panel can reach a conclusion. Number of incidents identified areas where lessons needed to be All All learnt and actions put in place.
*From April 2013 monthly data will be provided to inform improved analysis
Integrated Performance Report Page 28 of 37 Board Meeting 24 April 2013 Agenda Item 3.1
FOR DISCUSSION 3.1.7 Percentage of complaints responded to within 30 days
Number and Category of Complaints
Apr 2012 - Feb 2013 1st 3 Quarters 2012/13 Category (n )(% )(n )(% ) Complaints responded to in 30 Working Days 18 43% 17 49% Complaints responded to outside of 30 Working Days but within 6 Months 16 38% 12 34% On-going Complaints received within 1st 3 Quarters of 2012/13 8 19% 6 17% Totals 42 35
The data demonstrates an improvement in the number of complaints responded to in 30 days, although the percentage has not improved as the number of complaints has increased from 35 to 42. The increase in the percentage of complaints responded to outside of 30 working days can vary depending on the complexity of the complaints.
3.1.8 General Practice Clinical Governance Toolkit
All practices within Powys participate in the clinical governance toolkit and continue to review their self assessment of the matrices’ with a view to improving their self assessment.
Participation in the toolkit demonstrates a practice marker for quality and is a progressive tool to assist with GP revalidation. The toolkit is linked to the Standards for Health Services and provides an assurance to the Health Board that the GP practices have systems in place that are effective, or if not, that the practice is planning to introduce or improve such systems with the support of the Health Board and the Primary Care Training Group.
The chart below details an all Wales overview of participation in the toolkit (51 questions in total). Each bar represents all the practices within a health board area and each segment represents the number of practices who have answered the particular number of matrices that the shading signifies. To the far right is a test palette which gives a sense of the graduation employed. From the Powys perspective it confirms that all practices are progressing through the toolkit with: 24% completed and submitted; 5% completed 51 questions (but not yet submitted); 47% completed upto 51 questions, and 24% completed 41- 50 questions.
Integrated Performance Report Page 29 of 37 Board Meeting 24 April 2013 Agenda Item 3.1
FOR DISCUSSION All Wales Clinical Governanace Self assesment tool 2012/13 practice progress all matracies (number of questions with answer) health board area (March 2013)
Not started S-<10 S-10-20 S-21-30 S-31-40 S-41-50 S-51 Complete<50 Complete50 Complete 2 0 0 0 3 4 34 2 12 23 10 9 1 0 0 7 2 2 6 12 6 3 10 5 1 7 57 10 13 3 18 6 4 0 10 1 10 4 0 9 90 8 10 5 6 11 16 36 10 71 15 9 10 16 30 51 10 10 13 47 9 32 26 10 20 4 28 10 10 4 6 5 105 0 10 1 8 3 3 0 0 Aneurin Bevan Abertawe Bro Betsi Cardiff and Cwm Taf LHB Hywel Dda Powys LHB Wales tests pallet LHB Morgannwg Cadwaladr Vale University LHB University LHB University LHB LHB
(As at 12th March 2013. Adjusted for practices known to be closed; ‘Complete’ is completed all 51 & submitted; ‘s’ prefix is started or in progress; yellow are completes but less than 50)
3.2 Workforce: ensure staff are appropriately skilled to undertake their roles and develop to full potential
Key Performance Indicators 3.2.1 % of staff appraisals completed within last 12 months 3.2.2 % of staff undergoing Mandatory training within required timescales 3.2.3 Level of staff sickness absence
3.2.1 % of staff appraisals completed within the last 12 months.
The tHB has set objectives within its Corporate Plan to ensure that all employees receive individual performance reviews on an annual basis. The HB has struggled to effect change in the appraisal activity despite a range of actions to train line managers, review compliance through performance management mechanisms and a range of other actions.The table below provides the monthly trend in the percentage of staff in receipt of a review on a rolling 12 months basis up to February 2012. At that point, in addition to the actions previously reported to improve appraisal rates, the HB adopted a different approach detailed below.
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FOR DISCUSSION
Action
In the last eight weeks detailed reports of Directorate/Locality Performance on Appraisals have been circulated to Leads. These are broken down by Supervisors/Managers names in order to develop a targeted approach to drive performance and increase the uptake of appraisals and also to identify areas of good practice. The tables below demonstrate the level of improvement that this change of reporting and use of information has generated.
In addition, weekly updates have been circulated to all teams and advice and support has been provided by named individuals in the WOD department.
% % % % % % % % Total Staff Locality/Directorate Week Week 6 in Week 1 Week 3 Week 4 Week 5 Week 7 Week 8 Change 2 (18- (18- Post (11-Feb) (25-Feb) (04-Mar) (11-Mar) (25-Mar) (2 April) Wk 1-8 Feb) Mar) Directorate of Finance 28 24.00 13.79 24.14 24.14 24.14 24.14 62.07 89.29 65.29 Directorate of Workforce & OD 35 64.71 66.67 66.67 74.29 75.68 80.56 80.56 88.57 23.86 Directorate of Nursing 71 31.88 34.78 34.78 35.21 35.21 67.61 76.06 87.32 55.44 South Locality Management 415 44.76 50.35 52.69 55.14 53.68 60.95 64.52 76.39 31.63 Directorate of Therapies 23 53.85 52.00 54.17 50.00 52.17 52.17 52.17 73.91 20.06 Women & Children Directorate 219 61.06 59.38 58.48 58.48 64.57 65.77 65.61 72.60 11.54 Directorate of Medical Services 89 54.76 54.12 54.12 53.49 53.49 56.32 60.92 70.79 16.03 North Locality Management 401 36.39 38.68 39.34 41.16 43.92 47.89 59.80 67.33 30.94 Corporate 14 57.14 57.14 57.14 57.14 57.14 57.14 64.29 64.29 7.15 Mid Locality Management 270 44.56 54.71 56.36 56.73 55.80 57.04 59.57 61.85 17.29 Directorate of Planning 57 52.38 51.67 51.61 50.82 53.33 51.67 58.33 54.39 2.01 CHC 103 57.14 54.37 52.38 53.33 52.83 53.40 53.40 52.43 -4.71 Integrated Performance Report Page 31 of 37 Board Meeting 24 April 2013 Agenda Item 3.1
FOR DISCUSSION Grand Total 1725 46.26 49.23 50.17 51.32 52.32 56.85 62.33 66.72 20.46
% Reviews % Reviews Undertaken Locality/Directorate Undertaken 31st March 1 Apr-12 % 2013 Increase/Decrease Directorate of Workforce & OD 54.76% 88.57% 33.81% Directorate of Nursing Services 36.54% 87.32% 50.79% South Locality Management 54.98% 76.39% 21.41% Directorate of Finance 52.94% 75.00% 22.06% Directorate of Therapies 4.55% 73.91% 69.37% Women & Children Directorate 53.10% 72.60% 19.51% Directorate of Medical Services 47.50% 70.79% 23.29% North Locality Management 47.56% 67.33% 19.77% Corporate 42.86% 64.29% 21.43% Mid Locality Management 58.19% 61.85% 3.66% Directorate of Planning 44.83% 54.39% 9.56% CHC 6.06% 52.43% 46.37% Grand Total 48.75% 66.49% 17.74%
The HB will continue to utilise these processes to drive improvement.
3.2.2 % of staff undergoing Mandatory training within required timescales – indicator in development
53% of the tHBs staff have attended mandatory and Statutory training since April 2012 against a target of 100% over a two year implementation plan therefore marginally ahead of target.
3.2.3 Level of staff sickness absence In February 2011 Powys tHB was set an improvement target for Sickness Absence of 4.98%. This target is monitored monthly and is reflected over a rolling 12-month basis. Since this target has also been achieved the WG has set a more challenging target of 4.42% from October 2011.
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FOR DISCUSSION
The graph illustrates that the rolling 12 month rate is currently 5.33% compared to the target of 4.42%. Detailed absence reports for each service area are issued on a monthly basis. These indicate employees with high sickness levels in order that action can be taken to control absence levels. Monthly absence rates have continued to increase since July, exceeding the tHB target which has resulted in the upward trend.
Action
• A range of actions are underway to address the increasing long terms sickness absence rates (short term absence has continued to decrease over the monitoring period). These have been the subject of a separate report to the Integrated Governance Committee to provide assurances that all possible is being done. • The WOD team are currently working to develop a similar approach to that adopted for appraisals for both mandatory training and sickness absence management to drive performance improvement. This will be introduced from 1st April 2013/
Integrated Performance Report Page 33 of 37 Board Meeting 24 April 2013 Agenda Item 3.1
FOR DISCUSSION 4 ANNUAL PLAN AMBITION 4: INVOLVING THE PEOPLE OF POWYS
Proposed Key aims: 4.1 Consult with the Powys public 4.2 Consult with Powys tHB staff
ANNUAL PLAN 2012/13 - EXECUTIVE TEAM OBJECTIVES Ensure active two-way communication with Evidence of engagement available. Need to develop formal strategy and key stakeholders with an interest in Powys measuring process tHB services. Systematic, open, honest and active engagement with Powys residents in service planning and decision making.
4.1 Consult with the Powys public
Key Performance Indicators
4.1.1 Number of consultations with the public In the last year Powys teaching Health Board has held 14 Public meetings covering 3 consultation topics and a further 14 meetings covering 1 engagement topics. Attendance has varied from just 1 person at a meeting in Llandrindod to 200 in at a meeting in Llanidloes.
4.2 Consult with Powys tHB staff
Key Performance Indicators 4.2.1 Number of consultations with the Powys tHB staff
In addition to routine consultation and communication with staff and their representative, over the last year Powys teaching Health Board has held a range of different consultation events/processes. These include:
• Consultation over organisational change plans for the following services: o Builth Wells development o Radiography services o Midwifery services workforce deployment (on call) o Workforce and OD structures o Information function and structures o Stroke Services devleopment • Consultation over the development of the 2012/13 Annual Plan • Engagement in the development of the Mental Health Services vision • South East Powys programme • South Wales plan.
NB These indicators are still under consideration and will be developed to include a broader range of information.
Routine key briefing and more recently focus groups with the CEO are undertaken.
Integrated Performance Report Page 34 of 37 Board Meeting 24 April 2013 Agenda Item 3.1
FOR DISCUSSION 5 ANNUAL PLAN AMBITION 5: MAKING EVERY POUND COUNT
Proposed Key aims 5.1 Powys is achieving financial balance
ANNUAL PLAN 2012/13 - EXECUTIVE TEAM OBJECTIVES Deliver a balanced financial position for Separately reported in detail 2012/13
Develop a medium term service strategy Separately reported in detail which ensures the tHB lives within its Implement a whole system costs in the Action in hand; development of improved pathways of care resulting in overall reduced spend Develop the technical tools to expose Action in hand; unnecessary variation in spend across pathways and delivery modes Develop the technical tools to expose Action in hand; where resources utilised are not matched by health need Opportunities are maximised for securing Action in hand; value for money from corporate functions Opportunities are maximised for securing Action in hand; value for money from the shared service approach Ensure capacity and capability to deliver See accelarated OD programme financial balance The Finance Function provides support to Action in hand; the organisation in accordance with best practice Agree a clear clinical procurement strategy Action in hand; for securing quality and economic services to its population Agree a defined prioritisation strategy Action in hand; capacity to support process may be an issue which is based upon the triple aim of quality, patient satisfaction and value for money
5.1 Powys is achieving financial balance
Key Performance Indicators 5.1.1 Surplus/deficit against budget – actual indicator to be determined 5.1.2 Monthly Costs – Fixed and Variable 5.1.3 Monthly Change in FTE
Integrated Performance Report Page 35 of 37 Board Meeting 24 April 2013 Agenda Item 3.1
FOR DISCUSSION 5.1.2 Monthly Costs – Fixed and Variable (Source : Finance)
5.1.3 Monthly Change in FTE (Data source ESR)
The above chart shows there has been a net decrease of 193.12 FTEs, this is due primarily to the transfer of 209.93 FTE BSC staff and P2P and Payroll staff to the Shared Services Partnership offset by increases due to the appointment of staff to the All Wales Continuing Care and NISCHR
Integrated Performance Report Page 36 of 37 Board Meeting 24 April 2013 Agenda Item 3.1
FOR DISCUSSION functions; both are externally funded. The change also reflects the movement of seconded employees into substantive posts.
When the BSC and CHC staff are not included there is an increase of 6.31 FTEs between March 2012 and February 2013
Vacancies above pay Band 7 are reviewed, scrutinised and challenged by the Executive Team on a fortnightly basis to ensure that, where appropriate, both service and role redesign have taken place before a post is advertised.
Conclusion
The tHB is meeting the majority of its externally determined targets. Where performance is not on track, corrective action plans are in place to bring these in line.
As identified, further action is underway to refine the performance management and associated framework to enable the Health Board to assess its progress against its core objectives as well as meeting the targets set by the Welsh Government. This includes considering the recommendations of the information review.
Recommendation
The Board is asked to:- NOTE To progress being made on the delivery of the high level objectives included in the Annual Plan, and NOTE the progress in the development of the performance management framework.
Report prepared by: Presented by: Jo Davies and Paul Cronin Andrew Cottom Director of Workforce and OD and Chief Executive Senior Performance Analyst
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Background Papers Annual Plan 2012/12 Together for Health (2011) New Directions for Powys (2011) Quality Delivery Plan (2012) Financial Consequences Not addressed Other resource Implications Not addressed Consultees Not addressed
Integrated Performance Report Page 37 of 37 Board Meeting 24 April 2013 Agenda Item 3.1
FOR DISCUSSION
BOARD MEETING 24 APRIL 2013 AGENDA ITEM 3.2
CORPORATE RISK REGISTER – APRIL 2013
Report of Amanda Smith, Director of Therapies and Health Science
Paper prepared by Wendy Morgan, Head of Quality & Safety
Purpose of Paper To update the Board on the highest organisational risks through the use of the Corporate Risk Register
Action/Decision required The Board is asked to RECEIVE and DISCUSS the current high level risks for the organisation
Link to ‘Doing Well, This paper supports: Doing Better: Standards for Health Services in Standard 1 Governance and accountability framework Wales” Standard 22 Managing Risk and Health and Safety
Link to Health Board’s Corporate Plan • Improving Health & Wellbeing (health) • Ensuring the right access (services) • Striving for excellence (delivery) • Involving the people of Powys (people) • Making every pound count (money)
Acronyms and CAMHS Children and Adolescent Mental Health abbreviations Services GP General Practitioner ID Identity number IPFR Individual Patient Funding Requests tHB Powys Teaching Local Health Board WG Welsh Government Wte Whole time equivalent
Risk Register Page 1 of 7 Board Meeting 24 April 2013 Agenda Item 3.2
FOR DISCUSSION
CORPORATE RISK REGISTER – APRIL 2013
Purpose
The purpose of this paper is to update the Board on the highest organisational risks through the use of the organisation’s corporate risk register.
Background
Over the past two years the Risk Management Strategy and implementation plan has provided the steer in progressing associated activities. The risk register has been a key mechanism for the organisation to manage its risks on a day-to-day basis. This has contributed to a strengthened risk management framework in continuous support of good governance, which the Board have a key role to play in the ‘oversight’ of risk management and its associated activities. The current Risk Management Strategy expires in 2013. It is currently being reviewed and updated to include a greater emphasis on strategic risk management.
Risk Registers
This Board report focuses on high level organisation risks derived from the Corporate Risk Register.
Corporate Risk Register
In March two sessions were held with the Board of Directors to discuss the processes and mechanisms for the identification of risks ‘top down’. The first session focused on the management of risks and the discussion centred on the following key areas:
• Responsibilities of Directors • Strategic risks • Operational risks • Roles of Directors • Risk tolerance and risk appetite
It was agreed that there would be two levels of risk registers, the Corporate Risk Register containing the high risks to the Health Board in delivering against objectives and the second level the Locality/ Service Directorate/ Central Functions risk registers (the latter referring to finance, corporate services, workforce & organisational development, etc).
It was further identified that the purpose and membership of the current Risk Management Committee needed to be strengthened in order to support agreement of
Risk Register Page 2 of 7 Board Meeting 24 April 2013 Agenda Item 3.2
FOR DISCUSSION high level risks to go onto the Corporate Risk Register. The Terms of Reference are currently being reviewed to reflect this identified need.
The second session concentrated on identifying the corporate risks and how they affected the achievement of the organisation objectives. All Directors and Locality General Managers identified risks reflecting their portfolio responsibilities. Following discussion consensus was agreed on the top ten risks, which have been used as the basis of the revised Corporate Risk Register.
Existing risks were discussed and those that do not appear on the Corporate Risk Register have been allocated to Locality/ Service Directorate risk registers for further monitoring and action.
It is acknowledged that further discussions are needed re: risk tolerance and acceptance and a future workshop will be arranged to address this need. Additional resources for all staff in the form of flowcharts and information sheets are being produced to explain further the identification of risks ‘top down’ and ‘bottom up’.
The Corporate Risk Register is now accessible via the Datix software system. Previously, the register was an excel document maintained outside of Datix.
Locality/ Service Directorates
Work remains ongoing with the Localities / Service Directorates to continually review and update their risk registers. Each area is tasked with presenting their risks >15 to the Risk Management Committee bi-monthly for review and discussion, plus each area as part of a rolling programme present their top 20 risks.
Publication of Risk Register
The Corporate Risk Register will be published through the Publication Scheme. The first upload took place in October 2012 and features the previous Risk Register (August 2012). This will be replaced by the current version following the Board meeting.
Risks on the Corporate Risk Register
The current key risks and their control measures are:
• (No 1) Failure to achieve financial balance in year and over the longer term will lead to breach of statutory financial duty and qualification of the regularity opinion and the annual accounts.
o During the year the Board has continuously reviewed financial performance including areas where expected performance is off track and taken a range of additional measures with a view to reducing costs.
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However, these actions are not currently projected to deliver financial balance for 2012/13. o The establishment of a programme office to support the organisation in delivering sustainable clinical change and organisational effectiveness has taken place during the year. Although these are expected to link to improvements in financial performance as one of the key benefits, the programme work commenced in 2012/13 will not identify the total value of cost reductions required. o In view of the forecast financial position and as part of our mitigating actions, the board is now in discussion with Welsh Government and the rest of NHS Wales in managing our financial performance to the end of the financial year through potential brokerage arrangements with other organisations. It is currently not clear whether these arrangements will secure enough cover to meet our statutory target to break even and therefore there remains a significant risk.
• (No 2) Failure to recruit and retain a medical workforce to support service provision to Powys residents, particularly in the areas of: - GP (Medical Services); - (GP) Out of Hours; and - Consultants in Elderly Care; alongside the broader workforce planning and medical workforce strategy to provide service models in each Locality and Service Directorate.
o Development is underway of a sustainable medical workforce strategy in light of forthcoming Consultant vacancies in CAMHS, Geriatric Medicine and Psychiatry and an ageing GP workforce. o Implementation underway of a new medical service delivery model for North Powys o Review of job plans of Consultants in South East Powys as part of service change implementation. o Clinical placements for students, doctors and dentists to be extended and promoted to attract the future workforce. Work already underway to increase partnership working for post graduate and undergraduate placements with Universities.
• (No 3) Failure of The All Wales Retrospective Continuing Health Care reviews project to complete within 3 year time frame and to the required standard.
o During the latter part of 2012 a project review was undertaken examining progress and risk of non-delivery. Discussion with Welsh government resulted in increased resourcing from WG and other Health Boards to increase capacity of investigators and clinical advisors. o Reviewed and revised performance reporting arrangements have resulted in improved information. This is examined at each Board of Directors meeting (monthly). Further work is underway to review processes to remove waste/processes that do not add value or add little value.
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o Bi-monthly Steering Group meetings held between PtHB and WG. Improved recent performance in terms of number and speed with which cases are being reviewed is demonstrating a reduced risk and demonstrates that mitigating actions are effective. This needs however to be sustained ain order for the risk to be fully managed.
• (No 4) Failure to fully introduce and embed programme/ project methodology within organisation to ensure the delivery of change within required timeframes.
o Establishment of Programme Office and appropriate governance arrangements to ensure an organisation wide view of change which ensures projects and programmes are strategically aligned. o Increased awareness and management of programme level risks and issues. o Strengthened accountability and appropriate control ensured through governance and scrutiny processes providing assurance on key decisions and delivery.
• (No 5) Failure to maintain a safe environment as consequence of poor understanding of estate infrastructure issues, risk management and assurance systems. Actual issues noted to date: - Power failure at Llandrindod (Aug 12) - Asbestos Improvement Notice and failings with original surveys - Legionella issue at Llandrindod and subsequent improvement notice - Report from Facilities Services into Fire Precautions at Brecon Hospital identifies areas where the fire policy and site specific documentation, particularly fire drawings should be improved.
o Overall programme and risk based action plan have been produced for all areas except Ventilation and Control of Contractors. o A full assessment of the current estate is underway, following a series of incidents, in respect of the key areas of statutory compliance: mechanical and electrical, water management; fire safety; asbestos. o Renewal of Estates Strategy by March 2014.
• (No 6) Failure of organisational development programme to ensure development of sufficient organisational capacity and maturity to enable delivery of corporate and operational objectives.
o Continued implementation of the organisational development programme to build the capacity and capability of our locality and directorate teams and underpinning corporate infrastructure and processes.
• (No 7) Risk to Powys residents due to potential clinical fragility, gaps in services and sustainability of services provided within Powys.
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o Locality and Service Directorates capacity increased to enhance local management of services. o Development of Community Resource Teams promoting integrated work across teams and services. o Powys teaching Health Board developed an integrated workforce plan in May 2012. It outlines the workforce changes that need to take place to provide safe, high quality care. This year's workforce planning demonstrates significant improvements, having matured from a corporate level analysis to a more localised plan, with better anticipation of future service workforce needs. This has been commended by NLIAH and the progress also noted by the Wales Audit Office. o Business Continuity Plans need to be developed.
• (No 8) Risk that Powys Patients / Residents are unable to access safe, quality services due to service plan changes affecting service provision for Powys residents (internal and external).
o Currently, Powys is a partner in the South Wales programme that is specifically seeking to develop and implement a change programme to reduce the risk of fragile services. o Powys tHB has participated in the consultation around service change in Hywel Dda. A mid Wales board is proposed to take forward service planning for this area. o Powys tHB participation and engagement around the review of stroke services in England. o Participation and engagement in Betsi Cadwaladr Consultation. o Participation and engagement in CAMHS planning processes. o Ongoing active two-way communication with citizens and key stakeholders with an interest in Powys tHB services. o Systematic, open, honest and active engagement with Powys residents in service planning and decision making. o Internal and external monitoring of service provision and delivery through a variety of mechanisms, such as, audit, service reviews, performance monitoring, SLAs, contracts, etc
• (No 9) Failing to develop and sustain the IT infrastructure, capacity and capability required to deliver safe and efficient services.
o Joint ICT Strategy runs to 2014 and is aligned to support both organisations strategic change plans. This is subject to implementation through Section 33 agreement. o Practices have been encouraged to apply their business continuity plans; the Primary Care Department is facilitating migration training in April 2012. Practices will know in advance their migration date and therefore can make preparations to minimise disruption i.e. patient advance ordering of repeats, running emergency surgeries during down time.
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• (No 10) Failure to ensure the safe wellbeing of vulnerable adults and children both within Powys and those residents accessing services outside of Powys.
Children o (Local Safeguarding Childrens Board) has full participation of the tHB alongside other required agencies. Strong partnership working exists with a reflective and improvement approach. o Risks of destabilisation of any regional working need to be fully worked through - agreement of Powys organisations to ensure that proposals improve rather than detract from safeguarding effectiveness. o Sub-groups established to support work relating to Children placed from Other Local Authorities to ensure Toward Stable Lives and Brighter Futures is fully implemented. Adult Protection o Strengthened through appointment of Senior Nurse Adult Protection and associated processes. Further work required on strengthening safeguarding and training in the tHB plan. o Care Home Governance - good progress made however more to do. Monitoring and reporting process in place and annual governance review established. Further work required to embed across whole organisation. Further linkages being made with Quality and Safety Unit in relation to improving safeguarding and wellbeing of those people who access DGH and other commissioned services.
• (No 11) Failure to develop an effective commissioning function to properly identify and secure the services/ appropriate care for the Powys population.
o New structure in development to strengthen Locality commissioning role.
Conclusion
The Corporate Risk Register has been reviewed and updated demonstrating risks are being identified and managed, supporting assurance to the Board.
Recommendation
The Board is asked to RECEIVE and DISCUSS the Corporate Risk Register.
Report prepared by: Presented By: Wendy Morgan Amanda Smith Head of Quality & Safety Director of Therapies & Health Science
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BOARD MEETING 24 APRIL 2013 AGENDA ITEM 3.3
FRANCIS REPORT
Report of Director of Therapies and Health Science
Paper prepared by Director of Therapies and Health Science
Purpose of Paper The purpose of this paper is to advise the Board on the approved approach for the tHB to respond to recommendations set out in the 2013 Report on Mid Staffordshire Trust by Robert Francis QC.
Action/Decision required The Board is asked to DISCUSS and NOTE the approved approach for the tHB to respond to recommendations set out in the 2013 Report on Mid Staffordshire Trust by Robert Francis QC.
Link to ‘Doing Well, This paper supports: Doing Better: Standards Standard 1: Governance and accountability framework for Health Services in Standard 5: Citizen Engagement and Feedback Wales’: Standard 7: Safe and Clinically Effective Care Standard 8: Care Planning and Provision Standard 9: Patient information and Consent Standard 10: Dignity and Respect Standard 11: Safeguarding Children and Safeguarding Vulnerable Adults Standard 22: Managing Risk and Health and Safety Standard 23: Dealing with Concerns and Managing Incidents Standard 26: Workforce Training and Organisational Development Link to Health Board’s Striving for excellence (delivery) Corporate Plan Ensuring the right access (services) Involving the people of Powys (people)
Acronyms and tHB - teaching Local Health Board abbreviations WG - Welsh Government
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FRANCIS REPORT
Purpose
The purpose of this paper is to set out the key recommendations from the 2013 Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust January 2005 – March 2009 and to outline the agreed approach to carry out a self assessment and provide assurance against the recommendations.
Background
In February 2013 Robert Francis QC published his second report on the key findings of his public inquiry into the Mid Staffordshire NHS Trust. Robert Francis makes 290 recommendations for healthcare regulators, providers and government, saying "fundamental change" was needed to prevent the public losing confidence. The report attacks local health authorities and sharply criticises the trust board, but does not blame any one individual or organisation. The report highlights that years of abuse and neglect at the hospital led to the unnecessary deaths of hundreds of patients and that the failings went right to the top of the health service.
The report identifies numerous warning signs which could have alerted the organisation to problems that were developing. Specifically from the Board perspective key issues are identified as:
• ‘A culture focused on doing the system’s business – not that of the patients; • An institutional culture which ascribed more weight to positive information about the service than to information capable of implying cause for concern; • Standards and methods of measuring compliance which did not focus on the effect of a service on patients; • Too great a degree of tolerance of poor standards and of risk to patients; • A failure of communication between the many agencies to share their knowledge of concerns; • Assumptions that monitoring, performance management or intervention was the responsibility of someone else; • A failure to tackle challenges to the building up of a positive culture, in nursing in particular but also within the medical profession; • A failure to appreciate until recently the risk of disruptive loss of corporate memory and focus resulting from repeated, multi-level reorganisation’.
Essential and relevant recommendations include:
• ‘Foster a common culture shared by all in the service of putting the patient first; • Develop a set of fundamental standards, easily understood and accepted by patients, the public and healthcare staff, the breach of which should not be tolerated;
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• Provide professionally endorsed and evidence-based means of compliance with these fundamental standards which can be understood and adopted by the staff who have to provide the service; • Ensure openness, transparency and candour throughout the system about matters of concern; • Ensure that the relentless focus of the healthcare regulator is on policing compliance with these standards; • Make all those who provide care for patients – individuals and organisations – properly accountable for what they do and to ensure that the public is protected from those not fit to provide such a service’
In his concluding statement, Francis said what is required is nothing short of a "real change in culture, a refocusing and re-commitment of all who work in the NHS, on putting the patient first."
Francis Executive summary . pdf
Requirement
All healthcare organisations are required to consider these findings and decide how to apply them to their own organisation and, at the earliest opportunity announce which recommendations are accepted and how these will be addressed.
The Welsh Government has mandated a task and finish group to develop a template for self assessment against each of the 290 recommendations. It is proposed that this template be adapted for organisations to enable systematic scrutiny of each recommendation in terms of both relevance for that organisation and also mechanisms for reporting and assurance.
The National Policy Context in NHS Wales
Together for Health is the five year vision for NHS Services, under which, Achieving Excellence, The Quality Delivery Plan for the NHS in Wales (2012-16) sets out the framework for delivery. It describes the NHS in terms of a system with
• Clear values and goals. • A relentless focus on systematic improvement • Visible leadership at all levels. • Strong staff engagement & satisfaction. • Robust systems for learning. • Openness in all we do. • A common and consistent language and approach to improvement. • The ‘double goal’ of improvement and assurance. It sets out the expectation that we must demonstrate that for every patient, we are doing the right thing, in the right way, in the right place, at the right time, with the right staff.
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Safe Care Compassionate Care, the National Governance Framework to Enable High Quality Care in NHS Wales, was published by Welsh Government in 2013 alongside the publication of the Francis Report. This report describes a quality assurance system to be adopted by all healthcare organisations in Wales (see appendix 1) and specifically provides a set of Quality Triggers to alert Boards to potential issues:
• Are we providing safe care? • Are we meeting required standards of effective care? • Are we improving user experience? • Are we providing efficient services within resources? • Are we engaging the workforce? • Are we providing accessible and acceptable services? • Are we improving population health? • These quality triggers should be set within existing systems and processes for monitoring of quality standards and safety such as clinical audit and incident reporting. They are a means through which Boards will be able to establish a culture of listening and learning and strong leadership. They are also a means through which a weakness in one part of the system can be linked to another elsewhere to enable triangulation of issues to alert the Board to a potential area of high risk, or hot spot.
The Quality Assurance System describes the relationship between the organisation and its stakeholders, partners and service users and their necessary interdependencies.
Implications for Powys teaching Health Board
The teaching Health Board has engaged senior managers, the Executive Team and Board members in two learning and development sessions, designed to facilitate reflection regarding learning lessons from the issues highlighted in the report It is apparent from the recommendations that the culture and behaviour of the Board itself significantly influenced the issues that ensued. It was apparent, also, from the learning events that the issues raised in the report were largely transferable to other healthcare systems and that there were lessons to be learned with particular relevance for Powys.
Key areas for development include consistent and reliable gathering of patient feedback and engagement by Board members in analysis of this information on a regular basis. There is evidence in Powys that there is scope for use of quality triggers to triangulate data and other information to alert the Board to risk and or preventable incidents. For example, where weakness in leadership/staff vacancy exists in an area which also has poor health and safety audit report, a lack of engagement in carrying out investigations and learning and subsequently a patient safety incident, it is possible to look at those indicators as future triggers of risk to high quality care (see Appendix 2). Reliable sources of clear and appropriate information with transparent interpretation of this data is essential. Engagement with
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FOR DISCUSSION stakeholders, including the Community Health Council and GPs provides opportunity for triangulation of information.
Following the Board Development Session, discussion has been held with the Integrated Governance Committee regarding the required approach to self- assessment against recommendations arising from the Report and the identification of improvement actions for implementation. It was agreed by the Committee that the executive should undertake a self-assessment by the end of May 2013 with a scrutiny panel, consisting of Executive Directors and Independent Members, reviewing the information collated and agreeing a consequent improvement plan in July 2013. It was also agreed that, following finalisation of the tHB’s self-assessment, the Integrated Governance Committee would oversee delivery of the improvement plan.
Way Forward
It is evident from the wide-ranging recommendations of the report and the fundamental responsibility of the Board in the assurance of quality and safe care, that a comprehensive assessment of Powys tHB should be based on a range of approaches and system checks. The frameworks and tools available to the Board from WG and from the report itself, lend an opportunity for scrutiny of current systems and processes, without over-reliance on a ‘tick-box’ approach. In engaging in the required self-assessment process, the tHB can also triangulate information gathered to enable cross-checking to take place.
It is recommended that the following approach is taken to engaging in the tHB self- assessment process: • Safe Care, Compassionate Care Quality Assurance System to underpin the tHB approach to quality; • Work to be set in the context of the Board’s vision and values; • Governance and Accountability self assessment module of the Standards for Health Services to be revisited once amended by Health Inspectorate Wales to reflect priorities of Francis Report. The self-assessment based on the current Governance and Accountability module is completed. • Self assessment against those of the 290 recommendations that are relevant for Powys tHB will be undertaken by the end of May 2013. This will include recommendations addressed through existing Board assurance and arrangements • Scrutiny Panel to review the information collated and agree a consequent improvement plan in July 2013 • Outcome of self-assessment and improvement plan to be presented to Board in August 2013 • Integrated Governance Committee to oversee delivery of improvement plan • Annual Quality Statement , Annual Governance Statement and Annual Report published to provide assurance to public
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Recommendation
The Board is asked to DISCUSS and NOTE the approved approach for the tHB to respond to recommendations set out in the 2013 Report on Mid Staffordshire Trust by Robert Francis QC.
Report prepared by: Presented By: Amanda Smith Amanda Smith Director of Therapies and Health Director of Therapies and Health Science Science
Background Papers 1.Department of Health (2013) Report of the Mid Staffordshire Public Enquiry, February 2013, Chaired by Robert Francis QC
2. Welsh Government (2012)Together for Health , the five year vision for the NHS in Wales
3. Welsh Government (2012) Achieving Excellence, The Quality Delivery Plan for the NHS in Wales (2012-16)
4. Welsh Government (2013), Safe Care Compassionate Care, the National Governance Framework to Enable High Quality Care in NHS Wales
Financial Consequences Other Resource Implications Consultees
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APPENDIX 1
Safe care, Compassionate Care, WG, 2013
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APPENDIX 2
Example of factors that needed to be triangulated to ensure the Board is aware of risks
Vacancies in leadership roles
Board
Low number/ lack of Patient safety/ timeliness of PTR security incident – investigations “volunteer”
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BOARD MEETING 24 APRIL 2013 AGENDA ITEM 4.1
MEASLES OUTBREAK IN POWYS
Report of Interim Director of Public Health
Paper prepared by Interim Director of Public Health
Purpose of Paper To update the Board on the measles outbreak in Powys and actions being taken to prevent the further spread of measles.
Action/Decision required The Board is asked to NOTE the contents of this paper for information
Link to ‘Doing Well, This paper supports Standards Doing Better: Standards 3, 11, 13, 15, 18 and 19 for Health Services in Wales’:
Link to Health Board’s Improving Health & Well-Being Corporate Plan
Acronyms and Powys teaching Health Board – Powys tHB abbreviations World Health Organisation – WHO Welsh Government – WG Measles, Mumps, Rubella - MMR
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MEASLES OUTBREAK IN POWYS
Purpose of paper
The purpose of this paper is to update the Board on the measles outbreak in Powys and actions being taken to prevent the further spread of measles.
Background
About Measles
Measles is a highly infectious viral illness that can be prevented by MMR (Measles, Mumps, Rubella) vaccination. The virus spreads very easily, through breathing in droplets produced when an infected person coughs or sneezes or by touching a contaminated surface. The initial symptoms of measles include cold-like symptoms, red eyes, fever and spots in the mouth and throat. This is followed by a rash that starts behind the ears and then spreads around to the rest of the body. Measles can lead to complications such as meningitis and pneumonia and in rare cases it can be fatal.
MMR Vaccination uptake
Whilst MMR uptake rates are lower in Powys compared with Wales and are also below World Health Organisation and Welsh Government targets (95%), rates have been rising. Figure 1 shows current MMR uptake rates in Powys for October – December 2012.
Figure 1: MMR uptake rates in Powys compared with Wales. MMR1 MMR2 MMR1 MMR 2 (2 years) (5 years) (16 years) (16 years)
Powys 91.9% 89.3% 84.1% 74.3%
Wales 94.3% 89.9% 91.0% 82.4%
Source: COVER 105
Figures 2 shows childhood vaccination uptake rate trends, with all vaccination uptake rates increasing since 2004.
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Figure 2: Powys teaching Health Board trends in routine childhood immunisations 2004 - 2012 Quarter 4
Source: Public Health Wales quarterly COVER reports, correct as at February 2013
Figures 3 and 4 compare Powys MMR uptake rates with those of other Health Boards over a 5 year period (2007/08 to 2011/12). Uptake rates have consistently risen in Powys for both the first and second dose of MMR.
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Figure 3: Trend in MMR uptake for 1st dose of MMR
Source: Public Health Wales COVER reports
Figure 4: Trend in MMR uptake for 2nd dose of MMR
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In response to the low MMR uptake rate, particularly amongst teenagers, specific actions already underway to improve uptake included: • A MMR catch up campaign for teenagers in Year 10. • All children that were not up to date with their vaccinations at school entry were being identified by Health Visitors and this information was passed on to School Nurses to enable follow up of children. • Previously, all teenagers who were not fully vaccinated had been contacted and provided with health information, promoting the MMR vaccine.
Epidemiology of measles
In Spring 2012, there was a measles outbreak in Gwynedd and Flintshire, with over 100 measles notifications. In November 2012, a measles outbreak started in Swansea and Neath Port Talbot and has continued to increase in size, resulting in over 400 measles notifications in 2013 alone.
In 2012, 4 measles notifications were received in total for Powys by the Health Protection Team, Public Health Wales.
In January 2013, there was notification of 3 measles cases in Powys, although these were sporadic cases and not thought to constitute an outbreak. Since 11th March 2013, 47 measles cases have been notified, although most of these have yet to be confirmed through laboratory testing. Figure 5 below shows the number of weekly measles notifications in Powys.
Figure 5: Number of cases notified to Health Protection, Public Health Wales
Source: Public Health Wales.
Of these cases, 8 are in Brecknockshire Ystradgynlais area and 40 are in Montgomeryshire area. Those affected are aged between 1 year and 24 years, with the majority of cases aged 0-4 years or 10-19 years. Figure 6 shows the schools / Measles Outbreak Page 5 of 8 Board Meeting 24 April 2013 Agenda Item 4.1
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playgroups attended by children affected by measles. Most cases reported to date are in Llanfyllin High School.
Figure 6: Educational establishments attended by pupils with measles Montgomeryshire
Caereinion High School Llanfyllin High School Llangedwyn Primary School Llanrhaeadr Ym Mochnant Primary School Llanidloes High School Ysgol Pennant, Penybont Fawr Ty a Fi’, Penymount Fawr
Brecknockshire
Golwg Y Cwm Nursery Primary School, Ystradgynlais, Swansea
Swansea
Ysgol Gyfun Ystalyfera, Neath Port Talbot BrynTawi Comprehensive, Penlan, Swansea Ysgol Gymraeg Dyffryn y Glowyr, Cwmtwrch, Swansea
Actions to Reduce the Spread of Measles
An Outbreak Control Team (OCT) has been established in Powys. This group first met on 19 April and continues to meet on a regular basis. The role of the group is to provide a co-ordinated response to halting the spread of measles in Powys. The group is chaired by a Consultant in Communicable Disease and has membership from Public Health, School Nursing, Health Visiting, GP practices, Child Health Services and Communications. This group feeds into a Senior Response Team, which is led by Public Health Wales and meets on a weekly basis. The Senior Response Team provides an overview and co-ordinates a response to the measles outbreak across all areas of Wales. The OCT reviews the epidemiology of measles cases and ensures that adequate steps are being taken to stop the spread of measles. Steps being taken are:
Identifying susceptible children Work is underway to identify the number of children susceptible to measles in Powys i.e. those who have not had 2 MMR vaccines. This is being achieved by: • asking GP Practices for their MMR uptake data • comparing school attendance records with records from Child Health Services and GP practice data. This is a complex and laborious process. • Looked after children have been followed up by Specialist Nurses for Looked After Children. Measles Outbreak Page 6 of 8 Board Meeting 24 April 2013 Agenda Item 4.1
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Responses to individual cases Measles cases are notified to the Health Protection Team, Public Health Wales. The Health Protection Team follow up all cases, including: • providing exclusion advice to cases • identifying contacts of cases and advising MMR immunisation through GP practices. For vulnerable contacts (babies, pregnant women, immunosuppressed individuals), the Health Protection Team provide advice on the need for immunoglobulins • raising awareness at schools attended by affected pupils. Letters are sent to all parents at the affected schools, advising them to check their child’s immunisation status and have their child vaccinated.
Vaccinating susceptible children At present, vaccination of susceptible children is through GP Practices and also through schools. • Vaccinating through GP practices A Locally Enhanced Service is in place, whereby GP Practices can give MMR to susceptible patients. All practices have been contacted to make them aware of the measles outbreak. A request has been made that they vaccinate any children that are not fully protected who request the vaccination. Practices in affected areas have been actively encouraged to identify non immune individuals and proactively offer MMR vaccinations.
• Vaccinating through schools A school based vaccination campaign can be an effective mechanism for controlling measles outbreaks. Vaccination sessions were held at Llanfyllin High School on 27th March (last day of term) and 28th March (drop in clinic, the school was open for a teachers’ inset day). 27 pupils were vaccinated out of a total of 216 children who have not had 2 MMRs. The small number of children vaccinated was likely to be due the impact of the snow on school opening. Further planning is underway for a school based vaccination programme following the Easter school holidays. This will initially focus on schools with affected pupils.
Communications Public Health Wales is co-ordinating and leading a national communications campaign. A local press release was issued on 2 April 2013, as feedback suggested that pupils and parents did not consider Powys to be affected by the measles outbreak. Information has been posted on Powys tHB’s Facebook page (over 8,000 hits) and on twitter. Further local press releases are planned in order to continue to raise the profile of the measles outbreak. Schools are being provided with information through School Nurses as well as through Education Services. Information is being circulated through various community groups e.g. Young Farmers, Girl Guides and the Community Health Councils. Powys County Council Leisure Services and Youth Information Service are also displaying information promoting MMR vaccination.
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Collaborative Working with Shropshire Some children affected attend Powys schools but live in Shropshire or may be registered with GPs in Shropshire. There is close working with Public Health England Health Protection, as well as the Public Health team in Shropshire, in order to provide a co-ordinated response.
Conclusion A measles outbreak in Powys has affected 48 children since 11th March 2013. These cases are concentrated in Montgomeryshire and Ystradgynlais, and are mainly focused around schools. An Outbreak Control Team has been established to provide a co-ordinated response to halting the spread of measles.
Recommendation The Board is asked to NOTE actions taken to date for information.
Report prepared by: Presented By: Dr Sumina Azam Dr Sumina Azam Interim Director of Public Health Interim Director of Public Health
Background Papers N/A
Financial Consequences As determined by the report
Other Resource Implications As determined by the report
Consultees As determined by the report
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BOARD MEETING 24 APRIL 2013 AGENDA ITEM 4.2
POWYS TOBACCO CONTROL STRATEGIC PLANNING
Report of Interim Director of Public Health
Paper prepared by Senior Public Health Practitioner
Purpose of Paper To provide the Board with an update on the Powys Tobacco Control Strategic Group and Action Plan and to highlight implications for Powys teaching Health Board (PtHB) and Public Health.
Action/Decision required The Board is asked to: 1. Note the contents of this paper for information 2. Support the leadership role of Powys teaching Health Board to achieve a reduction in smoking prevalence including; strong partnership working, staff training in brief intervention, targeting smoking cessation services at pregnant women and pre-operative patients and the updating and maintenance of a smoke-free hospital grounds policy
Link to ‘Doing Well, This paper supports Standards 3,11,12,15,18 and 22 Doing Better: Standards for Health Services in Wales’:
Link to Health Board’s Improving Health & Well-Being Corporate Plan Making Every Pound Count
Acronyms and Powys teaching Health Board – Powys tHB abbreviations Stop Smoking Wales – SSW Brief intervention training – BIT World Health Organisation – WHO Welsh Government – WG National Institute for Health and Care Excellence - NICE Tobacco Control – TC Carbon monoxide - CO
Tobacco Control Strategy Page 1 of 34 Board Meeting 24 April 2013 Agenda Item 4.2
POWYS TOBACCO CONTROL STRATEGIC PLANNING
Purpose of paper
The purpose of this paper is to update the Board on the Powys Tobacco Control Strategic Group and Action Plan and highlight implications for Powys teaching Health Board (tHB) Public Health.
Background
In 2003 the World Health Organisation (WHO) identified tobacco smoking as the primary cause of premature illness and death in developed countries. Despite a fall in smoking prevalence rates in Wales in recent years, figures from the latest Welsh Health Survey (2011) show the Welsh prevalence for adult smokers is 23% and in Powys the prevalence is 21%. Tobacco smoking remains the biggest preventable cause of morbidity and mortality in the country and it is widely recognised as one of the main contributors to inequalities in health.
Recent research from Swansea University1 reported that treating smoking related diseases in Wales cost the Welsh NHS 7% of the total healthcare expenditure in 2007/8, which is equivalent to £129 per head of population. It is estimated that approximately 20% of all admissions and bed days are attributable to people suffering from smoking related disease resulting in significant costs to the NHS. Smoking also has significant cost implications to the NHS through working days lost. A review of the health and well-being of the NHS workforce in England found that among NHS employees, those who smoke are more likely to be absent due to ill- health and for longer than those who do not smoke.
The Welsh Government (WG) has set a target of reducing smoking prevalence in adults who live in Wales to 16% by 2020. Each local authority area is tasked with producing local Tobacco Control Action Plans based on the WG All Wales Action Plan 2012. Within the plan, four action areas are identified:
• Promoting better leadership and partnerships • Prevention (especially amongst children and young people) • Cessation • Reducing exposure to second-hand smoke
The Powys Tobacco Control Action Plan has been developed and approved by the newly formed Powys Tobacco Control Group (Appendix 1). This is a multi agency partnership group with a collective goal of achieving smoking cessation targets and ultimately a smoke free Powys.
1 Phillips, C.J. and Bloodworth, A. (2009) Cost of smoking to the NHS in Wales. Cardiff: ASH Wales.
Board Meeting 24 April 2013 The scale of the challenge
According to the latest Welsh Health Survey (2011), 21% of the Powys adult population smoke. The adult population of Powys is 110,473 (ONS, 2011), which means that there are approximately 23,199 adult smokers in Powys. To reach the target of 16% prevalence (17,675 smokers) by 2020, this means that 5,524 smokers would have to quit. Evidence from the General Household Survey (2010) shows that 7 out of 10 smokers wish to quit and 5% are successful. This means potentially 16,300 smokers in Powys want to quit.
Current smoking cessation services in Powys
Most of the smoking cessation services in Powys are delivered by Stop Smoking Wales (SSW) and the Powys tHB’s Level 3 Pharmacy Cessation Scheme. These services offer different levels of support to smokers who wish to quit. SSW offers a behavioural support programme, offering both group and one to one support over a six week period. Clients can self refer by phoning an “0800” number and make an appointment to be seen in a local clinic. The Pharmacy scheme offers motivational support to people who wish to quit over a 10 week period. Clients access this service directly through contact with their local pharmacy. Having both services means that smokers who wish to quit have a choice of cessation methods. It also means there is a good geographical spread of smoking cessation services across Powys (Appendix 2).
For 2011/12, 696 contacts were made to SSW, although this figure dropped to 318 smokers who actually attended SSW services in Powys. Many clinics were not filled. SSW is currently investigating the drop out from referral to attendance at a clinic. In 2011/12 499 adult smokers accessed Community Pharmacy Level 3 schemes. The number of peole who made initial contact and then dropped out prior to accessing the services is not recorded.
For 2011/12, 39% of Powys adult smokers who had attended SSW cessation service for treatment had a 4 week carbon monoxide (CO) validated success, compared with 40% of adult smokers attending the Powys Pharmacy Scheme smoking cessation services.
The National Institute for Health and Care Excellence (NICE) recommends smoking cessation services aim to treat 5 per cent of the smoking population annually. In Powys this equates to approximately 1,160 smokers. NICE also recommends smoking cessation services aim for at least 35% 4 week success rate.
The combined SSW and pharmacy figures for treated smokers in 2011/12 was 3.5% of the smoking population. Of this figure (817) 39% had a carbon monoxide validated 4 week quit.
Board Meeting 24 April 2013 Table 1: Smoking cessation services in Powys Powys Stop Total NICE Pharmacies Smoking recommendations Wales Contacts made 696 1195
Treated 499 318 817 1,160 (5% Powys smokers smoking population) Quit at 4 weeks 198 124 322 (CO validated) 4 week quit rate 40% 39% 35% (CO validated)
Currently we are not reaching the NICE recommended 5% of smokers attending smoking cessation services. However for smokers who do become ‘treated smokers’ outcomes are good. Clearly more smokers need to be referred to these services.
Pregnant smokers and pre-operative smokers are a priority for smoking cessation services, since there is overwhelming evidence of the benefits from quitting in these cases.
Pregnant smokers
The table below shows the number of estimated pregnant smokers in Powys.
Table 2: Pregnant smokers in Powys Year Powys Live Estimated number Estimated number who Births (Stats of smokers smoke before / during Wales) (based on 21% pregnancy (Infant feeding prevalence) survey 2010*) 2009 1232 258 86 2010 1188 249 83 2011 1217 255 85 * Infant feeding survey 2010 found approximately a third of women smoke throughout their pregnancy in Wales – higher than other areas of the UK
Figure 1 shows Powys maternity contacts to SSW. The number of contacts increased following the introduction of a new referral pathway in January 2011. Rates peaked at 5.98 contacts per 100 pregnant smokers. The mean rate of maternity contacts per 100 live births was 2.60 between April 2010 and March 2011. Recent data for January 2012 – December 2012 shows that the total number of Powys maternity referrals to SSW was thirty six.
Board Meeting 24 April 2013
Figure 1
Pre Operative patients
SSW offers a pre-operative cessation programme called ‘Get well Sooner’. This is aimed at smokers awaiting elective surgery. Smokers who quit before surgery have better health outcomes in terms of wound healing and fewer respiratory complications. This means a shorter hospital stay and cost savings.
Statistics from the 2011/12 show that for every 10,000 population there was less than 1 person referred for pre-operative smoking cessation support in Powys. Figure 2 shows the pre-operative contact rate for Powys.
Board Meeting 24 April 2013
Figure 2
Brief Intervention Training (BIT)
Health care workers can make a significant difference in helping their patients quit smoking2. Brief intervention is an evidence based approach to discussing smoking and quitting with smokers, with the aim of triggering a quit attempt. It can be delivered by a broad range of health and community workers. Research shows that people who attend Smoking Cessation services are four times more likely to quit than those who attempt a self quit. SSW offers BIT to frontline health staff. This is currently a whole day accredited training, but from April 2013 a shorter version of 3.5 hours will be available. The training supports staff to develop skills in smoking cessation, recognising the important role brief advice and brief intervention play in recruiting smokers to smoking cessation services, where they can access support to quit. The previous approach taken by SSW was to identify training venues and dates within Powys and advertise to local staff through their various communications networks.This has not always been successful in Powys and at least one training session has been cancelled through lack of bookings. The most successful approach has been to speak directly to key managers and arrange bespoke training e.g. 25 pre-operative staff were trained in 2010/11 and 22 therapists were trained in Autumn 2012.
2 Stead et al (2008)
Board Meeting 24 April 2013 Way Forward in Powys The Powys Tobacco Control Action Plan (Appendix 1) shows the actions required in Powys to achieve smoking cessation targets and a smoke free Powys. Key actions that specifically relate to Powys tHB are:
Increasing awareness • Improve communication, so that Powys tHB staff and key partners are aware of the current local smoking cessation services available. • Raise awareness, ensuring all staff are aware of the benefits of referring clients to local smoking cessation services.
Brief Intervention Training: • Train a large number of the Powys tHB front line staff in Brief Intervention, with the aim for all Powys tHB staff with close patient contact to be trained, giving priority to those who work in maternity and pre-operative settings. In addition, Health Visitors working in areas of high deprivation and those who work with patients with chronic conditions need to be trained. • Opportunities for smoking ‘brief intervention’ conversations between staff and patients need to be optimised by including brief intervention in all patient care pathways.
Pregnant women • Improve identification of pregnant women who smoke through maternity staff adherence to NICE guidance on CO monitoring. • Provide adequate support to pregnant women who smoke to maximise their quit attempts. This includes improving opportunities along the maternity pathway for quit attempts.
Pre-operative smoking cessation • Include pre-operative smoking cessation referral mechanisms into commissioning strategies as a matter of urgency.
Powys Smoke-Free • Launch the ‘Smoke Free Cars’ and ‘Smoke Free Homes’ campaigns in the Autumn, prioritising efforts with Flying Start staff. • Update and improve the current ‘Smoke free hospital grounds’ policy and launch in Autumn 2013.
Improved partnership working • Work with localities to motivate staff to attend BIT and to identify opportunities for joint working on smoking issues. • Work with partners to deliver the Powys Tobacco Control Action Plan • Improve working between the smoking cessation services in Powys, including developing an all Wales integrated data base. • Work closely with partners in SSW and Medicine’s Management to identify the best locations and times for sessions and advocate for further sessions according to need.
Board Meeting 24 April 2013 • Continue to work with primary care on smoking cessation issues and develop a mechanism for reporting back data on GP referrals to smoking cessation services.
Conclusion
A Powys Tobacco Control Strategic Group has been convened to develop and implement the Powys Tobacco Control Action Plan. The action plan reflects the WG All Wales Action Plan 2012, with four action areas identified: • Promoting better leadership and partnerships • Prevention (especially amongst children and young people) • Cessation • Reducing exposure to second-hand smoke This report highlights the specific actions that need to be taken forward within Powys tHB.
Recommendation
The Board is asked to: 1. Note the contents of this paper for information. 2. Discuss the role of Powys tHB in reducing smoking prevalence and working toward a smoke free Powys.
Report prepared by: Presented By: Kate Heneghan Dr Sumina Azam Senior Public Health Practitioner Interim Director of Public Health
Background Papers
How to stop smoking in pregnancy &followi
Financial Consequences As determined by the report
Other Resource Implications As determined by the report
Consultees The contents of this report draw upon presentations and discussions from the ‘Smoking Cessation Conference – Achieving the Seamless delivery of Smoking Cessation Provision in Wales: Targeting 2020 together. January 29th 2013
Board Meeting 24 April 2013 Appendix 1
Powys teaching Health Board’s Strategic Tobacco Control Action Plan 2013-2015 for a Smoke Free Powys
DRAFT
Board Meeting 24 April 2013 Table of Contents
1.0 INTRODUCTION ...... 11 1.10 Why this work is a priority for Powys ...... 11 1.1.1 Morbidity and mortality ...... 12 1.1.2 Cost benefit ...... 13 1.1.3 Addressing Inequalities ...... 13 1.2 Strategic Context ...... 13 1.3 Local Strategic Context ...... 14 2.0 CURRENT SITUATION ...... 15 2.1 Smoking prevalence in Powys ...... 15 2.1.1 Adults ...... 15 2.1.2. Young people ...... 15 3.0 ACHIEVING OUR VISION ...... 16 3.1 Action area one – leadership and partnership ...... 16 3.2 Action area two – Prevention ...... 16 3.3 Action area three – Reducing smoking prevalence ...... 16 3.3.1 Pregnant women ...... 17 3.3.2 Teenage girls ...... 17 3.3.3 Patients awaiting surgery ...... 17 3.3.4 People with mental health problems ...... 18 3.4 Action area four – Environment: Reducing exposure to second hand smoke ...... 18 4.0 Measuring performance ...... 19 Tobacco Control Strategic Action Plan for a Smoke Free Powys: 2012-14 ...... 20 References ...... 31 Appendix A: Suggested group membership ...... 33
Board Meeting 24 April 2013 1.0 INTRODUCTION
In February 2011 the Welsh Government produced a document for consultation called ‘A Draft Tobacco Control Action Plan for Wales’. This plan builds on and takes further current activity in Wales around Tobacco Control. A number of recommendations were made including that there should be a Tobacco Control Forum and Action Plan in all Local Authority areas in Wales led by local Public Health Teams. Following a Workshop in Powys in 2012 this draft Strategic Action Plan has been developed and is aimed at key partners who will make up this group. It provides the rationale and key drivers for such a group and seeks to work toward a shared vision for a smoke free Powys.
1.10 Why this work is a priority for Powys
In 2003 the World Health Organisation identified tobacco smoking as the primary cause of premature illness and death in developed countries 1.There has been a fall in smoking prevalence rates in Wales in recent years (Figure 1) from about 40% in 1978 to between 20 and 25% in 2010. However smoking remains the largest single cause of avoidable morbidity and mortality across the country 2.
Figure 1:
Board Meeting 24 April 2013 1.1.1 Morbidity and mortality
• In Wales, in 2010 around 5,450 deaths in those aged over 35 years were as a result of smoking. This accounts for 17.8% of all deaths in this age group. More men than women are affected (23% vs 13.1%) and may go some way to explain why women live longer than men3. • Almost a quarter of the Welsh adult population are smokers 4. • Smoking is associated with a number of cancers, heart disease and respiratory disease5. Smokers’ risk of dying before the age of 65 years is double that of non smokers. • There is also evidence to show that non smokers are affected by secondary smoke. In adults secondary smoke has been associated with lung cancer, and heart disease5. In children secondary smoking has been associated with respiratory disease, cot death, ear infections and asthma. • Using tobacco is a risk factor in six of the eight leading causes of unnecessary death worldwide. Mortality from smoking is higher than the next six most common causes of preventable deaths put together; drug misuse, road accidents, other accidents and falls, Type 2 diabetes, suicide and alcohol abuse6 (Figure 2).
Figure 2: Causes of preventable deaths (England) (DOH 2007)
Board Meeting 24 April 2013 1.1.2 Cost benefit
• Recent research from Swansea University reported that treating smoking related diseases in Wales cost the Welsh NHS 7% of the total healthcare expenditure in 2007/8, which is equivalent to £129 per head of population7. • Recent figures show an estimated 27,700 hospital admissions in Wales are caused by smoking each year3. • In the workforce, smoking is associated with loss of productivity from absenteeism15.
1.1.3 Addressing Inequalities
There is increasing evidence to show the link between smoking prevalence and socio economic class (Figure 3).
Figure 3:
• In Wales, rates for smoking attributable mortality in the most deprived parts are more than double those in the least deprived parts. • Recent evidence highlights an increase in this inequality gap over time8.
1.2 Strategic Context
There is widespread recognition of the severe impact cigarette smoking has on health and health inequalities in Wales. This has been recognised in a number of strategic documents in recent years. ‘Our Healthy Future’, Public Health Wales’ Strategic Framework has included the need to ‘reduce smoking prevalence in the population of Wales’ as one of ten key priority actions.9
Board Meeting 24 April 2013 In April 2007 legislation was introduced to ban smoking in all enclosed public places in Wales. A further legislative measure in the same year was to increase the minimum age for buying tobacco products from 16 years to 18 years. In February 2012 vending sales of tobacco products in Wales became illegal. In February 2011 the WG produced a document for consultation called ‘Draft Tobacco Control Action Plan for Wales’10. This plan builds on and takes further current activity in Wales around Tobacco Control. Four strategic action areas are identified; promoting better leadership and partnerships, prevention (especially amongst children and young people), cessation and reducing exposure to second- hand smoke. The plan introduces the Welsh Government’s aim of reducing smoking prevalence rates to 16% by 2020. The WG also lay down their intention to lobby the UK Government on non-devolved issues such as price increases through taxation and reducing tobacco imagery to young people10.
1.3 Local Strategic Context
The Powys Strategic Tobacco Control Action Group will lead the way in achieving a smoke free Powys for those living here and for generations to come. It will strive to ensure its aims are reflected in all strategic plans that relate to the health and happiness of the population of Powys. This will include: • Powys One Plan • Powys t HB annual plan • Powys Local Authority Corporate Plan
The Powys Strategic Tobacco Control Action plan aims to achieve a local co- ordinated approach to Tobacco Control. Key partners will be responsible for and take a lead on specific work streams.
Board Meeting 24 April 2013 2.0 CURRENT SITUATION
2.1 Smoking prevalence in Powys
2.1.1 Adults Figure 4
2.1.2. Young people Figure 5
Board Meeting 24 April 2013 3.0 ACHIEVING OUR VISION
The Welsh Government’s draft Tobacco Action Plan has identified four key action areas based on evidence of effectiveness. In line with this Powys will concentrate activity on the four action areas:
3.1 Action area one – leadership and partnership
Fundamental to achieving a shared vision for a smoke free Powys and the commitment to succeed is the engagement of key partners to own and take forward necessary action. Partners were invited to form a Powys wide strategic Tobacco Control group (Annexe A).
3.2 Action area two – Prevention
Reducing the number of people who take up smoking is paramount. Research shows smoking among school aged children increases with age. This suggests preventative measures would be most effective if they began in primary school (or earlier) and continue through high school and post 16 education. NICE guidance suggests:
• Schools should adopt whole school smoke free policies including staff training. This fits in well with the All Wales Network of Healthy Schools Scheme ethos where a whole school approach includes curriculum, school environment and links with family and community. • Information on smoking to be integrated into the curriculum at every opportunity e.g. science, geography and PSE • Schools to deliver evidence based interventions linked to national strategies.
There are also opportunities to work with the preschool scheme and to influence work with families where children are at a higher risk of seeing smoking as the norm.
Enforcement is also a key part of prevention including law on sales of tobacco to those under 18 years and illicit tobacco control.
3.3 Action area three – Reducing smoking prevalence
The WG’s Tobacco Control Action Plan for Wales highlights the need for the NHS to take an exemplar role in action to discourage smoking, including staff being trained in brief intervention for smoking cessation so they are better placed to motivate smokers to quit and refer to appropriate smoking cessation services. To balance this, effective evidence based behavioural support programmes need to be widely available across Powys to ensure equity of service. This would include Stop Smoking Wales, pharmacy support and individual services. A mapping of current availability and activity is being carried out.
Board Meeting 24 April 2013 Priority will need to be given to those groups where targeted action will have the greatest impact e.g. pregnant women, pre operative smokers and parents of young children. Areas of highest deprivation in Powys will also be prioritised.
3.3.1 Pregnant women
There is overwhelming evidence to show that babies born to smokers compared to non smokers have an increased risk of: • Low birth weight • Intra Uterine Growth Retardation (IUGR) • Pre-term birth • Stillbirth • Dying in the first month of life • Sudden Infant Death Syndrome (SIDS)11 Women who smoke during pregnancy have a higher risk of: • Ectopic pregnancy • Spontaneous abortion11
In 2010, around a quarter (26%) of mothers in the UK smoked before or during their pregnancy. Smoking levels before or during pregnancy were highest in Wales (33%) and lowest in England (26%). Mothers in Wales were most likely to smoke throughout their pregnancy (16%) compared with other home nation countries11. NICE guidance12 recommends a number of actions that midwives can carry out including: • assessing a pregnant woman’s exposure to tobacco at booking and subsequent appointments through discussion and also CO monitoring • Providing information e.g. leaflets to women about the risks of smoking to the unborn child • Referring pregnant smokers to a smoking cessation service Powys midwives will take the lead on reducing the number of pregnant smokers in county.
3.3.2 Teenage girls
Research has shown that girls are consistently more likely to smoke than boys and Powys is no exception (Figure 5). Teenage girls will be a focus of our work in Powys.
3.3.3 Patients awaiting surgery
Evidence shows that quitting smoking 6-8 weeks prior to surgery has a number of benefits. This includes • Fewer infections • Improved wound healing • A reduction in admissions to intensive care post anaesthetic • A shorter hospital stay • Financial savings to the NHS
Board Meeting 24 April 2013 Targeting pre-operative patients will be a priority in the Powys Tobacco Control Action Plan
3.3.4 People with mental health problems
Research shows that people with mental health problems are more likely to smoke than the general population. Smoking has been thought to relieve the symptoms of stress. However emerging evidence shows that this is not the case. Stop Smoking Wales are developing a mental health smoking cessation toolkit and we will take their advice on how best to promote it14.
3.4 Action area four – Environment: Reducing exposure to second hand smoke
Smoke free legislation in 2007 provides protection from exposure to second hand smoke in the majority of enclosed work and public places. However children continue to be exposed to second hand smoke in private dwellings and private cars. A report in 2010 from the Royal College of Physicians on Passive Smoking in Children13 has highlighted children’s vulnerability to second hand smoke. Because children have smaller lungs and underdeveloped immune systems they are more susceptible to respiratory and ear infections triggered by passive smoking. The report also showed an association between socio economic status and children’s exposure to smoke. Children from poorer backgrounds have higher exposure compared to children from more affluent homes.
Evidence shows13 the strongest individual predictors of passive smoke exposure are: • Where parents or carers smoke and whether they smoked inside the home. • In homes where the father smokes, children’s passive smoke exposure is about 3 times higher. o In homes where the mother smokes, about 6 times higher. o In homes where both parents smoke, nearly 9 times higher. • In children whose carers smoked their passive smoke exposure was 5 times higher (Figure 6).
We will focus action where it will have the biggest impact on reducing exposure to second hand smoke in children and young people.
Board Meeting 24 April 2013 Figure 6. Cotinine levels in non-smoking children aged 4-15 years according to smoking status of parents and carers (pooled data from 1996-2006)
© Royal College of Physicians 2010. All rights reserved.
4.0 Measuring performance
Success indicators are on the Action plan, although these need to be agreed by partners.
Board Meeting 24 April 2013 Tobacco Control Strategic Action Plan for a Smoke Free Powys: 2012-14 DRAFT 3
Aims of the Tobacco Control Strategic Plan
To provide a co-ordinated approach to Tobacco Control in Powys in order to reduce the risks to health and reduce the impact on inequalities associated with tobacco use and to achieve Welsh Government targets.
Objectives of Tobacco Control Strategic Plan:
1. To promote leadership in Tobacco Control.
2. To reduce the uptake of smoking.
3. To reduce smoking prevalence.
4. To reduce exposure to second hand smoke.
Board Meeting 24 April 2013 Objective 1: Promote leadership in Tobacco Control in order to promote joint working and ownership of the Tobacco Control process in county.
Action Notes Who / Timescale Outcome Update how/lead measure/indicator 1.1 Convene a Strategic TC Group Membership Public Health First group to Minutes from first 1st meeting to ensure an integrated approach from Powys tHB, to convene meet by 31st meeting Feb 2013 to planning, delivery and Powys County and support Dec 2012 TC actions included accountability for a Smoke Free Council Trading the group and in the strategic plans Terms of Powys Standards, establish of all members of the Reference Children and Terms of TC Action Group approved Young Person’s Reference. Partnership, 3rd Sector, Occupational Health, Primary Care, Public Health, Private Sector Housing landlords. 1.2 Group to develop, implement Powys TC Smoking prevalence Action and monitor a local multi agency Action Group rates (WHS) planned action plan to reduce current accepted with smoking rates from 23% to 16% % of 15year olds who some small by 2020 smoke (HBSC) changes
Group to consider developing a Contacts to SSW and communication strategy in quit rates at 4 weeks conjunction with PHW and 52 weeks communications and Powys tHB communications A minimum of 5% of smokers becoming
Board Meeting 24 April 2013 treated smokers per year.
No. of key staff attending BIT
No. of key staff completing SSW E- learning 1.3 Action plan to be reviewed and Powys County updated at meetings and lead Council organisations to take ownership Powys tHB for their area of TC work and for 3rd Sector updating the group. Public Health 1.4 Group reporting arrangements to Consultant in be agreed Public Health Facilitated by Public Health
Objective 2: To reduce the uptake of smoking.
Action Notes Who / how Timescale Outcome Update measure/indicator 2.1 De-normalise smoking Input on Public Health, Informal through: harms Pre-school talks with • Work with pre schools from co-ordinator Healthy scheme to support No tobacco in Schools lead Smoking Day, smoke training January free homes and smoke days for 2013
Board Meeting 24 April 2013 free cars schemes, pre-school information and staff. KH attended signposting for parents pre-school who want to quit, SSW event to advice to parents to posters present on NOT smoke in front of and cards TC and their children. available provide at pre- resources in • Provide ASH ‘Step school March 2013 outside to smoke’ settings - well leaflets to parents of received young children ASH leaflets available for pre- school parental packs 2.2 De-normalise smoking Local Ensure this measure Further work through : Authority is included in and required as • Maintenance of smoke Trading monitored through Trading free parks scheme Standards Local Authority Standards Trading Standards do not lead Strategic plan on this. KH to investigate 2.3 Increase number of schools Public Health, Number of children taking part in Smoke bugs Healthy recruited to the (8-11 year olds) Schools, scheme annually • Map current activity School Health
Board Meeting 24 April 2013 Nurses, % improvement on Primary previous year Schools 2.4 Provide the ASSIST PHW Health % 15 year olds Currently no programme to eligible high Improvement smoking weekly high schools schools (12-13 year olds) team (HBSC) in Powys meet eligibility criteria 2.5 Increase number of High Public Health, % improvement Resources Schools taking part in the Healthy year on year provided to ASH ‘Stamp it Out’ campaign Schools Healthy and or No Smoking Day Team, Schools via School School Nurses, Nurses High Schools 2.6 Influence and progress the Trading No. Of proof of age adoption of proof of age Standards cards applied for schemes (Local • Map current activity Authority) % increase on previous year 2.7 Reduce access to tobacco Trading No. of test through Standards purchases planned • Test purchasing (LA) exercises No. of completed • Increase enforcement test purchases measures to address underage and illegal % prosecutions sales/use, counterfeit related to illegal products, smuggled tobacco sales
Board Meeting 24 April 2013 products, tobacco houses • Raise awareness of TC offences through the Magistrate’s Courts (Welsh Heads of Trading Standards) and publicise enforcement • Scope out illicit tobacco sales
Objective 3: Reduce smoking prevalence
Action Notes Who Timescale Outcome Update measure/indicator 3.1 Establish a Smoking Progress Cessation Task Group (SCTG) Powys tHB Training needs with some to: supported by assessment carried staff groups • Assess BI training local public out needs across Powys health team Health BI training Visitor and • Establish a mechanism embedded into LHB midwives to for prioritising BI training attend training for key staff programmes for training in groups (through SSW senior staff the Autumn localities) adviser No. of training 17 Dental • Promote and deliver BI sessions delivered nurses to training receive BIT
Board Meeting 24 April 2013 Locality leads No. of staff training this • Develop mechanism for completed training year monitoring uptake of BIT amongst staff, particularly amongst different staff groups (? Keep a database) 3.2 Promote smoking cessation Powys tHB No. of staff who e-learning module training have completed e- for Powys tHB staff learning module 3.3 Map current SSW smoking Smoking Report Mapping cessation services across Cessation carried out. county and aim for an Task Group equitable service with good Discussions geographical spread on gaps in • Promote partnership services working with • Target most deprived Medicine areas first Management and SSW & Public Health 3.4 Reduce the number of pre- Powys tHB No. of pre-op operative patients who supported by referrals to SSW smoke by: Public Health • Ensuring staff who No of referrals from come into contact with GPs pre-operative patients have attended BIT and No. of referrals from refer patients to the secondary care
Board Meeting 24 April 2013 service • Providing Evidence of smoking training/updates to GPs cessation advice through CPD events given on patient (liaise with Institute of care pathways. Rural Health) to ensure they are aware of fast Evidence of in pre – track route for potential operative referral pre operative patients as a condition of when they refer commissioning patients for a surgical strategies for opinion. surgery • Work with secondary care providers (as part of commissioning strategy requirements) to refer pre-operative patients to SSW smoking cessation service. 3.5 Reduce the number of pregnant women who smoke Maternity No. of midwives by working with midwives on services attending BIT improving referral rates through: No. of midwives • Encouraging midwives completing E- to attend BIT learning • Ensure midwives have access to CO monitors Data on CO • Encouraging midwives monitoring (no. of
Board Meeting 24 April 2013 to use CO testing (as testings) per NICE guidance) • Encouraging midwives No. of referrals to to refer women who smoking cessation – smoke to smoking SSW cessation services • Sharing good practice Pharmacy referrals 3.6 Increase number of care Clinical leads Smoking cessation pathways that include at Powys tHB referral embedded smoking cessation for in all care pathways example chronic conditions 3.7 Work with GPs to increase Through Powys tHB No Smoking the referral rates to smoking QOF visits (Medical Day cessation services in county Director, materials through: Include locality sent to all • See 3.4 data managers) primary care • Proactively contacting collected Supported by practices to publicise for Level 3 Public Health, and promote smoking SSW advisor cessation services 3.8 Increase number of referrals Public Health, into smoking cessation SSW services by • Identifying partner organisations to support a smoke free Powys e.g. 3rd sector, Powys County Council • Training sessions • Distributing materials
Board Meeting 24 April 2013 3.9 Promote the provision of Powys tHB Smoke free smoking cessation in the well being at workplace policies workplace work team Map current activity in: Workboost Number of referrals • NHS Wales • Local Authority HSE Uptake of SSW • All work places Powys County Council, Uptake of pharmacy Corporate support Health Team 3.10 Continue to deliver the Medicine’s No. of pharmacies Pharmacy level 3 community management taking part in pharmacy stop smoking (Powys tHB) scheme. service in community pharmacies in Powys. No. of people accessing the service
4 week quit rate
Objective 4: Reduce exposure to second hand smoke
Action Notes Who Timescale Update
4.1 Promote ‘Fresh Start Wales Campaign’ Source materials Professionals Promoted and training who have to Early access to years parents of setting- 25 young children packs
Board Meeting 24 April 2013 given at training event 4.2 Promote ‘step outside to smoke’ campaign Source materials Professionals Discussed and training who have with Health access to Visitors at parents of 1st meeting young children Follow up in May 4.3 Promote ‘Smoke free cars’ scheme Source materials Professionals Discussed and training who have with Health access to Visitors at parents of 1st meeting young children Follow up in May 4.4 Update Powys tHB ‘Smoke Free’ policy Identify any gaps Quality & To be in current policy Safety. Well discussed Seek best Being at Work through practice from team Well Being other LHB areas. Kate Heneghan at Work Identify any to support meeting funding streams Spring e.g. WG 2013 Launch new policy
Board Meeting 24 April 2013 References
1. World Health Organisation (2003) Framework Convention on Tobacco control. Geneva: World Health Organisation (WHO)
2. Public Health Wales. Public Health Strategic Framework 2011/12 – 2012/13
3. Public Health Wales Observatory Tobacco and health in Wales (2012) Available at http://howis.wales.nhs.uk/sitesplus/922/page/49645 [Accessed 24th December 2012]
4. Welsh Assembly Government. (2010) Welsh Health Survey 2009. Cardiff: Welsh Assembly Government. Available at http://wales.gov.uk/docs/statistics/2010/100915healthsurvey09en.pdf [ Accessed 12 January 2012]
5. Dolman, R., Gibbon R, Roberts C.(2007) Smoking in Wales current facts. Cardiff: Wales Centre for Health
6. Department of Health. A Smokefree Future(2010) Available at http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPo licyAndGuidance/DH_111749 [Accessed 24th December 2012]
7. Phillips, C.J. and Bloodworth, A. (2009) Cost of smoking to the NHS in Wales. Cardiff: ASH Wales.
8. Public Health Wales NHS Trust (2011).Trends in mortality and life expectancy in Wales.
9. Welsh |Assembly Government. Our Healthy Future (2009). Available at: http://wales.gov.uk/topics/health/ocmo/healthy/?lang=en [Accessed 24th December 2012]
10. Welsh Assembly Government (2011) Draft Tobacco control Action Plan for Wales
11. The information centre for health and social care (2011) Infant feeding survey 2010:early results [online]. Available at: http://www.ic.nhs.uk/webfiles/publications/003_Health_Lifestyles/IFS_2010_e arly_results/Infant_Feeding_Survey_2010_headline_report2.pdf Accessed on 8 November 2012
Board Meeting 24 April 2013 12. NICE public health Guidance 26 (2010) How to stop smoking in pregnancy and following childbirth [Online] Available at: www.nice.org.uk/guidance/PH26 Accessed 8th November 2012
13. Royal College of Physicians. Passive Smoking and Children [Online] Available at: http://bookshop.rcplondon.ac.uk/details.aspx?e=305 Accessed 8th November 2012
14. Action on Smoking and Health (ASH) (2011). ASH Factsheets Smoking and mental Health.[Online] Available at : http://asg.org.uk/files/documents/ASH 120.pdf Accessed 8th November 2012
15. NICE Public health intervention guidance 5 (2007). Workplace health promotion: how to help employees to stop smoking [Online] Available at http://www.nice.org.uk/guidance/index.jsp?action=bypublichealth&PUBLICHE ALTH=Smoking+and+tobacco#/search/?reload Accessed 31st January 2013.
Board Meeting 24 April 2013 FOR APPROVAL/DISCUSSION/INFORMATION [delete as appropriate] Appendix A: Suggested group membership
Local Authority Trading standards Environmental Health Corporate Health Education Leisure Services Youth services Youth and family information worker Oral health promotion lead Housing officers Fire service Licensing CAIS
Voluntary Sector PAVO
Local Health Board Medicines Management Nursing Midwifery School Health Nurses Physiotherapists and other therapists
Public Health Healthy Schools Healthy pre-schools Local Tobacco Control lead
Private landlords and Housing Associations
Powys Tobacco Control Strategic Page 33 of 34 Board Meeting Planning 24 April 2013 Agenda Item 4.2
FOR APPROVAL/DISCUSSION/INFORMATION [delete as appropriate] Appendix 2
Powys Tobacco Control Strategic Page 34 of 34 Board Meeting Planning 24 April 2013 Agenda Item 4.2
FOR DISCUSSION
BOARD MEETING 24 APRIL 2013 AGENDA ITEM 4.3
IMPROVING QUALITY TOGETHER
Report of Interim Director of Public Health
Paper prepared by Safety and Quality Improvement Manager Assistant Director of Modernisation and Development Workforce Development Lead Interim Director of Public Health
Purpose of Paper To update the Board on the Improving Quality Together programme, which is due to be implemented from March 2013.
Action/Decision required The Board is asked to support implementation of the Improving Quality Together programme in Powys.
Link to ‘Doing Well, This paper supports Standards 6, 7, 18, 21, 22, 24 and Doing Better: Standards 26. for Health Services in Wales’:
Link to Health Board’s Striving for Excellence Corporate Plan
Acronyms and teaching Health Board – tHB abbreviations Improving Quality Together - IQT Quality Delivery Plan - QDP
Improving Quality Together Page 1 of 15 Board Meeting 24 April 2013 Agenda Item 4.3
FOR DISCUSSION
IMPROVING QUALITY TOGETHER
Background
The 1000 Lives Plus programme is moving from a programme with specific direction provided centrally to one where there is a greater responsibility placed on each Health Board to integrate Quality Improvement methodology at each level of the organisation. Health Boards will need to identify, commission and manage their own priorities for organisational development and service improvement.
Within Powys teaching Health Board (tHB), the following priorities have been identified for 2013-14.
1. The implementation of "Improving Quality Together", a programme to develop skills in Quality Improvement methodology across the tHB 2. Embedding existing 1000 Lives Plus ‘bundles’ of care and the support of future improvement work 3. To develop and implement a process for sharing, spreading and celebrating 4. Development of a process to identify future areas for tHB wide improvement work
This paper focuses on priority 1: Implementation of Improving Quality Together.
Improving Quality Together
The ‘Quality Delivery Plan’ (QDP, May 2012) sets a double goal for ensuring both quality improvement and quality assurance by the alignment of quality, performance and financial goals. Actions to drive quality improvement include: • Action 2: 1000 Lives Plus will continue to be the core NHS improvement programme, ensuring a common and consistent language and approach to improvement. • Action 4: Health Boards and Trusts will agree a plan to train 25 per cent of their directly employed and contractor workforce in quality improvement methodology by the end of March 2014, supported by 1000 Lives Plus.
To assist Health Boards in achieving these goals, the “Improving Quality Together” (IQT) programme has being developed for NHS Wales staff and contractors. This framework provides staff with the knowledge and skills to develop a common and consistent approach to improving the quality of services in organisations across Wales, enabling improvements to take place more effectively and quickly. These training needs cannot be met through existing central and local programmes. The training supports organisational development and enables transformational change. This standardised approach builds upon learning from programmes that have been developed internationally.
The content of the framework has being developed at a national level, but will be delivered locally by individual organisations from March 2013 onwards. It is expected
Improving Quality Together Page 2 of 15 Board Meeting 24 April 2013 Agenda Item 4.3
FOR DISCUSSION that 25% of staff will be trained in IQT by March 2014, although there is no specification on how many staff are trained in each level of attainment.
The IQT consists of four levels:
Bronze This is aimed at all NHS Wales staff and the contractor workforce across all services. It will provide modules that cover a broad foundation of improvement skills, from initial introduction to concepts of quality improvement to the Model for Improvement. The training package will be offered as three, 20 minute, e- learning modules via the Learning@NHSWales web site. It is hoped that a future resource pack will be offered by IQT central to enable classroom teaching. Appendix A displays screenshots of one of the training modules that has been developed.
Welsh Government have stated that staff compliance in achieving completion of these courses will not be the subject of formal performance management but that each Health Board should aim to have approximately 25% of its workforce qualified to this level by April 2014. The ultimate goal is for all staff to be qualified to Bronze standard by April 2017. 25% of the Powys tHB workforce would be approximately 420 individuals.
Silver This level is aimed at individuals across all services who lead teams and can include ward managers, practice managers, directorate managers and other department managers, e.g. estates. To attain Silver level, individuals will be expected to undertake 12 hours of classroom based learning over three days and to undertake their own quality improvement project over seven days. Individuals who have undertaken other Quality Improvement courses during the last 18 months may be able to achieve Silver level via a conversion course, comprising the three classroom days and a written submission. Welsh Government has stated that it would be a reasonable expectation that 5% of the workforce will be qualified to this level (84 staff in Powys tHB) Staff who wish to receive accreditation from Agored Cymru for achieving silver level may do so for a fee which will be under £25. Welsh Government however will not distinguish between staff who do or do not wish to have accreditation.
Gold This level will be for individuals who have a detailed understanding of quality improvement and who have experience in managing a number of quality improvements projects. They will be expected to qualify at both the Bronze and Silver levels It is likely that there will only be approximately 1 per 1,000 staff who will serve at this level (approximately 2 staff in Powys tHB). It does not represent a necessarily higher level of training but a deeper experience of quality improvement
Improving Quality Together Page 3 of 15 Board Meeting 24 April 2013 Agenda Item 4.3
FOR DISCUSSION work. The Gold level individuals will serve as mentors, instructors or examiners for the Silver level staff.
Board Training will be provided for Board members to enable them to rigorously interrogate the data that is presented to them.
Implementation in Powys tHB
A large number of the Powys tHB workforce will need to be trained within the first year in order to reach the target of training 25% of the workforce (approximately 420 staff in 2013-14). Joint working is underway to enable implementation of the IQT programme in Powys.
Mechanisms for implementation at each of the four levels have been identified: • Bronze This is likely to be delivered through targeting Bronze training at appraisers as well as incorporating training into the induction process and team meetings. Analysis is currently underway to understand which staff need to be approached in the initial implementation phase. Lack of access to IT equipment to enable training has been identified as a barrier to implementation in Powys. Training may be viewed as being an additional demand on staff time, particularly if it is not incorporated into work plans. The training will need to be contextualised to make it relevant to all the workforce. • Silver The materials for Silver level training are unlikely to be ready for use until Summer 2013. Mapping is currently being undertaken to understand which staff should be targeted for Silver training and identify those staff who are eligible to undergo Silver level “conversion”. • Gold Some staff that could operate at Gold level have been identified. This work is being taken forward through the development of an All Wales Gold Network. • Board The content of Board level training is still in development. However, a Board development session has been identified for training purposes.
To enable successful implementation of IQT, staff “buy in” and ownership of the programme is key. A cultural change amongst all staff, including clinical staff, managers and leaders in the organisation will be required to embed IQT in Powys and realise the benefits of improved service quality.
Conclusion
IQT provides a common and consistent approach to quality improvement across Wales. This programme will enable Powys tHB staff to understand and be skilled in quality improvement language and methods and will ultimately help deliver improved service quality.
Improving Quality Together Page 4 of 15 Board Meeting 24 April 2013 Agenda Item 4.3
FOR DISCUSSION
Work is currently underway to implement the IQT programme within Powys.
Recommendation The Board is asked to: 1. Support implementation of the IQT Programme in Powys
Report prepared by: Presented By: Dr Howard Cooper, Safety and Dr Sumina Azam, Interim Director of Quality Improvement Manager Public Health Dr Sumina Azam, Interim Director of Public Health Lynn Turner, Assistant Director of Modernisation and Development Louise Williams, Workforce Development Lead
Background Papers Quality Delivery Programme, May 2012
Financial Consequences As determined by the report
Other Resource Implications As determined by the report
Consultees As determined by the report
Improving Quality Together Page 5 of 15 Board Meeting 24 April 2013 Agenda Item 4.3
FOR DISCUSSION
Appendix A: Quality Improvement Bronze level training
Bronze level training seeks to introduce staff and contractors to the basic concepts of Quality Improvement methodology. A Wales-wide training package has been developed and the final product is planned to be available either as a one hour classroom session or as three 20 minute e-learning modules.
The training package begins with an introduction that explains that all staff have two roles; to do their job and to improve it.
(Note that these screenshots are from the beta version whilst under development by 1000 Lives Plus central team)
Staff are given an outline of their learning objectives together with an estimate of how long the module will take to complete.
….and a few inspirational messages
The training package then introduces the Institute of Healthcare Improvement’s strategic change triad; Will – Ideas – Execution. So that all types of staff can benefit from this training, the concept is introduced by way of a non-clinical example, that of an individual wishing to lose weight
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FOR DISCUSSION
Will
Ideas
Execution
The module then introduces the concept of the “Run Chart” as a method of determining whether your change idea has been successful of not.
The module then introduces the Model for Improvement which links the improvement triad to the Plan-Do- Study-Act methodology favoured by the 1000 Lives Plus programme.
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FOR DISCUSSION
The module considers an example involving storage of supplies on a ward
The module takes staff through the initial stages of problem analysis and the construction of a plan of action.
Moving on to the action stage where a small test of change is made.
The effects of this change are then recorded and measured over a period of time
Improving Quality Together Page 8 of 15 Board Meeting 24 April 2013 Agenda Item 4.3
FOR DISCUSSION
A conclusion is made as to whether the change that was introduced should be continued and spread to other applicable areas.
Finally the module gives some further clinical examples where improvement was achieved through the application of the Model for Improvement.
Two further modules are in development as well as a scoring module where staff can be tested on their understanding of the methods and concepts that have been covered in the training.
Improving Quality Together Page 9 of 15 Board Meeting 24 April 2013 Agenda Item 4.3
FOR DISCUSSION
Appendix B: Learning outcomes for IQT
Improving Quality Together Learning Outcomes; Assessment Criteria and Indicative Content
Bronze Level
For all staff this will provide pre-requisite knowledge for development to further levels.
Learning Outcomes Assessment Criteria KSF NOS (the learner will) (the learner can) Mapping Mapping 1. Understand how a 1.1 Identify how a health or C6 1 (b) (c) SCDHSC health or social care social care organisation (d) 0234 organisation benefits benefits from using a from using a person- person-centred approach centred approach
2. Understand how a 2.1 Identify how a health or C4 1 (a) (e) GEN63 health or social care social care organisation, organisation, individuals and others C5 1 (c) individuals and others1 benefit from quality benefit from quality improvement improvement
3. Understand the 3.1 Identify the principles of C4 1 (a) (e) principles2 of quality quality improvement in a improvement health or social care C5 1 (c) organisation
4. Recognise their role 4.1 Outline their role and C2 1 (a) GEN63 and responsibility in responsibility in improving improving the quality of the quality of services C4 1 (a) HSC23 services 4.2 Contribute, as C4 1 (a) (b) appropriate, to quality (c) (d) (e) GEN39 improvements within their service C5 1 (b) (c)
C5 2 (c) 5. Understand the 5.1 Outline the importance of C4 1 (b) (c) importance of measurement to quality measurement to quality improvement and service improvement and delivery service delivery
1 Patients, clients, carers and their family 2 IHI Triple Aim context Improving Quality Together Page 10 of 15 Board Meeting 24 April 2013 Agenda Item 4.3
FOR DISCUSSION
6. Understand what can 6.1 Identify messages from C4 2 (c) be learned from data displays displaying data3 IK2 2 (d)
7. Understand the Model 7.1 Describe how you could C4 1 (a) (b) GEN39 for Improvement use/have used the Model (c) (d) (e) approach to small step for Improvement to apply change a small step change in C5 1 (b) (c) their environment to address a local or IK2 1 (a) (c) organisational need
Silver Level: (wording subject to Agored Cymru accreditation process)
Learning Outcomes Assessment Criteria KSF NOS (the learner will) (the learner can) Mapping Mapping 1. Understand how a 1.1 Explain how and why a C6 1 (b) (c) SCDHSC health or social care health or social care (d) 0234 organisation benefits organisation benefits from using a person- from using a person- C5 4 (e) (f) centred approach centred approach C6 3 (d) (e)
2. Understand how a 2.1 Explain how and why a C4 1 (a) (e) GEN63 health or social care health or social care organisation, organisation, individuals C5 1 (c) individuals and others4 and others benefit from benefit from quality quality improvement improvement
3. Understand the 3.1 Explain the principles of C4 1 (a) (e) principles5 of quality quality improvement in a improvement health or social care C5 1 (c) organisation 3.2 Identify a range of quality G2 1 (a) BD7 improvement methodologies6
4. Be able to use quality 4.1 Produce a quality C4 3 (a) (b) M&LF1 improvement improvement plan, to (c) (e) (f) M&LC5
3 Run charts; Safety crosses 4 Patients, clients, carers and their family 5 IHI Triple Aim context 6 Model for Improvement; Lean; Six Sigma Improving Quality Together Page 11 of 15 Board Meeting 24 April 2013 Agenda Item 4.3
FOR DISCUSSION
methodologies to include: identify an area for • Developing a vision C5 3 (c) BD7 improvement for the area for improvement IK2 4 (a) (b) • Use a range of improvement tools7 to identify your area in need of improvement • Defining an improvement aim • Using evidence-based interventions. • Establishing a baseline of current performance in the area.
5. Be able to involve 5.1 Use the views of G5 3 (a) (b) SFJCPS1 others in quality individuals and others to (g) improvements identify the approach to quality improvement in a C5 3 (c) health or social care organisation. (This could include stories for improvement) C1 3 (a) (b) 5.2 Use stakeholder (c) engagement tools to M&LF1 identify champions to support quality improvement G5 3 (a) (b) 5.3 Explain how using (g) Human Factors8 methodologies can C5 3 (c) reduce adverse events due to human error
6. Use the Model for 6.1 Implement a quality C4 3 (a) (b) M&LF1 Improvement to improvement with team (c) (e) (f) implement a quality members, to include: PHS08 improvement in a • Using process C5 3 (c) health or social care mapping M&LC6 organisation • Collecting data IK2 3 (b) (c) • Analysing data (d) (e) (g) BAD322 • Evaluating results (h) • Differentiating
7 Root Cause Analysis; Process mapping; 5 Whys; Fishbone 8 Fallibility and human interaction in team working to create safe healthcare Improving Quality Together Page 12 of 15 Board Meeting 24 April 2013 Agenda Item 4.3
FOR DISCUSSION
between different types of statistical C4 3 (f) variation9 6.2 Undertake small tests of change using Plan Do C5 3 (e) (g) Study Act cycles. 6.3 Evaluate the C4 3 (b) (c) sustainability and (d) (e) potential for spread of the quality improvement, showing consideration of the following: • Defining the aim • Identifying the target population • Identifying the
measurement system • Identifying C4 3 (a) (b) infrastructure (e) requirements • Defining the timeframe 6.4 Identify priorities for next quality improvement
7. Be able to reflect on 7.1 Evaluate their own role C4 4 (a) (b) HSC33 quality improvement and the role of others in (c) (d) quality improvement to include: • Strengths • Weaknesses • Opportunities • Threats
Gold Level / Gold (Improvement Coach) Level:
Learning Outcomes Assessment Criteria KSF NOS (the learner will) (the learner can) Mapping Mapping 1. Be able to support 1.1 Explain the principles10 C5 4 (d) CHS198 others in implementing of quality improvement quality improvements 1.2 Explain the principles of person-centred care C6 3 (d)
9 Utilising Pareto; run charts; control charts and box plots 10 IHI Triple Aim context Improving Quality Together Page 13 of 15 Board Meeting 24 April 2013 Agenda Item 4.3
FOR DISCUSSION
1.3 Understand the principles of a range of quality G2 1 (b) improvement methodologies11 and their appropriate application
1.4 Support others to identify areas for quality improvement using a C4 3 (b) (e) range of tools outlined in (f) the Silver level
1.5 Support others in understanding the features, application and C2 3 (e) benefits of Model for Improvement
1.6 Support others the application of PDSA and process mapping C2 3 (e)
1.7 Support others to understand the principles of variation IK2 3 (b) (c) (d) (e) (g) 1.8 Support others to (h) understand the importance of C2 3 (f) measurement for improvement and associated tools
1.9 Advise on best methods and tools for planning quality improvement G5 4 (a) (c) M&LC4 according to context M&LC5 1.10 Advise colleagues in choosing the most appropriate tools for measurement including an understanding of C2 4 (e) trends in data IK 2 4 (g) 1.11 Advise on the
11 Model for Improvement; Lean; Six Sigma Improving Quality Together Page 14 of 15 Board Meeting 24 April 2013 Agenda Item 4.3
FOR DISCUSSION
sustainability of quality improvements within the organisation SFJHF23 C5 4 (c) (f) (g) BAH122
2. Be able to use a 2.1 Deliver the quality C2 4 (c) (e) learner-led coaching improvement Silver and (f) (h) style approach to Bronze level training deliver quality throughout their improvement training organisation
Board Level: (to be finalised)
Learning Outcomes Assessment Criteria (the learner will) (the learner can) 1. Understand the linkages between 1.1 Set priorities, align resources and quality improvement, a person-centred ensure accountability for quality approach and performance at an improvement. organisational level 1.2 Support the development of a high reliability culture, drive continuous improvement and provide positive assurance for all aspects of service quality. 2. Understand and use appropriate 2.1 Develop a plan of engagement for approaches to achieve system-wide staff and stakeholder groups in engagement of staff and stakeholder improvement work groups in improvement work
3. Understand the use of data and be able 3.1 Critique outcomes and impacts of to interpret information to support quality improvement programmes. effective scrutiny and quality assurance.
4. Understand the science of quality 4.1 Demonstrate knowledge of the improvement science of quality improvement.
Improving Quality Together Page 15 of 15 Board Meeting 24 April 2013 Agenda Item 4.3
FOR DISCUSSION
BOARD MEETING 24 APRIL 2013 AGENDA ITEM 5.1
FINANCIAL PERFORMANCE TO MONTH 11 (FEBRUARY 2013)
Report of Director of Finance
Paper prepared by Director of Finance Purpose of Paper The purpose of this report is to inform the Board of the financial performance of the Powys Teaching Health Board (tHB) for 2012/13
Action/Decision required The Board is asked to NOTE the financial performance of the tHB.
Link to ‘Doing Well, Doing 1. Governance & Accountability Better: Standards for Health Services in Wales’ Link to Health Board’s Making Every Pound Count Corporate Plan
Acronyms and ABHB – Aneurin Bevan Health Board abbreviations ABMu – Abertawe Bro Morgannwg University Health Board ACCP – Accelerated Clinical Change Programme AWCP – All Wales Capital Programme CHC – Continuing NHS Healthcare CIP - Cost Improvement Programme EMAs – Emergency Medical Admissions HR - Human Resources HQ - Headquarters MH - Mental Health NWIS – NHS Wales Informatics Service NWSSP – NHS Wales Shared Services Partnership PCC – Powys County Council PCT – Primary Care Trusts PSPP - Public Sector Payment Policy RATS – Remuneration and Terms of Service RJAH – Robert Jones and Agnes Hunt NHS Trust SaTH – Shrewsbury and Telford NHS Trust tHB - teaching Health Board VER – Voluntary Early Release WHSSC – Welsh Health Specialist Services Committee Month 11- 2012/13 Page 1 of 10 Board Meeting 24 April 2013 Agenda Item 5.1
FOR DISCUSSION WG – Welsh Government WOD – Workforce and Organisational Development Ytd – Year to Date
Month 11- 2012/13 Page 2 of 10 Board Meeting 24 April 2013 Agenda Item 5.1
FOR DISCUSSION FINANCIAL PERFORMANCE TO MONTH 11 (FEBRUARY 2013)
PURPOSE
The purpose of this paper is to provide a summary update on the financial performance of the Board at month 11.
This paper builds upon the month 10 reported position and highlights only where there have been changes to financial performance and associated actions one month on. As such, this paper does not restate issues already rehearsed within the month 10 position paper.
SUMMARY
The Month 11 position includes all allocations received and anticipated for the financial year including the additional £4.0M funding support received on a non recurrent basis for 2012-13, less the non recurrent brokerage repayment of £3.9M arising from 2012/13 outturn.
Our performance to month 11 and forecast to year end is as follows;
• The year to date variance is £5.629M (after factoring in 11/12th of the additional £4M) • The year to date variance is in line with previous month’s forecast for month 11 • The month 11 forecast variance for year end is £5.161M, which remains unchanged from month 10 • There are significant risks and some opportunities not included in this forecast • Actions continue to be taken by the Health Board to improve this current trajectory • All other statutory duties are on track for achievement
The following sections update from the month 10 performance by exception.
Month 11- 2012/13 Page 3 of 10 Board Meeting 24 April 2013 Agenda Item 5.1
FOR DISCUSSION REVENUE EXPENDITURE Table 1 – Year to date and forecast variance by Primary budget holder
(Brackets within the variance column denote adverse variance)
Revenue Performance by Budget Holder
Despite a small deterioration in the year to date variance of £0.063M during month 11, the year end forecast deficit has remained at £5.161M, the same level as Month 10.
The reasons for the main movements in year end forecast between month 10 and month 11 are as follows:
• A continuing deterioration in the expected achievement of savings plans against the Shrewsbury and Telford NHS Trust • A deterioration in the expected achievement of savings plans with Aneurin Bevan Health Board • An improvement in the forecast performance against the ABMu Health Board cost and volume contract and performance and associated savings plans • An improvement in the performance in Mental Health due to a review of Continuing Care step-down cases
With these changes in performance to date, the organisation still remains on track against the expected profile expected for month 11 as set-out in Graph 1 below.
Month 11- 2012/13 Page 4 of 10 Board Meeting 24 April 2013 Agenda Item 5.1
FOR DISCUSSION
Graph 1 Profiled Monthly variance to year end (Overspend)
(*) Month 7 profile and actual has been restated to include 7/12th of £4M additional funding from Welsh Government. Month 8-12 include 1/12th of £4M.
Forecast savings
The forecast savings achievement based on month 11 performance and assumptions are set out in table 2 below. This reflects that savings are anticipated to be achieved at the same level as Month 10 (£13.316M, 5.69%).
Table 2 – Forecast Savings Achievement M11
Plan February Savings Area (forecast year end achievement) £m % £m % Continuing Healthcare 0.282 11.07% 0.068 2.67% Commissioning 8.741 12.50% 6.602 9.44% Prescribing 0.791 2.87% 1.327 4.81% Mental health 1.971 4.75% 1.284 3.10% Provider 2.165 10.36% 0.859 4.11% Women & Children 0.200 2.87% 0.074 1.06% Dental 0.050 7.14% 0.050 7.14% HQ 0.652 6.22% 0.652 6.22% Accounting Gains 2.400 2.400
17.252 9.56% 13.316 5.69%
Commissioned services savings represents one of the largest elements of unachieved savings against plan. Further analysis of the main components of slippage against planned cost reductions are as follows
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Unscheduled care not demonstrating the reduction in volume targeted £1.659M Planned scope of contract challenges with providers not being evidenced £0.266M Waiting time extensions not delivery the expected reduction in volume £0.270M
Provider services underachievement of savings arises mainly through the planned reduction in workforce numbers not being achieved.
RISK ASSESSMENT
In line with previous reports, the organisation continues to assess risks and opportunities held which could impact on our forecast position. This analysis has identified a risk range of £3.711M - £7.951M overspend.
Table 3 Analysis of Risks
Worst Case Best Case £M £M
Most Likely Forecast outturn 2012/13 (5.161) (5.161)
New Retrospective CHC Cases 0.300 CHC variability risk (0.100) 0.100 Waiting list management (Wales) (1.000) Contract challenges (Wales providers) (0.440) Pricing (Wales providers) (1.000) Mental Health Challenge with Welsh providers 0.150 Primary care underspends 0.250 LD Service with Council (0.250) 0.150 Other Balance Sheet 0.400 Use of WG new allocated funds Further improvement in provider services 0.100
Total (7.951) (3.711)
The Health Board has been in a series of discussions with the Welsh Government regarding its likely forecast outturn and risks during the course of the previous months, the following section sets out the remaining opportunities and risks not already incorporated within our position.
• Retrospective CHC Cases
The health Board has maintains a provision within its accounts to cover any payments arising from retrospective CHC funding claims.
The tHB has received 41 new retrospective claims. These have been generated as a result of a recent awareness raising campaign running in England. However, our
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FOR DISCUSSION latest estimates indicate that these can be accommodated within the existing provision and furthermore that there may be an opportunity amounting to £0.3M
• Continuing NHS Healthcare The health Board currently has the lowest cost per capita of Continuing NHS Healthcare spend in Wales irrespective of our significant proportion of elderly care. Reducing costs is therefore, in this context, challenging to reduce cost further. We have however focussed on in-county variation by replicating best practice across all geographical locations in Powys. Our specific focus has been with the south of the county and within Mental health services. Our current performance demonstrates a 14% reduction in general CHC cases (10% reduction in cost) in the south and 3% reduction in cases (9% reduction in cost) in mental health cases in-year.
Whilst noting the volatility of this area of expenditure, our modelling suggests that there could be £0.1M opportunity or risk arising from CHC payments, although given the limited length of time to run to the end of the financial year, this expectation is diminishing
• Mental Health Secondary Care Costs The Mental Health services transferred from our direct delivery to three Welsh Health Boards in Wales in 2009.We expect Welsh providers of mental health services to Powys to provide a cost and clinically effective service. Financial efficiencies made through new service models are expected with Powys as commissioner benefiting from this.
A challenge has been made against our providers as to the efficiency of funding allocated to them. This has been counter challenged and therefore has not been brought into the position but it still being pursued.
• Learning Disability Services with Powys County Council An historical contract in place for the resettlement of clients has been reviewed by Powys tHB and this evidences that a reduction in contract value should be realised in year. This is an issue in dispute with the council but we are working towards a locally agreed solution. Some success is assumed in reducing the current cost within the current forecast and the worst and best case scenarios describe the risk uncertainty.
• Primary care underspends
As with commissioned services, expenditure on primary care services i.e. community dental, community pharmacy and prescribing is subject to volatility and information to make judgements on forecast expenditure is always some months in arrears.
Modelling suggests that the performance profiled based on year to date information could further improve by year end.
• Other Balance Sheet
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FOR DISCUSSION We have currently drawn £2.8M out from the balance sheet in-year, mainly associated with our successfully negotiated settlement of 2011/12 over-performance with Shrewsbury and Telford NHS Trust.
We are continually reviewing our balance sheet position. On the assumption that no further old year issues are raised with us between now and year end and without compromising our ability to prepare a set of accounts that meet audit requirements at the end of the year, we estimate that we may be able to remove a further £0.4M of creditors / provisions from our balance sheet providing non recurrent benefit in year.
• Welsh NHS Providers
A total of £2.4M risks have been quantified within our commissioned services budgets associated with contract challenges, implementation of the 36 week waits target and the pricing challenges. The majority of our Welsh providers have rejected our approach to these issues and therefore whilst out forecast position assumes success, there is the potential that the final outturn variance could deteriorate if the arbitration process that will need to be put in place to resolve, finds against us The Finance Director and Chief Executive have been in direct discussion and correspondence with each Health Board in Wales to aim to resolve these issues or pursue arbitration through Welsh Government. The Board will be further appraised of progress at the Board meeting.
CAPITAL RESOURCE LIMIT PEFORMANCE
The below capital allocation is based on the latest Capital Resource Limit received from Welsh Government.
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FOR DISCUSSION
Table 4 Capital Resource Limit and Performance to date
Scheme Capital Annual Planned Expenditure to Resource Expenditure 28th February Limit £M 2013 £M £M Discretionary Capital 0.342 0.159 0.020
AWCP Welshpool Renal 1.545 1.634 1.624 AWCP Orthopaedics 0.460 0.573 0.573 Llandrindod AWCP Orthopaedics Brecon 0.853 0.853 0.352 AWCP - Bronllys Sewerage 0.045 0.046 0.046 AWCP -Ward Vending 0.047 0.047 0.020 Machine AWCP – Pharmacy 0.073 0.025 0 Modernisation AWCP – Asbestos Removal 0.385 0.385 0.138 and Relocation of IT AWCP – Anti Ligature 0.160 0.160 0.018 AWCP – IT Equipment 0.077 0.077 0 AWCP – IPC 0.074 0.074 0 AWCP – Ultrasound Scanner 0.096 0.096 0 AWCP – LWH 0.130 0.130 0.030
Donated Asset Receipt 0 -0.020 0 Asset transfer to NWSSP 0 -0.356 0 TOTAL APPROVED 4.287 3.883 2.821 FUNDING
The tHB foresees no risk in achieving the capital resource limit for the financial year ending the 31st March 2013
PUBLIC SECTOR PAYMENT POLICY
The tHB is required to pay 95% of non-NHS suppliers within 30 days and is currently on track to meet this target. The tHB currently achieves a cumulative position of 95% of non NHS invoices paid within 30 days by value and 95% by number of invoices.
Cumulative Performance at 28th February 30 days 10 days Value of invoices 95% 79% Number of invoices 95% 85%
CASH MANAGEMENT PROGRAMME
The tHB has to manage payments to its creditors within the cash drawings limit allocated by Welsh Government. During 2012/13, there is a forecast overspend in the tHB financial position of £5.269M. This added to a predicted movement in
Month 11- 2012/13 Page 9 of 10 Board Meeting 24 April 2013 Agenda Item 5.1
FOR DISCUSSION working capital balances means that the forecast projection of shortfall on cash for March 2013 is approximately £5M.
The tHB finance staff have through February and March 2013 been working with other NHS organisations and the Local Authority to agree in advance, where possible, a delay in inter-nhs/local authority payments from March 2013 to April 2013. This has enabled the tHB to utilise this money for the smaller non - nhs creditors. The tHB has withheld payment of smaller inter-nhs invoiced activity where this does not relate to specific patient funding arrangements.
Any payments that are not made during March will be paid in early April 2013; therefore a maximum of a month in delay of payment can be expected for some tHB creditors. This delay may adversely impact on the Public Sector Payment Policy (PSPP) target for both March 2013 and April 2013 but the tHB has looked to manage the available payments to minimise this impact wherever possible.
CONCLUSION
• The tHB has identified an overspend of £5.269M to month 11 • The tHB has reported, based on current performance, a most likely forecast overspend of £5.161M to month 12 with associated risks identified • The tHB is on track to achieve its capital resource limit target • The tHB is on track to achieve the Public Sector Payment Policy
RECOMMENDATION
The Board is asked to note the financial performance of the tHB to month 11 and forecast for 2012/13 and to note the further actions in place to limit the risks against our forecast performance.
Report prepared by: Presented By: Rebecca Richards Rebecca Richards Director of Finance Director of Finance
Month 11- 2012/13 Page 10 of 10 Board Meeting 24 April 2013 Agenda Item 5.1
FOR DISCUSSION
BOARD MEETING
24 APRIL 2013
AGENDA ITEM 6.1a
REPORT FROM THE CHAIR OF THE QUALITY & SAFETY COMMITTEE MARCH 2013
Report of Quality & Safety Committee Chair
Paper prepared by Corporate Governance Manager
Purpose of Paper The purpose of this paper is to provide the Board with an update on the key issues discussed and any decisions made by the Quality & Safety Committee during March 2013.
Action/Decision required The Board is asked to RECEIVE this update for information and DISCUSS any issues arising.
Link to ‘Doing Well, 1. Governance and accountability framework Doing Better: Standards for Health Services in Wales’:
Link to Health Board’s Improving Health & Well-Being Corporate Plan Ensuring the Right Access Striving for Excellence Involving the People of Powys Making Every Pound Count
Acronyms and N/A abbreviations
Q&S Committee Briefing Page 1 of 5 Board Meeting March 2013 24 April 2013 Agenda Item 6.1a
FOR DISCUSSION
REPORT FROM THE CHAIR OF THE QUALITY & SAFETY COMMITTEE MARCH 2013
PURPOSE
The role of the Quality and Safety (Q&S) Committee is to provide: evidence-based and timely advice to the Board to assist it in discharging its functions and meeting its responsibilities with regard to the quality and safety of healthcare; and assurance to the Board in relation to the tHB’s arrangements for safeguarding and improving the quality and safety of patient-centred healthcare in accordance with its stated objectives and the requirements and standards determined for the NHS in Wales.
Therefore, the purpose of this paper is to provide the Board with a summary of the discussions held and any issues arising from meetings of the Quality and Safety Committee held in March 2013.
COMMITTEE BRIEFING: PRESENTATION
South Powys Home Treatment Team
The Committee received a presentation regarding the South Powys Home Treatment Team which had been part of a Welsh Government initiative to drive and modernise mental health services across Wales. The Committee noted that key objectives of the home treatment team were:-
to provide immediate multi-disciplinary community based treatment 7 days a week; to provide rapid assessment for working age individuals and acute mental health problems; to provide rapid assessment for working age individuals and acute mental health problems; to act as a gatekeeper to mental health inpatient services during hours of operation between 9:00am-9:00pm on weekdays and 11-7pm on weekends and Bank Holidays; to ensure that service users were treated in the least restrictive environment to maintain continued involvement with service user until the crisis was resolved and linked to on-going care or signposted to appropriate services; if hospitalisation was necessary, active involvement re: discharge planning and provision of intensive care at home to promote early discharge
The Committee was advised that to ensure delivery of the objectives a number of factors were paramount to the success of the team in order supporting the reduction of admissions and reduce the length of stay in hospital for patients. The key areas consisted of the mental health team’s active involvement with the Mental Health Act assessments. The Committee noted that during one review
Q&S Committee Briefing Page 2 of 5 Board Meeting March 2013 24 April 2013 Agenda Item 6.1a
FOR DISCUSSION period a total of seven Mental Health Act assessments in the community did not result in an admission to hospital, which would have occurred had the team not been in existence. In addition, a robust team structure and resources such as medical slots, pre pack medication, petty cash and the Siaradwyr Cymraeg (Welsh Speaker) contributed to an improving service.
The Committee received a summary of patient feedback (negative and positive) and acknowledged the benefits this service was providing to patients, families and carers.
GOVERNANCE & ASSURANCE
Sub-Committees Updates
Information Governance sub-Committee Committee received a verbal update in respect on progress made regarding the commencement of the Information Governance sub-Committee meetings 2013/14. A structured Information Governance Workplan had been developed and a Management Group had been established.
Mental Health Act sub-Committee Committee noted that Terms of Reference and a Workplan had been developed for the MHA sub-Committee and these would be presented to the Committee in May 2013 for approval.
Review of Committee Terms of Reference
The Committee undertook its annual review of its Terms of Reference. The Committee agreed that there were no changes necessary to the content of its Terms of Reference, however there were areas within the Committee’s role and delegated powers and authority where the Committee’s business could be strengthened. It was agreed that this matter would be discussed further at the Committee’s development session in April 2013.
IMPROVING HEALTH AND WELLBEING
Public Health Report
The Committee received a report from the Interim Director of Public Health which provided an update and assurances in respect of the work being carried out to improve Health and Wellbeing in Powys.
Committee noted that significant work was underway in two areas:- Implementation of Brief Intervention Alcohol Training Programme Increasing Influenza Immunisation Uptake
The Committee received a verbal update on a measles outbreak in Powys and was assured that appropriate action was being taken to manage the situation.
Q&S Committee Briefing Page 3 of 5 Board Meeting March 2013 24 April 2013 Agenda Item 6.1a
FOR DISCUSSION
Children’s Services Report
The Committee received a report from the Director of Nursing which provided the Committee with an overview of achievement against Children’s Services objectives within the Annual Plan. The Committee noted that good progress had been made during the year on achieving the planned objectives and that some work would transfer into the 2013/14 Annual Plan which would raise the ambition further regarding multiagency working and integration.
ENSURING THE RIGHT ACCESS
Mental Health Services Report
The Committee received a report from the Director of Nursing, which provided the Committee with an update in relation to the implementation of the organisations objectives for mental health.
The Committee was pleased to note that a clear strategic direction had been approved by the Board and good progress was underway in implementing a Crisis Resolution (CRHT) and Home Treatment Service for Montgomeryshire. In Radnorshire and Brecknockshire the CRHT was delivering excellent results and the Mental Health Measure was being implemented.
The Committee was pleased to note the progress made, however acknowledged that there was significant work still to be undertaken.
Dementia Care Report
The Committee received a report from the Director of Nursing which provided an update relation to the planning and delivery work underway regarding Dementia care in Powys. The Committee noted the demographic challenge was evident and therefore a number of key stakeholders were involved to help deliver services for the population of Powys.
The Committee was pleased to note that progress had been made against the objectives of developing a Dementia Plan for Powys and scoping work undertaken had identified potential gaps and improvement opportunities. The Committee noted that the Hearts and Minds Mental Health Strategy would provide a clear overarching strategic framework for the development of services for people with dementia and their carers.
STRIVING FOR EXCELLENCE
Serious Incident Reporting
The Committee received a report which provided an update on the work underway in reviewing and refining the process of serious incident management within the tHB. The Committee noted that good progress was being made and
Q&S Committee Briefing Page 4 of 5 Board Meeting March 2013 24 April 2013 Agenda Item 6.1a
FOR DISCUSSION acknowledged improvements in the tracking system, the investigation of individual incidents and learning from incidents for example.
The Committee also received an update in respect of new incidents and closure of completed cases.
Putting Things Right
The Committee received the Putting Things Right Report, which provided the Committee with an update on Putting Things Right /NHS Redress.
1000 Lives Plus Programme Report
The Committee received a Report of the Director of Nursing which provided an update of the work of the 1000 Lives Plus Programme, including the proposed priorities for the Quality Improvement Programme 2013/14. The Committee noted a strategic change and direction regarding quality improvement and that a greater responsibility would be placed on each Health Board to integrate quality improvement methodology at each level of the organisation. The Committee noted the initial 4 priorities of Powys tHB over the next 12 months and their four level of attainments; • Implementation of “Improving Quality Together” – a programme to develop skills in Quality Improvement Methodology across the HB • Embedding existing 1000 Lives Plus ‘bundles’ of care and the support for future improvement work • Develop and implement a process for sharing, spreading and celebrating • Develop a process to identify future areas for tHB wide improvement work
Care Home Governance
The Committee received a Report of the Director of Nursing which provided an update in relation to the implementation of the Framework for Care Home Governance.
The Committee was pleased to note that good progress had been made in a number of areas and that the improvements made affect the largest number of people placed in Care Homes and directly linked to safeguarding. The Committee acknowledged that there were outstanding issues relating to patients placed outside of Wales, pre-placement checklists and compliance with planned patient reviews.
Report prepared by: Presented By: Rani Mallison Gloria Jones Powell Corporate Governance Manager Chair of Quality & Safety Committee
Q&S Committee Briefing Page 5 of 5 Board Meeting March 2013 24 April 2013 Agenda Item 6.1a
FOR DISCUSSION
BOARD MEETING 24 APRIL 2013 AGENDA ITEM 6.1b
REPORT FROM THE CHAIR OF THE AUDIT COMMITTEE APRIL 2013
Report of Audit Committee Chair
Paper prepared by Corporate Governance Manager
Purpose of Paper The purpose of this paper is to provide the Board with an update on the key issues discussed and any decisions made by the Audit Committee at its meeting in April 2013.
Action/Decision required The Board is asked to RECEIVE this update for information and DISCUSS any issues arising.
Link to ‘Doing Well, 1. Governance and accountability framework Doing Better: Standards for Health Services in Wales’:
Link to Health Board’s Improving Health & Well-Being Annual Plan Ensuring the Right Access Striving for Excellence Involving the People of Powys Making Every Pound Count
Acronyms and N/A abbreviations
Audit Committee Briefing Page 1 of 3 Board Meeting January 2013 24 April 2013 Agenda Item 6.1b
FOR DISCUSSION
REPORT FROM THE CHAIR OF THE AUDIT COMMITTEE APRIL 2013
PURPOSE
The role of the Audit Committee is to advise and assure the Board and the Accountable Officer on whether effective arrangements are in place to support them in their decision making and in discharging their accountabilities for securing the achievement of the organisation’s objectives, in accordance with the standards of good governance determined for the NHS in Wales.
Therefore, the purpose of this paper is to provide the Board with a summary of the discussions held and any issues arising from a meeting of the Audit Committee held in April 2013.
INTERNAL AUDIT
The Committee received the following:-
Internal Audit Plan Progress Report Powys tHB Internal Audit Charter NHS Wales Shared Services Overview Report (Powys) The Committee received a report which outlined the audits undertaken by NHS Wales Shared Services Partnership for those services managed on behalf of Powys tHB Contractor Services Internal Audit Reports • General Ophthalmic Services (Mid & West) – Reasonable Assurance • General Dental Services (Mid & West) – Reasonable Assurance • Community Pharmaceutical Services (Mid & West) – Substantial Assurance • General Medical Service Contract (Mid & West) – Reasonable Assurance tHB Internal Audit Reports:- • Prescribing Services – Reasonable Assurance • ESR Central Application Systems – high level of assurance over central aspects of ESR • E-expenses – Reasonable Assurance
EXTERNAL AUDIT
The Committee received the following:-
Audit Outline 2012 (Progress Report) Draft Outline of Audit Work for 2013 – Financial and Performance Related NHS Wales Shared Services – Audit Assurance Arrangements An initial assessment of the Committee’s effectiveness Summary of the Committee’s Self-assessment and improvement actions identified
Audit Committee Briefing Page 2 of 3 Board Meeting January 2013 24 April 2013 Agenda Item 6.1b
FOR DISCUSSION GOVERNANCE & ASSURANCE
The Committee received the following:-
Committee Workplan 2012/13 Progress against outstanding audit recommendations:- o Therapies & Health Sciences Directorate o Nursing Directorate o Medical Directorate Losses and Special Payments – September 2012 to 28 February 2013 Powys tHB Annual Accounts 2012/13 The Committee received a summary of amendments to the 2012/13 format and accounting policies Risk Strategy Implementation Progress Report The Committee received a report which provided an update and assurances in respect of the work being taken forward to progress Risk Management Powys- wide. Cash Management Programme The Committee received a report of n the cash management programme which had been implemented during March 2013 to enable the tHB to remain within the cash limit currently available to the tHB. Review of Financial Management The Committee received a report from the Director of Finance which provided assurances that the recommendations made by the Wales Audit Office in respect of financial management were being progressed.
RECOMMENDATION
The Board is asked to RECEIVE this update for information and DISCUSS any issues arising.
Report prepared by: Presented By: Rani Mallison Gareth Jones Corporate Governance Manager Chair of Audit Committee
Audit Committee Briefing Page 3 of 3 Board Meeting January 2013 24 April 2013 Agenda Item 6.1b
FOR DISCUSSION
BOARD MEETING 24 APRIL 2013 AGENDA ITEM 6.1c
REPORT FROM THE CHAIR OF THE INTEGRATED GOVERNANCE COMMITTEE MARCH 2013
Report of Integrated Governance Committee Chair
Paper prepared by Corporate Governance Manager
Purpose of Paper The purpose of this paper is to provide the Board with an update on the key issues discussed and assurances in respect of the delivery of the organisation’s Corporate Plan, as discussed by the Integrated Governance Committee at its meeting in March 2013.
Action/Decision required The Board is asked to RECEIVE this update for information and DISCUSS any issues arising.
Link to ‘Doing Well, 1. Governance and accountability framework Doing Better: Standards for Health Services in Wales’:
Link to Health Board’s Improving Health & Well-Being Annual Plan Ensuring the Right Access Striving for Excellence Involving the People of Powys Making Every Pound Count
Acronyms and N/A abbreviations
Integrated Governance Committee Briefing Page 1 of 3 Board Meeting March 2013 24 April 2013 Agenda Item 6.1c
FOR DISCUSSION
REPORT FROM THE CHAIR OF THE INTEGRATED GOVERNANCE COMMITTEE MARCH 2013
PURPOSE
The role of the Integrated Governance Committee is to: maintain an oversight of the work of the Board’s Assurance Committees, ensuring integration of governance work across all business of the tHB and all issues which fall outside or between the work of the Committees are addressed; and review the tHB’s Assurance Framework, in-line with performance against achievement of organisation’s Corporate Plan, ensuring there is an accurate reflection of existing risks, key controls and assurances.
Therefore, the purpose of this paper is to provide the Board with an update on the key issues discussed and assurances in respect of the delivery of the organisation’s Corporate Plan, as discussed by the Integrated Governance Committee at its meeting in March 2013.
COMMITTEE BUSINESS
The Francis Report
The Committee received a presentation from the Director of Therapies and Health Sciences regarding the required approach to self-assessment against recommendations arising from The Francis Report and the identification of improvement actions for implementation. It was agreed by the Committee that the executive should undertake a self-assessment by the end of May 2013 with a scrutiny panel, consisting of Executive Directors and Independent Members, reviewing the information collated and agreeing a consequent improvement plan in July 2013. It was also agreed that, following finalisation of the tHB’s self-assessment, the Integrated Governance Committee would oversee delivery of the improvement plan.
Financial Management Review: Progress Report
The Committee received a report from the Director of Finance, providing an update of progress against recommendations arising from the Financial Management Review undertaken in April 2012.The Committee was pleased to note that a substantial number of the recommendations were complete and that many would be continuously improved upon.
Programme Management Framework
The Committee received a report from the Head of Programme Management which summarised the purpose of the newly established Transformation Board and the key characteristics of the Programme Management Office high delivery support model which would be implemented to meet the organisation’s current level of maturity in portfolio, programme and project management. The Committee noted the initial priorities of the Transformation Board as:- Emergency/non-elective pathways in the South Locality; Maximising elective services in the North and South Localities;
Integrated Governance Committee Briefing Page 2 of 3 Board Meeting March 2013 24 April 2013 Agenda Item 6.1c
FOR DISCUSSION
Mental Health – to agree the characteristics of a good adult mental health service for Powys and to develop a detailed service specification; and Information – The information portal and tools (IFOR) to be the central focus for collation, validation and delivery of data.
RECOMMENDATION
The Board is asked to RECEIVE this update for information and DISCUSS any issues arising.
Report prepared by: Presented By: Rani Mallison Roger Eagle Corporate Governance Manager Chair of Integrated Governance Committee
Integrated Governance Committee Briefing Page 3 of 3 Board Meeting March 2013 24 April 2013 Agenda Item 6.1c