Crude Mortality Rates for Cardiff and Vale UHB

CHAPTER PAGE NO: Executive Summary 2

CHAPTER PAGE NO: 1. Progress in Delivering 2015/16 Plan 6 1.1. Our Achievements in 2015/16 6 1.2. Our Awards for Excellence 9 1.3. Performance and Delivery in 2015/16 11

2. Health Board Profile 15 2.1 Overview 15 2.2 Range of Services 17 2.3 Cluster Working 18 2.4 Commissioning for Our Growing Population 18 2.5 Finance Summary 20 2.6 Performance Management 21

CHAPTER PAGE NO: 3. Strategic Context 23 3.1 Legislation Shaping Change 23 3.2 NHS National and Regional Context 26 3.3 Shaping Our Future Wellbeing 29

4. Local Health Needs and Challenges 34 4.1 Main Areas of Population Health Need 34 4.2 Population Assets 39 4.3 Themes from Engagement Activities 39 4.4 Local Pressures 40

5. Commissioning and Partnership Working 44 5.1 Commissioning for Population Health 44 5.2 Progressing Partnerships with Our Local Authorities 47 5.3 Collaboration with Our NHS Partners 52 5.4 Welsh Health Boards – Long Term Agreements 54

CHAPTER PAGE NO: 6. Addressing Health Inequalities and Access 58 6.1 Addressing Health Inequalities 58 6.2 Strategic Equality Plan 62 6.3 Welsh Language 63

7. Quality, Safety and Patient Experience 66 7.1 Context 66 7.2 Patient Quality and Safety 68 7.3 The Patient Experience 70 7.4 Mortality 73 7.5 A Framework for Patient Safety, Quality and Experience 75 7.6 Infection, Prevention and Control 77 7.7 Operational Services Quality and Patient Experience 83 7.8 Safeguarding 86 7.9 General Medical Services (GMS) 90 7.10 External Monitoring 90

CHAPTER PAGE NO: 8. Prevention 95 8.1 Context 95 8.2 Cross Cutting Actions for 2016/17 – 2018/19 98 8.3 Cross Cutting Actions – First Order Priorities 98 8.4 Cross Cutting Actions – Second Order Priorities 102 8.5 Targeted Actions 104

9. Planned Care 106 9.1 Context 106 9.2 Cancer 106 9.3 Dementia 108 9.4 Dental and Eye Health 109 9.5 Long Term Conditions 112 9.6 Maternal Health and Early Years 118 9.7 Mental Health 120 9.8 Other Areas of Key Service Change - Specialist 122 9.9 Sustainable Planned Care – Core Services 127

10. Unplanned (Emergency) Care 134 10.1 Context 134 10.2 Sustainable Unplanned (Emergency) Care – Core Services 135 10.3 Cancer 141 10.4 Dementia 141 10.5 Dental and Eye Health 142 10.6 Long Term Conditions 142 10.7 Maternal Health and Early Years 143 10.8 Mental Health 143 10.9 Stroke 144 10.10 Other Areas of Key Service Change 145

11. End Of Life Care 146 11.1 Context 146 11.2 Sustainable End of Life Care – Core Services 147

12. Resources 149 12.1 Context 149 12.2 Provisional Financial Framework 149 12.3 Improving Our Infrastructure 159 12.4 Workforce 165

CHAPTER PAGE NO: 13. Building Capacity and Delivery 180 13.1 Strategic Organisational Development 180 13.2 Engaging Leaders and Culture Change 182 13.3 Flexible and Sustainable Future Workforce 184 13.4 Productive, Efficient and High Performing Workforce 193 13.5 Building Capacity and Capability 194 13.6 Continuous Service Improvement 196 13.7 Accelerating Innovation and Improvement 198 13.8 Expanding Research and Development (R&D) 207 13.9 Transforming Information Management and Technology 210 13.10 Good Communications Matters 212

14. Stewardship and Governance 216 14.1 IMTP Development Process 216 14.2 Governing Delivery 216 14.3 Corporate Governance 217 14.4 Managing Risk 218 14.5 Financial Governance - Controls to Support Delivery of the 221 Financial Plan

CHAPTER PAGE NO: Appendix 1: Overview of health and wellbeing needs for Cardiff and 224 the Vale of Glamorgan, 2015-2025

Summary of reviews/amendments Version Date Date Review Summary of Amendments Number Review Published approved by Approved 1 07/12/2015 08/12/2015 AH Peer Review Submission 2 28/01/2016 29/01/2016 UHB Board Draft Welsh Government Submission 3

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Executive Summary

About this Plan

This Plan builds on the 2015/16 approved Integrated Medium Term Plan (IMTP) and represents a refresh rather than a complete re-write. We have refreshed the Plan in the context of our strategy, Shaping our Future Wellbeing which has now been finalised, and new legislation and national requirements.

This Plan is not intended to provide an exhaustive list of all that we do as an organisation, rather it provides a focus on the key priorities over the next three years as we implement our Strategy. It is realistic about what can be achieved within the constrained resources, whilst maintaining ambition and appropriate stretch.

Strategic Context

Our Strategy confirms a set of underlying principles (aligned with Prudent Healthcare) which now guide the way we plan and deliver services – these are: empower the person, home first, outcomes that matter to people and avoiding harm waste and variation. The Strategy also identifies the areas we need to prioritise in order to deliver a reduction in the stark health inequalities that still exist across and between our communities.

Our Plan for 2016/17 – 2018/19 responds to a number of national and local drivers: The population in Cardiff is growing rapidly, with an extra 46,000 people expected to be living in the city by 2025. The number of older people is also growing in line with national average, indicating more people requiring care and support; Responding to new legislation is changing the way we work, plan and deliver services. In particular the Social Services and Wellbeing Act (2014) and the Wellbeing of Future Generations Act (2015) will have a significant impact on how we plan and deliver services in the future, with a much greater emphasis on co-production, prevention and earlier intervention, very much in line with the direction of travel set out in our Strategy; Technology opportunities – we know that technology is advancing rapidly – the technology lifecycle has shortened considerably over recent decades and we need to ensure we are able to respond to the opportunity this presents to radically change the way we deliver care to ensure a more sustainable model for the future; We have workforce challenges in key areas, and whilst this presents a risk in the short-term, it also provides an opportunity to innovate the workforce through the introduction of new roles and new ways of working; and Much of our infrastructure is ageing and ongoing investment in maintenance, replacement programmes and upgrading has not kept pace with the requirements. We are now increasingly facing failures in our estate and equipment which is impacting directly on patient care.

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Progress in 2015/16

Significant progress has been made in a number of key areas: Our GP clusters have really developed over the year, and our primary care developments are supporting the shift in the balance of care away from hospitals. More people with a long term condition are being managed in the community (diabetes, INR and heart failure represent examples of transformation in the way we deliver care); our Community Resource Teams are now working seven days are week, helping to support timely discharges from acute hospital care, and preventing un-necessary admissions; we are providing more targeted health improvement interventions to increase immunisation and screening rates, and to improve healthy lifestyle behaviours, focusing on particular at risk communities; We have delivered the agreed plan for referral to treatment times, with a significant reduction in the number of people waiting over 52 and 36 weeks for treatment. This has been achieved by tackling the backlog of patients waiting, and putting in sustainable measures where demand outstrips capacity on an ongoing basis; We have improved our emergency care pathways resulting in the more timely delivery of unplanned (emergency) care – with key performance indicators showing the improvements made; We have introduced a number of actions to improve infection prevention and control, and whilst we did not achieve all of the national targets, considerable improvements have been sustained; We have delivered a number of significant capital development milestones with the completion of the Children‟s Hospital for Wales and the Adult Mental Health Unit at UHL; and Despite the ongoing financial challenges and service pressures, we are on track to delivered financial savings of £23m.

Our Priorities for 2016/17

Our ambition for 2016/17 is to continue the improvement trajectory we have achieved in 2015/16, with an emphasis on ensuring we apply our strategic principles to the way we plan and deliver care in order to ensure we remain on track to meet the strategic objectives we set out in our Strategy. Prevention – implementing a range of initiatives that improve lifestyle behaviour focusing on particular at risk groups; targeting secondary prevention (based on end-to-end pathways) to ensure people are better able to manage their conditions safely and deterioration is prevented where possible. Much of this work will be taken forward through the GP cluster plans, and in partnership with our local authority and third sector partners; Planned care – continue to improve the timeliness of planned care, further reducing long waiting times through improved pathways, better access to specialist advice, support and diagnostics, and addressing capacity gaps in key specialities; Unplanned (emergency) care – we will continue to build on the progress made during 2015/16 with an emphasis on eliminating the waits over 4 hours in the

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emergency department, ensuring adequate assessment capacity is available, and effective patient pathways that result in timely discharge home after an hospital stay; We will build on the good progress made in improving the quality and safety of the services we deliver and ensure that the experience of our patients continues to improve. We will finalise a framework that shapes our priorities in this area over the next three years; We will also build on the partnership with Cardiff University in relation to R&D and clinical innovation to ensure that we are maximising the opportunities presented by greater collaboration, ultimately improving the care we provide to patients; We will firm up our longer term infrastructure plans in relation to technology and estate, working with Cardiff University, our local authority partners and our neighbouring health boards; We want to deliver plans with partners to become world leaders in the field of dementia and diagnostics, recognising the expert knowledge already in place; and Building on work started in 2015/16, we will deliver the radical transformation of outpatient services in a number of key specialties and use the additional ICF funding to establish a „perfect locality‟ which demonstrates best practice in integrated local intermediate and primary care.

Dependencies

This Plan is dependent on a number of issues: Availability of revenue resources to support deliver (particularly in relation to planned care); Ability to address theatre capacity constraints; Ability to modernise the workforce in the timescales required (including addressing key shortage areas); The availability of infrastructure investment in key areas identified in the plan.

Risks to Delivery

In addition to the dependencies, there are a number of risks to the delivery of our plan which we are putting mitigating actions in place to manage. These include: Resources not matching population growth; Reductions to local authority services (particularly social services, housing and non-statutory services which play a vital role in health and wellbeing) which impact on demand for healthcare; Management capacity to support the scale of change required; and Specialist skills in key areas to support transformation programme.

We will mitigate the risks through tight programme, project and performance management arrangements which provide an early warning to key milestones being missed and remedial action being put in place.

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1. Progress in Delivering 2015/16 Plan

1.1 Our Achievements in 2015/16

Year 2 (2015/16) of Cardiff and Vale University Health Board‟s (UHB) three year Integrated Medium Term Plan (IMTP) built upon our intentions, successes and challenges from year 1 (2014/15). It remained focused on improving the health of our population, delivering quality services and ensuring equitable and timely access to services. The journey of transformation and progress against implementing the IMTP for 2015/16 continues to be challenging and whilst progress has been made, there is still much to be done.

In September 2015 the UHB Board approved our 10-year „Shaping Our Future Wellbeing Strategy. The Strategy has been framed using prudent principles and has been clinically led and co-produced in partnership with our community. It provides the focus to achieving joined up care based on home first, empowering people, delivering outcomes that matter to them and avoiding waste harm and variation.

Progress on achieving the challenges and aims set out in the 2015/16 IMTP and implementation of the strategy are summarised below.

Empower the Person Smoking cessation has been commissioned from community pharmacies in our most deprived communities, increasing access to evidence based services and promoting healthy living locally. Our diabetes co-production workshop, (see Prudent diabetes workshop June 2015) with a range of participants including people living with diabetes, recommended strengthening the community model, prioritising support within the community and greater access to education and physical activity opportunities to greater empower the individual. Initially this is being taken forward within the City and South cluster through the strengthening of their community service through a Diabetes Specialist Nurse role with education and support pilot work including delivering the Education for Patients Programme diabetes self care. Focused health improvement activities targeting more deprived communities in relation to smoking, obesity, alcohol and immunisations. The optimising outcomes policy is resulting in a steady rise in referrals to smoking cessation and weight management services. Adult social care and community health services are now fully integrated in the Vale Locality, ensuring a more streamlined and responsive service providing a social model of health which promotes physical, mental and social wellbeing.

Home First Implementation of the Welsh Government Primary Care Plan for Wales (including cluster plans) is on track.

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Community management of ambulatory care sensitive conditions e.g. an evidenced-based Chronic Obstructive Pulmonary Disease (COPD) pathway used within the primary care setting impacting on unplanned (emergency) care attendances. Clinicians from primary and secondary care are collaborating on the development and implementation of a number of evidence based pathways identified by the clusters that will support patients more safely and closer to home (supporting unplanned (emergency) care improvements and shifting services from hospital to community based settings). Joint working between secondary care clinicians and the GP Clinical Lead to develop a dermatology service model incorporating the use of teledermatology as a core function for GP practices to gain advice and treat within primary care or where appropriate refer. An Optometric Advisor has been appointed to act as the „Clinical Champion‟ for primary care providing professional and technical advice to support the development of pathways and engagement of secondary care clinicians and the shift of services into the primary care setting, this includes shifting post cataract follow up care to accredited high street optometrists and the ongoing development of a Wet Acute Macular Degeneration (AMD) Service within the community. Improved levels of support to individuals residing in Nursing Homes has been put in place through enhanced levels of medical and pharmacist input and support via Community Resource Teams (CRTs) preventing un-necessary admissions to hospital. Wellbeing Co-ordinators are being recruited at a cluster level to improve the interface between GPs and the community to deliver public health priorities and embed the social model of care through their use of community networks and experience of co-production. More community staff are able to access and update patient‟s records electronically within the patient‟s own home as part of the mobile working initiative that has led to over 200 netbook devices being rolled out to community staff. We have worked across all our contractor professions and GP OOH (Out of Hours) to review and develop the services we provide to ensure sustainable Primary Care services to meet the needs of our population, this work has improved access to services and provided services closer to people‟s homes. In partnership with Cardiff Council, the Third sector, housing associations, the Young Foundation and inQube/pumpco the UHB has led a co-produced approach to identify what would help older people stay well at home and the assets available in the community. More information can be found on the Citizen Driven Health web page at https://citizendrivenhealth.wordpress.com

Outcomes that Matter to People Patients in Cardiff and Vale are able to access care closer to home by all International Normalised Ration (INR) monitoring moving out to Primary Care GP practices. The Warfarin slow loading service has been implemented within primary care to allow patients to commence warfarin therapy for certain conditions within their GP practice avoiding them having to travel to a hospital site.

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More ambulatory blood pressure monitoring (ABPM) is taking place in primary care with Welsh Government investment leading to the purchase of ABPM equipment in each GP practice, ensuring improved accurate diagnosis of hypertension whilst reducing workload in practice releasing significant savings in time for the practice as well as inappropriate prescribing whilst also reducing the incidence of Transient Ischaemic Attack (TIA)/Stroke. The CRTs are preparing to operate on an extended hours basis over seven days a week to ensure more discharges from hospital can be facilitated over a seven day a week basis, and the service is able to respond to vulnerable and at risk patients on the weekend and bank holidays (from December 2015). The Diabetes Community Model provides consultant support and education to GPs with consultants in diabetes attached to named GPs for community clinics, case notes review and advice by email, allowing GPs access to senior decision making in a timely manner and avoiding unnecessary referrals to hospital OP clinics, resulting in a 35% reduction in OP referrals for type 2 diabetes. Patient experience scores have improved. The majority of concerns have been managed via the informal route and resolved within 2 working days (with room for improvement) – 1211 concerns from 1.5 million contacts. Referral To Treatment (RTT) in-quarter monitoring against target profile continues and we are on course to deliver the planned reduction to >36 week breaches. At Q3 the UHB is 50% lower than the same point in 2014/15 and on track to deliver our agreed target reduction by year-end. Greater access and lower waiting times to diagnostics, provided as planned e.g. Computerised Tomography (CT) and Magnetic Resonance Imaging (MRI) scans via additional sessions, mobile vans and alternative shift patterns. Outpatient follow-up transformation programme showing improvements in waiting times and number of patients waiting for follow up. Service/Workforce redesign: o Stroke Care has resulted in a 7-day rehabilitation service within the Stroke Rehabilitation Centre – implementation will be completed by March 2016; o Urology with flexi-cystoscopies performed in outpatients rather than theatre suite and a one stop service from January 2016; and o Ensuring prescribing is undertaken in the best location (e.g. redesigned anticoagulation service) and where appropriate using non-medical prescribers (nurse, pharmacist, therapist). A single point of access (communications hub) model has been developed for community health and adult social care enquiries to capture, process, triage, and signpost service users from Cardiff and the Vale of Glamorgan, ensuring better access and information at the initial point of contact.

Avoid Harm, Waste and Variation We are contributing to the All Wales Planned Care Programme plans through the Specialty Boards and are implementing those plans that have been published. Specifically, „Do Not Do‟s‟ are monitored, through our active Interventions Not Normally Funded (INNU) policy and intervention list (revised 2014), delivering opportunity savings. Validation of waiting lists is taking

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place, and implementation of Patient Reported Outcome Measures (PROMs) has begun (reduce inappropriate variation). We are piloting the use of Patient Activation Measures (PAMs) in people referred by primary care to orthopaedics. This will evaluate whether use of PAMs facilitates better assessment of an individual‟s care and support needs. Workforce attendance is improving – the September 2015 sickness level was the lowest for 20 months – consecutive reduction for 8 months. Major capital schemes are all on target; Hafan y Coed (Mental Health Unit at University Hospital Llandough (UHL)) scheduled to open Spring 2016. Our Leading Improvement in Patient Safety (LIPS) courses are building capacity and capability to deliver high priority improvements. Cohort 4 has recently completed with a total of 400+ participants. Cohort 5 is planned to commence in April 2016. Significant joint work undertaken to embed the prudent healthcare principles within medicines management with primary and secondary care clinicians and pharmacists developing prescribing pathways to reduce variation in prescribing (between practices as well as across the interface) and optimise prescribing. We have focussed action to improve Healthcare Acquired Infections (HCAI) – acknowledging that it is still above where it should be despite actions being taken. At end September 2015 Cardiff and Vale UHB‟s position over the 18 month target period was as follows: o C. difficile cases: 253 cases in total (28 cases above required number) Rate = 34.96 / 100,000 population o MRSA bacteraemia: 53 cases in total (34 cases above required number) Rate = 7.32/100,000.

1.2 Our Awards for Excellence

During the year we are delighted that a number of our staff achieved recognition for the care they provide and innovation they have shown. Some of the notable achievements are listed below. British Journal of Nursing - Nutrition Nurse Specialists for their service improvement project, improving patient safety and reducing the use of x-rays (Avoiding harm, waste and variation). Healthcare Financial Management Association – Chris Lewis, Deputy Finance Director of the Year (Avoiding harm, waste and variation). BMA Cymru Wales/BMJ Clinical Teacher of the Year Award for 2015 - Mr Owen Hughes, consultant urological surgeon, for excellence in supporting doctors in training and medical students in Wales (Outcomes that matter to people). BMJ Awards Gastroenterology Team of the Year - Multi-Disciplinary Team lead by Dr Barney Hawthorne for their work to train and support patients who require intravenous nutrition at home, and to provide life-saving intestinal surgery in South Wales (Home first, outcomes that matter to people and avoid harm, waste and variation).

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Royal College of General Practitioners Out of Hours team member of the Year, runner up - Jane Brown, Operational Head of Out of Hours for developments and improvements to the Out of Hours service, which was previously struggling to cope with demand (Home first, outcomes that matter to people and avoid harm, waste and variation). British Empire Medal – Stephen Tatnell, hospital porter for his services to the NHS and charitable fundraising (Outcomes that matter to people). NHS Wales Awards, Promoting Clinical Research and Application Award – Cardiff and Vale UHB, Aneurin Bevan UHB and Velindre NHS Trust - dedicated service for cancer associated thrombosis, improving care, safety and wellbeing (Home first, outcomes that matter to people and avoid harm, waste and variation). Institute of Medical Illustrators: (Outcomes that matter to people) o John Corney Video Award – Carl Rogers, for „Teddy‟s Story‟, Britain‟s youngest organ donor; o Wellcome Images Award – Nicola Kelley, photograph demonstrating an adverse reaction to a henna dye; and o New Voice‟s Award - Craig Harper, insight into a patients‟ perspective of wound photography. Promoting Independence Awards – Move on Team, supporting patients with mental health issues to return to local communities (Home first and outcomes that matter to people). RCN in Wales Nurse of the Year Awards - Emily Carne; Deborah Davies; and Emily Brace for driving change to achieve the best outcome for patients (Outcomes that matter to people). Society of Radiographers Wales Regional Team of the Year 2015 – Nuclear Medicine and Molecular Imaging multi-disciplinary team, for service delivery (Avoid harm, waste and variation and outcomes that matter to people). Employee of the Year, NHS Blood and Transplant – Angharad Griffiths, Specialist Nurse in Organ Donation, for overcoming complex ethical issues enabling organ donation from Britain‟s youngest donor, Teddy (Outcomes that matter to people). NMC Education and Engagement First Prize for innovation – Katie Johnson, Nurse, for ZAPPP (Zero Acceptance for Poor Patient Preparation), improving patient safety, patient service, service efficiency and reducing delays (Outcomes that matter to people and avoid harm, waste and variation). Neonatal and Paediatric Pharmacists Group, Prize for Innovation – Elizabeth Webb, Pharmacist and Jim Skingle IT Consultant – for the computerised outpatient prescribing system (COPPS) in a community child health clinic (Home first, outcomes that matter to people and avoid harm, waste and variation).

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1.3 Performances and Delivery in 2015/16

The UHB continues to face significant challenges in terms of delivery and performance although good improvements in key areas continue to be made.

It is useful to review some of the high level indicators, which illustrate the direction of travel that has been established and the achievements in last 3 years (2012/15):

Between 2012-13 and 2014-15 the UHB has: Reduced the prevalence of smoking to 21% overall and 18% in the Vale of Glamorgan. Reduced the number of patients admitted as emergencies by 7.7%, an indication of health gain, and improved assessment and discharge planning process within hospital services and improvements in the care and support being provided in the community. Increased the proportion of elective activity undertaken as day cases from 66% to 70% whilst maintaining the overall volume of activity undertaken for our local residents. Increased the volume of new outpatient attendances by 6000 (2.7%), whilst maintaining the new to follow up ratio at 1:2.4. This has been driven by an increase in the number of hot outpatient attendances. Increased the proportion of patients admitted who receive a procedure or intervention from 50.13% to 58.1% –an indication of more appropriate admissions. Reduced the number of overnight stays in mental health by 12%, in learning difficulties by 22.5% and in acute hospital services by 9%. The latter alone equates to a reduction of 52,000 bed days or 143 less beds. This is an indication of increasing capacity in the community and significantly improving efficiency in the acute sector, with lower lengths of stay (reduction from 4.2 to 3.8 days) and fewer admissions. Increased the number of calls taken by the out of hours service by over 5%, with steady improvement in responding to calls within 60 seconds (90%) and triaging urgent patients within 20 minutes (80%). Increased the number of patients discharged early through CRT homecare and therapy support by 25%. Managed a reduction in our financial allocation in real terms by £33 per head (2.21%) or £5.7m for our community – this is 4.7% or £103.4m less per capita compared to the Welsh average. Managed a 13% increase in the number of patients with a primary diagnosis of cancer.

The UHB‟s performance profile (table below) outlines the UHB‟s current position against the NHS Wales Delivery Framework. Good progress has been made in 2015-16 particularly in relation to the following: Continuing to reduce emergency admission and readmission rates for patients with chronic conditions in Wales – the best performing organisation in Wales.

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Whilst referral to treatment 26 and 36 week targets remain challenging, the UHB has dramatically improved performance in 2015-16 – moving from the worst to the best or second best performing provider in Wales. The UHB has significantly reduced the number of patients whose transfer of care was delayed although this continues to be a key area of focus for the UHB services and partner care providers in the local authorities, private and third sector. Reductions achieved in both the numbers of patients waiting for more than 12 hours in the Emergency Dept (best performer in Wales) and the hours lost in ambulance handovers.

Key challenges and areas of continuing focus: Achieving vaccination targets for children. Delivery of maximum 4 hour waiting time target in the Emergency Dept. Meeting cancer treatment time targets. Whilst the UHB is ranked 1st or 2nd best performer in Wales against 3 out of the 4 Stroke QIMs targets, there remains further pathway improvement work to improve stroke care across the pathway to improve performance against targets. The management of healthcare acquired infections has presented a major and ongoing challenge.

IMTP minimum Measure Target End of Q1 End of Q2 End of Q3 performance (Q4)

Number of emergency admissions for basket of 8 chronic conditions Reduction 6412 6412 6412 6411 Number of emergency readmissions for basket of 8 chronic conditions (rolling 12 940 940 940 939 months % uptake of the influenza vaccine in the following groups: Over 65's 71% 75% Under 65's in at risk groups 53% Annual Pregnant women 47% Healthcare workers 50% 51% % uptake of childhood scheduled vaccines up to the age of 4: 5 in1 age 1 93.0% 94.0% 95.0% 95% MenC age 1 94.0% 94.5% 95.0% 95% 95% MMR1 age 2 93.0% 93.5% 94.0% 95% PCV age 2 92.5% 93.0% 94.0% 95%

HibMenC Booster age 2 92.0% 93.0% 94.0% 95% own physical & mental & health own physical 5% % estimated LHB smoking population treated by NHS smoking cessation services 0.4% 0.5% 0.7% 0.80% (end of fin year)

40% % smokers treated by NHS smoking cessation services who are CO- validated as successful 41% 40% 42% 43% (end of fin year)

STAYING HEALTHY - I am well - I informed HEALTHY STAYING supported & to my manage % of reception class children (aged 4/5) classified as overweight or obese Reduction 23.7% 23.7% 23.7% 23.7% Non-Elective Crude Mortality Reduction 3.33% 3.33% 3.33% 3.33% WAMI 2014 Reduction 99 98 97 96 % valid principle diagnosis code 3 months after episode end date - monthly 95% 95% 95% 95% 95% % valid principle diagnosis code 3 months after episode end date - rolling 12 months 98% 96% 96% 96% 96% Number of NISCHR clinical research profile studies and Commercially Sponsored studies Improvement Our aim is to increase the number of high impact studies we are participating in by b/w 5-10% over the course of the year

care care successful Number of Audits the organisation is participating in against the national clinical Audit Programme Improvement 45/46 45/46 45/46 46/46

locally as possible & I I & possible as locally

EFFECTIVE CARE - I receive - I CARE EFFECTIVE contribute tothat making the right support care & as % people aged 45+ who have a GP record of blood pressure measurement in the last 5 yrs. Improvement % GP practices offering appointments between 17:00 and 18:30 at least 2 days a week Improvement 100% 100% 100% 100% % of GP practices open during daily core hours or within 1 hour of the daily care hours Improvement 76% 76% 76% 76% % of patients waiting less than 26 weeks for treatment – all specialties 95% 82% 83% 83% 83% Number of 36 week breaches – all specialities 0 3145 2378 2006-2493 1692-2609 % of patients waiting less than 8 weeks for diagnostics Improvement 6569 6310/6432/66465021/5509/63653733/4587/6085 % of new patients spend no longer than 4 hours in A&E 95% 84% 86% 88% 90% Number of patients spending 12 hours or more in A&E 0 0 in June 0 in Qtr 2 0 in Qtr 3 c. 0 in Qtr 4 % of Cat A Ambulance responses within 8 minutes 65% 60% 60% 60% 60%

Number of over 1 hour handovers Reduction avg = 200 p.m. avg = 200 p.m. avg = 200 p.m. avg = 199 p.m. about my care % of patients referred as non-urgent suspected cancer seen within 31 days 98% 98% in June 98% in Qtr 98% in Qtr 98% in Qtr

% of patients referred as urgent suspected cancer seen within 62 days 95% 64% in June 82% in Qtr 86% in Qtr 90% in Qtr

Patients treated by an NHS dentist in the last 24 months as % of population Improvement 56% 56% 56% 55.60%

33% SSNAP 4hr on clinical need & am actively involved in decisions needdecisions in involved am actively & on clinical

TIMELY CARE - I have timely access to timely have services - based I CARE access TIMELY % compliance with acute stroke bundles: 95% 37% 41% 45% domain % of assessments by the LPMHSS undertaken within 28 days from the date of referral 80% 97% 97% 97% 97% % of therapeutic interventions started within 56 days following assessment by LPMHSS 90% 90% 90% 90% 90% % of LHB residents (all ages) to have a valid CTP completed at the end of each month 90% 100% 100% 100% 100%

needs & % of hospitals with arrangements to ensure advocacy available to qualifying patients 100% 100% 100% 100% 100%

an individual, individual, an with my own

responsibilities - I am treated - I as

INDIVIDUAL CARE INDIVIDUAL CARE % of over 65 registered as having dementia with their GP practice Improvement 3169/65730 3908/65730 4648/67530 5387/67530 = 8%

% procedures postponed on >1 occasion, had procedure <=14 days/earliest convenience Improvement 50% 50% 50% 50%

same

others the

I am treatedI

with & dignity respect treat & Page - CARE DIGNIFIED | 12 Reduction DToC delivery per 10,000 LHB population - non mental health rolling 12 116 DTOcs in Avg of 116 Avg of 116 Avg of 116 months total in June DTOCs DTOCs DTOCs Reduction census recorded in Qtr recorded in Qtr recorded in Qtr DToC delivery per 10,000 LHB population - mental health rolling 12 months

Number of healthcare acquired pressure sores in a hospital setting Reduction 87.00 81.00 75.00 70

27 cases per 27 cases per 27 cases per 27 cases per Number of cases of C Difficile per 100,000 of the population 31 per 100,000 qtr qtr qtr qtr

Number of cases of MRSA per 100, 000 of the population 2.6 per 100,000 3 cases per qtr 3 cases per qtr 3 cases per qtr 3 cases per qtr from known harm % compliance with patient safety solutions - alerts Improvement 95.0% 95.0% 100.0% 100% % compliance with patient safety alerts - rapid response notices 98.0% 99.0% 100.0% 100%

Number of new Serious Incidents Reduction 16 p.m. 20 p.m. 16 p.m. 12 p.m. SAFE CARE - I am protected - I CARE SAFE from harm protect & myself Number of new Never Events 0 0 0 0

Reduction % staff absence due to sickness 5.30% 5.30% 5.60% 5% (4.85)

Consultants 86% 87% 88% 90% SAS 79% 81% 83% 85% % of total medical staff undertaking performance appraisals Others (Fellows 33% 35% 38% 40%

careful use careful them of & locums)

how the open NHS is & make resources can I &

transparent on its use of can find information find about can OUR STAFF & RESOURCES - I - I RESOURCES OUR& STAFF % of total non medical staff undertaking performance appraisals Improvement 64% 72% 80% 85% IMTP minimum Measure Target End of Q1 End of Q2 End of Q3 performance (Q4)

40% % smokers treated by NHS smoking cessation services who are CO- validated as successful 41% 40% 42% 43% (end of fin year)

care care successful Number of Audits the organisation is participating in against the national clinical Audit Programme Improvement 45/46 45/46 45/46 46/46

locally as possible & I I & possible as locally

% of patients referred as urgent suspected cancer seen within 62 days 95% 64% in June 82% in Qtr 86% in Qtr 90% in Qtr

Patients treated by an NHS dentist in the last 24 months as % of population Improvement 56% 56% 56% 55.60%

33% SSNAP 4hr on clinical need & am actively involved in decisions needdecisions in involved am actively & on clinical

needs & % of hospitals with arrangements to ensure advocacy available to qualifying patients 100% 100% 100% 100% 100%

an individual, individual, an with my own

responsibilities - I am treated - I as

INDIVIDUAL CARE INDIVIDUAL CARE % of over 65 registered as having dementia with their GP practice Improvement 3169/65730 3908/65730 4648/67530 5387/67530 = 8%

% procedures postponed on >1 occasion, had procedure <=14 days/earliest convenience Improvement 50% 50% 50% 50%

same

others the

I am treatedI

with & dignity

respect treat & DIGNIFIED CARE - CARE DIGNIFIED Reduction DToC delivery per 10,000 LHB population - non mental health rolling 12 116 DTOcs in Avg of 116 Avg of 116 Avg of 116 months total in June DTOCs DTOCs DTOCs Reduction census recorded in Qtr recorded in Qtr recorded in Qtr DToC delivery per 10,000 LHB population - mental health rolling 12 months

Number of healthcare acquired pressure sores in a hospital setting Reduction 87.00 81.00 75.00 70

27 cases per 27 cases per 27 cases per 27 cases per Number of cases of C Difficile per 100,000 of the population 31 per 100,000 qtr qtr qtr qtr

Number of new Serious Incidents Reduction 16 p.m. 20 p.m. 16 p.m. 12 p.m. SAFE CARE - I am protected - I CARE SAFE from harm protect & myself Number of new Never Events 0 0 0 0

Reduction % staff absence due to sickness 5.30% 5.30% 5.60% 5% (4.85)

Consultants 86% 87% 88% 90% SAS 79% 81% 83% 85% % of total medical staff undertaking performance appraisals Others (Fellows 33% 35% 38% 40%

careful use careful them of & locums)

how the open NHS is & make resources can I &

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2. Health Board Overview

2.1 Overview

Cardiff and Vale University Health Board (UHB) was established in October 2009 and is one of the largest NHS organisations in the UK. As a UHB, we have a responsibility for around 475,000 people living in Cardiff and the Vale of Glamorgan (from Trowbridge/St Mellons in the East to Llantwit Major/St Bride‟s Major in the West). This includes health promotion and public health functions as well as the provision of local primary care services (GP practices, dentists, optometrists and community pharmacists) and the running of hospitals, health centres, community health teams and mental health services. Together with some services from other Health Boards and key partners, these provide a full range of health services for our local residents and those from further afield in both Wales and England who use our specialist services. To deliver these highly diverse and complex services, we spend over £1.2 billion every year and employ around 14,000 staff.

We are also a teaching Health Board with close links to Cardiff University, which boasts a high profile teaching, research and development role within the UK and abroad. This is alongside other academic links with Cardiff Metropolitan University and the University of South Wales. Together, we are training the next generation of clinical and non-clinical professionals, in order that we develop our expertise and improve our clinical outcomes.

When many people think of the NHS they think of doctors and nurses, but it is important to remember the many varied roles that make all the care we provide possible. Allied healthcare professionals and health scientists comprise more than 40 different professions including dieticians, physiotherapists, radiographers, audiologists and laboratory scientists. Healthcare support workers play a key role in supporting staff to deliver direct clinical care and those providing non-clinical support include our portering staff, cleaning and catering staff, engineers, and many others.

An overview of the UHB‟s Shaping Our Future Wellbeing strategy can be seen on the previous page, and detailed information about the services we provide and the facilities, from which they are run, can be found on the Health Board‟s website in the section Our Services and Local Health Services Directory.

Led by the Chair and Chief Executive, the UHB Board is made up of Executive Directors, who are employees of the UHB, and Independent Board Members (IMs), who are appointed by the Minister for Health and Social Services via an open and competitive public appointments process. Health services are commissioned and provided within the UHB by eight Clinical Boards and a department of Public Health (see next page). Each Clinical Board is led by a Clinical Board Director, Head of Operations and Delivery, Clinical Board Nurse, Head of Finance and Head of Workforce and Organisational Development. Corporate services are aligned to Clinical Boards, providing professional expertise and support. We are also establishing a Service Board for Estates and Facilities services.

Page | 15 Cardiff and Vale of Glamorgan Primary Care Clusters

Cardiff and Vale University Health Board

Primary, Community and Intermediate Care Clinical Board Dental Clinical Specialist Services Board Clinical Board North West Cardiff Clusters*

General Medical South East Cardiff Services Mental Health Medicine Surgery Clusters* (GP Practices) Clinical Board Clinical Board Clinical Board

Vale Clusters*

Clinical Diagnostics and Children and Women Optometry General Dental Therapeutics Clinical Board Clinical Board Services Services

Community Pharmacy Services

Public Health

Corporate Services

* Primary Care Clusters are collaborative groupings of GP Practices, General Dental Practices, Optometry Services and Communi ty Pharmacies, supporting the UHB in planning and delivering services for local communities

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2.2 Range of Services

The UHB provides the full range of primary, community, mental health and secondary care health services for our resident population. Some of these services we commission from neighbouring health boards (in particular learning disabilities services are provided by Abertawe Bro Morgannwg UHB and Specialist Children and Adolescent Mental Health Services (CAMHS) from Cwm Taf UHB) and many we provide ourselves. We also provide specialist services for people across South Wales and in some cases the whole of Wales and England where we have developed specialist links with English Community Care Groups (CCGs), Area Teams and other teaching hospitals and Universities. Each Clinical Board has prepared a service profile as part of its Integrated Medium Term Plan which has informed the business planning process and is continually reviewed and progressed.

As a University Health Board we have a significant contribution to education and teaching; we offer under and post graduate medical education and training, managed through the Medical Director‟s Office. The UHB is required to deliver this training as set out in the Service Level Agreement (SLA) with both the Wales Deanery and Cardiff University School of Medicine. In order to reflect wider developments within medical education and support the delivery of teaching and training, the separate under and postgraduate departments were amalgamated into a single Department of Medical Education in January 2014. A joint medical education strategy is under development. We also train the largest number of Allied Health Professionals, Healthcare Scientists and Nurses of any health board in Wales.

In September 2015, the UHB employed 12,169 Whole Time Equivalent (WTE) staff which converts to 14,195 staff in post. Compared to our last report in the 2015/16 IMTP this represents a small overall net increase of around 20 WTE as during 2013/14 the UHB was averaging 12, 146 WTE. We have seen the increase spread across the majority of staff groups, however, the most notable change has been a higher proportional overall increase in Nursing and Midwifery which is a direct result of our specific drive and plan to recruit and fill nursing vacancies within budgeted establishment.(see Chapter 12 for further details).

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2.3 Cluster Working

Primary Care Clusters are collaborative groupings of GP Practices, General Dental Practices, Optometry Services and Community Pharmacies, supporting the UHB in planning and delivering services for local communities.

The map over leaf provides a high level summary of the range and volume of activity (2014) undertaking within Cardiff and Vale Primary Care Clusters.

The UHB is committed to the role of clusters as a means of transforming primary care and as such is continuing their development and the sharing of best practice.

2.4 Commissioning for a Growing Population

The population of Cardiff and the Vale of Glamorgan is growing and becoming more diverse. By 2025 we expect that an extra 50,000 people will need health and wellbeing services. This represents a 10% increase on today‟s figure. The shape of our population is also changing: The number of over 85s is increasing much faster than the rest of the population (32.4% increase by 2025); and Unlike the rest of Wales, there is also predicted to be an increase in children under the age of 4.

This change in the population presents a unique set of challenges for the UHB, as these groups generally have a greater need for healthcare. Currently the NHS in Wales spends around £1,700 per person per year on health and wellbeing services with significantly more being spent in the first year of life and on people over the age of 65.

We also face many of the same challenges as other health services across the developed world, for example: There are inequalities in health and healthcare provision. In Cardiff and the Vale there are differences between the most and least deprived areas, with up to 11 years difference in life expectancy and up to 22 years difference in healthy life expectancy; Unhealthy behaviours are common. In Cardiff and the Vale around 1 in 5 adults smoke, nearly half drink above guidelines, over half are overweight or obese, two thirds do not have a healthy diet and three quarters do not get enough physical activity; and More people are living with a long term health condition. In Cardiff and the Vale nearly 1 in 10 adults are recorded as having asthma or chronic obstructive pulmonary disorder (COPD), and 1 in 25 with diabetes.

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2.5 Finance Summary

The table below shows the high level financial performance of the UHB covering the period from 2010/11 to 2014/15. It also set out the forecast position for 2015/16.

UHB Summary Financial Performance 2010/11 2011/12 2012/13 2013/14 2014/15 2015/16 £m £m £m £m £m £m Income -1136 -1149 -1181 -1160 -1182 -1199 Expenditure 1136 1149 1181 1179 1205 1211 Performance against Revenue Resource Limit 0 0 0 19 21 12 Capital Resource Limit 64 57 47 58 84 39 Capital Expenditure 64 57 47 58 84 39 Performance against Capital Resource Limit 0 0 0 0 0 0

The UHB delivered £109m of financial savings from 2012/13 to 2014/15, amongst the highest made in NHS Wales. Notwithstanding this, the UHB has struggled to deliver its statutory break even duty. The UHB managed to break even in 2012/13 but only through £26m of non-recurrent strategic support from the Welsh Government. The UHB had a deficit of £19m in 2013/14 and £21m in 2014/15.

The 2015/16 – 2018/19 three year Integrated Medium Term Plan recognised the financial challenges faced by the UHB and aimed to minimise this deficit whilst working with the Welsh Government to restore the UHB back into financial balance and achieve recurrent financial sustainability. This has not yet been achieved and this work is ongoing and is reflected in this IMTP.

The refreshed financial plan sets out the financial strategy of the UHB which supports delivery of the service strategy outlined in the Integrated Medium Term Plan. The context for the UHB will be a very challenging three years. Despite the substantial financial settlement achieved for Health in 2016/17, and estimated 2% growth in future years, the financial pressures faced by the UHB are significant. The UHB is targeting the delivery of a further 3% savings annually and is aiming to make a further £78m of financial savings which is equivalent to 9% of relevant expenditure. Despite this ambitious savings plan, the UHB does not however, currently have a Financial Plan that manages to deliver a breakeven position over 2016/17 to 2018/19. The underlying position together with considerable new inflationary and growth pressures means that the UHB is still forecast a deficit over each year of this plan, despite allocation growth and a stretching savings target. This will be subject to further consideration at Board level and discussions on securing financial sustainability will need to continue with Welsh Government. Details of the overall financial plan are contained in the Chapter 12 of this plan.

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2.6 Performance Management

The UHB has formal performance management arrangements in place. These evaluate progress against delivery of the objectives set out in the Integrated Medium Term Plan and enable the UHB to determine whether it is achieving the proposed high level “direction of travel” and more detailed operational actions it has committed to undertaking. The UHB People, Planning and Performance committee „deep dives‟ into issues where the UHB Board seeks more assurance in terms of governance. Further detail on the Performance Management Framework is provided in Chapter 14.

2.6.1 Integrated Performance Reporting

The integrated performance report presented to the Board covers all NHS Wales Delivery Framework Measures including public health and has been agreed with the Community Health Council (CHC). Performance reports are provided at each of the UHB Board meetings and the latest is available here. An exception report on areas where the target is not being achieved is provided each month, focusing on actions to be taken to redress the position. These indicators, plus more detailed local indicators, are mirrored in the scorecard provided to each Clinical Board and Directorate each month. This then cascades into the ward dashboard which is available in real-time.

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3. Strategic Context

2015/16 has been a significant year in Wales, with the enacting of the „Well-being of Future Generations (Wales) Act 2015‟, and the „Social Services and Wellbeing (Wales) Act 2014‟. These world leading pieces of legislation, coupled with continued implementation of Prudent Healthcare and the launch of the UHB‟s Institute of Health Improvement (IHI) inspired the Shaping Our Future Wellbeing Strategy, and provide key context for the refresh of Cardiff and Vale UHB‟s Integrated Medium Term Plan 2016/17-18/19. Our partnership strategies „What Matters‟ and „The Vale of Glamorgan Community Strategy „ have shaped our approach and are reflected in all that we do.

3.1 Legislation Shaping Change

3.1.1 Well-being of Future Generations (Wales) Act 2015

The Well-being of Future Generations (Wales) Act 2015 places a well-being duty on public bodies to do things in pursuit of the economic, social, environmental and cultural well-being of Wales, in a way that accords with the principle of sustainable development. It requires public bodies to report on such action: including, setting and publishing well-being objectives that are designed to maximise its contribution to achieving each of the national well-being goals.

The national well-being goals are:

Goal Description of the goal An innovative, productive and low carbon society which recognises the limits of the global environment and therefore uses resources A efficiently and proportionately (including acting on climate change); prosperous and which develops a skilled and well-educated population in an Wales economy which generates wealth and provides employment opportunities, allowing people to take advantage of the wealth generated through securing decent work. A nation which maintains and enhances a biodiverse natural A resilient environment with healthy functioning ecosystems that support social, Wales economic and ecological resilience and the capacity to adapt to change (for example climate change). A society in which people's physical and mental well-being is A healthier maximised and in which choices and behaviours that benefit future Wales health are understood. A society that enables people to fulfil their potential no matter what A more equal their background or circumstances (including their socio economic Wales background and circumstances).

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A Wales of cohesive Attractive, viable, safe and well-connected communities. communities A Wales of vibrant A society that promotes and protects culture, heritage and the Welsh culture and language, and which encourages people to participate in the arts, and thriving sports and recreation. Welsh language A globally responsible Wales. A nation which, when doing anything to A globally improve the economic, social, environmental and cultural well-being responsible of Wales, takes account of whether doing such a thing may make a Wales positive contribution to global well-being.

In developing actions to address these goals, the sustainable development principle must be applied. Action must be; long term, integrated, collaborative, involving and preventative.

The Act comes into force in 2016 with the UHB having individual statutory duties as a public body and collective responsibility as a member of a Public Service Board. Public Service Boards must: Work jointly towards all well-being goals; Assess state of current economic, social environmental and cultural wellbeing; Set local objectives to maximise contribution to the well-being goals; and Take reasonable steps to meet the objectives in accordance with the sustainable development principle.

It is expected that change will be required across all aspects of the UHB: Corporate planning – we must ensure that in our corporate plans, the wellbeing objectives set are part of this process – not an „add-on‟ to what drives our organisation. Risk management – long term risks that will affect both the delivery of our services but also the communities we are enabling to improve. Use the wellbeing goals to frame what risks we may be subject to in the short, medium and long term. Workforce planning – a workforce with the right skills and support, will be instrumental for the transformation expected. Ensuring our workforce is fully engaged in this change, in order to adapt to the changing needs of our society, will be a critical success factor. Performance management - the well-being objectives should frame the way that we contribute to the well-being goals. Results Based Accountability is one of the tools that will help us adapt their business processes in line with the Act. Our evolving balanced-score card will be aligned to the wellbeing goals. Financial planning - financial planning through sustainable lens - ensuring the needs of the present are met without compromising the ability of future

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generations needs to be met. This will address the tendency for short-term priorities to overtake long-term interests. It is expected that financial planning is more closely geared to this whilst also looking to take preventative action when this is appropriate. Procurement - it is expected that public bodies comply with their existing legal obligations in relation to procurement and that they also apply the Wales Procurement Policy Statement which adopts the Sustainable Procurement Task Force's definition of sustainable procurement. Assets - the Act will enable us to strengthen arrangements for the effective management of our assets so that they can be used for the benefit of our communities; enabling them to be used over the long-term with safeguards in place for their retention at the community level.

Well-being of Future Generations (Wales) Act 2015

Health Board: Public Service Board: Public Service Board: •Individual organisations to •Publication of Wellbeing •Publication of Wellbeing set and publish Well-being Assessment no later than the Assessment no later than the Objectives start of May 2017 start of May 2017

2016/17 2017/18 2018/19

Health Boards and Local Health Boards and Local Health Boards and Local Authorities: Authorities: Authorities: •Jointly undertake the •Joint publication of the •Duties on Health Board population assessment of population assessment of and Local Authorities to the needs for care and the needs for care and plan response to the support, and the needs of support, and the needs of population assessment carers carers

Social Services and Well-being Act (Wales) Act 2014

3.1.2 Social Services and Wellbeing (Wales) Act 2014

The Social Services and Well-being (Wales) Act that became law in 2014 and which is to be implemented in April 2016, provides the framework for improving the wellbeing of people who need care and support, carers who need support and for transforming social services in Wales.

The Act aims to improve the delivery of social services by promoting equality, people‟s independence to give them a stronger voice and control, integrating and simplifying the law and providing greater consistency and clarity to: People who use social services; Their carers; Local authority staff and their partner organisations; and The courts and the judiciary.

The Act requires Local Authorities and their partners to consider the integration of care and support with health services where this would: Benefit the wellbeing of children, adults and carers;

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Prevent or delay the need for care; and Improve the quality of care and support.

The Act also requires a local assessment of population need for care and support to be undertaken in partnership, including mapping existing preventative services and identifying gaps in provision. Local authorities are required to look for opportunities to establish social enterprises, co-operatives, user led services and the third sector in the provision of care and support and support for carers.

3.1.3 Public Health (Wales) Bill

This Bill brings together a range of practical actions for improving and protecting health, including creating a national register of tobacco and nicotine product retailers, creating a mandatory licensing scheme for businesses carrying out acupuncture, piercing and tattooing, and requiring local authorities to plan for toilet facilities for public use. The Public Health Outcomes Framework for Wales has been developed in the context of other strategies and frameworks that also seek to improve the health of the people of Wales. In particular, it links to the national indicators for the Wellbeing of Future Generations (Wales) Act 2015.

3.2 National and Regional NHS Change

3.2.1 Prudent Healthcare

Launched during 2014/15 the concept of Prudent Healthcare has been refined into four key principles and work is underway to move from principles to practice.

Cardiff and Vale UHB has been working on the practical implementation of prudent healthcare principles since Spring 2014. The UHB Board has been engaged in discussion on prudent and agreed our approach which has also encompassed the Institute of Health Improvement (IHI) ‘triple aim‘ of improving population health, patient experience and cost per capita. The prudent principles are strongly reflected in our UHB strategy Shaping our Future Wellbeing’, which has at its core ‘caring for people, keeping people well’.

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3.2.2 Welsh Government Primary Care Plan

In launching „Our plan for a primary care service Wales up to March 2018‟(WG) in February 2015, a consistent message has been evident, and is captured in the Minister for Health and Social Services statement, following the launch:

“A prudent healthcare system, in which the avoidance of harm is our watchword, in which we pitch our interventions at the minimum necessary to address the problems which patients experience, will always have primary care at its heart”.

The aim of the plan is to develop a more “social” model of health, which promotes physical, mental and social wellbeing, rather than just the absence of ill health and draws in all relevant organisations, services and people to ensure the root causes of poor health are addressed. This includes the NHS, social services, housing, education, transport, environment and leisure services, the voluntary sector – now commonly referred to as the third sector – independent sector, carers and people themselves. The plan seeks a health system designed around providing preventative and ongoing care to meet individuals‟ needs close to their homes.

There are five priority areas for action: Planning care locally; Improving access and quality; Equitable access; A skilled local workforce; and Strong leadership.

Development of Primary Care Clusters is seen by the UHB as key to delivery of the Primary Care Plan and significant steps have been taken in 2015/16 and will continue into 2016/17 to do this.

3.2.3 South Wales Clinical Change

The South Wales Programme (SWP) was established in January 2012 to review those services deemed “fragile” in terms of their ability to deliver safe and sustainable models of care. The immediate challenges identified across South Wales and South Powys was the sustainability of four services that would require regional solutions: consultant-led maternity and neonatal care, in-patient children‟s services and emergency medicine (A&E).

Cardiff and Vale UHB is working with other UHB partners to implement the SWP recommendations through integrated governance arrangements forming the South Central Acute Care Alliance (ACA), which includes Aneurin Bevan, Abertawe Bro Morgannwg, Cardiff and Vale and Cwm Taf.

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The outcome of the SWP confirmed the following service changes within South Wales: Inpatient Paediatric services will not be delivered from the Royal Glamorgan Hospital (RGH) site in Cwm Taf UHB in the future, but implementation will take place once a new local assessment model is in place to ensure that the majority of children continue to have their care delivered locally at Royal Glamorgan during the day or Prince Charles Hospital should they need overnight admission. A small proportion of children from Cwm Taf will need to be admitted to UHW once the service at Royal Glamorgan moves to a day time based assessment service. Consultant maternity and neonatal services will be replaced with a midwifery led service at RGH. Some mothers will require admission at UHW and detailed implementation plans and supporting capital investment plans in extended facilities have been jointly developed to accommodate these service changes. This will require a significant expansion of the neonatal unit at UHW and some increase in obstetrics capacity and facilities. 24 hour consultant-led A&E services will not be delivered from the RGH site in the future but Cwm Taf Health Board are implementing a new model for a local A&E services and acute medicine to be in place before or at the same time as the changes take place.

Acute Medicine and Surgery – South Wales Context

There are similar sustainability challenges for other acute services outside of those included in the South Wales Programme consultation. These include acute medicine and surgery. Further work is being undertaken within the South Central ACA and at national level, through the NHS Wales Collaborative, in order to support the development of sustainable models of acute care for acute medicine and surgical services. Developing pathways and clinical support services to provide a sustainable model of acute medicine at UHL is a key priority for the UHB and options are being developed in the context of the evolving strategy for the South Central ACA. Cwm Taf plans to provide services to enable up to 90% of current patients requiring acute medicine services to continue to be treated at RGH through the implementation of new pathways for acute medicine. Cwm Taf plan to develop local general surgical models to support their acute medicine service model which will include emergency surgical assessment and hot clinics to optimise their local service provision to minimise the requirement for patients to travel to access surgical treatment. The expectation is that future service changes in surgical flows will be limited to those services where concentrating surgical expertise is required to ensure safe and sustainable care. The services where there will be joint working within South Central ACA to develop more integrated service models with provision of either complex elective and/or emergency inpatient services at UHW are: o ENT o Vascular surgery.

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Cwm Taf has also signalled its intent for the provision of regional diagnostic service support from RGH and collaborative opportunities are being tested.

The governance arrangements established to implement the South Wales Programme are described below and has seen the establishment of a South Wales Clinical Change Programme to provide overall UHB leadership.

Cardiff and Vale South Central Collaborative UHB ACA UHB Board ACA CEO Delivery Group South Wales Health Meeting Collaborative Board

South Wales Clinical ACA Implementation ACA Executive Steering Change Programme Group Leads Group

3.3 Shaping Our Future Wellbeing

3.3.1 Shaping Our Future Wellbeing Strategy

Locally, development of the Cardiff and Vale UHB IMTP is based on the principles set out in the UHB‟s ten-year strategy, Shaping Our Future Wellbeing, published in 2015, along with the organisation‟s „strategy map‟. Shaping Our Future Wellbeing sets out the strategic objectives for the UHB over the next ten years, the principles underpinning development of NHS services and how we will address local health and wellbeing needs. It recognises the need to take a balanced approach to achieving change for our population, our service priorities, our sustainability and our culture.

Caring for People; Keeping People Well is why the UHB exists, with a vision that a person‟s chance of leading a healthy life is the same wherever they live and whoever they are.

Informed by Prudent and the Institute of Health Improvement‟s „Triple Aim‟, the largely co-produced Shaping Our Future Wellbeing strategy, is built on a set of core principles. With the intention to deliver “Outcomes that matter to People”, the strategy also contains a framework, which focuses on population health and wellbeing by placing the needs of the population its centre. The integrated services that deliver these outcomes will give equal consideration to preventative, planned, unplanned and end of life care. Importantly, when provided by an integrated healthcare organisation, each of these elements of care should flow seamlessly.

The Shaping Our Future Wellbeing strategy will be operationalised through our annual planning cycle, informing the ongoing development and delivery of each year‟s IMTP. It will lead to very different models of care being delivered over time.

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Empower •Support people in choosing healthy behaviours the Person •Encourage self-management of conditions

Home first •Enable people to maintain or recover their health in or as close to their own home as possible

Outcomes that •Create value by achieving the outcomes and experience that matter to People matter to people at an appropriate cost

•Adopt evidence based practice, standardising as appropriate Avoid harm, waste and •Fully use the limited resources available, living within the total variation •Minimise avoidable harm •Achieve outcomes through minimum appropriate intervention

In 2015/16 the Shaping Our Future Wellbeing Principles were adopted as part of the UHB commissioning intentions. For 2016/17, the strategy features throughout the commissioning intentions, with their framework being based on the UHB strategic objectives.

Cardiff and Vale UHB Strategic Objectives:

For Our Population – we will Reduce health inequalities; Deliver outcomes that matter to people; and All take responsibility for improving our health and wellbeing.

Our Service Priorities – we will Offer services that deliver the population health our citizens are entitled to expect.

Our Sustainability – we will Have an unplanned (emergency) care system that provides the right care in the right place, first time; Have a planned care system where demand and capacity are in balance; and Reduce harm, waste and variation sustainability making best use of the resources available to us.

Our Culture – we will Be a great place to work and learn;

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Work better together with partners to deliver care and support across care sectors, making best use of out people and technology; and Excel at teaching, research, innovation and improvement and provide an environment where innovation thrives.

Building on the priorities of 2015/16, the Bold Improvement Goals (BIG) for 2016/17 focus on a number of areas where further transformation is needed: Integrated Health and Wellbeing - building on GP clusters and locality partnership working, design test and continue to implement the ‟perfect locality‟ with partners in the local authorities, third sector and community partners. Performance metrics include - reduction in public service spend overall, reduced unplanned emergency admissions for people with known long term conditions and patient experience outcomes. Dementia Innovation - building on the priorities set out in the Dementia Plan and working with Cardiff Universities and Dementia Plan partners, establish a „centre of excellence‟ for dementia research and development, innovation and excellence in care and support. Performance metrics include – those set out in the Dementia Plan. Outpatient Transformation – design and implement a new model for outpatient care in one or more key speciality, which results in a 50% reduction in the traditional forms of delivery. Performance metrics include – reduction in the number of outpatient appointments in a hospital setting, patient experience outcomes. Unplanned (emergency) Care – fully implement key service redesign, which will transform unplanned (emergency) care pathway. Performance metrics include – Welsh Government targets, patient experience outcomes.

3.3.2 Cardiff and Vale of Glamorgan Strategic Blueprint

2015 has seen key partners announce the development of Cardiff Capital Region – a confident, collaborative and connected region primed for economic growth. Its aim is to enhance the potential economic development success and job creation opportunities of this region, building on the City of Cardiff's reputation as a top UK city for quality of life and workforce loyalty, alongside Cardiff University being rated as one of the UK‟s top 5 universities in terms of the quality and impact of its research.

Building on this, and the UHB‟s Shaping Our Future Wellbeing Strategy, there has been agreement by Cardiff Local Authority, Vale of Glamorgan Local Authority, Cardiff University and the UHB to develop an overarching Cardiff and Vale Strategic Blueprint that: Creates an ambitious regional vision for integrated care and wellbeing; Highlights and factors in the impact of demographic and technology change; Builds upon existing engagement and planning work completed; and

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Identifies areas where we can become a national and international leader.

The Blueprint, due to be finalised by the end of 2015/16, will articulate the following: Implementation plans for strong collaboration between health services, local authorities and academia. Develop a shared view on what our wellbeing and care system should look like and a set of guiding principles for future collaboration. A common understanding of the benefits to our citizens with clear infrastructure plans for technology and estates. A strategy that has the support of key stakeholders with identified funding sources – both traditional and innovative.

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4. Local Health Needs and Challenges

4.1 Main Areas of Population Health Need

4.1.1 Background and context

This chapter is a summary of a detailed profile for Cardiff and Vale given in the Appendix, and three separate locality profiles developed in summer 2015 to aid local planning (covering Cardiff North, West and South West; Cardiff South, East and City; and the Vale of Glamorgan).

Information is presented at GP cluster and locality level where available.

During 2016/17 the process for identifying and collating information on population health needs will be aligned with the developing processes for the population needs assessment required for the Social Services and Wellbeing (Wales) Act 2014 and the wellbeing assessment required by the Well-being of Future Generations (Wales) Act 2015. This will ensure consistency of information and priorities for action provided to local policy makers and operational service leads, and avoid unnecessary duplication of effort.

4.1.2 Population Size and Composition

The population of Cardiff is growing rapidly in size, projected to increase by 13% between 2015-25, significantly higher than the average growth across Wales and the rest of the UK. An extra 46,000 people will live in and require access to health and wellbeing services.

The Cardiff population is relatively young compared with the rest of Wales, with the proportion of infants (0-4 yrs) and young working age population (20-39yrs) significantly higher than the Wales average. This reflects in part a significant number of students who study in Cardiff. There will be significant increases in particular in people aged 5-16 and the over 65s.

Figure. Proportion of population by age and sex, Cardiff, compared with Wales using ONS Midyear population estimates, 2014 (Public Health Wales, 2015)

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Wales Males Cardiff Males Wales Females Cardiff Females

90+ 85-89 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 8 6 4 2 0 2 4 6 8 The population of South Cardiff is ethnically very diverse, particularly compared with much of the rest of Wales, with a wide range of cultural backgrounds and languages spoken. Arabic, Polish, Chinese and Bengali are the four most common languages spoken after English and Welsh. Cardiff is an initial accommodation and dispersal centre for asylum seekers.

The population age structure of the Vale of Glamorgan is very similar to the Wales average, with the exception of a slightly lower number of young adults (20- 24yrs). The population of the Vale will increase modestly over the next 10 years, by around 3% or 4,000 people. However, this masks significant growth in the over 65s and over 85s categories.

Figure. Proportion of population by age and sex, Vale of Glamorgan, compared with Wales using ONS Midyear population estimates, 2014 (Public Health Wales, 2015)

Wales Males Vale of Glamorgan Males Wales Females Vale of Glamorgan Females

90+ 85-89 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 8 6 4 2 0 2 4 6 8

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4.1.3 Risk Factors for Disease

Unhealthy behaviours, which increase the risk of disease are endemic among adults in Cardiff and the Vale: Nearly half drink above alcohol guidelines (44% Cardiff, 43% Vale); Around two thirds don‟t eat sufficient fruit and vegetables (66% Cardiff, 67% Vale); Over half are overweight or obese (55% Cardiff, 54% Vale); Around three quarters don‟t get enough physical activity (74% Cardiff, 73% Vale); and Around one in five smoke (21% Cardiff, 18% Vale).

There is considerable variation in rates of unhealthy behaviours within Cardiff and the Vale: Smoking rates vary between 14% and 33% across Cardiff, and between 17% and 29% across the Vale. Similar patterns are seen for other behavioural risk factors for disease.

Many children in Cardiff and Vale are also developing unhealthy behaviours: Two thirds (67%) of under 16s don‟t get enough physical activity; and Over a third (34%) of under 16s are overweight or obese.

Figure. Proportion of children who are overweight or obese, 3 years combined data, 2011/12- 2013/14: Children aged 4 to 5 years, Cardiff and Vale UHB.

Air pollution is a significant cause of illness and deaths It is estimated 143 deaths each year in Cardiff and 53 each year in the Vale among over 25s are due to man-made air pollution. The burden and impact of environmental air pollution is worse with increased deprivation, and Cardiff has the worst air pollution measured by PM2.5 levels in Wales It is estimated that long-term exposure to man-made air pollution is responsible for 5.1% of all deaths in Cardiff and Vale

Page | 36 Comparison of life expectancy, healthy life expectancy and disability-free life expectancy at birth, Cardiff 2001-05 and 2005-09 4.1.4 Equity,Produced Inequalities by Public and Health Wider Wales Observatory, Determin usingants ADDE/MYE of Health (ONS), WIMD/WHS (WG) 2001-05 2005-09 95% confidence Inequalitygap interval (SII in years) There are stark inequalities in health outcomes in Cardiff and Vale: Life expectancyMales for men is nearly 12 years lower in the most-deprived areas comparedLife with those in75.9 the least-deprived areas. 12.9 The numberexpectancy of years of76.9 healthy life varies even more, with a gap12.8 of 22 years Comparison of life expectancy, healthy life expectancy and disability-free life expectancy at birth, Wrexham 2001-05 and 2005between-09Healthy the lifemost- and63.0 least-deprived areas. 22.5 expectancy 63.7 22.7 Produced by Public Health Wales Observatory, Premature using ADDE/MYE death (ONS), rates WIMDWIMD/WHS(WG) are 2008 nearly(WAG) three times higher among the most-deprived areas Disabilitycompared-free withlife the59.2 least deprived. 17.2 59.8 expectancy 2001-05 2005-09 17.1 Males Females FigureComparison. Life ofexpectancy life expectancy, in years, healthy in Cardiff life expectancy and Vale. and Source: disability Public-free Healthlife Wales 75.9 Life expectancy expectancyLife at birth, Cardiff and80.6 Vale UHB 2001-05 and 2005-09 8.8 Observatory77.3 (2011). Producedexpectancy by Public Health Wales Observatory,81.7 using ADDE/MYE (ONS), WIMD/WHS (WG) 10.0 63.9 Healthy life expectancy Life expectancy with 95% Inequality gap 64.7 2001-05 200565.4-09 21.0 Healthylife confidence interval (SII in years) 60.8Males expectancy 65.9 22.0 Disability-free life expectancy 61.5 76.1 11.6 Life expectancy 62.1 Disability-free life 77.3 12.3 11.8 Females expectancy 62.5 12.9

79.9 Healthy life 63.4 22.5 Life expectancy 81.0 expectancy 64.2 22.7

65.5 Healthy life expectancy 66.1 Disability-free life 59.6 16.7 expectancy 62.0 60.1 16.7 Disability-free life expectancy 62.5 Females 0 10 20 30 40 50 60 70 80 90 Life expectancy 80.7 8.5 81.8 9.9

Healthy life 65.7 20.2 expectancy 66.3 21.3

Disability-free life 62.1 12.3 expectancy 62.5 12.9

There are also significant inequalities in the „wider determinants‟ of health, such as housing, household income and education: For example, the percentage of people living without central heating varies by area in Cardiff and Vale from one in a hundred (1%) to one in eight (13%).

There are inequalities in how and when people access healthcare: For example, immunisation uptake varies considerably, with uptake of infant vaccines ranging from 89% to 98% across Cardiff and Vale.

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Figure. Uptake of the 5 in 1 primary in Health Board resident children reaching one year of age during 01/07/2013 to 30/06/2014, by MSOA of residence

4.1.5 Ill Health and Service Use

The disease profile in Cardiff and Vale is changing: The number of people with two or more chronic illnesses in Cardiff and Vale has increased by around 5,000 in the last decade, and this trend is set to continue. Around 1 in 7 (15%) people consider their day-to-day activities are limited by a long-term health problem or disability. Many people with chronic conditions are not diagnosed and do not appear on official registers. Due to changes in the age profile of the population and risk factors for disease, new diagnoses for conditions such as diabetes and dementia are increasing significantly.

Around 1 in 5 adults have visited their GP within a 2-week period; and nearly three quarters visit a pharmacy over a year period.

The highest rates of attendance at the Emergency Department are from people living in more deprived areas of Cardiff and Vale.

Figure. Emergency Unit attendances, UHW, C&V residents (2013)

Llanedeyrn / Rumney / Llanishen estate Pentwyn Trowbridge Mynachdy / Llandaff North

Splott / Tremorfa

Butetown

Grangetown / Riverside

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Rates of delayed transfer of care for social care reasons are nearly twice as high in Cardiff and Vale than the Wales average.

Heart disease, lung cancer and cerebrovascular disease are the leading causes of death in men and women.

Preventable illness and deaths. Many (but not all) of the most common chronic conditions and causes of death may be avoided by making changes in health-related behaviours

4.2 Population Assets

In addition to health needs, each community has „assets‟, such as social capital, community groups or community buildings.

A current gap in our knowledge of our local area relates to community „assets‟. An understanding of assets is important not only to balance the traditional „deficit‟ model of assessing a community‟s health, but also because without this the Health Board and public and third sector partners are missing the opportunity to work more closely with the community, building on and making best use of its current strengths and co- producing solutions to health issues.

Building on current service delivery baseline, Cardiff and Vale asset mapping will take place in 2016/17 to support the population needs assessment required by the Social Services and Wellbeing (Wales) Act 2014.

4.3 Themes from Engagement Activities

As part of the development of „Shaping our Future Wellbeing‟, residents and service users from Cardiff and the Vale were asked their views on what they wanted to see from their local NHS over the next 10 years. The following statements summarise these views, in particular those relating to the local community:

I want or need... To have the tools and support that enable me to live a healthy life, minimising my risk of disease. Rapid access to services which can diagnose my disease at an early stage. Easy access to high quality advice. This could be via helplines or websites but, when I have a complex problem, I want to be able to talk to people who know me and understand my disease and its treatment. To have ownership of how and where my care is delivered at the end of my life. To stay close to my community and family.

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Rapid access to knowledgeable healthcare professionals who can advice me when my health deteriorates, allowing treatment alterations that allow me to stay at home as much as possible. Care which is delivered close to where I live and work, so that I can continue to lead as normal a life as possible, whilst still working closely with clinical teams to ensure the best outcomes for me. To maintain independence and have the best quality of life possible during my care. To die with dignity in a place of my choosing. A co-ordinated service, including out of hours, so I don‟t repeat the same story. To always be offered the best, most effective treatments, regardless of where I live and which health professional I see. Decisions regarding my care to be made by experienced clinicians who have an understanding of my condition, whatever time of day or night. To receive holistic care from a range of health professionals, who communicate effectively with each other and work as a team.

4.4 Local Challenges

Whilst specific risks are identified through the Corporate Risk and Assurance Framework (CRAF) [Chapter 14 for more details]; a number of broad themes emerge as challenges for the UHB.

The challenges faced by the UHB in part drive the need to change what we do as both a commissioner and a provider of services to our local population and beyond. Our key challenges can be summarised as: How we best join up care to reduce inequalities in health which arise because of inequalities in society; particularly how we manage risk factors and conditions which will have the biggest impact on our local population now and in the future; and How we ensure that the services we provide now and those we expect to provide in the future are sustainable.

The following are the key overarching risks and challenges that impact on the development of the 2016/17 IMTP plan. A number of planning assumptions, priorities and actions are identified in the service change Chapters 6 – 12 which support the delivery to mitigate these risks, with the actions being taken to build capacity for the future featuring in Chapter 13, Building Capacity and Delivery.

4.4.1 Service Challenges

As constraints to service delivery grow, the challenge for the UHB is keeping a focus on outcome delivery for people and populations whilst meeting service pressure and financial pressure demands. Balancing delivery of immediate improvement versus

Page | 40 sustainable long term change in meeting key NHS Wales Delivery Framework Measures particularly: Referral to Treatment targets – specifically paediatric surgery, orthopaedics and dermatology Cancer targets – specifically dermatology and gastroenterology Diagnostics – specifically endoscopy and Magnetic Resonance Imaging (MRI) demand Outpatients – follow ups, particularly in ophthalmology Planned Care Board Programmes e.g. ophthalmology and orthopaedics HCAI Smoking cessation targets

Potential changes to reduce local authority budget allocations for social care and housing will require careful monitoring and management to minimise adverse impact upon UHB prevention and „home first‟ plans. In part this drives the UHB to maximising the opportunity presented through strengthened Primary Care Clusters

South Wales Regional Change - see section 3.2.3

Capacity constraints in key service areas: Primary care capacity – in particular OOH Primary care estates capacity Main theatres at UHW at capacity. Opportunities have been taken to: o despite continuing to optimise capacity through efficiency improvement programme to increase theatre utilisation (ongoing) and extend working day through longer sessions or three session days o redeploy all lower acuity activity to surgical short stay (SSSU), UHL theatres, outpatient/community settings e.g. minor daycases and cystoscopies o Transfer of Paediatric surgery to the Children‟s Hospital for Wales Critical Care – implementation of PACU has protected elective capacity but demand for critical care beds routinely exceeds capacity Medical assessment capacity – there is currently no separate facility for Ambulatory Care at either UHW or UHL which impacts on the capability to provide more efficient management of suitable patients and increases congestion in the medical assessment units impacting adversely on both efficiency and patient experience

4.4.2 Workforce Challenges

Culture challenges: Engaging with staff Supporting the health and wellbeing of staff Supporting integrated workforce re-design across the professions and support staff

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Compliance with Equality and Welsh Language legislation when planning and delivering care Improvement in PADR and Statutory and Mandatory Training compliance Timely identification of opportunities for innovative workforce transformational change Meeting deanery expectations to deliver educational contract requirements for medical trainees in key specialties requiring e.g. Changes to paediatric surgical rotas, 1:11 rota arrangements in general paediatrics and obstetrics, reductions to the number of outpatient clinics in some surgical specialites Implementing and further developing national workforce strategies e.g. modernising scientific careers, advance practitioners and healthcare support workforce development

Recruitment challenges: Shortage in doctors and inability to recruit in areas such as Emergency Medicine, Paediatrics, Psychiatry, GP‟s (out of hours), Occupational Health Shortage in a number of other workforce groups including Nursing, Speech and Language Therapists, Radiologists, Cardiac Scrub Nurses, Operating Department Practitioners, Qualified Mechanical and Electrical tradesmen (full listing is contained in Chapter 12) Shortage of suitable applicants with breadth of experience required for Executive and Senior Management posts Shortfalls in recruitment process such as delays due to NWSSP and UHB line management action; timely completion of all pre-employment checks, most notably DBS

Affordability and Ineffective use of Resource challenges: Reduce workforce cost to underpin 10.5% savings identified in financial framework Reduce sickness absence further to meet the UHB and Welsh Government targets Meet Staff Seasonal Flu Vaccination target Avoid financial penalties resulting from an inability to monitor Junior Doctor Rotas

4.4.3 Infrastructure Challenges

A comprehensive assessment of the state of the UHB estate was conducted in 2014/15. It concluded that there is a significant challenge in ensuring that the UHB infrastructure (buildings and critical medical equipment) remains fit for purpose. Following a prioritisation exercise, good progress has been made in 2015/16 in managing the estates maintenance and equipment replacement backlog, however challenges remain including: Theatres – compliance risks including catheterisation labs Availability of hybrid theatre to support regional service centralisation plans

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Neonatal and obstetric capacity until the implementation of planned capital schemes Endoscopy capacity at UHL Theatre - capacity and functional suitability of red and black theatres at UHL Renal Dialysis – functional suitability at UHW Critical care - capacity and functional suitability Cystic Fibrosis Unit – capacity and functional suitability Primary Care – capacity and functional suitability of some premises Mental Health - functional suitability of some community premises Community service estate Modernisation of our information technology infrastructure , which must be driven by service need and use

4.4.4 Financial Challenges

The UHB is facing a number of financial challenges in the delivery of its IMTP [Chapter 12 for more details]; however the key challenges for are set out below: Balancing the Financial Plan - The Financial Plan does not manage to deliver the UHBs statutory financial break even duty over the period of the plan. The UHB has significant financial pressures resulting from an underlying deficit and substantial cost increases due to inflation and growth pressures. The management of this will require further Board level and Welsh Government consideration. Further discussions with Welsh Government will be needed to explore the options available to mitigate this risk to deliver financially sustainable services. Achievement of savings targets - The forecast out-turn position for the period of this plan is only deliverable based on achievement of the Health Board‟s savings targets. Given the scale of the savings required (3% per annum), and the context that savings delivery gets harder year on year, this is the key financial risk in delivering the plan. South Wales Plan - Despite best endeavours, there is a possibility that whole services could transfer in an unplanned way that could present capacity, service and financial pressures outside of an agreed process or mechanism. The UHB is being proactive to try to avoid this and is working with partner organisations to ensure that this risk is minimised. Population Growth – The Health Board has the fastest growing population in Wales. It does not however, receive a corresponding increase in funding. This impacts upon hospital, community and primary care services and places additional financial pressures on this Health Board. Provider of Specialist and Tertiary Services – The UHB believes that it is not always adequately funded for the specialist and tertiary services it provides for the population of South Wales. Work is underway to review this with the aim of identifying areas of income under-recovery so that mitigating actions can be taken.

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5. Commissioning and Partnership Working

5.1 Commissioning for Population Health

The UHB is developing an outcomes based commissioning approach to secure the services it requires to deliver our 10 year strategy Shaping our Future Wellbeing. The approach enables a whole systems view and is closely aligned with our partnership joint commissioning and delivery work.

We have set out commissioning intentions which have been informed by our population needs and assets assessments. These in turn have been built from primary care cluster and neighbourhood profiles and plans, with local community input. This ensures we are focused on outcomes that matter to our local population. This commissioning based outcomes approach is developing to ensure that assessment translates into services planning, followed through to procurement, delivery, monitoring and continual improvement (a cycle).

Our commissioning intentions have built on the priorities and achievements in 15/16.

Our outcomes based Planning and Commissioning Framework sets out the process for planning and commissioning services for the population at all levels including new consideration of services or interventions, service development or disinvestments. We are working to embed the use of the framework throughout the UHB .This is an iterative and evolving process, and we have put additional resource and capacity into its development and to embed its use within the UHB.

The UHB is developing the capacity and capability to support the changes required to enable the models of care articulated within our strategy. We have begun with the design and implementation of integrated patient pathways. The learning is being used to develop commissioning tools and support for service change programmes.

Ensuring a whole systems approach, enables us to take a view across health, local authorities and other public services so that account is taken of impacts of all services on outcomes required within commissioning intentions. Delivering outcomes where resources are constrained means that it is important to understand the impacts decisions taken by one partner will have on demand and supply of services provided by other partners.

The UHB‟s Commissioning Intentions will support the shaping of service provision by including consideration of the following areas:

System Identifying and enabling: Structure services that are required to meet the needs of our population capabilities that are required from our services and from partners System Determining and ensuring: Stewardship the relevant information to be able to inform services and partners

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how commissioning is placed within the organisation How stakeholders are involved in service design and delivery Working in Determining and delivering: partnership How we design the best value delivery mechanisms How we ensure that the needs of patients and carers are built into services How we create opportunities for designing and delivering integrated services within and outside the organisation Driving Ensuring: performance Development of service specifications across clinical services Performance indicators delivering patient outcomes For external partners these are embedded in the associated contracts delivering health outcomes Maximisation of the value of investments and existing service delivery Commissioning Securing: capability Development of commissioning skills and capability within the organisation Delivery of prudent healthcare principles

We will continue to develop our capability across each element of the commissioning cycle:

Data Collection and Analysis The UHB will continue to make increasing use of information to inform decision making; further developing our analytical capacity to enable more analysis of available data and use of projections, including demand and capacity modelling and benchmarking. This will include data from people about their needs, preferences and the extent to which the service in delivering intended outcomes.

IMTP and Planning We will ensure support to Clinical Boards and strategic partners to make short, medium and long term decisions about how services need to change and how this will happen. The IMTP process will provide clarity about the options available to the health board for investment, disinvestment and service redesign and change. It will support consultation on achievement of best outcomes and value.

Service Delivery A commissioning cycle and intentions aims to guide delivery of agreed strategic outcomes. Service delivery plans are expected to be informed by commissioning intentions. The intentions do not cover the totality of UHB and its partners business and we will continue to refine the translation of intentions into plans and delivery.

The outcomes based commissioning approach supports effective commissioning and decommissioning of services, and supports the procurement systems. We are

Page | 45 continuing to develop capability and capacity to ensure service quality, specification and both appropriate and innovative deliver and procurement models.

Performance Monitoring We are taking an evidence-based approach to monitoring, reviewing progress and making adjustments in the light of changing circumstances. This will assess we are achievement of strategic objectives and the effectiveness of procurement arrangements. Feedback from users, carers and other partners will be an essential element of evidence in progress reviews and performance monitoring.

The outcomes bases commissioning cycle will be supported by organisational development processes. Our systems supporting commissioning are also being developed for example: how we develop and assess business cases for new or amended services: how we prioritise investment or disinvestment.

As the UHB develops the discipline of commissioning to serve an integrated organisation, for the services we both commission and provide, it also acts as a more traditional commissioner of other providers.

We will commission (externally): Specialised services - as a member of Welsh Health Specialist Services Committee (WHSSC) (this will include services provided by the UHB itself); Specialist Children and Adolescent Mental Health Services CAMHS from Cwm Taf UHB – supported through service specifications and long term agreements; Adult learning disabilities from Abertawe Bro Morgannwg UHB Specialist Forensic Mental health services - through a collaborative commissioning arrangement; Services from Welsh Ambulance Services Trust (WAST) – through Emergency Ambulance Services Committee (EASC) as a collaborative commissioner; Specialist cancer services from Velindre NHS Trust– through long term agreements ; Secondary care services in neighbouring health boards (Abertawe Bro Morgannwg, Cwm Taf, Aneurin Bevan) – through long term agreements and reciprocal arrangements; Prevention and community based service with 3rd providers - supported by service specifications and accompanying contracts; and Services for continuing health care - through independent sector contracts and collaborative arrangements and joint commissioning with partners.

We continue to develop capacity and capability for our external commissioning function to better assure specification of services including quality, outcomes and value.

As an integrated health board Cardiff and Vale UHB expects to provide the majority of care for its residents.

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5.2 Progressing Partnerships

5.2.1 Joint Planning to Meet Local Need

Chapter 4 of this plan sets out in detail how our population is changing, and outlined the key characteristics of our communities that shape demand for services. In particular the large variation in deprivation and health outcome, the significant numbers of children living in poverty and the growth in our older population, dictates the need for a strong working relationship with partners to ensure the wider determinants of health are being actively tackled. It also requires an alignment of service provision. The purpose of our joint working is twofold, to: Secure a reduction in health inequality within our community; and Meet the citizen and patient expectations of seamless service provision regardless of the host organisation.

From April 2016, Local Service Boards will become Public Service Boards guided by the Well-being of Future Generations (Wales) Act 2015. The UHB, as one of the designated public bodies affected by the Act, will be working closely to build on the relationships and single integrated plans developed via existing Local Service Boards on a shared agenda of securing better outcomes for the population of Cardiff and the Vale of Glamorgan, with an emphasis on priorities, pace and performance.

In Cardiff, a collective vision and a set of high level priorities for the city are set around seven shared citizen outcomes. The Cardiff „What Matters 2010:2020‟ ten year strategy and Delivery Plan can be found at www.cardiffproudcapital.co.uk. The strategy and priority workstreams are currently being reviewed to ensure they reflect the Strategic Needs Assessment 2015 and continue to align to partner organisation priorities. Current programmes are: families and young people; education development; safer and cohesive communities; older people; emotional, mental health and wellbeing; healthy living; thriving and prosperous economy; urban environment.

In the Vale of Glamorgan, an integrated Community Strategy has been prepared around ten overarching priority outcomes supported by a population needs assessment. The Vale of Glamorgan Community Strategy 2011-2021 and Delivery Plan can be found at www.valeofglamorgan.gov.uk/communitystrategy. The Delivery Plan 2014-18 is structured around the three themes of the Welsh Government Tackling Poverty Action Plan; the three workstreams are: preventing poverty; helping people into work; mitigating poverty.

We are a joint signatory to both strategies, which are aligned to this plan, and our range of plans that sit below the IMTP, such as those improving mental health, developing dementia care, tackling smoking, obesity and unsafe drinking. The priorities reflect our local population assessment and needs and the public health priorities contained within the local public health plans. The Single Integrated Plans are key documents for us and inform our IMTP; likewise, the changing needs which

Page | 47 emerge from the development of our ongoing planning processes are fed into and inform the Integrated Plans on an iterative basis.

In both local authority areas, the development of integrated strategies has led to the establishment of new models of joint working that aim to provide a more effective and streamlined means of addressing the major challenges. Embedded within them is an emphasis on delivering outcomes, a business intelligence function, locality working, effective performance management and personal accountability. Partners typically include local authorities (social services, education, housing, economic regeneration), third sector, police, probation, fire and rescue, Natural Resources Wales and the independent sector.

Engaging with partners to help shape UHB service change plans is crucial to ensuring they are sustainable and that the impact of proposed change is explored collaboratively. The UHB is working with local authority colleagues to consider Council budget savings proposals in order to develop a shared approach to managing impact and mitigating risks.

Local Authority Local Development Plans (LDPs) are another key area of partnership working where a far more proactive approach has been established early on in the process to embed a commitment to health improvement outcomes into the LDPs and to involve UHB Clinical Boards in identifying infrastructure and service capacity implications. There has been significant input from the UHB to ensure that health and access to healthcare services is embedded across the plans including work to ensure a commitment to broader health improvement outcomes, access to well- maintained quality open spaces, active travel, access to health care facilities and access to a food growing environment. There is a commitment to work collaboratively to further explore the development of multi-functional use community facilities that include health services and the use of the Community Infrastructure Levy to fund some elements of these facilities.

Co-production in the design and delivery of services is an approach increasingly being adopted by all partners in Cardiff and the Vale of Glamorgan. Notable examples where this is shaping service development locally include: Community Resource Team development with local authority and third sector partners to support people to regain and maintain their independence in the community; joint work with Welsh Ambulance Service, social care, General Practice and the hospital assessment units to produce pathways such as the Falls Pathway; work with the Independent Sector on the commissioning of long term care in care homes and citizen driven health care to maximise the benefits of co-ordinated preventative care and support.

5.2.2 Local Service Boards

Each Local Authority currently hosts a Local Service Board. Details of how they operate and priority work programmes can be viewed via the web links above. A Cardiff and Vale Joint Local Service Board is now operating with the purpose of

Page | 48 working collaboratively across organisational boundaries to agree joint action to achieve better outcomes for citizens in Cardiff and the Vale of Glamorgan, in line with the Cardiff What Matters Strategy 2010-2020 and the Vale of Glamorgan Community Strategy 2011-2021. The joint LSB is overseeing a work programme that includes the redesign of health and social care (see Regional Collaboration Fund below), targeted focus on preventative interventions with vulnerable groups and embedding co-production and citizen engagement in the development and delivery of services.

We are represented on the Regional Collaboration Fund (RCF) Board, and three of the projects have direct involvement of the NHS – Integrated Health and Social Care, Sexual Assault Referral Centre and the Alcohol Treatment Centre. Work continues with Welsh Government and wider partners to agree sustainable delivery solutions in response to the reduction in the RCF grant.

In Cardiff, Six Neighbourhood Partnerships provide a focus for developing local solutions to local issues identified through quantitative and qualitative needs assessment. These six groups have a clear link to the UHB Locality Teams and are aligned to the GP clusters enabling them to be increasingly influenced by cluster plans. Neighbourhood Intelligence Reports are updated every six months and provide access to local intelligence that can support tailoring of services to better meet local need.

In the Vale of Glamorgan, an updated Unified Needs Assessment supported the development of a Delivery Plan for 2014 – 18. This needs assessment was shared with UHB Clinical Boards, facilitating alignment of the Delivery Plan with IMTP service change plans.

There have been open discussions with both local authorities during the development of our Plans for 2016/17 so that we each understand each other‟s service, workforce and financial pressures, and to consider how we can support services together during this time. We have also agreed that we will share any proposed changes to, for example, SLAs/contracts with Third Sector organisations so that we can understand whether there will be a disproportionate impact on any due to our collective actions. Conversations with local authority colleagues have emphasised the need to establish a collaborative approach to managing the issues around the co-dependencies of our services and how we can work in an integrated way to deal with the severe financial pressures while minimising the risks to the population we jointly serve. There is recognition that there is a real opportunity to use the need to make savings as a catalyst to be much more radical on the integration front. This was successfully tested in 15/16 by redesigning substance misuse counselling services enabling the required decrease cost but maintaining a service to citizens.

We also continue to lead some and work closely with other cross boundary groups such as the Area Planning Board for substance misuse services and the Local Safeguarding Children Board, as set out in last year‟s IMTP.

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5.2.3 Integrated Health and Social Care Partnership

The UHB has developed a strong working relationship with Local Authority and third sector partners through the Integrated Health and Social Care Partnership. In 2016- 17, the Partnership has committed to implementing virtual integration of services relating to the care of older people across adult social services and community health services. In recognition of the links between this intention and the requirements of the Social Services and Wellbeing (Wales) Act 2014, the Partnership will take on the structure outlined below in order to maintain a streamlined approach to delivery.

The Partnership will continue to utilise opportunities afforded by the Intermediate Care Fund to build upon integration of key services at an operational level, working across health, social care, housing and the third sector. The Fund will be used to deliver services, which are focused upon a „home first‟ philosophy: admission prevention, admission avoidance and expediting hospital discharge.

Together, we will also seek to build a similar relationship with the Independent sector as we look towards securing the availability of appropriate long term care provision for our population.

5.2.4 Working with the Third Sector

In 2012, the UHB published a Strategic Framework for Working with the Third Sector, implementation of which has been supported annually with an action plan. The Framework sets out our ambitions for working collaboratively with the third sector to enhance the lives of our population. It focuses on embedding strengthened partnership working with the third sector into core UHB business and seeking more integrated solutions to addressing increasingly complex needs. A major review of the Framework is now underway to re-appraise the relationship to ensure it is fit for purpose to support delivery of Shaping Our Future Wellbeing and that it appropriately reflects the ambitions and potential of the third sector locally. A questionnaire was circulated and structured interviews undertaken to explore how the UHB and third sector can work together to maximise the Third Sector contribution to the UHB Strategy and what the relationship needs to look like in the future.

The next phase of the review will be to bring the findings from this survey work to the annual UHB „Keeping in Touch with the Third Sector‟ event. This year it is being run as a joint workshop with Glamorgan Voluntary Services (GVS), Cardiff Third Sector Council (C3SC) and Cardiff and Vale Action for Mental Health (Cavamh) to allow third sector, UHB and partner colleagues to come together to explore where collaboration is best focused.

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5.2.5 Working with Cardiff and Vale Community Health Council

The UHB is in ongoing dialogue and meets regularly with Cardiff and Vale Community Health Council through the CHC‟s four key areas of work: Visiting/monitoring of services and facilities; Consultation and involvement with service change; Complaints advocacy; and Public engagement.

We value the input of the CHC and this collaboraton will continue in 2016/17 building on strengthened arrangements for continuous engagement developed over the last year between the CHC and UHB clinical boards as well as corporate teams.

We have a well-established Service Planning Committee in place, and bi-monthly operational meetings were established during 2015/16 to ensure that operational issues were addressed swiftly. The CHC also established a serious of overview and performance scrutiny committees that mirror the clinical boards, providing an interface between the CHC and Clinical Boards to bring about increased understanding around service plans and performance issues.

The CHC is also represented on many planning and topic specific project and working groups to provide a valuable patient voice in the discussions, and a critical friend where appropriate.

5.3 Collaboration with our NHS Partners

In developing and refreshing our 2016/17 IMTP, we have sought to ensure that these integrate effectively with those of our key partners. An important part of this process has been to fully engage with the NHS Wales Peer Review. Specific developments with Local Health Boards are picked up in the service change Chapters 6-12, however below is a short summary of interfaces with some of our key partners:

5.3.1 Welsh Ambulance Services Trust

The Welsh Ambulance Service (WAST) has been through major change over the last twelve months. 2015 saw the introduction of the Quality Outcomes and Commissioning Framework leading closer working with both the Chief Ambulance Services Commissioner (CASC) and the Emergency Ambulance Service Committee (EASC).

The UHB will work closely with WAST in a number of areas over the course of this plan, but particular focus will be on delivering and embedding the new Clinical 5 Step Model - ensuring a clinically focussed approach that focuses on patient benefits and outcomes and the new 111 service.

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5.3.2 Velindre NHS Trust

The specialist tertiary nature of a number of UHB services means that the Cardiff and Vale UHB / Velindre NHS Trust relationship is a particularly important one. We are working closely as part of the Transforming Cancer Services in South East Wales Programme, with a shared principle of „Home First‟. This means inputting to both the Outline Business Case (OBC) for a new Velindre Cancer Centre; ensuring tertiary services are designed to meet the needs of the Cardiff and Vale population, and to the Programme Business Case (PBC) relating to the overarching clinical model aligning to the UHB programme for three locality based Local Health and Wellbeing Centres.

In addition the UHB is committed to supporting Welsh Blood Service‟s demand management approach in 2016/17.

5.3.3 NHS Wales Informatics Service (NWIS)

NWIS have a clearly set approach to deliver their 2016/17 – 2017/18 IMTP, which will be required to take into account local as well as national priorities. Their strategy is based on the principles of Prudent Health; that effective and efficient information systems will give: Welsh citizens access to information they need to support their own health and wellbeing; Empower People in Wales to co produce their own care with Health and Social Care providers including their families, carers, and Care providers the information they need to deliver better outcomes, more safely and more efficiently.

Through the sharing of IM&T programmes, a clear priority for both NWIS and the UHB has been identified as „keeping the lights on‟ with substantial support required from NWIS deliver this work. However, both organisations are clear that a transition is needed to focus strongly on using information more dynamically in support of improving outcomes. In addition we are looking at finding mechanisms to innovate and enable a step change in securing information technology to support health and wellbeing care delivery.

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These shared priorities will be progressed through continued working with the NHS Wales Informatics Management Board and regular local stakeholder meetings.

5.3.4 Public Health Wales (PHW)

We are working closely with Public Health Wales to plan and implement prevention and wellbeing programmes for 2016/17-2018/19. During Q3 and Q4 2015/16 a series of national workshops have taken place between PHW and and LHBs, on priority prevention topics. To date these have covered tobacco, childhood obesity and immunisation. The workshops have identified key areas for further work at national and local level, and ensure work undertaken by PHW and LHBs is aligned and avoids duplication or significant gaps in coverage. The key priorities for prevention outlined in sections 8.2-8.4 and detailed in the Local Public Health Plan for 2016/17-2018/19, and the UHB priorities set out in Shaping our Future Wellbeing, align with the six PHW priorities set out in „A healthier, happier and fairer Wales‟ strategic plan

An additional meeting took place in January 2016 between PHW and local public health IMTP leads to discuss and co-ordinate the approach to planning. These workshops and meetings will occur annually (with operational meetings throughout the year as required) to feed into the planning cycles of the LHBs and PHW.

These discussions support the regularly meeting of the Directors of Public Health for the seven LHBs and Directors from PHW.

Work has started on firming up the commissioning and partnership agreement with PHW.

5.4 Welsh Health Boards – Long Term Agreements

The UHB has Long Term Agreements (LTAs) with other Welsh Health Boards to reflect services provided by the UHB for residents of other Health Boards (for which income is received), and services provided by other Health Boards for Cardiff and Vale residents. In addition, the Welsh Health Specialist Services Committee (WHSSC) is the responsible commissioner for Specialised Services for Wales. As the main provider of Specialist Services in Wales, the UHB has material income flows in relation to these services in addition to expenditure to WHSSC relating to services for Cardiff and Vale residents commissioned on the UHB‟s behalf. Any additional activity required is undertaken at an agreed marginal cost rate.

The planning, procuring of specialist services is complex, and whilst lead by WHSSC on behalf of LHBs, has support and input from Executive Directors and other senior officers within the UHB. The UHB also has a team that works with other health boards in providing services to our residents as well as the UHB providing services to non Cardiff and Vale residents.

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The income and expenditure associated with these LTAs are summarised in the table below:

2015/16 LTA Income and Expenditure £m Commissioning Income WHSSC 191 Other Welsh NHS Organisations 83 Total 274 Commissioning Expenditure WHSSC 111 Other Welsh NHS Organisations 60 Total 171

This clearly shows that the UHB is a net provider of services and with regard to specialist and tertiary services provides a key partnership and supporting role to other commissioning organisations. The UHB does however need to ensure that it is properly reimbursed for the work it does for other residents and will be seeking an inflationary uplift to its LTA values in 2016/17. This intention has been shared with the relevant NHS organisations.

The UHB‟s financial plan is heavily influenced by its external commissioners and providers and the UHB is in close contact with WHSSC, NHS Trusts and other LHB commissioning teams to ensure, as far as possible, that our respective plans are aligned. This is especially important with WHSSC as it has the largest impact on both commissioned and provided services.

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The actions set out in this section are intended to make a measurable improvement to:

Strategic Theme – Our Population

1. Reduce health inequalities

NHS Outcome NHS Delivery Framework Measure The gap between the least and most deprived of the 6.1 Inequalities that may prevent percentage of the people with hypertension whose GP latest me from leading a healthy life are recorded blood pressure is 150/90 or less reduced Evidence of assessment and plans to identify and target needs of vulnerable groups of all ages in the local area

2. Deliver outcomes that matter to people

NHS Outcome NHS Delivery Framework Measure 6.2 My individual circumstances Implementation of the All Wales standard for accessible are considered communication and information with sensory loss 6.3 I get the care and support Evidence of compliance with the Welsh language Act through the Welsh language 4.1 I receive a quality service in all % procedures postponed on >1 occasion, had procedure care settings <=14 days/earliest convenience Evidence of lessons learnt from patient experience 4.2 My voice is heard and listened framework to Timely and responsive handling of concerns and complaints Number of GP practices teams that have completed mental health Direct Enhanced Service in dementia care or other 4.3 I experience a care system direct training where are participants are treated with compassion and respect Result of the Fundamentals of Care audit Incidence of patient violence on NHS staff

Strategic Theme – Sustainability

7. Reduce harm waste and variation sustainably making the best use of the resources available to us NHS Outcome NHS Delivery Framework Measure

Number of cases of C Difficile per 100,000 of the population

2.3 I receive a high quality safe Number of cases of MRSA per 100,000 of the population service whilst in the care of the NHS Number of avoidable hospital acquired thrombosis Number of healthcare acquired pressure sores in a hospital setting

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Compliance rate with national and Wales patient safety alerts and rapid response notices Of the Serious Incidents due for assurance within the month, % which assured in agreed timescale Number of Never Events Implementation of the universal case note mortality review process 3.3 Interventions to improve my % Crude Mortality health are based on good quality and timely research and best RAMI 2015 practice

6. Addressing Health Inequalities and Access

6.1 Addressing Health Inequalities

6.1.1 Context

Reducing health inequalities is a priority for Cardiff and Vale UHB and part of the organisation‟s overarching vision. The prevalence of risk factors, and outcomes for most illnesses, are strongly correlated with deprivation.

While work is being undertaken across Health Board-delivered services, in many cases to address the root cause of inequalities action must be taken on the wider determinants of health, such as housing, employment, education and the built and natural environment. Much of the work to tackle inequalities is therefore undertaken in the wider partnership arena, particularly with Cardiff and the Vale of Glamorgan Local Authorities, Communities First and local third sector organisations.

Actions to address health inequalities are designed to contribute to reducing poverty including child poverty and food poverty locally. The Health Board‟s long-term approach to inequalities will be also be reviewed during 2016/17 to ensure it aligns with and contributes to meeting the wellbeing goals, including „A more equal Wales‟ in the Wellbeing of Future Generations (Wales) Act 2015.

More information on health inequalities in Cardiff and Vale is given in Chapter 4, Local Health Needs and Challenges, and the Appendix.

6.1.2 Key programmes of work for 2016/17-2018/19

Key programmes of work to reduce health inequalities include:

Families First and Flying Start The UHB contributes significantly to Families First programmes in Cardiff and the Vale. In Cardiff, the Health Board leads delivery of two major packages: Early Years and Healthy Lifestyles. These packages include provision of

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targeted support for childcare, perinatal mental health, volunteer-led home based support, schools based counselling, domestic violence, sex and relationships education and outreach, and smoking prevention in schools. During the first year of the IMTP period potential risks and mitigations will be reviewed for different scenarios of future central funding for Families First. Flying Start provides targeted support to improve health and development of children aged 0-3 years in the most deprived areas of Cardiff and Vale, including targeted interventions from health visiting, speech and language therapy and dieticians. Outcomes: Increased access to early high quality 1-1 support, childcare, health and wellbeing advice for families in greater need in Cardiff, improving health and wellbeing and life chances of future generations.

GP cluster and neighbourhood partnership working Increased focus on local need, planning and actions, through nine GP clusters across Cardiff and Vale, and six wider neighbourhood partnership teams in Cardiff, including new Wellbeing Co-ordinators. Outcomes: Increased focus in LHB and cluster planning on sub-Health Board/LA level needs, tailored and targeted actions to local neighbourhoods.

Targeted actions to address risk factors for disease Comprehensive actions across key risk factors including tobacco use, diet, physical activity and alcohol, targeted at communities with higher prevalence of unhealthy behaviours. See Prevention chapter and Cardiff and Vale Local Public Health Plan. Outcomes: Reduced prevalence of risk factors for disease among local population, particularly in more deprived areas, with fewer new disease diagnoses and slower progression of existing disease.

Support for asylum seekers and refugees Provision of dedicated Cardiff Health Access Practice (CHAP) primary care service. Provision of community midwife responsible for asylum seeker service, and dedicated health visitor service. Providing a safe and sustainable service model for asylum seekers, refugees and other vulnerable groups. Outcomes: Easy access to high quality primary care services for asylum seekers and refugees; increased screening and reduction in safeguarding risks.

Welfare reform support Multi-agency support in Cardiff and the Vale for local residents affected by recent and forthcoming changes to welfare. As part of the integration with social services and housing, we will ensure more people are sign-posted to the right service, including accessing eligible financial support. Outcomes: Support to manage significant changes in personal finances, reducing potential for adverse impact on health and wellbeing.

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Targeted actions to improve immunisation uptake Detailed equity analysis of ethnicity and immunisation; black and minority ethnic (BME) community development programme, focusing on immunisations; in-house development and distribution of quarterly practice immunisation profiles, using data supplied by national PHW Vaccination Prevention Disease Plan team; on-going pilot of targeted postcard reminders translated into common languages spoken in Cardiff, using behavioural insights techniques, to raise uptake of early years and preschool immunisations. Outcomes: Improved immunisation uptake in preschool children, particularly those from more deprived areas and in BME groups; aiming to meet our national targets.

Targeted actions to address low birth weight Continued reduction in low birth weight (LBW) babies by addressing the root causes of LBW including smoking, sexual health and teenage pregnancy. This includes the provision of a substance misuse midwife and targeted interventions to reduce smoking in pregnancies (see 8.3.1). Outcomes: Reduction in low birth weight babies, particularly in more deprived areas, leading to better life chances, health and wellbeing for future generations in these areas.

Food Cardiff Award-winning Sustainable Food City programme, jointly funded by Cardiff Council, Cardiff and Vale Local Public Health Team and the Soil Association, to improve access to healthy and nutritious food within Cardiff, and reduce food poverty. Successful School Holiday Enrichment Programme (SHEP) run in summer 2015 to provide nutritious food, physical activity and learning during the school holidays, with positive evaluation findings, to be further expanded in 2016 Outcomes: Improved access to healthy, affordable food in Cardiff in a supportive environment, particularly among those from more deprived areas, contributing to an increase in household food security

Support for people with learning disabilities (LD) Develop and implement LD care bundle across UHB. Mirror child health transition service developments for children with learning disabilities, with those made in general paediatric transitions. Develop and improve LD primary and community care service model. Work with people with learning disabilities to develop programme for EPP (Education Programmes for Patients) Ensure pathways and access to special care dental services are clearly defined to improve access. Outcomes: Improved access to high quality services for people with learning disabilities.

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Addressing exploitation programme Safeguarding communities and protecting vulnerable individuals affected by sex work; and improve identification and support for victims of human trafficking. Outcomes: Improved engagement and access to health and wellbeing and prevention services by sex workers; early identification and support for victims of human trafficking.

Clinical Board programmes to reduce inequalities in access to services Systematic programmes within each Clinical Board to analyse equity of access to services in key clinical pathways, and put actions in place to reduce any inequities identified, including: o Community Mental Health Team review to balance resources to geographical need, which is related to deprivation. o Translation of mental health self help material into five common languages in Cardiff. o Investigation to review if BME groups are over-represented in secondary specialist mental health caseloads. o Review community therapy services against the C&V framework for health inequity, including outpatient based community services. o Improve links between primary care and Communities First programmes and develop a time credit approach in Primary, Community and Intermediate Care (PCIC) services. (Cardiff is the first „Time-banking City‟ in the UK recognising the significant contribution time-banking is now having in our communities (health impact indicators show significant reduction in demand for healthcare by those participating in time-banking activities.) o Continue transfer of services into community and development of community clinics. o Act on recommendations of Prison health needs assessment to improve health and wellbeing. o Provide fast track access to hospital services for serving military personnel in line with the national pathway. o Work with partners to improving signposting for military veterans to services such as veterans NHS Wales. o Continued development of community-based diabetes services. o Develop one stop breathlessness / heart failure clinic in one or two GP clusters. Clinics will be located in areas of highest deprivation. o Review access to secondary care heart failure clinics for people with severe disease. o Improve equity of access to renal dialysis through re-provision of dialysis units across Cardiff and Vale. o Act on recommendations of diabetic retinopathy needs assessment, with majority addressed by end of 2016/17, to improve equity of access to services. Outcomes: Reduced inequalities in access to specialist community and secondary care services

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The UHB, in common with the rest of NHS Wales, is a Living Wage employer so directly contributes to reducing in-work poverty by providing salaries above the statutory minimum wage.

In addition, as a significant provider of employment within Cardiff and Vale, Cardiff and Vale UHB have a number of apprenticeship roles in the organisation, and also provides a significant number of volunteering opportunities.

6.2 Strategic Equality Plan

The UHB always strives to put patients first. The UHB operates in one of the most ethnically and culturally diverse areas in Wales. Stakeholders, including the public, patients and members of staff, expect the UHB to be proactive about equality, diversity and human rights as well as meeting its obligations under the equality, diversity and human rights legislation. The UHB recognises that it also has a social, moral and ethical obligation to promote equality of opportunity and outcome, foster good relations and eliminate discrimination, victimisation and harassment and to uphold human rights principles.

During 2015/16 we have consulted upon a new four-year Strategic Equality Plan (SEP). We have developed a set of refreshed objectives by engaging with patients, staff, partners, equality organisations and other people. We have asked them what they thought the equality priorities should be for the Health Board. We also identified what research and information was already available to help in the development of the objectives.

For the refreshed objectives we also asked patients, staff, partners, equality organisations and other people if the previously set objectives described should be kept as they are, changed or whether we need to add new ones. An analysis of complaint letters, patient feedback forms and staff surveys were also considered.

This resulted in 4 clear messages: People are and feel respected; this includes patients, carers and family members as well as staff. We communicate with people in ways that meet their needs (whether this is through written communication, face to face, signage, Welsh or other community languages including British Sign Language). More people receive care and access services that meet their individual needs. Reduce any gender or other protected characteristic pay gap to promote equality in pay.

We aim to take these messages from our engagement and use them to form both our Strategic Equality Objectives for the next 4 years and develop actions to ensure these objectives are met.

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Progress will be monitored by linking our actions/improvements to each of the UHB strategic objectives. Every year we will continue to produce an Annual Equality Report which will show how we are doing. Previous reports can be found on the Health Board‟s website: http://www.cardiffandvaleuhb.wales.nhs.uk/equality-diversity-human-rights-policy

We will also hold workshop events twice a year so that we can continue to engage with relevant stakeholders. The responsibility for implementing the SEP falls to all employees, Board members, volunteers, agents or contractors delivering services or undertaking work on behalf of the UHB.

Examples of other key areas of work have included: In May 2014 the UHB Board approved the proposal to take a focused approach to an equality theme in 2014/15. Given the launch of the national standards it was agreed that a focus on sensory loss was timely and needed. This approach has been warmly welcomed and in December 2014 a Sensory Loss Workshop was held with Clinical Board representatives and external representatives from the third sector, local authorities and Community Health Council. The output of this workshop is helping us progress against the implementation of the All Wales Standards for Communication and Information for People with Sensory Loss. Progress against the UHB aim of being in the Top 100 employers Stonewall Workplace Equality Index (WEI). (At December 2014 the UHB was 102nd out of 380 organisations) – this had seen a progress increase in UHB‟s ranking from 293 in September 2011. The UHB has been named one of Wales‟ most gay-friendly employers, appearing in Stonewall Cymru‟s Top 10 Employers for the first time. We are the only Health Board/ Trust to do so. Progress with embedding the Equality Impact Assessment (EQIA) into service planning and decision-making. Equality and Welsh Language training delivered to GP and Practice Managers coordinated by PCIC. Welsh Language skills have been assessed in each GP surgery, and the information is publicly available on the UHB website. Establishment of a group led by the UHB Chair with a number of BME consultants to consider mentoring and support to increase opportunities in leadership, research and award.

6.3 Welsh Language

The UHB approved its Welsh Language Scheme in 2010 with the aim of providing good quality bilingual healthcare for the people of Cardiff and the Vale of Glamorgan.

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The UHB recognises that members of the public can express their views and describe their symptoms and needs better in their first language, and that enabling them to use that language is a matter of good practice rather than a concession. In context, 11% of the people who live in the Cardiff and Vale area are Welsh speakers and following recent audit work, it is estimated that 10% of the UHB workforce has welsh speaking language skills. Initiatives, such as lunch-time social meetings to explore opportunities for increased integration across Welsh Language across the UHB, have been launched to encourage and build confidence in staff to use Welsh Language in day-to-day interactions.

6.3.1 Welsh Language Standards

Due to the Welsh Language Measure 2011, the organisation‟s Welsh Language Scheme will be replaced in 2016/17 with the new Welsh Language Standards. The Welsh Language Commissioner will expect the UHB to comply with these standards, which cover all aspects of healthcare and public services provided. They will also expect the organisation to increase the opportunities for staff to use the language internally. These Standards have largely kept the original requirements of the Scheme but have strengthened them further, for example: Offering the choice of language of English or Welsh for patients; Providing appointments and consultations in their chosen language; and Bilingual information for patients and service users.

The Standards are expected to be introduced to the organisation in 2016/2017 and we are awaiting confirmation from the Welsh Language Commissioner of the range of standards we are required to comply with. A 30-day consultation period will follow this notification for the UHB to provide feedback on them. The Standards will help the organisation in the long term to improve the quality of services for patients/service users who prefer to speak Welsh.

The UHB is committed to ensuring the services patients receive, policies and initiatives are consistent with the Welsh Language Scheme and to support this the Equality Impact Assessment process includes a section to identify how service changes impact on welsh speakers. The UHB is committed to the Welsh Government More Than Just Words Strategy and has put in place Corporate and Clinical Board action plans to meet the requirements of the strategy and improve bilingual patient information, recruitment of welsh speaking staff, and education, awareness and training.

The Wayfinding Group, set up by the organisation to improve the quality of public signage, continues with its aims and objectives of developing best practice; examples of improved signage across the organisation can be found in the development of new capital projects:

New car parking complex at University Hospital Llandough; New In-patient mental health unit at University Hospital Llandough; and The second development phase of the Children‟s Hospital, UHW.

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The organisation has also taken steps to congratulate and support staff members who have provided excellent care through the medium of Welsh. The annual staff excellence awards have a specific Welsh language category for staff members who have been found to provide good quality healthcare or develop excellent practice.

6.3.2 Welsh Language Key Priorities for 2016/17

There are 4 key priorities for the UHB during 2016/17: Making further progress of the provision of bilingual patient information leaflets and letters. Although we have achieved some recent progress it is recognised that we have a long way to go with this work. A detailed roll out plan had been put in place to deliver against this commitment during 2015/16 and this is being monitored through the Equality, Diversity and Human Rights Committee. Development and implementation of the UHB Bilingual Skills Strategy. The continuing development of the More than Just Words Strategy (Welsh Language in Healthcare Framework Strategy), including the development of active choice for patients and services users. Replacing the Welsh Language Scheme with the Welsh Language Standards and undertake baseline assessment to enable implementation.

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7. Quality, Safety and Patient Experience

7.1 Context

The quality of the care that we provide for patients continues to be a central focus to all that we do in the UHB. During 2015/16 we focused on responding to patient safety and quality issues raised through the following: „Trusted to Care‟ – with our own extensive review of the issues this raised, and assurance about our own position; Feedback from our internal „inspection‟ processes and assurance mechanisms, including the Board safety Walkrounds, and our ward Board Rounds; Responding to issues raised through our complaints and concerns, and incident reporting; and Mortality reviews, with focused work on particular areas of concern.

In responding to these issues our focus has been to improve our assurance mechanisms, ensure lessons are learnt and improvement actions are completed, and build the capacity and capability of our staff to improve patient care, through initiative such as LIPS - Leading Improvements in Patient Safety.

There has also been a significant focus on infection prevention and control – including hospital acquired infections, and whilst good progress has been made – particularly in relation to Clostridium Difficile (C Diff) – we have an action plan to further improve the position, recognising that some of our poor infrastructure has a significant impact.

We have also strengthened our approaches to listening to patients at many different levels, from engaging patients in the shaping our future models of service delivery (as per the development of our clinical services strategy), to completing our „two minutes of your time‟ surveys to get real time feedback on the care people are receiving.

7.1.1 National Context

Together for Health published in 2011 remains the overarching strategic direction for the NHS in Wales. It reflected on the importance of bringing a sharper focus on quality and set the ambition that „over the next five years, systems for assuring high quality care will match the best in the world‟. The Quality Delivery Plan 2012 – 2016 (QDP), described how the new quality improvement and assurance arrangements would operate in achieving this vision of excellence and how they would ensure better alignment of quality, performance and financial goals. We have been working within these frameworks to inform and drive our own quality and improvement work.

We acknowledge that the pressure on resources has never been greater which means that it is critical for us to ensure our staff work together in teams across all disciplines – clinical, managerial and financial. While it is accepted that services

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The principles which underpin the Quality Delivery Plan are fully embedded within the UHB: Quality is key to the operating framework for the UHB, underpinned and aligned with financial, workforce and information plans and goals; Quality drives service and system improvement; Service delivery is focussed around the needs of the person - patient/ service user and not those within the organisation; Robust processes will be in place to provide assurance; Streamlined data collection – provided once, and put to multiple use; Alignment with social care and other partners to ensure that the care and treatment takes a whole person perspective; and Absolute transparency and information sharing with the public.

Safe Care, Compassionate Care – A National Governance Framework to enable high quality care in NHS Wales published in 2013, sets out the NHS Wales response to the Francis report with a pledge to build on the progress made and to ensure that the system is: Providing the highest possible quality and excellent patient experience; Improving health outcomes and reducing health inequalities; and Getting high value from all our services.

These are all reflected in the overarching strategy for the UHB which we have refreshed and refined this year.

The delivery of safe, high quality care is not just about systems, but also the culture, values and behaviours that exist within the organisation. We understand that it is this which has the greatest impact in ensuring all patients and service users get the very best standards of care. The Board is committed to ensuring that an appropriate culture exists and is cultivated within the organisation and that it reflects the core values of NHS Wales. This is reflected in the values of the organisation, our revised strategy which aims to ensure that we provide a great place to work. We want to know that: Staff put quality and safety above all else: providing high value evidence based care for our patients at all times; Improvement is integrated into everyday working and that we take positive steps to eliminate harm, variation and waste; We focus on prevention, health improvement and inequality as the key to sustainable development, wellness and wellbeing for future generations of the people of Cardiff and the Vale; We work in true partnership with partners and organisations and with our staff; and finally that We invest 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.

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Achieving Excellence – the Quality Delivery Plan for NHS Wales from the Welsh Government places improving patient and user experience central to the day-to-day activities of NHS Wales. This is reinforced and implementation is supported in the 1000 Lives Plus publication „The Listening Organisation‟, which describes what is important to our users and why and how we should listen and act on the feedback.

„Trusted to Care‟ published in June 2014, followed an independent review at two hospitals in Abertawe Bro Morgannwg University Health Board into concerns raised about standards of care and practice. Specific issues of concern related to: Giving patients medication; Ensuring patients were adequately hydrated; Overuse of night sedation; and Continence care.

In response to the report a number of internal unannounced visits and inspections were carried out by UHB Board members, senior managers and senior and lead nurses. More recently we have carried out a series of unannounced inspections in Mental Health Services for Older People. Members of the Community Health Council were also involved. This has provided assurance that the failings identified in the Trusted to Care report have not been identified in our Health Board. However, we will not be complacent on this issue and unannounced visits, inspections and Safety Walkrounds continue to form an important part of our internal assurance mechanisms.

In March 2014, Welsh Government published the Evans report “Using the Gift of Complaints”. This described the concerns process, which is often felt to be unfathomable to the public, slow in response and implementation of action(s); often with no transparent learning from issues raised. The report made numerous recommendations, which are being taken forward by an All Wales group on which the UHB has representation.

More recently concerns in relation to the provision of mental health services in Wales, led to a series of unannounced visits from Welsh Government and the Community Health Council. No significant issues in relation to patient care were identified but again there is no room for complacency.

7.2 Patient Quality and Safety

We aim to continue to drive quality improvement through a system that provides robust quality assurance. To this end we are taking forward a number of actions, targeted to the areas of greatest risk. We have a significant and challenging Patient Quality, Safety and Experience agenda to progress across the organisation. We have already embedded arrangements to respond to the actions aligned to the strategic direction of NHS Wales and progress against these actions is being monitored through the Quality, Safety and Experience Committee of the Board, which has a comprehensive work programme developed to meet the requirements of national strategic drivers, as well as key quality and safety issues in the Corporate

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Risk Assurance Framework and the Healthcare Inspectorate Wales (HIW) Work Programme.

However, we recognise that like all NHS organisations the need to continue to pay increased attention to how we are going to improve the quality and safety of the services we provide as well as ensuring an excellent patient experience. What really matters for our patients, carers and citizens must be central to our decision making, so that we can use our time, skills and other resources more wisely.

Our staff and those who we commission services from take this responsibility very seriously, and whilst we are rightly very proud of the excellent care provided in the majority of cases, there are times when we do not always provide the level of care expected or required.

There is compelling evidence that while healthcare brings enormous benefits to us all, errors occur and patients are harmed.

Patient Quality and Safety Priorities

Areas for targeted action during 2016 -2017:

Actions to drive quality improvement which will include: Further embedding and delivering the requirements set out in Delivering Safe Care, Compassionate care; Continuing to support Clinical Boards to ensure that patients and service users are at the centre of all that we do as equal partners; Implementing and embedding the revised Standards for Health Framework; Securing year on year increases in patient and staff satisfaction; Increasing the numbers of staff with improvement skills within the UHB; Strengthening the ways in which we manage and respond to the findings of large national evidence based reports and NICE Guidance; and Strengthening of the current approach to Safety Walkrounds so that they are focused,themes and trends are identified and used to improve the quality of services.

Actions to drive quality assurance which will include: Reacting and responding to the findings of external inspections to ensure that key themes and issues are identified and addressed; Ensuring that there are robust processes in place to provide our Board, Clinical Boards and teams with timely and meaningful information not only on our own services but also on those we commission from others; In addition to the agreed national Tier 1 priorities, the UHB will also introduce and monitor a range of quality indicators, which will be adapted as quality triggers to inform its Annual Quality Statement; Continue to develop the open and transparent culture for reporting the number of incidents and serious incidents reported.

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Further embedding of Quality assurance within our internal Performance Management arrangements; Strengthening the function of Clinical Audit so we gain continuous assurance that the services we are delivering are patient centred, evidence based, safe and are delivering excellent outcomes for our patients in line with or exceeding national best practice; Further development of mortality reviews to enable more senior medical input; and Developing a framework of nursing performance indicators, which will demonstrate the provision of high quality nursing care within the Health Board. The intention is to provide ward-based staff with an “at a glance” view of their performance building on a combination of existing and new key indicators. Work has already begun on this.

7.3 The Patient Experience

National and local evidence shows that the three, key determinants of a good patient experience are: First and lasting impressions of a service or care, including being treated with dignity and respect; Being cared for in a safe, supportive environment; and Being involved and understanding the care and treatment provided

The Health Board has an integrated system in place to ensure that it listens to all the feedback it receives through “Putting things Right”. Formal and informal concerns are analysed to identify the key themes, using the national service user experience framework and these are linked with the UHB improvement methods and processes to address the commonly occurring themes across the UHB. This results in our ability to truly demonstrate learning alongside demonstrable improvements in patient experience.

During 2015/16 we focused on adopting a strategic approach to learning from patient experience feedback in partnership with Clinical Boards and other corporate departments to support and improve how we care for people. The Patient Experience Team currently provides services to support the UHB Clinical Boards, which includes: An integrated system in place to ensure that it listens to all the feedback it receives through “Putting things Right”, that formal and informal concerns are analysed to identify the key themes, using the national service user experience framework and that these are linked with the UHB improvement methods and processes to address the commonly occurring themes across the UHB – resulting in the UHB being able to truly demonstrate learning alongside demonstrable improvements in patient experience. A Central concerns team which aims to resolve informal concerns quickly and can signpost patients to appropriate support where necessary – this will

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directly impact on the number of formal concerns received and which need to be investigated by the Clinical Boards; A PALS lead has been appointed to further develop the advisory service over the next year. A sustained carers support, information and involvement framework, delivered in collaboration with third sector and local government partners, that is understood and utilised by all staff coming into contact with carers and the people they support – resulting in more carers feeling that they are involved in decisions about the care of those they care for, focusing on early recognition of carers and proactive involvement in specific areas e.g. discharge planning. Volunteers in hospital and community settings who are available to complement and support clinical staff in their delivery of care as well as providing additional support ensuring they enhance the patient experience. The Health Board continues to develop and deliver a single, clear vision for person centred care, with strong leadership and direction brought about by a close, integrated working relationship between clinical boards and the skills and expertise in Patient Experience, Corporate Nursing, Quality and Safety, Innovation and Improvement and Learning Education and Training

Based on known growth factors (Chapter 4) demand for services and support will continue to grow over the coming years. The ageing population and resource reductions will bring increased demands for example in volunteering support. It is predicted that more people will want to access reliable, accredited information about their condition, choices and treatments and there is an increasing demand for information on non clinical issues such as welfare benefits, bereavement support, relationships and money management.

The number of unpaid carers has risen by 10% since the last census and is expected to continue to rise. This is almost certainly an under-estimate, as many people do not recognise themselves as carers. The number is therefore expected to rise as there is greater awareness amongst staff and the public as to who is a carer.

The UHB vision for the Patient Experience and Concerns is that during 2016/2017 the UHB will have in place a comprehensive range of feedback methods to ensure that: A sample of patients and service users in each service area are regularly asked for their views using the national survey with the results available „real time‟ to frontline staff incorporating Clinical Boards. Public events continue to be held in conjunction with Third Sector Colleagues ensuring that all patients and service users are made aware of the importance that the Health Board gives to their views, and are given the opportunity to share their experience through a wide range of mechanisms. Demonstrating that the UHB wants to „Hear the Voice‟ of the public. A number of annual themed large scale surveys are carried out. The widespread use of patient stories and the feedback from patient groups and third parties is embedded within Clinical Boards. There is a reporting framework for frontline staff, clinical services, the Board and the public to share the outcomes of feedback and actions taken.

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An infrastructure is in place that supports Clinical Boards to respond to concerns in a timely and appropriate manner whilst being aware of themes arising from concerns. There is greater use of IT to ascertain „real time‟ feedback, complimenting paper surveys.

Success will be determined by the measures of patient experience improving, formal concerns relating to the patient experience reducing and an indication that the general public demonstrate increasing confidence in the services we provide.

7.3.1 Patient Reported Outcome Measures (PROMs) and Patient Reported Experience Measures (PREMS)

Patient Reported Experience Measures (PREMS) and Patient-reported Outcome Measures (PROMS) are methods which together can ascertain patients‟ views of symptoms, functional status, quality of life and patient experience.

The UHB has longstanding experience of using a methodology to gather PROMS and PREMS data via the Health Improvement and Patient Outcome (HIPO). This process historically was initially developed on a cost neutral basis due to the attraction of commercial support.

PROMS have been used in England, for example within the elective surgery areas of hip or knee replacement, groin hernia repair, and varicose vein surgery. Within the UHB we currently use PROMS in hip and knee surgery.

7.3.2 Patient Experience and Concerns Priorities for Services

Areas for targeted action during 2016-2017 include: Ongoing implementation of the Framework for Assuring Service User Feedback (Tier 1 target), ensuring the opportunities to feedback are extended. Increasing the number of UHB volunteers and roles undertaken to enhance the patient experience. Introduction of an additional Information and Support Centre at Barry Hospital adopting the model utilised at UHL, engaging further partners from the Third Sector to support. Early identification and support of Carers in line with the Social Services and Wellbeing (Wales) Act 2014 that will be implemented April 2016. Robust application of „Putting Things Right‟ regulations pertaining to Concerns, Claims and Personal Injury e.g. improving 30 day response times and implementation of a Concerns training programme. Increasing the resource available to manage and co-ordinate the Volunteering and Carer‟s agenda.

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7.4 Mortality

7.4.1 How are we doing?

In June 2014 Professor Stephen Palmer published his report and independent review of the risk adjusted mortality data „RAMI‟ for Welsh Hospitals considering to what extent these measures provide valid information. Amongst his many conclusions was the fact that there are major problems in trying to derive any meaning from (Risk Adjusted Mortality Index) „RAMI‟ in Wales and that the data are „not a meaningful measure of quality of care‟. The extent to which statistics and in particular the use of single figures and data sets actually help our learning and identify problems of care is highly questionable and may not be a meaningful measure of quality of care.

Reporting to the UHB Board will continue on:

Crude mortality (i.e. number of deaths) based upon rates of hospital activity (measured in hospital “spells”); and Condition specific mortality rates. Trends in performance over time and the condition specific mortality rates are shown in the figures below:

Welsh RAMI 2014 Statistics 120

100

Wales UHW UHL

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Crude Mortality Rates for Cardiff and Vale UHB

2.0%

1.8%

1.6%

1.4%

1.2%

1.0%

UHB UHW UHL

Cardiff and Vale UHB Condition Specific Mortality Rates

Condition Specific Mortality Rates 20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0%

Heart Attack Stroke Hip Fracture

7.4.2 What actions are we taking?

Through the combined work which has been ongoing throughout Wales, a Universal Mortality Review tool (UMR) was developed to standardise information collected from reviews and to identify potential causes of concern (Stage 1 review) for which a more in-depth second stage review should be carried out. In Cardiff and Vale UHB this has been done by the doctor writing the death certificate who are mostly junior doctors. Thus the quality of the reviews was questioned but it fitted into an already

Page | 74 established process and did not compromise it. There will be a review of current processes to enable greater input in to mortality reviews and death certification details by consultants/other senior clinicians.

The Electronic Mortality Audit Tool (EMAT) launched in September 2014 enables the recording of Death Certification details and the recording of both Level 1 (universal mortality reviews) against the patient record in and alongside the Patient Management System (PMS). Information is available at UHB, Clinical Board, Directorate and individual consultant level, thus providing more comprehensive and useful clinical information to inform Level 2 reviews and mortality and morbidity meetings. If the system is maintained it provides up to date performance information. There will be regular reporting of outcomes to the Quality, Safety and Experience Committee.

The quality of mortality reviews and causes of death on the death certificates will be improved by reviewing the process and enabling more consultant/senior clinician input.

The UHB continues to work with the Welsh Government and other LHBs to finalise a suite of mortality measures. We are undertaking targeted work of National Audit outcomes at a UHB level. This includes work around the National Audit for Fractured Neck of Femur and also soon to be published the National Emergency Laparotomy Audit (NELA) which is leading to considerable changes in working practice in general surgery. This is in addition to work at Clinical Board and Directorate level where we are monitoring responses to the National Audit outcomes.

7.5 A Framework for Patient Safety, Quality and Experience

The UHB is currently working with key stakeholders including the Community Health Council and UHB staff to develop a Quality, Safety and Improvement Framework which sets out a strategy to deliver the required improvements and to further embed a culture of openness and improvement across the organisation. The framework will set out how we will drive quality improvement within the UHB supported by a reliable system of quality assurance.

The Berwick Report 2013 – „A promise to learn – a commitment to act - Improving the Safety of Patients in England‟, summarises the safety and quality issues being faced by the NHS on a daily basis. The framework will set out how we will deliver the recommendations of the Berwick Review and improve our systems to: Listen to and learn from the voices of staff and patients; Provide strong leadership; Build capacity and capability within our workforce so that we build on our strong culture of learning and further develop staff who have the skills to deliver quality improvement; Measure patient safety, quality and experience and improve the way that we analyse and triangulate data to help support quality improvement; and

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Increase our organisational learning and the more rapid spread of learning.

The UHB is committed to create staff capacity and capability in leading improvements for patient safety, to deliver the outcomes that matter to people. The introduction of Leading Improvement in Patient Safety (LIPS) is contributing to the UHB patient safety improvement capability, based on the work of the Institute for Healthcare Improvement (IHI), the work of the Health Foundation through its Safer Patient Initiative (SPI) and more recently the NHS Institute‟s own programme of LIPS.

This targeted and focused learning concentrates on how to improve safety and helps staff to acquire a skill set that is heavily associated with higher quality outcomes and lower cost. Skills delivered through LIPS include: Effective leadership skills; Collaborative problem solving skills; Improvement skills; Communications skills; and Non-technical human factor management skills.

There have been two cohorts per year with about 100 staff in each leading to 400 senior clinicians, managers and frontline staff completing the programme during 2014/15/16. Further similar sized programmes are planned for 2016/17.

Ensuring we are meeting required standards of effective care is vital. The evidence that reliable care processes lead to improved outcomes is often well understood, but not translated consistently into practice. Monitoring key areas where the process/outcome link is clear is an effective indicator of a wider commitment to delivering consistent care standards. The UHB will introduce an agreed set of measures to assess whether we are providing safe care. Safety measures can never be fail-safe, and can always be improved. Improvements should be detectable in reductions in avoidable mortality and harm while recognising that increasing levels of incident reporting can also be a strong positive indicator of safety awareness and focus.

The following areas are where quality triggers will be focused: Incidence of failure to observe patients i.e. National Early Warning Scores (NEWS) scores not done; Incidence of failure to act on deteriorating patients, measured through NEWS scores; Incidence of sepsis; Incidence of Venous Thrombo Embolism (VTE); Health Care Associated Infection (HCAI) clusters; Incidence of pressure ulcers; Increasing Crude and/or Risk Adjusted Mortality Indicators (RAMI) or specialty mortality rates; Incidence of failure to complete mortality reviews; Clusters of themes from mortality and harm reviews;

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Low levels of incident reporting; Incident and near miss reporting clusters; Complaint/concern clusters; Negative or deteriorating feedback from feedback gained via application of the National Service User feedback framework; Negative or deteriorating feedback from Fundamentals of Care (Health Standards) audits; Negative feedback from unannounced Dignity and Essential Care Inspections and WG Trusted to Care inspections; and Negative feedback from internal dignity spot-checks; Low levels of engagement in user feedback initiatives.

Many of the actions set out in this section were reflected in the Annual Quality Statement for 2014-2015 and will be reported next year in our Annual Quality Statement for 2015-2016. We set out the statement focusing our actions in seven areas: Staying Healthy; Providing safe care; Effective care; Timely care; Treating people as individuals; Dignity and respect; and Our staff and volunteers.

7.6 Infection Prevention and Control

Two key Welsh Government documents underpin the work of the UHB: Commitment to Purpose: Eliminating Preventable Healthcare Associated Infections (HCAIs). December 2011. http://wales.gov.uk/docs/dhss/publications/111216commithcaien.pdf; and Code of Practice for the Prevention and Control of Healthcare Associated Infections. June 2014 http://wales.gov.uk/topics/health/cmo/publications/cmo/2014/cmo- june14/?lang=en .

Our approach to reducing HCAIs is to ensure that it is everybody‟s business and a zero tolerance of preventable infections is expected within the UHB. The Welsh Government code of practice outlines the minimum necessary arrangements and standards for NHS organisations and we have adopted these.

Following the publication of Commitment to Purpose we developed an action plan, which was monitored through our Infection Prevention and Control Group. The reorganisation to form Clinical Boards necessitated a change of approach and a framework document incorporating the requirements of the two documents above was agreed with the Clinical Boards in September 2014. During 2015/16, we have been working to translate the framework into practice across the whole system and to provide appropriate specialist support to the organisation. The framework will be

Page | 77 refreshed in early 2016 following review meetings with the clinical boards in Autumn 2015 and will incorporate the new reduction expectations for C. difficile and Staph. aureus bacteraemia (MRSA and MSSA) issued in WHC/2015/058 (30th November 2015).

7.6.1 Review of progress against NHS Delivery Framework standards for HCAI set over 18 month period April 2014 to September 2015:

Against the baseline figures for the financial year 2012/13, the targets set were to achieve a population based rate of 31 cases of C. difficile per 100,000 population and 2.6 cases of MRSA bacteraemia / 100,000 population by end September 2015.

C&V UHB‟s position at end September 2015 was as follows:

C. difficile: In 2012/13 the rate for C. difficile cases for the health board was 71 per 100,000 population. The rate achieved for the target period was 35 (28 cases more than the required case number to achieve the target); this is however a 51% reduction in rate. Our efforts in achieving this significant reduction was commended.

MRSA bacteraemia: In 2012/13 the MRSA bacteraemia rate for the health board was 6.1 cases per 100,000 population. The rate for the target period is 7.3 cases per 100,000 population, which is a 20% increase compared to the baseline. Our rate for the current financial year (April to November 2015) has however reduced substantially to 3.7 / 100,000 population.

MSSA bacteraemia. MSSA (Methicillin-Susceptible Staphylococcus aureus) bacteraemia was not specifically targeted under the tier 1 targets for April 2014 – September 2015, but were still monitored through the same reporting system. Figures for MSSA bacteraemia are shown below for the same time period:

On average 12 cases of MSSA bacteraemia are diagnosed every month across the Health Board.

7.6.2 How we compare with other Health Boards in Wales:

The tables below show the end of target position of all the Health Boards for C. difficile and MRSA bacteraemia.

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Current position to end November 2015 (financial year April 2015 to November 2015)

WHC/2015/058 was issued on 30th November 2015 providing the Health Board with the C. difficile and Staph. aureus bacteraemia HCAI reductions required by March 2017.

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The five major health boards which includes the UHB are to ensure a rate of: NO more than 28/100,000 population of C. difficile is delivered in the final six months of the reduction period (1st October 2016 – 31st March 2017); and NO more than 20/100,000 population of Staph. aureus bacteraemia in the final six months of the reduction period.

The setting of a combined reduction expectation for all Staph. aureus bacteraemia, including MRSA and MSSA bacteraemia, is aimed at tackling the increasing trend in MSSA bacteraemia seen across the UK. Reductions are however expected in both MRSA and MSSA bacteraemia.

The tables below show how this translates into expected monthly cases of C. difficile and Staph. aureus with data for the other health boards also for comparison:

To achieve the set reductions the UHB will have to deliver 11 or fewer cases of C. difficile per month and 8 or fewer cases of total Staph. aureus across the whole health board.

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In order to keep our patients and staff safe from the risk of HCAIs we are taking the following actions: Ensuring that evidence based practices to reduce the incidence of infection are implemented consistently across the organisation: Hand hygiene; Insertion and maintenance of medical devices; Reduction of Surgical site infections through implementation of NICE guidance; Effective decontamination of all reusable medical devices, for example surgical equipment, endoscopes and ultrasound probes; Ongoing training of staff in practices to prevent HCAIs and the spread of infections; and in the use of personal protective equipment to protect them; Rapid Investigation and management of outbreaks; Appropriate placement of patients with infections in the organisation to prevent onward spread of infections; Effective cleaning of the environment; Developing an environment that minimises the risks of infection; and Practice of Antimicrobial stewardship to minimise the risks of antimicrobial resistance and C. difficile disease.

Specifically to address the C. difficile and Staph. aureus bacteraemia burden we are undertaking the following work:

C. difficile: As shown above we have seen improvement in the overall burden of C. difficile, but are facing a significant challenge to reduce further. Following the increased number of cases seen in September 2015, data for the first six months of the financial year has been reviewed and hot spots identified.

Improvement groups are being developed in these areas to focus on the following key areas: Antimicrobial usage in these areas; Treatment of cases of C. difficile; Testing and isolation of patients; and Cleaning and IP&C measures (hand hygiene).

We are also reviewing our recurrence rate and evaluating more effective use of Fidaxomicin, as well as exploring improving the therapy of recurrent cases with faecal microbiota transplantation (FMT).

MRSA and MSSA bacteraemia:

Since June 2015 we have introduced PVC insertion packs, which are being embedded across the Clinical Boards. This work will be further supported by the implementation of Aseptic Non-Touch Technique (ANTT), which is a priority for 2016/17.

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The CEO chaired MRSA bacteraemia Root Cause Analysis (RCA) reviews will continue, with lessons from these sessions being extended to consider MSSA challenges also.

Whilst the tier 1 targets or reduction expectations focused on C. difficile and Staph. aureus bacteraemia are useful indicators of performance in HCAI prevention; there are many other challenges across the broader burden of healthcare associated infections.

The recent closure of the Neonatal Intensive Care Unit (NICU) due to an outbreak of Acinetobacter baumanii and Enterobacter cloacae demonstrates clearly that spread of resistant infections amongst our most vulnerable patients can bring a service to a halt with severe disruption across the network.

Key risk areas are: Emerging resistant organisms such as Carbapenemase producing enterobacteriacea and multi-drug resistant Acinetobacter; Decontamination issues; Water Safety; Infrastructure / Isolation facilities; and Cleaning.

Areas for targeted action during 2016/17: Implementation of ANTT and PVC insertion packs across the Health Board. Effective learning from RCA process with resultant interventions to reduce the burden of Staph. aureus bacteraemia and C. difficile cases. Antimicrobial stewardship, implementation of the Antimicrobial Delivery Plan. Implementation of Carbapenemase Producing Enterobacteriacea (CPE) / Multi-Drug Resistant Policy and accompanying screening protocol. Continue to address findings of the All Wales Decontamination Audit and engage with repeat audit. Fully implement the recommendations of the Welsh Government document “Decontamination of Medical Devices: a development plan for healthcare organisations”. Continue to work toward full compliance to decontamination requirements described in Health and Care Standard 2.4 Infection Prevention and Control (IPC) and Decontamination. Implement revised Water Safety Plan. Support innovations in cleaning and decontamination. Include HCAI issues in the wider quality improvement programmes of the health board as they contribute significantly to service delivery issues and winter pressures.

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7.7 Operational Services Quality and Patient Experience

Our Facilities services (housekeeping, catering, portering and routine estates maintenance) play a vital role in providing a good patient experience, and contribute to the quality of the care we provide to patients and their carers. Our operational services operate a site management model allowing site users to have a single point of contact for any query. The main priorities for services in 2016/17 are:

Service Priority Improvement in Quality and Patient Experience Maintaining and replacing Equipment works more efficiently, ageing plant and patient care and experience will not be equipment that becomes compromised by old equipment older, less reliable and continually breaking down. This will prone to breakdown. also allow estate maintenance staff to respond quicker to other demands for their services.

Meeting client Contributes to a balanced financial Estate expectations from within position and an improvement in the Maintenance available resources patient experience. (recognising that resources benchmark well below Wales and UK levels).

Implement Service Board Combined service model leading to to ensure integration to integrated approach to service delivery. services. Helipad Increasing the availability Service faces the possible increase in of Fire Fighter and patient activity if the UHW becomes the Rescue staff to meet the Major Trauma Centre as per the NHS demands of night Wales Health Collaborative. There is landings. the risk of non-compliance with Civil Aviation Authority regulations if there are insufficient suitably trained fire fighters. By increasing the number of suitably trained staff through flexible roles and retraining, an increased number of severely injured patients will be able to be transported by Air Ambulance to a major trauma facility for treatment.

Continued implementation This will mean all ward housekeeping Housekeeping of Free to Lead Free to staff will be the direct responsibility of Care. Nurse in Charge. This will allow the

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Service Priority Improvement in Quality and Patient Experience ward staff to decide on areas that require cleaning and the housekeeper being integrated into the ward team.

To improve public area Undertake audit and complete action cleanliness. plan.

Modernise roles to This will result in a flexible multi support service disciplined motivated workforce able to developments in new undertake a number of tasks. The builds and improve initiative will be taken forward in flexibility of service partnership with staff representatives delivery in all areas. with the aim of providing improved services to patients, staff and visitors.

Assess the benefits of Greenvale were successful with a linen tagging system „spend to save‟ bid to Welsh employed by Greenvale Government for a linen tagging system. Laundry. The benefits to the UHB will include being able to track linen losses which in turn will allow the Laundry to return Linen more clean linen more frequently to the UHB. This should reduce linen shortages, improve the patient experience and the quality of care provided to patients.

Achieve a minimum Food At an inspection the Environmental Standards Agency rating Health Officer (EHO) will check three of 4 or above. elements; how hygienically the food is handled, the condition and structure of the building, and how the business manages what it does. A Food Safety Agency rating of 4 is classed as Good Patient with the maximum rating being 5 and Catering Very Good.

Review and evaluate Physical footprint and location at UHW option of transferring limit the ability of the unit in patient catering Central streamlining processes and expanding Processing Unit services service to cover retail outlets. to UHL. Planned replacement Continuity of service. Patient programme for ward Catering based kitchen equipment.

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Service Priority Improvement in Quality and Patient Experience Continue a ward based This is a significant cost pressure but it service to previously is important to patients that whilst in unfunded areas such as hospital they receive a nutritious meal EU and Suite 19. service.

To provide a menu in line All menus have been analysed by and fully compliant with dietetic staff to ensure compliance with the All Wales Menu Nutrition standards and texture Framework that meets modified meals comply with therapeutic dietary and therapeutic requirements. The All Wales Menu needs. Framework is based on previous work piloted and implemented by the UHB.

Support the unscheduled By ensuing that sufficient porters are care pathway. available to EU it will assist in reducing the number of delayed transfers from EU to the ward.

Portering Development of 2 way Leaner service which will increase radio service. response times.

Develop integrated porter Porter/Cleaner. roles. Achieve a minimum Food At an inspection the EHO will check 3 Standards Agency rating elements; how hygienically the food is of 4 or above. handled, the condition and structure of the building, and how the business manages what it does. A FSA rating of 4 is classed as Good with the maximum rating being 5 and Very Good. Introduction of Improvement in the facilities offered to convenience store at UHL patients, staff and visitors. The Restaurant Plaza. convenience store will be managed by Services the NHS with all profits being reinvested in the service. The store will also contribute to the rehabilitation of Hafan y Coed patients by offering a village shopping experience.

Implement Public Health Ensure that healthy eating options are agenda and „UHB available at all catering outlets Restaurant Services and operated by the UHB and in retail units Retail Outlet Standards‟. managed by the UHB.

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Service Priority Improvement in Quality and Patient Experience Smooth transition of The transfer of HCS to shared services Hospital Courier Service will see an investment in technology to (HCS) to Shared Services meet the performance needs of the as per outcome of UHB. This will include service McClelland Review. provision to support the National Transport Pathology Review.

Review of staffing grades This is a joint venture with Cardiff at Joint Equipment Council. Council staff are currently paid Service. a higher band NHS staff.

Achieving full compliance Reduces the risk of prosecution by with waste segregation in Natural Resources Wales and ensures line with the Hazardous that the UHB meets Welsh Waste Legislation. Governments Green Agenda. Appropriate segregated waste reduces the risk to patients and staff of sharps Waste injuries. Management

Implementing Cardboard There is a significant financial savings Sharp boxes for IV giving from this scheme, which will contribute sets. to the UHB financial savings for reinvesting in patient care.

7.8 Safeguarding

Safeguarding is everyone‟s responsibility and all staff who, during the course of their employment have direct or indirect contact with children and families and adults at risk, or who have access to information about them, have a responsibility to safeguard and promote the welfare of children and adults at risk.

The Safeguarding Children Team and the Senior Nurse for Safeguarding Adults have now co-located, coming together to provide an integrated corporate safeguarding service. The team continues to provide assurance to the Board that the UHB is discharging its duties in line with Standards for Health in Wales, Standard 11 as well as conforming to UK legislation and WG guidance such as The Children‟s Act (1989) and (2004) and The Wales Interim Policy and Procedures for the Protection of Vulnerable Adults from Abuse (2013).

The Safeguarding Team delivers a comprehensive safeguarding training programme and provides safeguarding supervision to health Designated Lead Managers, nurses, midwives, health visitors, doctors and others involved in safeguarding cases. Section 28 of the Children Act 2004 places a duty on agencies to ensure their

Page | 86 functions are discharged with regard to the need to safeguard and promote the welfare of children. The Safeguarding Team will continue to support the UHB in the discharge of its statutory functions across the four key areas of training, supervision, advice and support, and audit.

Training is a key priority for the Safeguarding Team to ensure that the Clinical Boards and front line staff are aware of the current safeguarding agenda and have the knowledge and skills to signpost patients to relevant expert services. Safeguarding children and adults relies on effective interagency working and as such the Safeguarding Team works collaboratively with partner agencies that include the local authority, education, probation and the police, to ensure the best outcomes for children and vulnerable adults.

Both Cardiff and Vale Local Safeguarding Children Board‟s (LSCB) have recently merged to form the Cardiff and Vale of Glamorgan LSCB, and a key priority for the Safeguarding Team will be to continue to support the merger and to ensure effective multiagency working continues, along with effective representation on the LSCB and its sub-groups. It will be necessary to follow a strategic approach in partnership with Clinical Boards to ensure that there is a two way exchange of pertinent information, and that this information is disseminated and acted upon appropriately, by the Clinical Boards.

The Executive Nurse Director is the UHB representative on the LSCB; the Deputy Executive Nurse Director along with the Named Doctor for Safeguarding Children are also members of the Board. The Deputy Executive Nurse Director is a member of the Local Safeguarding Adult Board (LSAB); members of the team will continue to contribute to all of the sub-groups and task and finish groups that come under both the LSCB and the LSAB.

The UHB is working closely with the Local Authority and South Wales Police to develop an integrated approach to the management of referrals which will lead to the development of a Multiagency Safeguarding Hub which will be in place by April 2016.

The LSAB has developed in line with the Ministerial directive, which sets out the direction of travel for safeguarding arrangements in Wales. The UHB will respond and continue to participate in strategic activity aimed at promoting best practice in the field of safeguarding adults.

The Cardiff and Vale Deprivation of Liberty Safeguards (DoLS)/Mental Capacity Act (MCA) Team operate the Supervisory Body responsibilities of the Deprivation of Liberty Safeguards on behalf of Cardiff and Vale UHB, City of Cardiff Council and Vale of Glamorgan Council. This is a tripartite agreement undertaking the coordination of DoLS assessments as requested by managing authorities. Other activities undertaken include supervision and workload management of over forty multi-agency Best Interest Assessors, advice and support to health and social care teams across the sector in relation to DoLS/MCA issues and training.

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Since the Supreme Court ruling in March 2014 when the legal test for a deprivation of liberty was revised, there has been an unprecedented request for assessments. Hospital settings are deemed to have a higher proportion of urgent authorisations; referrals for this setting are prioritised. However it is acknowledged the increased requests for assessments has impacted greatly upon the workload of the DoLS/MCA team.

Safeguarding children and adults relies on effective interagency working and as such the Safeguarding Team works collaboratively with partner agencies that include the local authority, education and the police, to ensure the best outcomes for children and vulnerable adults.

The Safeguarding Team supports the development of strategic direction and delivery of the agenda through the UHB Safeguarding Steering Group. This is a joint adult and children strategic group, which works with Clinical Boards and Corporate functions to provide assurance to the executive lead that the UHB is compliant with statutory and best practice requirements.

The safeguarding agenda is now much wider than child protection and the protection of adults at risk: it involves all aspects of safeguarding including for example, Child Sexual Exploitation, Neglect, Human Trafficking, Female Genital Mutilation, Domestic Abuse, PREVENT and Deprivation of Liberties Safeguards. The agenda has the ability to impact upon every Clinical Board and team within the UHB. It is recognised that there are many additional pressures facing Clinical Boards and frontline staff, and as such there is a clear need for the Safeguarding Team to support Clinical Boards in meeting their safeguarding responsibilities.

It is important to note that as the scale of the agenda grows, so too does the complexity of the cases being handled through both the child protection process and the safeguarding vulnerable adults process. This has, and will continue to result in greater need for safeguarding supervision for staff directly involved in case management, and also the need for timely expert advice and support.

As well as supporting and enabling the delivery of robust safeguarding advice, training and related activities to staff, the safeguarding team also plays a key role in providing advice and support to managers and Human Resource personnel in relation to professional abuse matters. Support is offered to UHB staff when completing police statements and preparation for Court attendance.

The team also participates in the Wales Safeguarding Children NHS Network, which is chaired by the Safeguarding Children Service, Public Health Wales. The Network has issued a new Safeguarding Children Quality Outcomes Framework (SCQOF), the outcome of which will, it is expected, shape the children safeguarding activity across NHS Wales. The Safeguarding team has collated the response to the SCQOF through collaboration with each of the Clinical Boards and relevant corporate teams. It is expected that this process will continue on an annual basis. It is also expected that the SCQOF will support the UHB completion and submission of Standard 11, Standards for Health in Wales.

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The Social Services and Wellbeing (Wales) Act 2014 introduces mandatory duties on organisations such as Health, with regards to Safeguarding Adults at risk. Introduction of the Act will lead to the necessity for staff training on a wide scale, which will in turn, potentially increase the number of safeguarding referrals relating to adults.

Areas for targeted action during 2016/17: Operational management of the PPN (Police Protection Notice) process (safeguarding communication from the police) is a significant challenge for the team, and work is ongoing to ensure the timely management of the information (including risk assessment and categorisation) and dissemination to appropriate UHB staff; Review of the current resource within the safeguarding team, in particular the Adult Safeguarding support, is being reviewed in light of the implementation of the Social Services and Wellbeing (Wales) Act in 2016, that will place safeguarding vulnerable adults on a statutory footing, along with the growing domestic violence agenda, it is probable that the level of resource will require strengthening; Review of information sharing mechanisms. The constraints of limited information sharing mechanisms (IT) are challenging and whilst a secure email system has been adopted as a temporary measure pending provision of a secure portal arrangement, this system is not intended to be used long term, and is not appropriate for use on a wide scale Adoption of the „Intercollegiate Document – Safeguarding Children and Young People: Roles and Competencies for Health Care Staff‟ (ICD) which leads to the necessity to review and update all current safeguarding children training packs that are delivered by the safeguarding team, to ensure all relevant competences are addressed in line with the ICD; Introduction of the Social Services and Wellbeing (Wales) Act and Violence Against Women, Domestic Abuse and Sexual Violence (Wales) Bill will lead to the necessity for staff training on a wide scale, which, potentially could increase the number of adult safeguarding referrals. Consideration of the impact of the expediential rise in the number of referrals; DoLS referrals to ensure compliance with statutory timescales within the DoLS process. Implementing and delivering changes to the SS&Wb Act ensuring Senior Staff are aware of changes; Consideration of resources within the Team and the development of Multi Agency Safeguarding Hub (MASH). PARIS (the electronic health record for Mental Health and community based services)- - to document all safeguarding activity and advice given to staff. Reports will be available for audit purposes; Increase in training commitments for safeguarding children and adults as well as the National Training Framework for Domestic Abuse, Female Genital Mutilation and PREVENT, the Home office anti –terrorism training; Undertake a LIPS project from a safeguarding perspective addressing an issue that affects all Clinical Boards;

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Ensure that safeguarding of children and adults at risk are considered in RCAs and Serious Incidents; Increase Safeguarding Team direct involvement in Child Practice Reviews and Domestic Homicide Reviews; Continual internal improvement with safeguarding adults process; disseminating lessons learnt and promoting improved and standardized practice across the UHB; and Consider supervision methods currently undertaken with specific health groups and how this may be improved and more effective.

7.9 General Medical Services (GMS)

Achievement against the Quality and Outcomes Framework (QOF) is one measure used to monitor the performance of General Practitioners. An All-Wales comparison of achievement within the UHB and externally against other Welsh LHBs areas is available on an annual basis. Further more detailed local analysis is undertaken annually and individual UHB practice QOF achievement is compared to identify low achievement and significant variance. This process also informs priority areas for the QOF programme of visits.

The UHB operates a three-year rolling programme for visits. The programme of visits each year comprises: Practices due a routine visit (so not visited in the preceding two years); Revisit for practices visited in the previous year where performance issues were raised and remedial action recommended; and Practices whose QOF achievement in the previous year reflected poor performance, or a significant variance to the previous years performance.

Visits this year have been very positive. The practices we have revisited have been able to demonstrate improvement as a result of recommendations made last year. Any visits where issues have been highlighted will be considered by the team and recommendations for remedial action made. This could result in a revisit next year or sooner if deemed necessary. There is a broad agreement that a peer-to-peer (it is now largely a GP to GP discussion) approach that we now take to QOF visits makes the process much more constructive than they have been previously.

7.10 External Monitoring

7.10.1 Healthcare Inspectorate Wales (HIW)

HIW is the independent inspectorate and regulator for all health care in Wales. The core role of HIW is to review and inspect NHS and independent healthcare organisations in Wales so that independent assurance can be given to patients, the

Page | 90 public, the Welsh Government and healthcare providers that services are safe and of good quality.

During 2015 there have been a number of announced and unannounced HIW monitoring visits to different wards and departments in the Health Board. These visits include Dignity and Essential Care Inspections (DECI inspections) as well as Mental Health Act monitoring visits. These provide a very valuable form of external assurance into the quality of clinical care being provided. Feedback generally has been very positive although there have been some areas of practice identified during two visits which required immediate improvement. Other actions are followed up to ensure completion through Clinical Board Quality and Safety arrangements as well as periodic review and follow up by HIW. Regular assurance reports on the findings of external inspections are also presented to the Quality, Safety and Experience Committee.

7. 10.2 Cardiff and Vale Community Health Council (CHC)

The CHC works closely with us to provide valuable independent feedback on patient experience through a number of mechanism, in particular service visits which are reported to CHC meetings, and advocacy support to the management of complaints

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The actions set out in this section are intended to make a measurable improvement to:

Strategic Theme – Our Population

3. All take responsibility for improving our health and wellbeing

NHS Outcome NHS Delivery Framework Measure % uptake of the influenza vaccine: Over 65‟s, Under 65‟s in at risk groups, Pregnant women 1.1 I have a healthy and active life % uptake of the influenza vaccine: Healthcare workers

% uptake of childhood scheduled vaccines up to the age of 4 1.2 My children have a good healthy start in life % of reception class children (aged 4/5) classified as overweight or obese % estimated LHB smoking population treated by NHS smoking cessation services % smokers treated by NHS smoking cessation services who are CO- validated as successful Number of contacts to the mental health C.A.L.L 1.3 I can access the support and information I need, when I need it, Number of contacts to the Wales Dementia helpline in the way that I want it Number of contacts to the DAN 24/7 helpline Of those practices set up to use MHOL, % who are offering appointment bookings Of those practices set up to use MHOL, % who are offering repeat prescriptions

Strategic Theme – Our Service Priorities

4. Offer service that deliver the population health our citizens are entitled to expect NHS Outcome NHS Delivery Framework Measure 3.2 I receive the right care and support to either improve or % people aged 50+ who have a GP record of blood pressure manage my own health and measurement in the last 5 yrs. wellbeing 3.1 Health care and support are Locality Clusters are demonstrating rolling improvements delivered at or as close to my against agreed plans home as possible % of assessments by the LPMHSS undertaken within 28 days 6.2 My individual circumstances are considered % of therapeutic interventions started within 28 days % of LHB residents (all ages) to have a valid CTP

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%LHB residents sent their outcome assessment % of hospitals with arrangements to ensure advocacy available to qualifying patients % of over 65 registered as having dementia with their GP practice 5.1 I have easy and timely access Patients treated by an NHS dentist in the last 24 months as to primary care services % of population % of patient referred as non-urgent suspected cancer seen within 31 days % of patient referred as non-urgent suspected cancer seen within 62 days 1: First 5.2 To ensure the best possible hours outcome, my condition is bundle diagnosed early and treated in 2: First days accordance with clinical need % compliance with acute stroke bundles bundle 3: First 3 days bundle 4: First 7 days bundle Welsh Government Delivery Plan Measures

Strategic Theme – Sustainability

5. Have a unplanned (emergency) care system that provides the right care, in the right place, first time NHS Outcome NHS Delivery Framework Measure

% of new patients spend no longer than 4 hours in A&E 5.2 To ensure the best possible outcome, my condition is Number of patients spending 12 hours or more in A&E diagnosed early and treated in % of Cat A Ambulance responses within 8 minutes accordance with clinical need Number of over 1 hour handovers

6. Have a planned care system where demand and capacity are in balance

NHS Outcome NHS Delivery Framework Measure Number of emergency admissions for basket of 8 chronic conditions 1.1 I have a healthy and active life Number of emergency readmissions for basket of 8 chronic conditions % GP practices offering appointments between 17:00 and 5.1 I have easy and timely access 18:30 at least 2 days a week to primary care services % of GP practices open during daily core hours or within 1 hour of the daily care hours 5.2 To ensure the best possible % of patients waiting less than 26 weeks for treatment – all outcome, my condition is specialties

Page | 94 diagnosed early and treated in Number of 36 week breaches – all specialities accordance with clinical need % of patients waiting less than 8 weeks for diagnostics

Number of over 1 hour handovers Number of follow-up appointments delayed past their target date (booked and not booked)

7. Reduce harm waste and variation sustainably making the best use of the resources available to us NHS Outcome NHS Delivery Framework Measure 2.1 I am supported to protect my National prescribing indicator rate own and my family‟s health 2.2 I am kept safe and protected DToC delivery per 10,000 LHB population - mental health from avoidable harm through appropriate care, treatment and DToC delivery per 10,000 LHB population - non mental support health 3.3 Interventions to improve my % valid principle diagnosis code 3 months after episode end health are based on good quality date - monthly and timely research and best % valid principle diagnosis code 3 months after episode end practice date - rolling 12 months 7.1 Financial resources are used Financial balance over 3 year rolling plan efficiently and effectively to improve my health outcomes % staff absence due to sickness

New OP DNA rates for selected specialties (E&P measure) 7.2 I work with the NHS to improve the use of resources Follow up OP DNA rates for selected specialties (E&P measure)

8. Prevention

8.1 Context

8.1.1 Choice of Priority Areas

It is estimated that around a quarter of premature deaths are avoidable, with much of this burden relating to ischaemic heart disease and lung cancer (ONS, Avoidable Mortality in England and Wales, 2012).

A relatively small number of modifiable behaviours in the population contribute to a significant amount of illness and early mortality in the population, notably tobacco use, food and physical activity. Preventative actions therefore have these factors as their major focus, along with immunisation as a cost-effective intervention to prevent significant disease. Morbidity due to influenza, for example, is a major contributor to seasonal pressures on primary and acute services, and a significant factor in seasonal excess mortality.

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Priority areas were chosen because, with targeted action, they will lead to the biggest health benefits for the local population. Through a targeted approach to reduce inequalities, many also contribute to the reduction of poverty, including child poverty. Making Every Contact Count is a methodology which supports the implementation of the priority areas. The first order priorities are also aligned with those in the 2016/17 NHS Wales Delivery Framework, and those of Public Health Wales NHS Trust.

Table. Priority areas for prevention and population health action

Priority area More information First order priorities Tobacco Obesity (including food and physical activity) Immunisation See section 8.3 Inequalities (cross-cutting) Making Every Contact Count (cross-cutting) Second order priorities Alcohol Sexual health Falls prevention See section 8.4 Health at work Health protection Healthcare public health

8.1.2 Focus of Actions

While targeting prevention action at individuals with risk factors will continue to be a key part of our strategy, increasingly the role the broader environmental context plays in subconscious „choices‟ made by individuals is recognised. For example, poor diet is often the result of unconscious behaviour due to the widespread availability and promotion of poorly nutritious, high calorie food, rather than a conscious choice to have an unhealthy diet.

In order to reduce the prevalence of unhealthy behaviours including tobacco use, diet and alcohol, the wider landscape must be addressed in addition to individual awareness and empowerment. As well as being an important component in tackling the health of adults who have already developed unhealthy behaviours - 97% of adults in Wales exhibit one or more regular unhealthy behaviour (Chief Medical Officer for Wales Annual Report 2014) - it is even more vital when ensuring that these behaviours do not develop in future generations.

8.1.3 Wellbeing of Future Generations (Wales) Act 2015

The Wellbeing of Future Generations Act provides a significant opportunity to co- ordinate and garner efforts across the public sector to address the major issues future generations will face, including risks to health. Recognising this opportunity, we are reviewing our prevention plan in line with the seven Wellbeing Goals laid out in the Act.

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Figure. Wellbeing goals in Wellbeing of Future Generations Act 2015

In 2016/17 we will use obesity (including food and physical activity) as a „pathfinder‟ topic, committing fully to changing the way we approach this topic, considering it from the perspective of future generations and what actions we need to take now to safeguard their wellbeing. This is likely to shift our focus further „upstream‟ and change the balance in decision-making between short-term and long-term impacts of policy decisions. Based on lessons learned with obesity during 2016/17, and where our focus provides the most „added value‟, we will then introduce this new approach across all our prevention topic areas from 2017/18.

The upstream shift and further integration with partner agencies to consider future wellbeing issues may also lead to a broadening of the preventative focus for the NHS, such as increasing the focus on the environmental determinants of health including climate change.

8.1.4 Social Services and Wellbeing Wales) Act 2014

During late 2015/16 and early 2016/17 a population needs assessment will be carried out, co-ordinated by public health, to assess care and support needs of the population in line with the Social Services and Wellbeing (Wales) Act.

This work will align with an assessment of preventative services in place, which will also identify any gaps in these services, to meet the identified needs. The population needs assessment process will also be aligned to the processes for future needs assessment for the IMTP and the Wellbeing assessment for the Wellbeing of Future Generations Act.

8.1.5 Working with Our Partners

Successful actions to protect and improve population health and tackle inequalities cannot be delivered by the UHB alone. Therefore effective partnership working with

Page | 97 local authorities, third sector organisations and local communities is essential across our priority areas. The UHB, local Public Health team, and partners work closely with Public Health Wales as described in section 5.3, Collaboration with our NHS Partners.

Screening programmes are co-ordinated by Public Health Wales Screening Division, with the exception of diabetic retinopathy which is currently co-ordinated directly by the UHB. The Health Board has prioritised raising uptake of screening programmes, primarily through cluster working and new Wellbeing Co-ordinators in primary care.

The commissioning and delivery of a comprehensive package of substance misuse interventions are co-ordinated jointly across the two local authorities and the UHB.

8.1.6 Promoting Self-Care

A number of actions promoting self-care in primary care and the community, for example, web podcasts on self care, district nurse community sessions on self care and co-production, Citizen Driven Health, Prudent diabetes education and support, and education on how to change simple dressings, all have potential to help manage and prevent progression of existing conditions.

8.2 Cross-cutting actions for 2016/17-2018/19

The Cardiff and Vale Local Public Health department provides strategic co-ordination of prevention programmes locally, with delivery increasingly embedded within routine Health Board care pathways, with support from other NHS, local authority, university and third sector partner organisations. Working with GP clusters and neighbourhood partnership teams is a key part of programme delivery.

The full three-year work plan, key performance indicators and trajectories, and outcomes are detailed in the Cardiff and Vale Local Public Health Plan for 2016/17- 2018/19. Priority areas for action and anticipated outcomes of the programmes are summarised below.

8.3 Cross-cutting actions - first order priorities

8.3.1 Tobacco Implement the wider partnership Cardiff and Vale Tobacco Control Action Plan which includes actions relating to environmental tobacco work such as „Smoke Free Beaches‟, „Smoke Free Parks‟ and Smoke Free Homes and support to national campaigns such as Stoptober (October) and No Smoking Day (March);

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Implement the Smoke-Free UHB Action Plan including continuing to reduce the number of infringements on hospital sites and transition to new Mental Health accommodation at UHL; Introduce a new model for smoking cessation support for pregnant women; and Outcomes: Reduction in adult smoking prevalence in Cardiff and Vale; and reduction in children starting smoking.

8.3.2 Obesity

As described above, the obesity prevention programme will be refocused from 2016/17 around the seven wellbeing goals of the Wellbeing of Future Generations Act, and act as a pathfinder to identify the best ways locally to implement this new approach for other prevention topic areas.

Wellbeing Obesity actions for 2016/17-2018/19 Goal A Promote the availability of Healthy Options awards to food businesses prosperous in Cardiff and the Vale Wales Encourage active travel arrangements and „healthy‟ workplace design, to benefit staff and increase attractiveness of working in Cardiff and Vale Work with local authority planners to encourage low carbon, easy and accessible active travel arrangements for tourists and visitors to area Outcomes: increased availability of healthy food in Cardiff and Vale; reduced employees overweight/obese in local businesses; more attractive workplace policies among local employers; increased tourism A resilient Support ACE Communities First team and other areas to develop Wales community cafe(s) to offer opportunities for local training, volunteering and healthy food Increase number of people trained in Making Every Contact Count within communities and organisations, to increase social capital around healthy diet and physical activity Outcomes: increased availability of healthy food in Cardiff; increased training opportunities for residents in deprived area of Cardiff; increased social capital around healthy diet and physical activity A healthier Delivery of Food and Physical Activity Action Plans Wales Support the primary care teams and Clusters to deliver actions that address the food and physical activity needs of their populations Through the Cardiff and Vale Health and Wellbeing Board, begin to develop a network of organisations, groups and individuals who contribute to building health-supporting local environments Implement and monitor hospital restaurant and retail outlet food standard policies, and use experience to spread good practice to public sector partners

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Support the implementation of healthy workplace food environments through Corporate Health Standard and Employers‟ Network Continue to work with schools on food and physical activity through the Healthy Schools and Healthy and Sustainable Preschool schemes Improve access and uptake of maternity overweight and obesity support, and breastfeeding support Work with local retailers and suppliers to encourage availability of healthy affordable food Continue to encourage healthy environments through implementation of Local Development Plans Outcome: reduced prevalence of obesity and risk factors for obesity in current and future populations including school and pre-school children A more Expand the reach and engagement of the Food Cardiff programme. equal Wales Expand the School Holiday Enrichment Programme (SHEP) Improve access to green spaces, active travel options, low traffic and pollution areas, especially in more deprived areas Work with local authority planners on density of hot food takeaways in deprived areas and near schools Improve access to support and treatment services for nutrition, physical activity and obesity Outcomes: more equitable access to healthy, affordable food and reduced food poverty; more equitable access to active travel and leisure activities especially in deprived areas; more equitable access to support and treatment services A Wales of Increase use of social movement approach for obesity, using best cohesive practice and local examples such as Food Cardiff communities Continue to work with and focus within Communities First areas Work with local communities to maximise existing assets around food and physical activity, e.g. opportunities for community growing, community social exercise events (e.g. fun runs, regular park runs etc.) Outcome: increased community engagement and cohesion around topics of food, nutrition and physical activity in Cardiff and the Vale; maximise use of existing community assets A Wales of Work with local authority planners to place active travel such as vibrant walking and cycling at the heart of transport and planning strategy, for culture and example promoting increase in easily walkable areas of Cardiff and thriving Vale, increase ease and safety of cycling, fully integrated active Welsh transport for commuting and tourism language Outcomes: normalising culture of walking, cycling and active transport rather than driving, increased tourism A globally Encourage direct alignment of national and local planning and responsible transport policies to address the obesogenic environment and reduce Wales air pollution Encourage active travel, connectivity across and between communities, food growing spaces, access to open spaces

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Outcomes: a built environment which supports both health and lower carbon emissions

8.3.3 Immunisation Implement the Cardiff and Vale Immunisation Steering Group plan, including: o Further roll-out and ongoing evaluation of colourful postcard reminders to parents of preschool children missing their immunisations; o Continued refinement of one page quarterly practice-level immunisation profiles introduced in C&V in 2015, and introduction of similar profiles for schools, and within the UHB; o Scoping and, if viable, implementation of schools-based immunisation team; o Introduce new vaccination programmes as directed by Welsh Government; and o Continue community development work in South Cardiff, focusing on BME groups, to increase engagement and awareness around immunisation issues. Implement and continue to refine the rolling seasonal flu action plan, including: o Further increasing social media presence internally and externally; o Continued transition to Flu Champion peer vaccination model; and o Further embed implementation of Staff seasonal flu vaccination policy. Outcomes: Uptake of preschool vaccinations to exceed 95%; uptake of staff flu vaccination to exceed 50%; significantly improved (by more than 5%) uptake of flu vaccine among eligible individuals aged under 65; successful implementation of new/extended programmes.

8.3.4 Inequalities Actions for the health improvement priorities listed here are focused on those most in need, working through GP clusters and focusing on Communities First and Flying Start areas, with the aim of reducing inequalities in risk factors and disease. Details on actions to address inequality in each priority area given in the Cardiff and Vale Local Public Health Plan for 2016/17-2018/19. See chapter 6 for wider work being undertaken across the UHB and with partners to reduce health inequalities. Outcomes: Making healthy lifestyle behaviours the easiest choice, particularly among those in highest need, ultimately reducing the gap in healthy life expectancy between areas in Cardiff and Vale.

8.3.5 Making Every Contact Count (MECC) Making Every Contact Count is a methodology which supports the implementation of the key priority areas. MECC training empowers staff in the UHB and partner organisations to appropriately and confidently discuss lifestyle issues, and signpost to appropriate support. Training is also made available to community groups Actions for 2016/17 include:

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o Develop a train-the-trainer model to further improve the dissemination and accessibility of training and support for staff o Raising the profile of MECC through implementation of a communications plan to include the use of modern media, an improved website and access to online resources Outcomes: Increased number of UHB, public and third sector partner staff who are confident in discussing lifestyle issues with their service users, and signposting to further support,

8.4 Cross-cutting actions - second order priorities

8.4.1 Alcohol Implement the Alcohol Action Plan in partnership with local authorities, police and third sector, including: o Provide alcohol education and training for teachers and youth workers in Cardiff and Vale as part of the Universal Services substance misuse package; o Continue to deliver and evaluate effectiveness of Alcohol Treatment Centre; o Deliver Alcohol Brief Interventions training across Cardiff and Vale; o Deliver alcohol awareness campaigns for UHB and partner organisations; o Support workplaces to take best practice approach to raising awareness on alcohol use; o Work with universities to raise student awareness and understanding of alcohol issues; and o Work with Alcohol Licensing Committees to influence licensing decisions, including use of „last drink data‟. Outcomes: Reduced prevalence of unsafe drinking behaviour.

8.4.2 Sexual health Deliver the Sexual Health and Wellbeing Action Plan for Wales, 2010-2015 locally, including: o Focus activity to address teenage pregnancy and prevent Sexually Transmitted Infections (STIs), particularly in areas of high deprivation; o Deliver the C-Card Scheme for young people in Cardiff and Vale; o Provide Sex and Relationship Education (SRE) delivery support to schools and youth organisations; o Target work with vulnerable young people, including provision of 1 to 1 support, and improving access to (long-acting reversible contraception) LARC for vulnerable young people including looked after children. o Ensure all end of pregnancy services have access to LARC at point of service (Empower to Choose intervention). Outcomes: Reduced number of teenage conceptions and improved access to LARC.

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8.4.3 Falls prevention Sustain improved compliance with the numbers of those aged 65+ screened for falls risk in Unscheduled Care through support and education. Increase use of GP Falls pathway and exercise decision-making tool through GP cluster plans. Continue to identify opportunities to develop the continuum of falls prevention focused exercise opportunities in community settings. Outcomes: Reduced harm from falls among over 65s.

8.4.4 Health at work Continue to deliver a Cardiff and Vale of Glamorgan Employers Network that engages major employers from all public sector partners, the Third sector, academia and the private sector. Deliver Health and Safety at Work Enforcement Plans. Encourage uptake of flu vaccination among eligible under 65s working for local employers. Implementation of UHB Hospital Restaurant and Retail Catering Outlets Food Standards. Outcomes: Improved achievement by UHB and local organisations against Corporate Health Standard.

8.4.5 Health protection Contribute to health protection on-call and outbreak and environmental incident management (led by Public Health Wales health protection team). Outcomes: Disease outbreaks and environmental incidents which occur in Cardiff and Vale are successfully managed.

8.4.6 Support to healthcare public health Support development of key clinical pathways across the UHB including diabetes and dementia. Embed prevention into healthcare pathways, including further implementation of UHB „Optimising Outcomes‟ policy. Work within the UHB and with partner organisations to ensure specialist public health advice and information is available to support strategic and planning decisions, including working with Clinical Boards and Strategic Planning. Work across UHB including Strategic Planning, PCIC and Public Health to assess need for, and access to, services for new housing developments Outcomes: Clinical pathways developed which support Shaping Our Future Wellbeing principles; Dementia 3 Year Plan actions achieved; more patients supported to improve health behaviours

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8.5 Targeted Actions

General cross-cutting preventative actions described above will have a significant positive impact on the UHB priority pathways below. Additional specific actions for each are described here.

8.5.1 Cancer Further integrate screening awareness and cluster-level screening uptake data into routine GP cluster discussions, focusing on programmes and clusters with lowest uptake. Healthy living days to educate women on breast awareness.

8.5.2 Dementia Continue implementation of C&V dementia 3 year plan including roll out of dementia supportive communities and dementia friends training. 75% of frontline staff to have dementia awareness training by end of 2016/17 Dementia advisor for each GP cluster. MDT training on young onset dementia. Expansion of „butterfly scheme‟ to support staff development and training within non-specialist settings. Ensure nutritional assessment and dietary support is available for all patients with dementia. Falls prevention programme.

8.5.3 Dental and Eye Care Designed to Smile programme actively promoting toothbrushing in young children. Designed to Smile oral health education programme, including healthy eating advice, delivered to children via classroom talks. Long term inpatients receive an oral health assessment and oral care as part of the 1000 Lives+ mouth care bundle. Forthcoming relocation of Open Source Cluster Application Resource (OSCAR) peripheral dental unit to University Hospital Llandough to provide full dental care to patients with mental health issues. Implement recommendations, where possible, from recent Cardiff and Vale diabetic retinopathy and maculopathy needs assessment.

8.5.4 Long Term Conditions Continue to work closely with Cardiff and Vale Long Term Conditions Alliance to promote and co-produce primary and secondary prevention pathways for long term conditions. Vascular rehabilitation and exercise classes and programmes. Specific, targeted Making Every Contact Count (MECC) training e.g. with physiotherapy and in outpatient settings. Further embedding Optimising Outcomes Policy across UHB. Development of local pulmonary rehabilitation services. Implementation of staff weight management model led by dietetics.

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Diabetes o Continued strengthening of diabetes community model; o Implementation of diabetic foot care bundle; o Expand provision of structured diabetes education, including X- PERT group education programmes; group diabetes awareness sessions; DAFNE type 1 education programmes; o Further develop point of care testing for patients at home; and o Implement Think Glucose.

8.5.5 Maternal Health and Early Years Continued reduction in low birth weight (LBW) babies by addressing the root causes of LBW including smoking, sexual health and teenage pregnancy. This includes the provision of a substance misuse midwife. Develop service model for obesity in pregnancy in partnership Improving vaccination rates, including seasonal flu vaccination, during pregnancy and in early years, by implementing comprehensive immunisation action plan. Encourage and support breastfeeding wherever possible and appropriate, to reduce childhood and subsequent adult obesity. Develop short films as part of antenatal care concerning weight gain and managing pelvic girdle pain. Provide dedicated maternal mental health support.

8.5.6 Mental Health New Mental Health inpatient unit at Hafan y Coed will be a no-smoking unit with smoking outside in designated areas only. Implementation of national dual diagnosis framework for substance misuse. Ensure all people prescribed medical treatment for psychosis have routine physical health screening for 12 months following initiation and shared care monitoring after 12 months. Increase efficiency of delivering self help material.

8.5.7 Stroke Ambulatory care sensitive conditions pathway development for atrial fibrillation. Improve SSNAP rating across the stroke pathway domains

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9. Planned Care

9.1 Context

As part of the development of Shaping our Future Wellbeing, there was an emphasis on developing new models of planned care with a focus on delivery in the community and a desire to better empower patients to participate in the planning of their own care. For each of our priority service areas, the UHB has co-produced a strategic framework outlining the required standards for the delivery of planned care.

The UHB is also participating as a member of the National Planned Care Board and progressing to implement improvements e.g. Eye Care and Orthopaedics. In addition the UHB has delivery plans for all of the Welsh Government National Delivery Plans. The key deliverables for planned care in these priority service areas are summarised below.

9.2 Cancer

Considerable progress has been made in improving information and support and also access to cancer services in both primary and secondary care in 2015/16. Improvements in service provision are focussed along the whole pathway from prevention, earlier detection, access to diagnostics and treatment as well as improved patient experience and ongoing or palliative care. The Framework for Cancer in Primary Care focuses on early diagnosis and living with cancer.

The national priorities for 2016/17 are: Improved access to diagnostics; Primary care oncology; Develop and improve cancer pathways, including the implementation of a single cancer pathway; Patient experience; and A focus on lung cancer.

The UHB‟s Cancer Plan outlines the key proposals for the development of specific services and pathways to respond to these priorities. The UHB‟s annual report details the significant progress and improvements that have been commissioned and delivered for the benefit of its local population. These include improvements targeted at prevention, improved access to diagnostics and advice and also pathway management improvement and redesign particularly in primary care with the input from the Macmillan GP Facilitators but also in secondary care. These are focussed on improving outcomes for patients as well as reducing time from referral to definitive treatment.

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In delivering the Urgent and Non-urgent Suspected Cancer targets for 2016/17, there are a number of areas which present a particular challenge: Dermatology – the growth in demand nationally is reflected locally and has exceeded capacity, despite the implementation of innovative new services such as tele-dermatology to enhance traditional capacity. A comprehensive review of service provision across the whole pathway has been undertaken within the UHB and further capacity to address both backlog and sustainable capacity is planned as a key service development priority for 2016/17. This capacity expansion will be reviewed in the context of ongoing evaluation tele-dermatology services and future pathway development opportunities that may provide alternative opportunities in the longer term.

Lung cancer –continue to work with Welsh Health Specialised Services Committee (WHSSC) to implement the recommendations from the task and finish group, to improve the sustainability of thoracic surgical services across South Wales, increase the volume of activity undertaken and increase resection rates to improve overall survival rates from lung cancer in South Wales.

NB Availability of additional theatre capacity (infrastructure and staffing) and consultant staffing presents a risk to delivering level of surgical service required. A business case is currently with WHSSC for consideration of the revenue requirement.

Gastroenterology – the UHB currently has a significant backlog and capacity shortfall in endoscopy and proposes to increase clinical and infrastructure capacity to develop a sustainable service – this will include the development of a 6th endoscopy room. In addition, there will be short-term non-recurring capacity commissioned to reduce the backlog. Further detail is included in section 9.9.

Urology – the UHB has produced a proposal to develop robotic surgery to meet increasing demand for Robotic-Assisted Laparoscopic Prostatectomy and to enhance capacity to support the expansion of the All Wales service, which will be delivered in partnership with other South East Wales health board partners. In addition there is a Primary Care Clinical Director leading the development of pathway work to support improved access and outcomes.

Develop agreed model for meeting national standards for Paediatric oncology including the implementation of an electronic prescribing system for Paediatric chemotherapy.

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9.3 Dementia

Cardiff and Vale‟s Dementia Plan was developed in 2014 in collaboration with Cardiff and Vale Councils and Third Sector partners and presents a comprehensive, integrated and robust approach to proactively tackling some significant challenges presented by the growing need to better support people with dementia and their carers. Much has been achieved both nationally and locally for people with dementia and their carers. However, gaps remain and the UHB continues to plan for the future predicted increase across health, social care and the Third sector.

The plan is structured around four key themes: Making structural changes to economic, cultural and environmental conditions; Improving infrastructure and access for all; Strengthening communities; and Strengthening individuals.

A Dementia Task force with six supporting sub-groups has been driving the implementation of the plan and evaluating performance through a monitoring framework. Cardiff and Vale‟s Dementia Plan and 2014/15 report demonstrate that there has been excellent progress made in developing and implementing truly joined up services across all service stakeholders and partners. Detailed action plans have been developed for all stakeholders and there are clearly defined responsibilities that have been shared within the UHB services to ensure that all clinical boards have clear objectives to continue to contribute to the improvement of services for patients who have dementia.

Good progress has been made in: Promoting healthy living initiatives in dementia and increasing public awareness and understanding of dementia. Ensuring timely diagnosis of dementia – the UHB continues to increase its diagnosis rate. Ensuring early management and support post-diagnosis through improvements in the early management and support provided post diagnosis. Ensuring appropriate use of anti-psychotic medication and ensure alternatives to anti-psychotic medication are available. Implementing use of telecare and assistive technology.

The Dementia Plan report details a range of actions that will be progressed to continue to develop and improve services to people with dementia across Cardiff and Vale which form an integral part of service planning across all partners and within the UHB. The key challenges specifically for the UHB include the percentage (<5% target) of people with severe dementia at time of presentation to memory services (of all diagnosed with dementia) and providing timely access to the UHB‟s Memory team.

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The UHB has designed a care bundle for dementia, which identifies the primary drivers and measures to improve prevention or delay of dementia onset, to provide appropriate assessment, timely diagnosis and management and optimisation of outcomes across the pathway:

The areas targeted for improvement in 2016/17 include:

Provide dementia advisors for each of the Primary care clusters and to develop dementia champions in the Community Resource Teams.

To develop dementia registers in primary care.

Identify dementia leads for Butterfly scheme across all clinical boards and roll out dementia awareness training and MECC.

To roll out learning within community and secondary care from pilots exploring alternatives to anti-psychotic medication.

To extend Memory Clinic capacity to meet increasing demand and comply with waiting times targets (6 weeks) and implement NICE guidance.

9.4 Dental and Eye Care

9.4.1 Dental Care and Oral Health:

In commissioning local oral health care the UHB‟s Local Oral Health Plan identifies eight strategic priorities: Reduce the prevalence of dental decay, especially in young children; Ensure that consistent, key preventative messages and interventions are delivered; Reduce inequalities in accessing primary dental care services; Ensure that high quality, appropriate dental services are planned and provided for at risk groups; Ensure the delivery of specialist NHS services responsive to need; Maintain arrangements to ensure the planning and provision of high quality primary and community dental care services; Ensure access to unscheduled, out-of-hours and elective dental care is available to all; and Work with the dental profession to ensure that the dental workforce is properly prepared and equipped to provide high quality patient centred care.

The UHB provides dental services through general dental services (GDS) and personal dental services (PDS) for specific specialist groups and community dental services (CDS) for vulnerable groups in the community. In secondary care, dental service provision comprises oral medicine, oral and maxillo-facial surgery (OMFS),

Page | 109 oral cancers, orthodontics and restorative dentistry and specialist tertiary services through the university dental hospital and specialist surgical service.

The national oral health service priorities for 2016/17 are: Enhance contract monitoring and reviews of GDS/PDS contracts with high value Units of Dental Activity (UDA); Ensure better compliance with NICE guidelines on recall intervals; Monitor “splitting” courses of treatment; and Work to guidance on NHS Orthodontics in Primary Care, particularly during contract renewal. Clear plans on how residents will access specialist dental services in Primary Care (specialists/Dentists with Enhanced Skills) in the Community Dental Service and/or secondary care, and ensure an integrated approach to the delivery of these services.

Much progress has been made in the development of local oral health improvement services within Cardiff and Vale through „Designed to Smile‟ and additional investment in provision of additional capacity in the GDS service. Actions have been taken to introduce services in an attempt to alleviate pressures within primary care dental through the establishment of additional new and urgent patient contracts, a Dental Helpline within the C&V communications hub (allowing a single number for general dental enquiries and access to, where appropriate, in hours emergency treatment slots [across primary care, community dental services and the university dental hospital]). It is anticipated that these contracts will be implemented next year.

In addition the primary care team has met with NHS dental practices to ensure NICE guidelines are being followed to encourage practices to adhere to appropriate patient recall intervals. The primary care dental team have also piloted, and now introduced, a system whereby every NHS dental practice in Cardiff and Vale can access and update their NHS access status on the C&V web site so that patients can view a live dental access screen.

The priorities for targeted action in 2016/17 include: Develop collaborative engagement between primary and secondary care to pilot the development of integrated pathways with nominated lead in specific cluster with highest oral health needs.

Roll out the agreed pathway documentation for implementation through the Managed Clinical Network for Special Care Dentistry in SE Wales.

Provide oral health assessment to patients on admission to care home in compliance with WHC2015 001 to improve oral health for older people living in a care home.

Explore options for one-stop oral surgery clinic for 50% extraction referrals.

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Secure additional OMFS theatre capacity to enable treatment capacity to be optimised in order to meet demand and to reduce backlog of patients waiting for treatment (section 9.9).

Procure and embed additional community based capacity.

Deliver Oral Health Training to ward nurses as part of 1000 Lives+ mouth care bundle.

9.4.2 Eye Care:

The UHB‟s Local Eye Care plan outlines the vision and key themes for improving local eye health. These are: Raising awareness of eye health and the need for regular sight tests. Early detection of eye health and sight problems. Providing access to high quality, integrated services and support; o Primary and community services; o Specialist hospital services; and o Supporting people with sight/dual sensory impairment.

National Priorities for 2016/17 are: Roll out of IT for eye care- optometry referrals and Open Eyes; Implementation of the Planned Care Board priorities for eye care including implementation of the national pathways for cataracts and ocular hypertension, which will see the development of community optometry services and developing IT services such as e-advice to support the pathways. Reduce the Follow-up Backlog in Ophthalmology and re-design the patient booking system Accurately determine demand and capacity, and develop data Collection and Outcome Measures (including Certificate of Visual Impairment) Maximise the shift of service for those patients who can be appropriately treated in a community setting.

The UHB has faced significant challenges in meeting demand for eye care services and there has been a deficit in available capacity to meet a range of eye health needs in Cardiff and Vale. There is a strong emphasis on prevention and the further development of optometry delivered services with the simplification of pathways to reduce duplication of assessment. Adoption of the national pathways will support the required changes.

The priorities for targeted action in 2016/17 include: Ensuring 100% referral of patients with diabetes for retinopathy screening through primary care monitoring. However the UHB will introduce varying the screening intervals according to clinical risk. The evidence shows that it is

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clinically safe for low risk patients to be screened biennially, with high-risk patients remaining on annual recall. UK programme capacity has been unable to match the growth in the diabetic population and has increasingly been unable to meet the primary objective of annual screening for all. This change will allow programmes to focus resources on higher risk patients to ensure appropriate screening to further reduce sight loss, whilst also reducing inconvenience and inappropriate intervention for lower risk patients.

Optometry post-operative cataract follow-up to be implemented alongside nurse- led community based post-op cataract follow up to compare outcomes and value for money.

Provide additional Wet Age-Related Macular degeneration services in three community hub practices across Cardiff and Vale to improve access to these services in the community.

Additional capacity for secondary care services to meet increasing demand for outpatient and treatment capacity (see section 9.9).

9.5 Long Term Conditions

Considerable improvements have been made in working with patients, carers and providers across service boundaries within health and across other public and third sector boundaries to improve the UHB‟s approach to commissioning, co-designing and delivering services to our resident population with chronic or long term conditions.

There has and continues to be a strong focus on promoting prevention and education programmes as well as improving access to specialist advice and care in the community.

Due to the nature of these conditions, some of the service priorities and proposed targeted actions described in this section are not confined exclusively to planned care pathways but will also reduce the need for and/or improve access to unscheduled care services.

9.5.1 Diabetes (Long Term Condition)

Diabetes services are one of three priority service areas that the UHB has prioritised for commissioning for improvement in 2016/17.

The UHB‟s Diabetes Plan outlines the key proposals for the development of specific services and pathways to respond to these priorities. The UHB‟s diabetes annual

Page | 112 report details the significant progress and improvements that have been commissioned and delivered for the benefit of its local population.

The national priorities for 2016/17 are: Implementation of 2014/15 projects. Health boards to ensure 100% referral rates to DRSSW, measure times from referral by DRSSW to review by an ophthalmologist, ensure suitable local infrastructure to support new DRSSW clinic model. Health boards to provide NICE compliant insulin pump therapy service by improving expertise and annual training updates, meeting safety standards, providing patients with a choice of devices. Health boards to ensure all inpatient staff and staff caring for people living with diabetes have adequate knowledge and training to safely manage diabetes.

The UHB has designed a care bundle for diabetes which identifies the primary drivers and measures to evaluate the intended reduction in the incidence of type 2 diabetes in the local population and the secondary prevention and optimal care for citizens living with type 2 diabetes both in the community and in the hospital setting. It is clear from the diabetes annual report that the UHB has made some excellent progress this year right across the spectrum of diabetes prevention and service provision. It evidences strong delivery in prevention and highlighted a range of action taken to improve diabetes services. The community model continues to be strengthened and the UHB has actively collaborated with people living with diabetes to assess how we look at diabetes through a „Prudent‟ lens. This has given a very clear message that there needs to be better access to a range of education and support, networking opportunities and physical activity opportunities for people living with diabetes in the community. The UHB has taken significant steps to strengthen the approach to tackling hypoglycaemia in the inpatient setting but there is a need to continue this focus to improve the quality of care for inpatients who also have diabetes, particularly where that is not the reason for admission.

Whilst the diabetes delivery plan details the wide range of service improvements and initiatives that are currently in place and those that are planned, the critical challenges and areas of major service change for 2016/17 are: Continue to support prevention programmes, particularly in reducing obesity as part of our local prevention programme and participating in the national programmes for cardiovascular and diabetes risk reduction.

Embed and strengthen community diabetes service for adults and children to continue to increase provision of care and support in the community to improve patient education and continue to reduce outpatient demand in secondary care.

Introduction of established Diabetic Nurse Specialists in GP clusters.

Continue to roll out Think Glucose and ensure all inpatient staff have adequate knowledge and training to safely manage patients with diabetes. In addition, there

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will be a requirement for a foot assessment within 24 hours of admission for all people living with diabetes – compliance will be monitored.

Promote diabetic retinopathy screening across all GP practices in Cardiff and Vale. Monitor and report prevalence and referrals to ensure 100% referral rates to DRSSW.

9.5.2 Heart Disease (Long Term Condition)

There has been excellent progress in 2015/16 in the on-going implementation of Cardiff and Vale‟s Heart Disease Delivery Plan that focuses on the key themes of promotion of healthy hearts, timely detection of heart disease and improving information. Some of the UHB‟s specialist services are commissioned for the wider South Wales population either through contracting arrangements with neighbouring health boards or through WHSSC commissioning arrangements for tertiary care. The most recent annual report providing detailed update on delivery and performance for the UHB can be found here. This report demonstrates the key areas of success and also identifies the areas of on-going challenge that form the basis of our priorities in the next year.

The national priorities for 2016/17 are: Roll out and implementation of a consistent model for the delivery of cardiovascular risk assessment. Improve pathways offering consistent and timely access to cardiac diagnostic tests and treatments focusing on: o Improve outcomes by increasing participation and case ascertainment in national clinical audit with regular feedback to clinical leads. o Drive measurable service improvement in Cardiac Rehabilitation services to meet national standards by delivering services consistently and equitably. o Improve the capacity, recruitment and retention of the cardiac physiologist workforce and support the development of educational programmes for advanced and extended roles to support delivery of improved pathways. o Implement the Out of Hospital Cardiac Arrest Strategy for Wales.

The areas for targeted action in 2016/17 include: As with diabetes, continue to develop a strongly prudent culture in the development of these services with a particular emphasis on the continuation of the wide range of prevention activities and development outlined in the section above and in more detail in the heart disease delivery plan.

Roll out of heart failure clinics in the community with GP champions, training and support from secondary care and physiology and specialist nursing support. These will be supplemented from April 2016 with primary care based services for

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atrial fibrillation, palpitations and angina management focussing on GP clusters with highest need.

Embedding of e-referral and e-advice services to reduce avoidable outpatient referrals.

Remodelling cardiology outpatients and diagnostics to provide increased capacity to meet demand and reduce waiting times for first outpatient appointment and specialist diagnostic tests. (N.B. Capital funding and location has been agreed but is delayed due to interim measure to support NICU) .

Expansion in cardiac MRI capacity to increase activity to meet the WHSSC commissioning intentions will require additional staffing and activity costs to be funded by the three Health Boards in South East Wales for their local populations. A capital case will be developed during 2016/17 for the additional scanner that will be required to deliver further activity increases for year 3 of the plan onwards.

Additional capacity in cardiac surgery is required to meet increasing demand, with the infrastructure and activity costs funded through the WHSSC contract. NB Theatre (workforce and availability of additional operating lists) presents a significant risk to delivery.

Strengthen and improve primary percutaneous coronary intervention (PCI) pathway for SE Wales.

Continue to support the All Wales Cath Lab replacement programme and implement proposals once capital funding becomes available during 2016/17.

9.5.3 Respiratory (Long Term Condition)

As with other national, condition-specific delivery plan services, the focus in Cardiff and Vale in developing respiratory services in the last year has provided a very strong emphasis on the prevention and development of services in the community to empower patients and community clinicians to provide more and better care in the community. The UHB‟s respiratory delivery plan and the most recent annual report provide a detailed update on delivery and performance for the UHB. It should also be noted that the UHB hosts the national clinical lead for Respiratory health.

The national priorities for 2016/17 are: Supporting self-management by developing better patient information and care plans; Promoting lung health by delivering a Love Your Lungs Campaign in the community; Developing specialist services and improving standards and pathways;

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Improving diagnosis by rolling out wider Association for Respiratory Technology and Physiology (ARTP) spirometry accreditation for primary care; and Reducing prescribing variation by raising awareness and producing guidance national pathways for asthma and COPD.

The areas for targeted action in 2016/17 include:

Develop pulmonary rehabilitation in primary care to cope with the rapidly expanding clinical workload focusing on the South East cluster.

Embedding of COPD pathway in primary care as part of the UHB strategy to develop enhanced services in primary care for ambulatory care sensitive conditions in the community.

Ensure all Cardiff and Vale UHB practice nurses are trained up to ARTP levels over the next year.

Further develop primary care access through the roll out of e-advice services.

Further development of the Interstitial Lung Disease (ILD) service, to be commissioned by WHSSC, including the appointment of a dedicated respiratory radiologist.

Develop service and accommodation capacity to meet increasing demand in cystic fibrosis service.

9.5.4 Neurological Conditions (Long Term Condition)

The UHB collaborates and co-operates with organisations at a national and local level to provide integrated and comprehensive services to those affected by a neurological condition whether they are local residents or patients from other health boards across South Wales either through direct commissioning arrangements or through WHSSC commissioned services.

The national priorities for 2016/17 are: Developing a co-productive approach to increasing awareness of neurological conditions; Delivering clear consistent patient information; Delivering access to neurology services, for patients of all ages, consistently throughout Wales; Developing consistent and coherent neuro-rehabilitation services, for patients of all ages; and Developing and responding to patient experience and outcome measures.

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There has been good progress and developments within Neurosciences at Cardiff and Vale during the previous 12 months for example in in developing a structured education programme for GPs and practice nurses and the development of improved referral pathways and plans to develop a community neuro-rehabilitation service incorporating Stroke as well as developments for neuro-muscular patients. The UHB‟s neurological conditions delivery plan and the most recent annual report provide a detailed update on delivery and performance for the UHB.

There remain significant challenges for the coming year and the following are the key priorities for the service in 2016/17:

Develop service transfer plan and support the development of the Full Business Case to transfer the current specialist neuro and spinal-rehabilitation service from Rookwood hospital to a purpose-built specialist rehabilitation unit at UHL.

Implement the Magisterially funded and WHSSC commissioned Assistive Augmentative Communications project with Cardiff and Vale UHB being the hub site for Wales.

Improve patient information working with patient representatives and Third sector partners to continue to support patients with common neurological conditions in order to increase confidence to self care in the community.

Continue to embed e-referral and e-advice services to improve specialist support to primary care and reduce avoidable referrals to secondary care.

Further improve waiting times for posture and mobility services to meet tier 1 and Children‟s NSF targets and improve the patient experience.

Delivery of tier 1 waiting time targets for neurosurgery for which additional capital and revenue funding will be required.

Undertake demand and capacity work for neurology services across Cardiff and Vale and Cwm Taf regions to improve equity of access.

Improve inpatient admission waiting times through the repatriation of patients from specialist neurology and neurosurgical beds to local hospitals as soon as clinically appropriate.

Work with WHSSC to scope out the future requirements for delivery of a fast and effective neurosurgical service including commissioning a sustainable neurovascular and interventional neuroradiology service for South Wales.

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9.6 Maternal Health and Early Years

The UHB‟s children and young people services provide a diverse range of acute, community and specialist/tertiary services including neurology, gastroenterology, oncology, cardiology, Ear Nose Throat (ENT), renal, Neonatal Intensive Care Unit (NICU), Paediatric Intensive Care Unit (PICU) and specialist and general surgery. The strategic context for the provision of children and young people‟s services takes account of the increasing population for under four year olds, the increasing obesity and unhealthy lifestyles, implementation of the outcome of the South Wales programme, the increasing need for unscheduled care/primary care interface and the need to streamline inpatient activity in relation to minimised length of stay and increased day of surgery admission. The implementation plans to support both contingency and final service configuration plans for the proposed paediatrics and neonatal service changes in Cwm Taf are being refined to respond to commissioning requirements.

The strategic drivers impacting on the provision of maternal services include the increasing birth rate and population size. Also, the implications of the SWP decision to remove consultant led obstetric services from neighbouring Royal Glamorgan Hospital, whilst interim measures are currently in place, will ultimately increase demand for more complex obstetrics led births at UHW. As with paediatrics and neonatal services, detailed joint planning is continuing with Cwm Taf and neighbouring health boards to ensure that the UHB can provide the support required to facilitate the necessary service changes in Cwm Taf.

There are comprehensive and integrated health promotion and health improvement plans for maternal and early years services, which are closely monitored against a suite of outcome indicators. There are areas of good performance and also areas of improvement in optimising the health and wellbeing of mothers and children in Cardiff and Vale.

There has been good progress in encouraging healthy behaviours and improving pathway development between primary, community and secondary care services to provide the most appropriate support and interventions by the most appropriate clinician in the most suitable environment. There has been a strong emphasis on embedding prudent care and improving efficiency across services with good bed, theatres and clinic utilisation performance.

However, there are significant challenges in providing adequate capacity in some of the general acute specialities and sustainable service models for some of the smaller, more fragile paediatric specialist services and specialist foetal medicine (see section 9.9)

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The priorities for targeted action in 2016/17 are:

Maintain focus on targeted initiatives delivered through community and antenatal service teams aimed at promoting maternal and foetal health in line with public health targets.

Development of dietetic service models for obesity in both childhood and pregnancy in partnership with Public Health and Children and Women services in the UHB.

Maintain services delivered by primary, community and school based teams to promote the range of early years programmes to promote the health of the child – building on all opportunities to improve the integration between primary and secondary care through e.g. allocation of Paediatricians to GP clusters.

Extend pathway development with primary care and secondary care clinical leads to develop further paediatric pathways common reasons for referral e.g. Neuro- development and continence.

Develop capacity and support in primary care to re-provide paediatric venepuncture in the community.

Extend pre-assessment for Paediatric patients to improve patient experience and improve service efficiency to reduce length of stay and improve theatre utilisation.

Prepare to deploy contingency support plans for potential interim changes to paediatrics and obstetrics service models in Cwm Taf.

Increase labour ward cover to meet Royal College of Obstetrics guidelines - the additional deliveries associated with the South Wales Programme (SWP) Obstetrics flow from Cwm Taf will take the unit well above the delivery threshold requiring enhanced labour ward cover.

NICU medical and nursing cover will also need to be increased in order to meet increased demand from SWP service changes and to meet British Association of Perinatal Medicine (BAPM) workforce standards.

Development of sustainable medical workforce model for Paediatric surgery – the UHB will continue to work with WHSSC to jointly develop sustainability options for this and other fragile specialist services (e.g. Foetal Medicine) for wider stakeholder engagement. NB Theatre capacity (infrastructure and staffing) and middle grade staffing present a challenge to delivering level of service required.

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9.7 Mental Health

The UHB‟s mental health services are delivered across the primary, community, inpatient and tertiary levels of care and include core mental health services along with a number of tertiary and specialist services including neuropsychiatry, substance misuse, and low secure services.

The 10-year Welsh Government strategy „Together for Mental Health‟ (2012) along with a prescribed delivery plan for 2012 to 2016 set the national strategic context within which the UHB is taking forward the development of mental health services in Cardiff and the Vale of Glamorgan. The approach has been to place service users and carers in the driving seat of these partnership arrangements and hold us directly to account for progress against our collaborative strategy. The plan for 2016/17 builds on the redesign work already undertaken and has been developed within the context of the changing population, the prevalence of mental health issues, health inequalities and unhealthy behaviours which impact on the demands placed on the service. The plan continues to focus on developing recovery models of care which support each individual to become more empowered to manage their lives in a manner that allows them to achieve a fulfilling, meaningful life and a positive sense of belonging to, and an opportunity to contribute to, their communities. This strategy puts the Mental Health Measure at the centre of service planning and delivery.

Good progress has been made in redesigning mental health services and supporting pathways at national and local levels. Care is more often provided in more integrated teams in the community increasingly closer to or in patients‟ homes. Also, one of the UHB‟s mental health service‟s key priorities in 2015/16 was the completion of Hafan y Coed, the new adult and specialist inpatient unit at University Hospital Llandough which will replace functionally unsuitable and environmentally inadequate facilities at Whitchurch Hospital in 2016/17. In terms of mental health measure and planned care access targets, the UHB performs generally well although there are still some patients waiting more than 10 weeks to access an outpatient appointment.

The priorities for targeted action in 2016/17 include: Develop and implement redesigned simple single entry service pathway for Older People with mental health problems to reduce duplication in referrals and assessments, more timely access and interventions and a clear and responsive service so that patients are seen by the most appropriate person.

Develop and implement integrated proposal to provide a more integrated health and social care day service for over 65s with mental health problems and relocate the Turnbull Day Hospital and Morfa Day Hospital to more appropriate integrated facilities.

Conclude whole systems review of adult community mental health services to improve experience for service users, improve integration across Community

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Mental Health Teams (CMHTs), Primary Mental Health Support Service (PMHSS) and Crisis Team and to optimise care and treatment for service users through standardisation of Cardiff and Vale practice standards – this will involve extensive consultation process with service users, carers, staff, GPs and other interested stakeholders.

Develop and implement prudent matched care in Primary Care Counselling Service (PCCS).

Undertake consultation to develop improved psychological health and wellbeing services (PAWB) to deliver evidence based, least intrusive psychological intervention to develop service users psychological skills and resilience for self- management.

Consult on the relocation of inpatient beds from the Iorwerth Jones unit to a more clinically appropriate environment.

Relocate the existing Supported Recovery Unit to an environment in which it can continue to operate at its current capacity of 14 beds, with the potential for increasing the number of beds in the future, to support the demand for recovery- focussed care being encouraged by the Department of Health and Royal College of Psychiatrists. Additionally, the 10-bed longer term complex care ward, currently based at Cefn Onn Ward, Iorwerth Jones Unit, is co-located with the Supported Recovery Unit (within Hafan y Coed). This will provide the most appropriate environment and service model to optimise the provision of local rehabilitation and facilitate the repatriation of step-down patients.

Establish a project to support the redesign of patient flow to further improve reduction in DTOC, optimise repatriation opportunities and improve procurement and contract management of placements.

Child and Adolescent Mental Health Service - CAMHS Repatriate neurodevelopment pathway oversight to Community Child Health from Secondary CAMHS in Cwm Taf. Develop integration with secondary CAMHS, particularly around co-morbid mental health conditions.

Commission new Emotional Wellbeing Service to provide single point of access to UHB services and provide low level early interventions as appropriate.

Bring Primary Mental Health workers back into Community Child Health from Secondary CAMHS and develop service model to link into new commissioned Emotional Wellbeing Service and specialist CAMHS.

Work with Cwm Taf to develop the expansion of the Psychological Therapies services in secondary CAMHS across Cardiff and Vale, Cwm Taf and AMBU.

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Agree, sign off and implement a standard service specification for Secondary CAMHS across Cardiff and Vale, Cwm Taf and ABMU.

Development of transition arrangements for young people into adult services as appropriate.

Implement revised referral criteria for specialist CAMHS following implementation of new schemes.

Commission and integrate new Emotional Wellbeing Service to provide rapid access for GP referrals and provide support for young people prior to accessing CAMHS services.

Repatriate Primary Mental Health services from the Cwm Taf commissioned services and TUPE staff.

Identify specific roles to liaise and integrate with local authorities, specifically around looked after children, linking in to partnership initiatives to improve corporate parenting and the Cardiff Adolescent Resource centre.

Implement the Neurodevelopment multidisciplinary team service within Community Child Health.

Support Cwm Taf in the implementation and embedding of the new crisis service and the expanded psychological therapies.

9.8 Other Areas of Key Service Change - Specialist

9.8.1 Care of the Critically Ill

The critical care service in Cardiff and Vale has made considerable progress in delivering against national and local priorities, which are described in detail in the refreshed Delivery Plan for the Critically Ill and the most recent annual report for the plan. The critical care service provides both planned and emergency care in specialist hospital units as well as providing outreach support to the wards. Around 20% of the admissions to critical care services in Cardiff and Vale UHB comprise surgical elective patients (compared to around 30% in the rest of the UK).

Key national priorities: Reducing delayed transfers from critical care by 10% per quarter. Defining and implementing core standards for critical care to support the introduction of peer review and the reconfiguration of critical care services. Developing and delivering a programme to support transition to all-Wales adoption of a universal electronic patient information system and supporting eICU hubs for critical care.

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Developing and implementing consistent and coherent policies on end of life care within critical care and escalation of care to critical care to ensure that appropriate patients and their families discuss and agree options with their consultant within 24hr of admission, if possible. Undertake and respond to the findings of the National Carers‟ survey.

There have been significant developments in supporting planned care services through the provision of a Post Anaesthetic Care Unit (PACU) at UHW to manage the post operative level 2 care requirements of elective surgical patients to optimise outcomes and reduce recovery time as well as reduce the number of operations cancelled due to lack of critical care capacity.

Priorities for 2016/17 Continued focus on proactive pathway management and working with Patient Access and the Continuous Service Improvement team to secure the reduction of DToCs.

Develop roll out plan and secure capital funding for the implementation of eICU.

Further expand critical care outreach services to provide monitoring and support to enhance skills at ward level to recognise deteriorating patients, ensure appropriate escalation of deteriorating patients and deliver improved patient outcomes.

Continue to support compliance with core clinical service standards and guidelines (e.g. NEWS, RRAILS, Sepsis 6) including the potential to improve and further develop ward based services to improve compliance with guidance such as Acute Kidney Injury and NELA.

Develop service scope and model to accelerate proposals for a major trauma centre service at UHW.

9.8.2 Neurosurgery

In the context of planned care, the priority for 2016/17 is to ensure that the neurosurgical department can deliver a timely and appropriate service in order to meet WHSSC commissioned activity and ensure that demand and capacity is in balance.

In order to achieve this, the following priorities for targeted action in 2016/17:

Establish a pre-assessment service.

Implement Day of Surgery Admission model for appropriate patients.

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Develop, agree and implement repatriation policy and protocol with referring LHBs.

Agree with WHSSC and deliver the additional capacity required to support South Wales neurosurgical demand including commissioning a sustainable neurovascular and interventional neuroradiology service for South Wales.

Develop service scope and model to support major trauma centre service.

Theatre capacity (infrastructure and staffing) and medical staffing presents a challenge to delivering the level of service required.

9.8.3 Bone and Marrow Transplant

This service has experienced increasing demand due to the improvements in patient outcomes, range of treatment regimes available and therefore the number of patients eligible for transplantation, revised indications for transplant and improved donor rates. The capacity of the service has reached a ceiling meaning that clinical priorities need to be under continuous review and some patients are waiting longer for transplant than clinically indicated; the functional suitability of accommodation continues to be a major constraint for this service and was highlighted in the recent Human Tissue Authority (HTA) and Joint Accreditation Committee ISCT and EBMT (JACIE) inspection reports. Appropriate accommodation and infrastructure is critical to sustain this service. This is a fundamental priority for 2016/17.

9.8.4 Liver Services

A key priority for 2016/17 is to progress the implementation of the new Liver Plan developed in November 2015.

The key national priorities for 2016/17 are: Prevention of liver disease; Timely detection; Fast and effective care; Supporting people living with liver disease; Improving information; and Targeting research.

The UHB‟s Liver Delivery Plan details the range of proposals being developed to respond to these priorities.

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9.8.5 Medical Genetics

The key priorities for 2016/17 are to:

Continue discussions with commissioners and to work collaboratively with other health boards and the All Wales Genetics Laboratory to progress proposals for an integrated All Wales Medical Genetics service in order to: Create an equitable service delivery model throughout Wales, whist maintaining a high quality of service. Set specific and sustainable standards to assess risk in patients and families in a timely manner. To build a flexible and sustainable workforce, ensuring that we have the right number of appropriately skilled staff. To replace the existing All Wales Medical Genetics Laboratory Service, Laboratory Information Management System (LIMS) To develop the All Wales Medical Genetics Laboratory Service to meet the specification required to become a Genomic Central Laboratory Hub as part of NHS England‟s re-commissioning of genetic and molecular diagnostic services. This will also provide the platform to deliver translational genomic medicine services to support the Precision Medicine Catapult and economic growth in partnership with Public Health Wales, Cardiff University and industry partners. Synergies for capital estate projects will also be explored with the All Wales Pathology Collaborative Cellular Pathology project. The non-financial option appraisal indicated that the top 2 clinically preferred models for South Wales both have a regional Cellular Pathology Services in Cardiff. Cardiff University are committed to supporting this option.

9.8.6 Organ Donation

In 2013 NHS Blood and Transplant (NHSBT) published „Taking Organ Transplantation to 2020‟, a strategy to improve organ transplantation rates.

The Wales Action Plan, published in January 2014, sets out what needs to happen in Wales to deliver this strategy. Over the next few years, we need to drive continuous improvement on all aspects of organ donation and transplantation. It sets out actions right across the pathway, from ensuring that everybody has the opportunity to make their decision known, whatever that may be, to ensuring that those who receive transplants have the appropriate after-care and follow-up. The Wales Action Plan commits health boards to deliver certain outcomes by 2020.

2015 saw the implementation of the Human Transplantation (Wales) Act 2013 and on 1st December 2015, Wales was the first UK country to introduce a soft opt-out system for organ and tissue donation.

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The local priorities for Cardiff and Vale University Health Board‟s organ donation plan are: Engage with key stakeholders to optimise and increase critical care capacity to prevent missed opportunities for capacity reasons.

Increase engagement with Paediatric Intensive Care.

Implementation of the legislation – supporting and teaching clinical staff.

Improve consent rates across the University Health Board.

Strive towards 100% referral rate in all departments, to eliminate any risk of missed potential.

Continue to maintain and build further relationships with key stakeholders e.g. Critical Care, Theatres, Emergency Unit, Transplant Unit, Mortuary.

9.8.7 Clinical Immunology The key priorities for 2016/17 are to:

Develop a proposal for a sustainable model for clinical immunology to provide a timely service for our local and tertiary population with the aim to improve both life expectancy and quality of life for adults and children with primary immuno- deficiencies and adult allergy. The aim of which would be to: Ensure equity and timely access in accordance to best practice standards, based on current guidelines for diagnosis and management for patients with Primary Immunodeficiency Disorder and related complications. Implement an electronic clinical consultation system in the specialised adult allergy service in order to manage increasing demand, to enable patients to be seen much more efficiently, radically improve the accessibility of the service, gather data that will reduce or eliminate the need to attend hospital and to drastically reduce waiting times. Build a flexible and sustainable clinical workforce in order to train the next generation of healthcare professionals. Maintain a service that is at the forefront of clinical research and development. Agree with WHSSC additional resources required to manage a growing prevalent population of primary immune deficient patients.

9.8.8. Renal Services

This service has been working closely with the Welsh Renal Clinical Network to provide improved and integrated inpatient and satellite services for patients requiring dialysis. Significant environmental improvement will be made to accommodation at UHW (suite 19) and options to develop the models of care within suite 19, UHW inpatient services (on B5) and satellite units to improve emergency care and renal outreach support to the UHW site, and planned care through increased capacity and capability within the satellite units.

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9.9 Sustainable Planned Care – Core Services

The commissioning and delivery of elective and diagnostic services to meet national waiting times targets continues to present a considerable challenge across Wales and also within Cardiff and Vale UHB.

Our commissioning intentions describe the UHB‟s intention to provide planned care services which: Are patient-focused and support greater health self-management and earlier prevention, treatment and re-ablement. Ensure clinical practice and models of service delivery are consistent with best practice and in pursuit of recognised standards. Ensure a systematic approach to realising quality and efficiency benefits of new technologies. Ensure services, wherever possible, are based on strong qualitative and quantitative evidence. Are sustainable making efficient and effective use of resources. Are safe and accessible. Are delivered as close to a patient‟s home as possible, while preserving the safety, quality and sustainability of health services.

In order to provide a planned care system in which demand and capacity are in balance, the UHB has established a Planned Care Board to oversee the development and delivery of plans to test their fit with the criteria above.

Clearly, balancing this dynamic system requires continuous review of performance data and a flexible approach to demand and capacity management solutions. There are many existing, evolving and proposed services that the Planned Care Board continues to oversee to ensure that a prudent approach is taken across the whole system.

This requires a significant focus on earlier identification of risks or symptoms and intervention in primary care to provide the right support and information to patients to ensure that treatment can be optimised or even avoided in some cases. Optimising treatment can mean either receiving it sooner (which may sometimes mean a less complex intervention) or closer to home and by the person who is most appropriate to provide that care. This is evident in the service model and pathway improvements proposed in the preceding sections of this chapter.

The RTT performance is clearly a key measure in testing the extent to which the demand and capacity for planned care is in balance.

The forecast year-end waiting list position at 31st March 2016 is presented by specialty below. The summary position is as follows:

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Diagnostics Mar 2015 Mar 2016 Mar 2015 Mar 2016 > 8weeks > 8weeks >14 weeks >14 weeks Diagnostics 3500

Number of patients Number of patients Specialty waiting more than waiting more than 36 52 weeks weeks Cardiac Surgery 0 Dermatology 30 ENT 85 300 Gastroenterology 40 100 General Surgery 15 166 Gynaecology 50 Medicine 50 Neurosurgery 11 40 Ophthalmology 150 Orthopaedics 15 500 Paediatric Surgery 94 156 Urology 30 150 Total 290 1692

The UHB made provision within its allocation of £6.3m to address capacity deficits and maintain the RTT waiting time position during the course of 2015/16. This was subsequently increased with the provision of a further £10.3m by Welsh Government in December 2015. The UHB is now forecasting a 2015/16 year end position of 290 patients waiting over 52 weeks and circa 1700 patients waiting over 36 weeks.

The UHB has explored a range of costed options for 2016/17 to improve RTT performance and reduce diagnostic waits: a) Eliminate > 36 week waits and reduce > 8 week waits for endoscopy to a maximum of 500. The estimated investment required to deliver this position is £16.5m but there are significant delivery risks associated with this option. b) Reduce > 36week waits to 1200 and reduce > 8 week waits for endoscopy to a maximum of 1000. The estimated investment required to deliver this position is £10m and whist there are a number of delivery challenges associated with this plan, there are a range of mitigation opportunities which can be pursued. c) Maintain 2015-16 RTT position (circa 1700) and maintain > 8 week waits for endoscopy at maximum of 1500. The estimated continuing investment to provide the required capacity to deliver this position is £8.5m.

All of the above investment requirements described in the above scenarios include £6.3m of core funding that is ring fenced within the UHB‟s allocation.

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The headline challenges and proposed service change priorities to deliver a sustainable planned care system are summarised below:

9.9.1 Delivering Prudent Healthcare Across the Whole System

Further developing pathways to embed the prudent approach to planned care with Community Director leads in Primary care working with Secondary Care nominated leads in: Dermatology; Gastroenterology; Urology; and Musculoskeletal.

These pathways will embed the learning from the national planned care programmes and will also apply the UHB‟s Optimising Outcomes Policy to ensure patients have the support to stop smoking and reduce their weight if necessary in preparation for the next stage of their care whether it is surgery or another therapeutic intervention.

9.9.2 Provision of Alternative to Secondary Care Capacity in the Community

The UHB has focussed on the maturing cluster plans to help to identify the opportunities and priorities for shifting services from secondary care into primary and community care settings.

Priorities for 2016/17 include: Development of post operative cataract follow ups in the community, to increase local access to services in the community and new outpatient capacity in Ophthalmology.

Explore potential to provide wet AMD services in the community to improve local access and reduce the number of clinics at UHW.

Implementation of Musculoskeletal community assessment service as an alternative to Orthopaedic clinic referral in line with the requirements of the Orthopaedics planned care programme.

Development of community based audiology services in three community hub practices in line with the strategy for Audiology services in Wales and good practice planned care services for ENT and also to reduce outpatient clinics at UHW.

9.9.3 Structured Pathway Redesign

Significant work has been undertaken during 2015/16 to streamline specific service pathways in secondary care to reduce e.g. duplication of or non-value added

Page | 129 activities, avoidable delay and to optimise efficiency and outcomes through closer pathway management – this has been applied to Urology, Dermatology and will be rolled out across other high volume specialties.

The surgical specialties of ENT, Ophthalmology and Urology will formally adopt the national planned care board action plans to review and redesign services to respond to the three primary drivers for change: Clinical value prioritisation – structured approach to applying the principles of prudent health care. Integrated care – i.e. establishing collaborative care groups (between secondary, community and primary care) Best in class i.e. measuring value for money and benchmarking against top performing organisations.

Other proposals for 2016/17 include: Pathway redesign for patients presenting with acute biliary disease to receive planned surgery within 10 days of onset of severe symptoms to improve patient outcomes, experience and service deficiency.

9.9.4 Efficiency Improvements

Key priorities for 2016/17 include: Optimising use of electronic booking tools to improve attendance and reduce DNAs with a focus on improving the uptake and use of the Fully Automated Booking („FAB‟) system for new outpatient appointments and further system development to automate follow up bookings.

Structured roll out of e-advice services providing GPs with swift access to secondary care specialist expertise across high referral speciality services including cardiology, ophthalmology, rheumatology, respiratory, gastro and child health services.

Roll out of electronic referral systems enabling GPs to refer directly into secondary care.

Focus upon outpatient clinic templates to deliver better scheduling and enhanced clinic utilisation.

Review processes, systems and functions of the temporary staffing department in order to maximise the use of bank staff and minimise agency staffing spend.

Improvement to pre-assessment services to improve patients‟ fitness and readiness for surgery in order to reduce avoidable cancellations.

Improvements to pre-scheduling theatre sessions to improve utilisation.

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Full implementation of dedicated Post Anaesthetic Care Unit (PACU) to optimise elective surgical volumes and case-mix and clinical outcomes.

Continued improvements in theatre productivity and expansion of capacity through optimising three session scheduling – assuming successful recruitment to theatre support workforce plan.

9.9.5 Additional Capacity

Short term additional capacity

This has been and will continue to be provided in a number of specialties in order to respond to non-recurring backlog pressures, in order to reduce waiting times including additional bed capacity in the community and secondary care as well as some outsourcing.

Recurring additional capacity There are significant „hot spots‟ in some surgical specialities and diagnostics that would require targeted additional capacity from the start of 2016 to ensure that the underlying capacity deficit is offset. The UHB will also face further challenges to the maintenance of existing elective capacity with changes to the education contract for trainees required by the Wales Deanery. This is required to enable the trainees to secure adequate operating experience to meet GMC requirements and, unless otherwise funded, will require a reduction in outpatient capacity to release the juniors to undertake more supervised operating. Additionally, there are increasing pressures in surgical specialities to provide „protected‟ on-call for consultants so that they are not required to continue to undertake elective surgical operating whilst they are also providing emergency on-call. This is becoming an increasing problem in high volume surgical specialties and will become more acute as higher volumes and acuity of patients present at UHW in the future.

The UHB‟s Planned Care Programme Board will lead the continued development, co-ordination, implementation and monitoring of the planned care improvement projects and initiatives to ensure that there is a coherent, whole system approach that will continuously inform the planning, delivery and continuous performance improvement cycle. This is a key component of the UHB‟s delivery structure.

Each service area for which there is a projected shortfall in recurrent capacity to meet demand will demonstrate the following for all high volume conditions: Prevention and public health opportunities are being explored and implemented; Pathway and other primary care based demand management tools are in place; Secondary care resources are being prudently deployed to deliver the outcome that matters to the patient; and Efficiency and productivity opportunities are optimised.

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The following developments include the components of the UHB‟s Planned Care plan that have been reviewed in the context of 2015/16 experiences, observations and analysis of key capacity gaps across all parts of the pathway.

2016/17 Planned Care Plans

This year the Health Board has undertaken an early assessment of its 2016/17 demand and capacity for planned care services and developed schemes in every area to address these deficits. A summary of the demand and capacity assessments for the key specialties is presented below:

New outpatients Inpatients / Daycases 16/17 16/17 RTT Specialty Demand Surplus / Demand Surplus / Capacity Capacity (incl. (Deficit) (incl. (Deficit) backlog) backlog) Cardiac Surgery 675 780 (105) 900 627 273 Dermatology 12,741 8356 4385 3569 3059 510 ENT 10,263 9865 578 3042 2319 723 Gastroenterology 3949 3807 142 General Surgery 13,536 12,530 1006 4964 3821 977 Gynaecology 7634 6439 1195 2607 1904 703 Neurosurgery 1596 1572 24 11,654 945 219 Ophthalmology 9697 9205 492 4328 3962 366 Orthopaedics 11,533 9826 1707 9042 8107 935 Paediatric Surgery 1810 1282 528 997 779 218 Urology 5929 5245 684 5652 5092 560

16/17 Demand (incl. Diagnostics Capacity Surplus / (Deficit) backlog) Endoscopy 14,169 7726 6443 MRI 23035 19800 3235 CT 38078 36923 1155

Evidently, there are considerable capacity deficits across all the key specialties, with recurring shortfalls in most. Dermatology and Endoscopy, in particular, have emerged as significant pressures during 2015/16, with Orthopaedics a growing concern and now the Health Board‟s largest breach specialty. For the majority of specialties there are existing schemes in place to partially address these deficits, which are anticipated to roll-over into 2016/17. Furthermore, each specialty has devised additional solutions to address the residual gaps.

The totality of these plans has been distilled into the three high-level options described in section 9.9, i.e. eliminate, reduce or maintain. As stated there are significant risks with some of the proposed schemes, so the option of eliminate is unlikely to be fully deliverable. Nonetheless the organisation is ambitious to improve and will continue to pursue these schemes throughout 2016/17.

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The reduce option is stretching but considered achievable given the progress made during 2015/16. However, both the reduce option and the maintain option are contingent upon additional investment beyond that within the financial allocation.

In addition, all of the plans are dependent upon a number of assumptions: WHSSC fund the delivery of all WHSSC specialties (paediatric surgery is the most significant specialty in this category); No impact from major service reconfigurations (incl. UHL/UHW, vascular, ENT, surgery etc); No loss of theatre capacity due to refurbishment or other downtime; Outsourcing will continue as an option but will have limitations (both volumes and casemix); and Limited Liability Partnership option can continue and be extended, but is preferably not a long-term arrangement.

The extent to which the Health Board can further improve waiting times will in part be dependent upon infrastructure constraints: in particular theatre capacity, endoscopy theatre capacity, bed capacity and MRI capacity. Existing plans mean each of these supporting resources will be at maximum capacity (or over-subscribed) during 2016/17, hence the current reliance on external providers.

The UHB is developing a long term plan for both capital and revenue investment to improve and expand theatre and critical care facilities across UHW and UHL sites, in order to meet service need and provide accommodation which is safe and fit-for- purpose. This programme takes account of the context of the hospitals‟ strategic roles in meeting local, regional and tertiary care needs in the medium and longer term.

There will need to be some contingency plans deployed over the next two years whilst the investment cases are prepared and the necessary capital secured. The contingency plans will include: Close collaboration with neighbouring LHBs to ensure that elective flows are managed to optimise all available capacity across the region‟s health boards. Running theatre facilities on a 7-day basis to fully utilise local assets - this will require a flexible approach to provider utilisation as the UHB will not be able to run theatres with existing workforce on 7 day basis. Develop robust Organisational Development and workforce plan for theatres and critical care to improve recruitment and optimise retention of nursing staff. Utilising private sector providers for appropriate low complexity surgery.

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10. Unplanned (Emergency) Care

10.1 Context

In recent years within Cardiff and Vale, there has been significant and comprehensive redesign of primary and community services - within the UHB and more widely across other local authority and Third sector partners to provide a much more integrated social model of care to better respond to the holistic needs of our local population. These developments have focussed strongly on working with our communities to develop support and services to promote good health, prevent or delay ill health and early intervention as close to people‟s homes as possible.

The Integrated Health and Social Care Partnership has enabled the delivery of various initiatives which have established a partnership approach to „home first‟ service development in the community. This includes: Development of community resource teams bringing together health, social care and third sector expertise to provide a home-focused approach to admission avoidance and expediting discharge. More recently, these teams have been further expanded to provide a 7 day service using Primary Care funding; Use of an Accommodation Solutions Teams to expedite the provision of alternative accommodation or alterations to existing homes in order to facilitate hospital discharge; Building a single point of contact for members of staff and the public seeking information on various community services; and Providing advice and signposting to members of the public seeking services to maintain their independence and ongoing wellbeing in the community.

These developments have allowed more people, especially those with long term conditions, to receive better support and care in their home environments, reducing the need to go to hospital and this is reflected on the reduction in the rate of emergency hospital admissions and re-admissions for people living with a long term condition.

The UHB will promote and share good practice at all levels using a range of information and platforms to communicate to the public, service users and service partners to reinforce good choices and discourage unhelpful behaviours.

This move is underpinned by the requirements of the Social Services and Well-being (Wales) Act 2014 which places increased focus upon improving the well-being of people requiring care and support through enhanced partnership working. In particular, the focus upon prevention, joint needs assessment and safeguarding are key areas, which will require careful management across the Partnership.

The Integrated Health and Social Care Partnership has already secured a commitment from Local Authority and Third Sector partners to take forward virtual integration of services relating to the care of older people across adult social

Page | 134 services and community health services. In 2016/17, we will build upon the community-based developments, which have been already established, moving towards a defined plan for home-focused services to enable out-of-hospital care wherever possible.

10.2 Sustainable Unplanned (Emergency) Care – Core Services

Despite these important service improvements in prevention and the considerable increase in the amount of care provided by GPs and community based carers, the demand for emergency care continues to place both primary and acute services under severe pressure. This is exacerbated by the increasing frailty of our growing and ageing population as people are living longer often with one or more long-term condition. This is compounded by the significant increase in new residential developments, in Cardiff in particular, which is growing the base resident population.

Traditionally, patients requiring an acute medical emergency admission have been admitted to both UHW and UHL (with some specific conditions excluded at UHL). As specialist and supporting diagnostic services have evolved and developed at UHW, there has not been corresponding investment and uplift in UHL services.

UHW provides a full A&E and full range of associated secondary care emergency admitting specialities including acute stroke and tertiary care, for example emergency neurological, vascular and cardiac conditions, whilst UHL provides acute general medicine emergency care for GP emergency referred patients. There are significant challenges to maintaining this traditional arrangement in terms of medical workforce, timely access to clinical support services and specialist advice and the provision of effective training to clinical staff. In addition, the existing clinical pathways do not always provide patients with the right care in the right place, first time.

Added to this , there is continuing clinical evidence to support the consolidation of more complex care to fewer hospitals where specialist skills, facilities and equipment can be effectively and efficiently organised to provide safer care and therefore better outcomes for patients. Examples of this include centralisation of vascular emergencies, STEMIs and acute stroke. Some of these services have been centralised at UHW to support our local population (e.g. stroke) and others to support South or South East populations (e.g. STEMIs). This trend is likely to continue and place further pressure on the UHB‟s emergency pathways and capacity at UHW in particular.

Work is also being undertaken with the NHS Wales Collaborative to develop a South Wales Major Trauma network for patients who suffer severe traumatic injuries. This important service will require the provision of a single major trauma centre that will provide a sustainable, accessible and comprehensive range of core specialist services. South Wales is the only part of the UK without a Major Trauma Network. Evidence from England shows that the rapid and safe transfer of patients to a

Page | 135 dedicated major trauma centre significantly increases the odds of survival for major trauma patients.

The UHB is committed to becoming the Major Trauma Centre and recognises the requirement for strong clinical leadership, cross health board working and robust planning. In order to facilitate this planning, the UHB has approved the establishment of a virtual major trauma directorate. This will be led by a clinical Trauma Director and Deputy, supported by two dedicated major trauma nurses with appropriate project management and administrative support.

The clinical pathways and supporting processes and technical and physical infrastructure to support effective patient flow from admission to discharge are complex and the focus of continuous review. Key challenges to support a redesigned service model include the technological infrastructure in terms of clinical and patient information systems, diagnostics capability and capacity and physical infrastructure in terms of environmental and functional suitability.

The processes and capacity to support patients on discharge are similarly complex and variable and the capacity provided in the nursing care home sector is also particularly at risk as social services budgets are reduced and private providers are less able to maintain viable business models.

Taking account of these drivers for change, i.e. the: Change in the size and needs of the local population; Increasing demand from wider SE Wales population for complex emergency care; Workforce challenges – recruitment and training of medical staff in primary and secondary care; Requirement to meet increasing clinical standards to improve outcomes for patients; Requirement for the provision of a major trauma centre; Increasing complexity and diversity in care pathways and capacity for care provision; and Technological infrastructure and out-dated buildings which are not fit for purpose in terms of both environmental condition and functional suitability.

The UHB‟s intention is to develop a new model of unplanned care based on our design principles of: Empowering the Person; Home First; Outcomes that matter to People; and Avoiding Harm Waste and Variation.

This approach will underpin the transformation of services for which some core foundations have been developed in the last couple of years – in particular the strengthening of primary and community service and the focus on building

Page | 136 relationships, structures and services to encourage real integration of health and social care services.

The longer term, flexible and sustainable service model for unplanned care services in Cardiff and Vale will require significant engagement with our wider service stakeholders to inform the redesigned service model where there is likely to be the need for change to patient flows and/or significant capital or revenue investment in new models of emergency care. These changes will be necessary to ensure that a sustainable model of unplanned care is developed that will provide safe, equitable and effective care for our population e.g. the future role and function of both UHW and UHL as key components of a local and regional network of acute unplanned care, along with the role of some of the UHB‟s community hospital sites. This will also be the case with the new major trauma centre for South Wales – the engagement regarding this development will be co-ordinated by the NHS Wales Collaborative.

The UHB services and facilities will be remodelled to provide a dynamic, flexible and integrated emergency services in partnership with WAST, partner LHBs, local authority, third and private sector partners to provide local, regional and tertiary level care. The model of out of hospital, acute and specialist emergency care will take account of the drivers for change, apply the UHB‟s strategic design principles and provide clear demand and capacity projections to inform the enabling workforce, technology, infrastructure and facilities plans required to underpin the required transformation care.

In 2016/17 the UHB‟s model for unplanned care will continue to evolve, building on existing platforms of good practice and addressing priority areas for urgent improvement. The development and implementation of the unplanned care programme will be co-ordinated by the UHB‟s unplanned care board chaired by the Chief Operating Officer.

The key priorities of targeted action for 2016/17 for general unplanned care include: Priority for Home First: Develop new and innovative clinical roles within Primary Care Out of Hours, to include: Clinical Practitioners to provide increased clinical capacity within the service and pilot Advanced Paramedic Practitioners (APPs) seeing patients face to face in their homes to release GP capacity to more effectively meet demand. Additionally, recruit pharmacists to help with patient education with regard to repeat prescriptions and the prescription pool during busy periods.

Continue to develop pathways between primary and secondary care for ambulatory sensitive (ACS) conditions to improve support to patients to manage long-term conditions in the community. Also improving access within Primary Care to ensure appropriate use of the Unscheduled Care System and improvements in access arrangements within primary care across C&V through the multi agency PCIC Access group.

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Continued expansion of the Community Resource Teams to cover extended days 7/7 to support patients diverted and referred from the Emergency Unit (EU) as well as extending nursing home cover to prevent avoidable emergency referrals.

Establishment of a multi-disciplinary Primary Care Support Team to improve reliance of fragile services and practices within the UHB and to facilitate service change and improvement through the provision of training, advice and targeted intervention where required.

Continued development of the highly successful Customer Contact Centre to provide single point of access for Cardiff and Vale localities health and social care services to optimise appropriate and timely access to community based health and social care services which will reduce waiting times for patients and optimise use of community resources.

Develop integrated service models for the provision of additional GMS capacity co-located with a broader range of community services for the area and third sector/local authority services in line with the social model of care including co- production. The actions for this are being taken through the „Delivering Local Health Care‟ programme. Established to design and deliver integrated, local health and well-being services across Cardiff and the Vale with a focus on the redevelopment of local community hospital facilities within the three UHB localities – CRI, Barry and Whitchurch.

Further develop the Cardiff Health Access Practice (CHAP) service to provide improved screening and additional support for growing refugee and asylum seekers.

WAST – support emergency pathways to optimise provision of care to patients in situ and ensure that alternative choices and pathways for patients are integrated with WAST 5 step model.

Optimising Clinical Processes Continue to review and revise „front door‟ pathways in the context of evolving changes to acute services across hospitals within the South Central ACA i.e. Royal Glamorgan, Prince Charles and UHL.

Develop and implement Ambulatory Emergency Care service model at UHW to optimise patient experience and roll out to UHL to reduce avoidable congestion in the medical assessment unit.

Enhance medical assessment capacity at UHW and continue to develop acute physician led model to optimise patient experience, outcomes and efficiency.

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Centralisation of acute emergency admissions for ENT for South Central region to meet clinical standards of care, optimise outcomes for patients and provide a sustainable emergency service model – assuming successful engagement and support from South Central service partners and stakeholders.

Expansion of the Frail Older Persons‟ Assessment and Liaison (FOPAL) Service to increase access for frail and elderly patients to early geriatric assessment when they are referred to hospital as a medical emergency including the establishment of a dedicated clinical area for FOPAL assessments and short-stay admissions.

Surgical Assessment Unit - extend the capacity and opening hours of SAU 24/7 on a permanent basis to support the delivery of Emergency General Surgery (EGS) and assist the flow of emergency surgical patients in a timely and consistent manner and to support the implementation of new surgical pathways e.g. ambulatory emergency surgery, NELA and acute biliary symptoms.

Provide first seizure assessment in EU by epilepsy nurse specialist to reduce avoidable hospital admissions.

Effective Hospital Site Management Implement flow programme recommendations from Leaner and Fitter 2: Establish a hospital „drumbeat‟ to ensure a shared understanding of the hospital status.

Develop and roll out discharge targets to individual wards based on detailed data analysis.

Support consistent use of multi disciplinary ward and board rounds.

Encourage use of the predicted date of discharge upon admission.

Encourage staff to fully utilise and update the ward clinical workstation in order to develop a live and real time bed state.

Roll out visual management (of the bed state) across wards to ensure widespread awareness of the system flow and status.

Well-Managed Patient Care Undertake continuous review of demand and bed and workforce capacity to manage peaks in demand.

Implement flow programme recommendations form Leaner and Fitter 2:

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Develop and roll out an ambulatory emergency care model.

Review the use of comprehensive geriatric assessment early in the patients‟ journey in order to prevent longer hospital stays and rapid deterioration.

Effective Care Transfer Implement flow programme recommendations from Leaner and Fitter 2 i.e. Engagement with primary care, community and local authority partners in a concerted approach to capacity planning and provision to address challenges around delayed transfers of care and to provide sub-acute capacity to meet demand.

Progress the implementation of the Delayed Transfer of Care action plan for Cardiff and Vale co-ordinated through the Integrating Health and Social Care Partnership.

Develop and implement robust „Discharge to Assess‟ integrated service provided from local nursing homes to improve patient discharge process from hospital and protect critical capacity in the community.

Develop a plan for long term care (respite, residential and nursing) requirements in the community.

Build upon effective links with housing and accommodation services and third sector organisations.

Further develop the integrated Continuing Health Care programme across the UHB and key partners to develop a complex care team to prevent decline in vulnerable patients and optimise the rehabilitation opportunities for all patients.

Agreed Care Pathways Implement flow programme recommendations from leaner and Fitter 2: Develop and roll out an ambulatory emergency care model.

Review of medical assessment flow and gate keeping.

Update map of emergency care pathways from all sources (e.g. self-referral into A&E, GP referral or 999) into defined receiving points (A&E, AU, AEC, SAU, CAU etc) and onward flows into receiving departments/destinations (Home, ESCU, MDU, Wards etc) to ensure pathways are clearly understood by service users, partners and providers.

Extend the District Nursing service to expand the clinical triage function at the Customer Contact Centre as well as extending services to patients in the community including post hospital discharge support, vene-puncture and end of life care.

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In terms of the challenges and requirements in providing unplanned care within our service priority areas, many of the challenges and proposed responses are already covered in the preceding sections either under planned care (where some of the pressures and solutions impact both planned and emergency care) or under the above section relating to general unplanned care.

The sections below outline the challenges and developments proposed to address unplanned care requirements that are specific to our priority services that have not been covered previously in any of the above sections:

10.3 Cancer

The emphasis and promotion of public health programmes continues to be central to the UHB‟s approach including the Add to Your Life self assessment as part of our responsibilities to provide the public with information about how to protect their health and wellbeing, alongside a range of immunisation and screening programmes. We will focus on reducing inequities in screening uptake and continue to improve bowel screening uptake as part of the work on early diagnosis and prevention.

Ensuring that GPs are supported to provide earlier diagnosis for patients with cancer remains a key priority. Access to timely diagnostics is a key requirement and the UHB aims to continue to improve capacity for key diagnostics, in particular endoscopy, which currently has a significant backlog and capacity deficit.

Embedding and developing the UHB‟s acute oncology service will be one of the key areas of focus for the delivery of hospital based services. Key priorities for 2016/17 are largely reflected in the planned care section of this document

10.4 Dementia

As one of the UHB‟s BIG (Big Improvement Goals) for 2016/17, Dementia awareness and care improvement will be at the very top of the UHB‟s agenda and the UHB is committed to making dementia care everybody‟s business and to support „dementia supportive communities‟ to build awareness and inclusivity.

The key priorities in 2016/17 for target action include: To develop a RAID model of liaison psychiatry for over 65s in order to prevent unnecessary admissions to DGH beds and provide training and support for DGH staff.

Provide Dementia Champions in each cluster.

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Further strengthen the memory team‟s role to provide early support for people with suspected dementia.

Strong focus and promotion of Making Every Contact Count (MECC).

10.5 Dental and Eye Care

The key priorities in 2016/17 for target action specifically in respect of unplanned care include: Implement the evaluation/learning following the eye casualty pilot working across both Primary and Secondary Care.

Provision of additional „urgent‟ contracts in primary care for patients requiring emergency dental treatment to take them out of pain.

10.6 Long Term Conditions

The aim to continue to reduce avoidable admissions and readmissions continues to be a high priority for the UHB with a continued expansion in ACS pathways through clinical leadership in Primary Care dedicated to working with secondary care experts to develop and embed locally (see Long Term Conditions section in Planned Care above).

Further key priorities in 2016/17 for target action include: Provision of diabetic specialist nurses in GP clusters to reduce avoidable emergency admissions.

Frailty Nurses, linked to Cardiff CRTs to provide additional support to GPs in managing patients identified as high risk of admission.

Cluster based Well-being Co-ordinators to bridge the gap between the GP practice and the Community, contributing to the social model of health.

Community-based Cluster Pharmacists – focus on polypharmacy review – improving outcomes and reducing unplanned pressure on GPs.

Provision of Integrated Care Team doctor in the Eastern Vale, linked to the Vale CRS to provide additional support to GPs in managing patients identified as high risk of admission.

Strengthen and improve the primary PCI pathway for SE Wales.

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10.7 Maternal Health And Early Years

The key challenges in providing optimal unplanned care are: Increased development of immunisation team to improve performance and improve equity of access.

To develop and implement sustainable models and capacity for Paediatric CEPOD and Paediatric MRI.

Develop a „single point of entry‟ for Paediatric emergency attendances/admissions to hospital co-located with EU at UHW for optimal assessment and patient experience.

10.8 Mental Health

The key priorities in 2016/17 for target action specifically in respect of unplanned care include: To develop first episode psychosis (FEP) support to Children and Women and CAMHS services to improve the delivery of evidence based interventions for first episode psychosis.

Increase Psychiatric Intensive Care Unit capacity from 5 to 10 beds in Hafan y Coed in order to comply with national standards and provide appropriate capacity to meet demand and provide safe patient care in the most appropriate environment.

Review model of service at the crisis house following transfer of inpatient services to UHL – the service model may need to be adjusted to facilitate early discharge rather than admission avoidance due to lack of proximity to inpatient services following transfer of services from Whitchurch.

CAMHS

Implement revised criteria for specialists CAMHS following conclusion of consultation in 2015/16.

Roll out new Primary Mental Health Emotional Wellbeing service to provide rapid direct access for GP referrals to provide support for young people prior to accessing CAMHS service.

Implement the Neurodevelopment multidisciplinary team service.

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10.9 Stroke

Stroke services remain a key priority for the UHB and much work has been undertaken in 2015/16 to improve primary and secondary prevention for example in the diagnosing and treatment of atrial fibrillation in the community. There has been continued collaboration with Cwm Taf to support a regional Out of Hours thrombolysis service as well as further development of specialist acute stroke services at UHW.

Despite progressing a programme of ongoing continuous improvement activities, compliance with the Stroke bundles remained challenging in 2015-16. The service has undertaken a comprehensive review to identify outstanding opportunities and implemented a plan for 2016-17 to improve patient outcomes and experience. The UHB‟s Stroke delivery plan and the most recent annual report provide a detailed update on delivery and performance.

There are a range of key deliverables for 2016/17 including: Maintaining the emphasis on embedding public health actions through improving awareness and focusing on promoting healthy behaviours e.g. Healthy early years, schools and workplace programmes already in place.

Implementation of „Code Stroke‟ following ASHICE call to facilitate prompt diagnosis and thrombolysis in EU where appropriate and timely admission to the acute stroke unit

Implementing phase 1 of the integrated workforce plan (IWP) to deliver resilient and effective 7-day specialist rehabilitation to ensure recovering stroke patients have optimal outcomes and stay within an inpatient setting no longer than is necessary. Consider how the IWP process can be expanded to incorporate the acute and community workforce.

Commission the community neurorehab/stroke team which aligns to current ESD and CBIT thereby increasing capacity to deliver ongoing rehabilitation and 6 monthly reviews

Implement the recommendations of the national scoping exercise (PenCHORD) of Hyper Acute Stroke Unit and thrombolysis services for Wales.

In line with the above recommendations review the provision of intra-arterial thrombolysis or mechanical thrombectomy as an adjunct to the current thrombolysis service.Identification of AF patients in primary care and their appropriate management.

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10.10 Other Areas of Key Service Change - Specialist

10.10.1 Care of the Critically Ill

The key deliverables for 2016/17 are: Reducing delayed transfers from critical care by 10% per quarter.

Defining and implementing core standards for critical care to support the introduction of peer review and the reconfiguration of critical care services.

Developing and delivering a programme to support transition to all-Wales adoption of a universal electronic patient information system and supporting eICU hubs for critical care.

Undertake and respond to the findings of the National Carers‟ survey.

The acute service model at UHL will determine the level of critical care support required for emergency patients in the longer term - either 24/7 senior medical anaesthetic cover with stabilisation and transfer of patients requiring on-going high dependency or intensive care (this is similar to the current service provision) or day time anaesthetic cover with a „crash‟ team at night to manage patients requiring immediate stabilisation or transfer and retrieval.

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11. End of Life

11.1 Context

As part of Shaping Our Future Wellbeing, End of Life Care was raised as needing dedicated focus. Everybody is affected by the death of a family member or friend who has gone through a final phase of illness. Not only do people need rapid assessment and the best possible treatment, they also need ongoing support and information about choices when treatment may no longer be effective. The UHB and its key partners; Marie Curie, George Thomas Hospice, work closely with patients and families to explain clearly the options and their implications to an individual and their family at the end of life.

As indicated in Chapter 4, Local Health Needs and Challenges, the population of Cardiff and the Vale of Glamorgan is growing. Projections suggest by 2030, the population of over 65 year olds will increase by 44% in Cardiff (19,710 people) and by 53% (12,480 people) in the Vale of Glamorgan. In particular, the numbers of the very elderly (85 yrs +) will increase markedly (10.4% increase over 2013-17). The increase in the number of older people is likely to cause a rise in chronic conditions such as circulatory and respiratory diseases and cancers and therefore increased palliative care needs.

The 2011 Census shows that 15.3% of the population of Cardiff described themselves as non-white. In the Vale of Glamorgan this figure was 3.6%. The Welsh average was 4.4%. Recognising this specific area of health need Marie Curie appointed a Black and Minority Ethnic (BME) key worker in 2013 as part of a 3 year scoping project to work closely with ME communities to promote greater awareness of health issues and the role of palliative care. The table below shows the impact of this project on uptake of existing services.

The use of Hospice/Palliative Care Services by BME communities in C&V UHB area Year % increase since Number of patients 2012 using hospice and community services 2012 (before project) Pre-project 31 Oct 2012 / Sept 2013 29.0% 40 Oct 2013 / Sept 2014 80.6% 56 Oct – Dec 2014 (3 12 months data) Dec – Mar 2015 (3 12 months data)

Place of death can be a critical contributor to the quality of death for a person, their family and friends. It affects their physical, mental, social and spiritual comfort and may provide the opportunity for family and friends to be present during the final hours of a person‟s life.

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Recent figures show less people are dying in hospital and there are a higher percentage of people dying in a hospice in Cardiff and the Vale of Glamorgan compared to other areas of Wales. For many, the preferred place of care and death is the Marie Curie Hospice Cardiff and Vale, which has a long established good reputation in the area. There are proportionally more hospice beds in Cardiff and the Vale of Glamorgan compared to other areas ensuring speedy access to beds from the hospital or community. However, the percentage dying at home or care home is just below the Welsh average. The UHB has identified the need to establish a Hospice at Home service working with the District Nursing service to enable more people to achieve their preferred place of care.

11.2 Sustainable End of Life Care – Core Service

The UHB‟s local End of Life Care Plan outlines the vision and key themes for improving End of Life Care. These are: Supporting living and dying well; Detecting and identifying patients early; Delivering fast, effective care; and Reducing the distress of terminal illness for the patient and their family.

Following on from the initial strategy development, further End of Life Shaping Our Future Wellbeing workshops have been run through 2015, with development of the following workstreams: Maximise resources to deliver equity of access to Specialist Palliative Care; Reform the Referral Pathway; Develop a single structured Core Assessment; Enhance Medicines Management; and Expand Information sharing.

The key priorities of targeted action for 2016/17 for End of Life Care include: Working with Marie Curie, extend the contract of the current Black and Minority Ethnic (BME) key worker to build on the progress already achieved.

Increase awareness of the use of the GP Palliative Care register and Advance Care Planning building on the recent appointment of MacMillan GP facilitators.

Continue to support education of senior nursing home staff through the Cardiff University End of Life Care degree module. The aim has been for 10% of nurses in Cardiff and Vale to have completed the module, and this has been exceeded in some areas (300 completed to date). We would expect to see measurable improvement in advance care planning and preventing unnecessary acute admissions.

Implement the All Wales Care Decisions document and establish systems to ensure regular clinical audit is continued.

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Jointly implement a flexible responsive Hospice at Home Service with Marie Curie, leading to an increase in the percentage of those dying at home.

Build on the successful specialist palliative care outreach work, Marie Curie nurse led specialist palliative care assessment pilot, located in a Barry GP practice and the Cardiff based, George Thomas Hospice specialist day centre review.

Build on work with non-cancer groups including 7-day Clinical Nurse Specialist (CNS) weekend service and OOH Consultant advice and joint non-cancer outpatient clinics.

Take forward the actions from the End of Life Shaping Our Future Wellbeing workshops.

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12. Resources

12.1 Context

This chapter sets out the resource requirements in terms of finance, infrastructure (Estate, critical medical equipment and IT) and workforce to enable the service changes outlined in Chapters 6-11. They are designed to support the strategic direction of the UHB in delivering improvements in population health for the agreed service priorities, whilst ensuring sustainability through making the best use of the resources we have.

12.2 Provisional Financial Plan

12.2.1 Introduction and Background

The UHB‟s 2015/16 – 2017/18 IMTP was approved by the Minister in August 2015, conditional upon improved performance in a number of key areas. The UHB has managed to deliver upon these conditions and approval was reaffirmed in November 2015. A summary of the financial plan over this period is shown below.

Summary of IMTP Financial Plans 2015/16 – 2017/18

Annual Annual Annual Plan Plan Plan 2015/16 2016/17 2017/18 £m £m £m Income 1,203.1 1,220.5 1,233.7 Expenditure (1,216.4) (1,232.7) (1,242.1) Planned Surplus/(Deficit) (13.2) (12.3) (8.4)

Therefore, whilst not having a balanced financial plan, the current IMTP is approved. This however, without any further support from Welsh Government, would still result in the UHB breaching its financial duty. The UHB continues to work with Welsh Government to explore the options available to mitigate this risk and to deliver financially sustainable services. This work is likely to be progressed in the last quarter of 2015/16.

As the UHB has an approved IMTP, the advice from Welsh Government is that this plan should not be a rewrite but a refresh of the current plan. This plan is provisional at the moment as:

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The UHB is still working through what support is available from the Welsh Government including the requirement to repay deficits and the timescale for doing so; Whilst assumptions have been made around Welsh Government allocations and associated growth for 2016/17, the details have not yet been confirmed; Good progress has been made in assessing unavoidable cost and demand pressures but further work is needed to finalise these; An assessment of the funding required to support performance against key tier 1 targets and other areas of agreed investment needs to be finalised; Cost savings proposals are in their early stages of planning and require considerable additional work to conclude.

The financial environment in which the NHS Wales has been operating has been extremely challenging for a number of years. The UHB has had to make significant efficiencies to meet the costs of unfunded inflation and other cost pressures. The cash releasing efficiencies made by the UHB in recent years is summarised in the following table.

Cash Releasing savings made 2012/13 to 2015/16

Actual Actual Actual Forecast 2012/13 2013/14 2014/15 2015/16 Savings made £36m £46m £28m £23m % saving of relevant baseline 4.4% 5.6% 3.4% 2.8%

These savings are amongst the highest made in NHS Wales and reflect the good progress made in mitigating financial risks faced by the UHB. Notwithstanding delivery of these savings, the UHB has struggled to deliver its statutory breakeven duty. Over the same time period, the UHB: Managed to break even in 2012/13 but only through £26.2m of non-recurrent financial support provided by Welsh Government; Had a £19.2m deficit in 2013/14; Had a £21.4m deficit in 2014/15; Is forecasting a £12.2m deficit in 2015/16, which is after receipt of £14.7m non recurrent funding.

In considering this is should be noted that the UHB compares well on provider efficiency against other Welsh LHBs and has the lowest spend per head of resident population in NHS Wales. This points to the UHB having a structural financial problem that it is finding difficult to overcome. This is supported by the latest update to the Townsend direct needs formula, which indicates that the current UHB Discretionary allocation is 8% lower than the updated Townsend formula share, which is based on updated datasets. The UHB continues to work with Welsh Government in respect of its deficit and underlying financial problems and the UHB‟s three year Integrated Medium Term Plan therefore, needs to be considered in this context.

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12.2.2 Progressing the Financial Plan

The financial plan is very much work in progress and the first draft will need to be finalised before submission to Welsh Government at the end January 2016. Further work is required on assessing the brought forward underlying deficit, allocation increases, inflationary and demand pressures, investments to be progressed and the savings requirement. It is however clear that the next three years will present the UHB with difficult choices and financial challenges to overcome.

When finalised, the Financial Plan will set out the financial strategy of the UHB which supports delivery of the service strategy outlined in the Integrated Medium Term Plan. The context for the UHB will be a very challenging three years. The UHB is anticipating having to make significant further savings over those already made to mitigate against the pressures of an underlying deficit, and cost pressures and service change investments above allocation increase levels.

Over the next three years, the UHB is likely to need to deliver circa 3% saving per year. The ability to achieve this constant level of saving must be seen as a risk, especially as delivery gets harder each year as efficiency opportunities are utilised. The scale of savings achievable, and the resultant impact upon the financial sustainability of the UHB will need to be subject to further discussions at Board level, before the draft plan is finalised and submitted to Welsh Government for consideration.

The Financial Plan will need to: Deliver significant levels of savings through improving provider efficiency, prudent healthcare and whole system changes; Support service transformation to achieve more effective and higher quality delivery of services closer to home; Continue to redesign services that are closer to home and make further progress in shifting resources from secondary care into primary care and community recognising that specialised commissioning is also a future area of likely growth; and Support the planned improvements set out against the key Welsh Government Delivery Framework priorities.

The following assumptions are currently being used in working through the finer financial details in the plan: The UHB will not be required to repay its previous years deficit. The arrangements around this need to be confirmed with the Welsh Government; Given the high level of provider inflation in 2016/17, the UHB will be successful in securing an appropriate LTA uplift of circa £1.5m (between 1.5% and 2.0%) No loss of income from the SIFT review recently completed. This approach has previously been confirmed by Welsh Government; The commissioning approach from WHSSC and neighbouring LHBs does not destabilise the UHB.

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12.2.3 Resource Planning Assumptions

Underlying Deficit

The underlying financial position brought forward into 2016/17 looks particularly challenging due to: Recurrent shortfalls in the delivery of 2015/16 savings targets; Investments made in 2015/16 which were outside of the budget plan; Recurrent impact of the 2015/16 shortfalls in assumed provider share of allocation increase; Other operational pressures.

These issues are currently being worked through to assess the opening position of the UHB. Given the current 2015/16 forecast deficit of the UHB and the non- recurrent funding that supports this, it is likely that the brought forward deficit will be considerable higher than set out in the approved IMTP.

Cost Pressures and Income Assumptions

Whilst making good progress, the UHB is still working through an assessment of its inflationary and demand pressures for the period of the plan. The UHB has used the latest All Wales National Cost Assessment to help inform the expected cost pressures from 2016/17 to 2018/19 and this has been amended is more accurate information is available locally.

The following table shows the latest assessment of new income and expenditure pressures.

Assessed Cost Pressures

2016/17 2017/18 2018/19 Inflationary and Cost Pressure Cost Cost Cost £'000 £'000 £'000 Cost Growth Pay Inflation 5,805 4,693 4,740 Incremental Drift 1,271 952 952 Pensions Costs 7,729 2,431 2,431 Non pay Inflation 1,100 1,500 1,500 Statutory Compliance and National Policy 265 1,000 1,000 Continuing Heath Care 400 400 400 Funded Nursing Care 75 75 75 Total Cost Growth 16,645 11,051 11,098 Demand / Service Growth NICE and New High Cost Drugs 5,810 3,500 3,500 Continuing Heath Care 6,000 3,500 3,500 Funded Nursing Care 225 225 225 Prescribing & Community Pharmacy 1,000 2,000 2,000 Specialist Services 2,400 2,000 2,000 Local cost pressures TBC 2,500 2,500 Demographics / Demand on acute services TBC 2,000 3,900 Page | Total152 Demand / Service Growth 15,435 15,725 17,625 Other Cost Pressures Welsh Risk Pool 1,000 700 700 Income reductions 1,700 1,000 1,000 Transformation & Service Improvements TBC 2,000 3,000 Contingency 3,000 3,000 3,000 Total Other Cost Pressures 5,700 6,700 7,700

Total Inflationary and Cost Pressures 37,780 33,476 36,423 2016/17 2017/18 2018/19 Inflationary and Cost Pressure Cost Cost Cost £'000 £'000 £'000 Cost Growth Pay Inflation 5,805 4,693 4,740 Incremental Drift 1,271 952 952 Pensions Costs 7,729 2,431 2,431 Non pay Inflation 1,100 1,500 1,500 Statutory Compliance and National Policy 265 1,000 1,000 Continuing Heath Care 400 400 400 Funded Nursing Care 75 75 75 Total Cost Growth 16,645 11,051 11,098 Demand / Service Growth NICE and New High Cost Drugs 5,810 3,500 3,500 Continuing Heath Care 6,000 3,500 3,500 Funded Nursing Care 225 225 225 Prescribing & Community Pharmacy 1,000 2,000 2,000 Specialist Services 2,400 2,000 2,000 Local cost pressures TBC 2,500 2,500 Demographics / Demand on acute services TBC 2,000 3,900 Total Demand / Service Growth 15,435 15,725 17,625 Other Cost Pressures Welsh Risk Pool 1,000 700 700 Income reductions 1,700 1,000 1,000 Transformation & Service Improvements TBC 2,000 3,000 Contingency 3,000 3,000 3,000 Total Other Cost Pressures 5,700 6,700 7,700

Total Inflationary and Cost Pressures 37,780 33,476 36,423

The UHB is still working through its investment requirements for 2016/17 which will add to this assessment. In some areas these pressures are higher than previously planned. This together with an anticipated increase in the underlying deficit will put greater financial pressure on the UHB, especially in 2016/17.

The UHB‟s financial assumptions also include the following: No net adverse financial impact as a result of decisions around the South Wales Plan; WHSSC risk shares are only changed if they are done on a cost neutral basis; The UHB will receive its allocation share of the £200m that has been announced as part of the 2016/17 NHS financial settlement (£28.8m). It will then receive a 2% uplift to allocations in 2017/18 and 2018/19. The cost of Hepatitis C drugs will be funded by Welsh Government.

Savings Programme

In order to mitigate against the UHB‟s underlying deficit and new cost pressures the UHB will again need to find significant savings. For planning purposes, the maximum that is deemed achievable is 3% of net relevant expenditure . Given the achievements made in recent years, this is at the top end of what can realistically be delivered.

In order to address this savings target, the following principles have been agreed for 2016/17: The scale of the challenge should be minimised by cost avoidance and being rigorous in scrutinising investments and support for cost pressures. The aim should be to maximise the value of any additional spend;

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Clinical Boards should be tasked with managing their brought forward underlying deficits. This will incentivise Clinical Boards in applying downward pressure on costs in 2015/16; The savings programme should be based upon a number of UHB wide cross cutting supported by a local efficiency target. This will inevitably lead to differential CIP targets, but would better reflect where the opportunities lie.

LHB Directors of Finance have been sharing their savings proposals for 2016/17. Savings opportunities have been identified through benchmarking of savings plans, the requirements of service transformation in a number of specific areas, and from experience of what has been deliverable in previous years.

The key UHB wide cross cutting savings opportunities have been identified as follows: Referral management Remodelling unscheduled care Medicines management Planned care / theatres Nursing productivity / Temporary Staffing Outpatients modernisation / booking and scheduling Repatriation of Mental Health CHC placements Prescribing Prevent decline and optimising reablement (CHC) Disposal of assets Overseas patients Procurement (Including Income opportunities) Prudent Healthcare Workforce productivity Energy utilisation Commissioning

These themes will form part of the UHB‟s continuing Leaner and Fitter efficiency programme. Delivery will require considerable work in order to more fully scope and produce robust plans for delivery. These will be driven and supported by the Programme Management Office through a formal programme management structure with work stream leads. Project management resource and supporting finance and analytical resource will be provided for each major work stream. Each theme will be assigned an Executive Director sponsor, but the delivery and accountability will still rest with delegated budget holders.

A clear phasing of the financial savings will be established and deviation from this profile will trigger an escalation process for remedial action. Reporting will take place through the existing Leaner and Fitter mechanism with robust challenge provided by the Chief Operating Officer and Director of Finance.

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In addition to these corporate themes, budget holders will need to deliver local efficiencies. The identification of these will be supported by benchmarking and best practice information.

12.2.4 Financial Summary (to be completed when detailed work is finalised)

12.2.5 Income and Expenditure(to be completed in the next draft)

12.2.6 Shifting funding from acute to primary/community care The UHB continues with its ambition to move services and funding from hospital services to community and primary care with the aim of providing safe and sustainable services closer to home with its design principle being home first. A major theme of the three year plan is a focus on community and primary care and shifting the care settings. The UHB has set out its plans to develop and enhance community and primary care services and with assistance from Welsh Government investment has made considerable progress in this area in 2015/16. The UHB is planning upon building upon this with further transformational changes in 2016/17. The UHB intends to focus greater attention and capacity into this area to ensure that this is achieved.

12.2.7 Cash flow (to be completed in the next draft)

12.2.8 Financial Risks

The UHB is facing a number of financial risks in the delivery of its Integrated Medium Term Plan. The key risk for are set out below: Balancing the Financial Plan - The Financial Plan is currently out of balance. The management of this will require further Board level and Welsh Government consideration. Further discussions with Welsh Government will be needed to explore the options available to mitigate this risk to deliver financially sustainable services. Funding assumptions – The UHB has assumed a certain level of allocation growth during the period of this plan and this must be seen as a risk until this funding is confirmed. It has also assumed that it will be funding for basic LTA inflation. Whilst this is a reasonable assumption, until this is secured it will be a risk. Achievement of savings targets - The forecast out-turn position for the period of this plan is only deliverable based on achievement of the Health Board‟s savings targets. This will require both acceptance and buy in from the areas concerned and the Board‟s continued commitment to monitor and identify further savings to replace any slippage. Given the scale of the savings required, and the context that savings delivery gets harder year on year, this is the key financial risk in delivering the plan. Inflationary and demand cost pressure assumptions - There is a risk that some of these cost pressures may end higher than initially predicted. CHC, prescribing and NICE are areas of particular risk based on historic trends.

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WHSSC risk - It will be important that there is early alignment on commissioning and financial plans between the UHB and WHSSC. It is also important that genuine service growth issues are recognised and that the UHB is not disadvantaged due to it being a provider of specialist and tertiary services. In addition, work is being progressed by WHSSC to realign the risk sharing agreement. The UHB has again assumed that this will be cost neutral. South Wales Plan - Despite best endeavours, there is a possibility that whole services could transfer in an unplanned way that could present capacity, service and financial pressures outside of an agreed process or mechanism. The UHB is being proactive to try to avoid this and is working with partner organisations to ensure that this risk is minimised.

As highlighted in this section of the plan, there are a number of financial risks that could impact upon the successful delivery of this plan. The Health Board recognises this and is taking mitigating actions in order to ensure that these risks are appropriately managed. To help manage this risk the UHB has also set aside a contingency reserve in each year of the plan, albeit this is set only at a modest level.

12.2.9 Draft Capital Expenditure

The UHB has confirmed capital funding of £24m for All Wales Capital Schemes and £9.914m for discretionary capital schemes. The details below are draft and will be reviewed by the Capital Management Group.

Upon request from the Welsh Government, the UHB has completed a ten year capital plan and submitted it for comment and consideration in June 2014. During 2014 the UHB undertook a comprehensive assessment of the state of the estate and equipment as part of the WG‟s All Wales review of capital. The UHB review identified that a significant level of funding would be needed to bring our estate and equipment to the functional level needed to provide modern sustainable services. The annual discretionary capital allocation will only cover the highest priorities identified in the 10-year capital plan. The UHB will therefore be seeking additional discretionary funding from WG to support the key risks identified in the capital review and other capital priorities. A prioritised list of capital requirements includes: Essential statutory estates compliance; Essential IM&T investment; Critical medical equipment replacement; Urgent SWP requirements to provide the capacity to accommodate increased activity that will flow into the UHB; and Urgent changes to support service development and delivery of the IMTP.

The UHB has experienced numerous difficulties and incidents relating to the age and condition of its estate in the last three months of the year which had an impact on operational delivery. A large proportion of this additional funding is required to sustain the UHB‟s estate and equipment which is now ageing and requires modernising and replacement. Full details of additional capital funding requirements are set out in the following programme. Further discussions are needed with Welsh

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Government to confirm any additional funding that may be available and therefore this programme is provisional at this stage.

All Wales Capital 2016-17 Approval All Wales Priority Scheme 2016/17 £m

Neonates phase 1 4,192 Rookwood Replacement 14,531 Adult Acute Unit 1,223 CHFW 1,676 24,018

Discretionary Capital 2016-17 Approval All Wales Priority Scheme 2016/17 2016/17 £m £m

Funding WG Annual Funding 9,914

Total Funding 9,914

Expenditure Annual Commitments UHB Capitalisation of Salaries 440 UHB Director of Planning Staff 165 UHB Revenue to Capital 215 UHB Accommodation Strategy: 200 UHB Misc / Feasibility Fees 100 1,120 Brought Forward Schemes

0 IMTP

0 Statutory Compliance Fire Risk Works 50 Asbestos 200 UHB Essential Plant Upgrading 2,350 Dedicated Team 200 2,800 Other Schemes Backlog Medical Equipment 1,000 Backlog Estates / Compliance Remedials 1,000 Backlog IM&T 500 BMT Database 300 Cardiology O/P 130 Ward Upgrade - Bathrooms 500 Contingency 2,564 5,994

Total Expenditure 9,914

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The Clinical Boards have identified a number of capital schemes to support their service delivery; these need to be prioritised. IMTP Clinical Boards 2016/17 Est Medicine UHL 6th endoscopy room Cystic Fibrosis Helipad Infusion room Drying cabinets endoscopy Radiofrequency abilation - Gloucester patients EU patient Flow Ambulatory care/Assesment Unit/Med admissions 0 Surgery Redevelopment of SSSU theatres 7 conversion of anaesthetic room Main Theatre Refurbishment Enabling Contract Hybrid Theatres Anaesthetic room theatres refurbishment UHL laminar flow Theatres - critical care expansion Refurbishment to black & grey theatre (UHL) UHW 2nd opthamology theatre (OPD) 0 Specialist Critical Care PACU further expansion Medical Genetics shire database replacement Critical care system - EICU Haematology ward Paeds South Cath Labs 2,396 Cardiac MRI Suite 19 nephrology transplant Rookwood Replacement CRI enabling works Neuro Science Seminar Room (MDT) Rookwood refurbishment Boiler Rookwood (Estates) 15/16 Old House Rookwood (Estate) Cardiac Out patients department 130 Critical care UPS 2,526 CD&T Stem Cell nitric oxide tanks 120 Pharmacy remodel dispensary (med management) 100 Labs ISO accreditation equipment replacement (£3m inc stream) 200 Central Decontamination MR Scanners Radiopharmacy Refurb & Equipment PACS change of supplier equipment compatibility 420 Womens & Children Neonates BJC Phase 1 4,192 BJC Phase 2 Paeds single point of entry 4,192 Primary Care CRI/Barry/Whitchurch (Major pipeline) Lansdowne/Ely/Dinas Powys/Maelfa GP Audiology Rooms (community facilities, west keys/CRI/others) CRI Capacity Whitchurch decomission 0 Mental Health Whitchurch Decomissioning Iorwerth Jones Older People Community Team 0 Dental Re-model the 3rd floor Production Laboratory plaster rooms in line with modern practices and risks associated with redundant pipework 160 Replace 2 x Patient and 1 x service lifts PACS change of supplier equipment compatibility 800 Major improvement and positioning of decontamination facilities at St Davids Out Reach Unit to conform to HTM01-05 60 UDH Window re-sealing / replacement due to major leaks 50 1,070 IM&T IT Infrastructure 3,300 3,300

7,316

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12.3 Improving Our Infrastructure

During 2014/15, we completed a comprehensive assessment of the state of our estate. It confirmed that we have a significant challenge in ensuring that our infrastructure (buildings and equipment) remains fit for purpose to deliver the services we are planning. Many of the facilities in which we deliver care are not of the standard we would like, reflecting that they are no longer functionally fit for today‟s healthcare, and have not been maintained to the levels necessary. Inspections, reviews and Community Health Council visits often highlight poor estate as a concern. As described in Section 12.2.7 – Capital Expenditure, we have a significant estates maintenance and equipment (IT and medical) replacement backlog, which was risk assessed during 2014/15 to inform future plans.

Our strategy over the next three years is to address the urgent priorities for equipment replacement and estates maintenance, as the importance of good quality facilities to patient outcomes and infection prevention is well recognised, whilst supporting the UHB to provide modern and effective services that provide good service user experience. Good progress has been made in 2015/16 but not to the anticipated planned levels, due to operational pressure against the discretionary capital programme.

Over the course of this IMTP, we will continue to implement the major capital schemes already in progress (including those in SOP development) to replace estate that is not fit for the delivery of modern care. We will also continue to reduce our estate footprint where appropriate – facilitated by new models of care and new ways of working – so that we are in a better position to maintain our estate going forward. During 2016/17 it is proposed to further rationalise the UHB assets. It is currently planned to dispose of the following properties, which are no longer required:

CRI West Wing.

We will also be improving the delivery of our estates maintenance function using benchmarking information to identify areas for targeted activity to improve productivity and outcomes.

We are also looking further ahead to develop a „master plan‟ for our estate, reflecting the requirements falling out of our clinical services strategy, the SWP and opportunities for collaboration with partners – particularly Cardiff University, Cardiff Council and the Vale of Glamorgan Council – to develop shared assets in the community where possible. We are looking to appoint Healthcare Planners to assist in developing the „master plan‟.

12.3.1 Discretionary Capital

The review of our estate, IT and medical equipment has identified a list of capital developments and critical medical equipment replacement requirements totalling over £153m. Despite the recurring discretionary capital allocation the investment

Page | 159 needed is significantly above the funding available. Therefore a prioritisation framework has been agreed by the Major Capital Working Group to guide the allocation of funding. In order to address the most urgent priorities and to deliver the developments needed to support achievement of our service change and financial savings plans, additional discretionary capital is being sought from Welsh Government.

Over the next three years our aim is to: Ensure that all business cases seek to minimise the footprint of UHB buildings, while meeting the operational needs of the UHB, including flexibility of use. Address potential catastrophic equipment failures (IT and medical equipment). Address statutory compliance maintenance issues. Prioritise developments that are critical to the delivery of service change and saving plans. Ensure Clinical Boards have direct involvement in the management of the UHB discretionary Capital Programme. This will be achieved via wider membership arrangements of the Discretionary Capital Management Group. Ensure the UHB mandatory Capital Resource Limit target is achieved.

The UHB recognises that it needs to make significant investment in refurbishing the existing estate, both in the community and hospitals, to enable us to provide care from fit for purpose accommodation. This will need to be a significant call on our spending in future years. The need to expand primary care facilities to respond to the rapidly growing population, either by developing existing practices or establishing new provision (and probably both) has become a higher priority and we are looking to work closely with Welsh Government officials to agree the most appropriate routes to address this issue.

12.3.2 Strategic Projects

Current large projects in development including the following: £88m Adult Mental Health Unit (Hafan y Coed) at Llandough (UHL) is now nearing completion for April 2016. Business Justification Case stage 1 for UHW Neonatal and Obstetrics Service (NICU) has been approved by Welsh Government and BJC 2 is currently being developed.

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The bathroom replacement programme has been developed following feedback from Trusted to Care, HIW, CHC and internal inspections. Surveys have been undertaken to identify bathrooms needing urgent replacement – the scale of the programme will be determined by the capital available and the impact on operational service delivery.

There are also a number of future projects currently being developed through the WG full business case procedure, that are in the early stages of planning and development – see table below. Detail on the expenditure of all major capital schemes is set out in 12.2.7.

All strategic capital projects are reviewed monthly at the Capital Management Group, which is chaired by the Chief Executive and reports into the People, Planning and Performance Committee of the Board. There are also separate Project Boards that meet on each project, chaired by the Director of Planning. There are also a number of sub project groups that provide user input and guidance.

Scheme Stage Anticipated Completion Date Making a Difference: Outline Business Case January 2016 (subject Redevelopment of approved by WG. to business case specialist spinal and Progressing with FBC approvals). neuro-rehabilitation services. Programme Business Overarching Case for Locality Health Programme Business SOC by August 2016. and Treatment Centres Case development. across UHB footprint: CRI Phase II; Strategic Outline Case Whitchurch; and (SOC) for CRI Phase II Barry. Locality Health and treatment Centres. Cystic Fibrosis Unit, Business Justification October 2016 for UHL Case to be completed submission of BJC Conversion of the by UHB for submission currently vacant 1st floor to WG of the CF centre into fit for purpose 15-20 bedded en-suite ward Hybrid Theatre UHW Business Justification Develop a Hybrid Case to be completed theatre to support the by UHB for submission strategy of vascular to WG centralisation and raise the standards of vascular surgery

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Cardiology Out Patients Development of June 2016 Department and Cardiac Business Justification Physiology Suite at Case. UHW.

All Wales Cardiac Business Justification Awaiting Welsh Catheritisation Case submitted Government Approval Replacement Programme Bone Marrow Strategic Outline Case Accommodation to be Transplant Unit. (SOC) developed

Renal Dialysis Unit Development of 2016/17 (relocation from CRI Business Justification West Wing and Case. refurbishment Suite 19 UHW).

SWP Implementation Development of Delivery required in first (South Wales Health programme to deliver 6 months of the year. Collaborative). necessary changes. Theatre refurbishment. BJC to address urgent October 2016. need to replace old plant and ventilation systems.

12.3.3 Maintaining our Estates

The annual budget allocation for estates maintenance is just over £5m; with a ring- fenced allocation to address estates backlog issues annually of £250,000. Each year, the department undertakes 14,985 planned preventative maintenance tasks, along with 37,876 break-down requests – in 43 individual buildings. The department will focus on local management on the major UHB sites and an increased emphasis on maintenance of community buildings, through increased flexibility and efficiency across the workforce. The Department clearly demonstrates good value for money in that the maintenance of their estate is much less than all of their peers. Annual benchmarking information suggests that the UHB spends considerable less per square metre on maintenance than other health boards in Wales or peer organisations in England. The restructuring of the estates function – which will be completed in 2016/17, will ensure that the resource is delivering the best possible outcomes as investment in maintenance (with the exception of statutory maintenance) is not currently affordable within the financial constraints we are working in.

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Hospital/Trust/UHB Floor Area Maintenance WTE £m2 M2 Budget£ Barts and the 252,611 11,990,446 126 47.46 London NHS Trust Imperial College 294,591 8,164,880 152 27.92 Healthcare NHS Trust Central 279,514 10,338,644 121 36.92 Manchester University Leeds Teaching 522,323 11,161,298 217 22.32 Hospital NHS Trust Nottingham 310.463 8,109,737 161 26.16 University Hospitals NHS Trust University Hospital 278,747 5,598,254 126 20.14 of Leicester NHS Trust Oxford Radcliffe 316,688 8,634,772 148 27.30 Hospitals NHS Trust Average 350,000 6,903,456 141 26.58 Cardiff and Vale 349,725 5,161,865 114 14.75 UHB University Hospital 185,875 2,191,144 74 of Wales 11.79 UHL, Barry and 56,732 1,525,883 28 CRI 26.90 Whitchurch, 107,118 1,444,838 12 Rookwood, Community 13.49 All Wales Average 20.90

Table: Comparison 2013/14 Estates Services cost and workforce comparison

Our priorities for 2016/17 are to continue to develop the estates maintenance function as part of the integrated facilities department so that it is responsive to the needs of the clinical boards, and to ensure that our statutory maintenance programme is progressed, using specialist expertise where necessary.

12.3.4 Sustaining Information Technology – Keeping the Lights On

During 2015/16 discretionary capital funding has been used to sustain and improve the UHB IT infrastructure. This continues to be a priority in order to shore up fragile

Page | 163 facilities and increase the UHB capability for using IT to drive new models of care, such as virtual clinics.

On behalf of the UHB, the „Keeping the Lights On‟ function ensures that there is: Infrastructure (networks, servers, system support) maintenance and improvement; Appropriate IT stewardship and governance; Business continuity disaster recovery; Corporate reporting, data quality and coding; and Training and system administration.

2016/17 priorities for „Keeping the Lights On‟ – improving standardisation and resilience are: Infrastructure upgrades and system support (80% of resources) Addressing End of Life Hardware and Software New Intranet Site; Data Quality – Attribution and Accuracy; Access and training to the Business Intelligence System for clinicians; and Coding EU / AU data.

12.3.5 Improving Efficiency Through Technology

The UHB is committed to supporting its successful Efficiency Through Technology Fund bids which were formally submitted by the Director of Therapies and Health Science on behalf of the UHB. Successful bids include:

Laboratory Information Management System (LIMS) for the all Wales Genetic Laboratory Installation of Digital X-ray Imaging in the Dental Clinical Boards Community Service Proms, Prems and Effectiveness NHS Wales Cellular Pathology digital slide scanning. This will also enable full ISO 15189 accreditation of the UHB‟s Cellular Pathology service Implementing Screening for Trisomies 13, 18, 21 by Non-Invasive Prenatal Testing All Wales Post-Partum Haemorrhage (PPH) Collaboration Delivering Shared Well

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12.4 Workforce

The Workforce and OD Directorate have developed their IMTP based upon the following objectives, aligned to the UHB strategy, in order to underpin the department‟s purpose: To deliver actions which enable the UHB to be a ‘great place to work and learn’.

1 Promoting health and wellbeing 2 Engaging leaders and culture change 3 Building a flexible and sustainable future workforce 4 Building capacity and capability 5 A productive, efficient and high performing workforce

This is further expanded and cross-referenced in the diagram in Chapter 13.

12.4.1 Workforce Planning Assumptions and Priorities

The high level workforce assumptions over the IMTP 3 year period include: Continuing requirement to reduce workforce cost to underpin 10.5% savings identified in financial framework; Meeting short term capacity requirements, especially in nursing; and the need to flex workforce recruitment to support winter pressures and unplanned capacity requirements (further outlined in section 12.4.3); Increasing need to develop future workforce; new ways of working and innovative workforce transformational change; Workforce impact and drivers associated with reconfiguration of Acute Services identified in the South Wales Programme; Increasing need to engage with workforce as demand for service increase; Increasing need to develop organisational leadership and management skills; Increasing need to embrace new technology; and Increasing need for accurate workforce information and analysis.

The current and 2016/17 workforce high level productivity priorities for the UHB are: Ensuring the total pay-bill remains within budget; Continued reduction of sickness absence; Ensuring appropriate nurse staffing levels and staff in place with supporting recruitment and retention strategies are developed to support this; Reducing temporary agency and locum expenditure and eradicating use of „off contract‟ nurse agencies; and Staff engagement with focus on implementation of local action plans (also linked to UHB workforce KPIs).

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12.4.2 Workforce Profile

As further context, the following charts provide an overview of the UHB‟s current staffing profiles.

Age Profile Pay Banding Profile

Gender Ethnicity

Distribution by Staff Group

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12.4.3 Productive, Efficient and High Performing Workforce

Workforce key performance indicators The information included in the table below provides data against the UHB‟s workforce KPIs. Performance against these KPIs is monitored on a monthly basis through the UHB Executive Performance Management meetings with Clinical Boards and also at the Health Systems Management Board (HSMB). There are a number of other KPIs, which are monitored in more detail by each Clinical Board, including Recruitment Process - Decision and Time To Hire, Sickness Hotspots, Statutory and Mandatory Training.

Table: UHB Workforce Key Performance Indicators 2014- Comparison 15 YTD Monthly with Key Performance Outtur (Oct Actual Previous 2015-16 Indicator n 2015) (Oct 2015) Month target 1. Vacancy Rate (WTE) 4.72% 5.16% 5.12% 0.01% 5.00% 2. Turnover Rate 7.0% - (WTE) 8.53% 8.47% 8.47% 0.04% 9.0% 3. Sickness Absence Rate 5.71% 5.48% 4.89% 0.06% 5.00% 4. PADR Rate 57.02% 58.29% 58.29% 0.41% 85.00% 5. Pay Bill Over/ Underspe Underspend 3.70% 0.64% 1.81% 0.19% nd 6. Variable Pay Rate 8.95% 7.45% 7.79% 0.05% No target

Actions for Improvement against the 6 Workforce KPIs

KPI 1and2 Vacancy and Turnover

All Clinical Boards and Corporate Directorates scrutinise their vacancy and turnover rates at departmental level to implement local recruitment and retention strategies. A key cross-cutting theme has been a focus on registered nurses at Band 5 level.

Nursing Workforce Sustainability Action Plan

The UHB currently has an overall nursing and midwifery vacancy rate of 5.27% (292 FTE vacancies) against a budgeted establishment of 5539 FTE. The entry level registered nurse vacancy rate (i.e. Band 5 nurses) is currently 8.55% down from 12.2% 12 months ago (September 2014) despite an increase in overall Band 5 nurses. The net gain after recruitment and retention efforts is that we have 84.24 FTE more nurses in the establishment than a year ago as well as 68.33 FTE vacancies less than where the UHB was a year ago. Our vacancy rate at Band 5 is

Page | 167 therefore 3.73% less than last year, or, put another way, we are now 91.5% established with Band 5 registered nurses.

Although this is a good improvement, there is still a risk that without a strong nurse establishment in place the UHB faces a constant challenge of meeting service capacity needs and providing the level of quality and safe care required. Key risks that may impact patient care include: the vacancy rate and turnover against a shortage of nurses in the UK; Clinical Boards not planning and delivering against nurse establishment challenges creating higher nurse agency costs; and the winter plan needs a robust nurse staffing plan. The nursing establishment is reviewed on an annual basis by the Director of Nursing and Clinical Board Nurses with their teams with overall sign off of the establishment by the Director of Nursing.

In January 2015, the Workforce and OD function initiated „bulk‟ one-stop shop recruitment days to boost the levels of recruitment activity needed by the UHB. Following these four bulk recruitment events, Clinical Boards have been using this leaner hiring methodology locally holding specialist nurses events to boost recruitment offers made to nurses. The table below summarises the total recruitment of 345 nurses in 2015 showing 194 external hires.

Table: UHB 2015 Registered nurse recruitment activity (source: Shared Services)

Internal External Total hires hires 4 bulk recruitment events Jan – March 2015 10 96 106 Clinical Board recruitment events 141 98 239 Dec 2014 – Aug 2015

Total 151 194 345

It should also be noted that whilst this recruitment has been taking place, there has been an increase in employee turnover at this level (table below). This means that there is a challenge of hiring external new recruits at Band 5 and retaining them as well, given they have a number of options available to them in the current shortage climate for this level of nurse.

Table: Band 5 Nursing Establishment (Source: ESR)

Vacancy Rate Turnover Sep- Sep- Sep-14 15 14 Sep-15 Band 5 Nursing Registered 12.28% 8.55% 8.61% 10.68%

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The risk of not being able to hire from outside Europe due to new rules meant that the UHB has been competing with other NHS organisations to recruit from the same talent pool within Europe. The recent outcome of national lobbying has helped to mitigate this. A national Temporary Staffing Steering Group (co-chaired by the Interim Workforce and OD Director at the UHB) has commenced joint work on eradication of „off-contract‟ nurse agencies and reduction of agency use, with the aim of synchronising actions across Health Boards to achieve a behavioural change amongst nurses and agencies. To this end, a Wales joint CEOs letter regarding intentions to use only „on-contract‟ nurse agency usage has been published on the UHB website with further communications to staff by payslips and through the local channels. This national group work is an opportunity for the UHB to reflect upon the effectiveness and impact of its own nurse agency reduction plan currently being implemented.

Taking all the above progress into account, there is a need for the UHB to have a robust plan in place with specific deliverables to continue the positive progress made in 2015 so far in ensuring a stronger nurse establishment is in place. This can be measured by further reduced vacancy rate, reducing employee turnover, and filling of hard-to-fill specialist areas (theatre nurses, cardiac nurses, paediatric nurses), as well as other metrics such as staff engagement scores and patient experience results.

The Workforce and OD team, Clinical Board Nurses and Operations team have been working together to form a „Nurse Workforce Sustainability Plan‟ which includes short, medium and long term actions to ensure the nurse workforce needed in the future is available (future talent pipeline and developing current staff), sustainable (ideally at 95% established Band 5 nurses) and adaptable (able to flex to the fluctuating demands of the service).

1. Short term plan (winter period) A task and finish group is currently scoping possible solutions to create the 35 wte needed to staff 43 extra beds (C2 and Delyth) this winter i.e. 1st December 2015 to 31st March 2016. Scoping to date has included looking at the following possible options: Create a pool of ward-based temporary staff solely to support opening of winter capacity within Medicine; Maximise use of agency staffing by further block-booking agency workers; Substantive staff who do bank shifts to be paid at their substantive AfC band; Formally offer all ward staff the opportunity to carry annual leave over into 2016/17 or consider a buy-back option; and Identify new ways of working / review skill mix.

2. Medium term Plan (next 6-18 months) Actions to support a nurse establishment for the medium term include the following themes:

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Increase recruitment and retention activity (continue local, European and international recruitment, analyse offer to „on-boarding‟ to mitigate „dropouts‟, collaborate with other HBs, analyse reasons for leaving); Reduce agency usage (both off and on contract agencies); Review temporary staffing (bank pay rates, process mapping of Temporary Staff department, review hiring ability, reduce demand); Increase bank fill rate (communications, improve booking process and availability for shifts); and Review use of Rosterpro (audit compliance with key measures).

3. Long term Plan (next three to five years) More student nurse places have been commissioned for the next five years so that we have more new local hires coming into the NHS and into CVUHB. For example, in 2015 the UHB submitted commissioning needs for 200 nurse placements („adult‟ only), which is an increase of 80 places compared to 2014 (see table below). These 200 students will commence training in autumn 2016 and therefore graduate in 2019. This equates to a 40% increase for the UHB annual number of places.

Table: CVUHB Nurse Education Commissioning Requests 2010 – 2015

Submission Years Course Title 2010 2011 2012 2013 2014 2015

Bachelor of Nursing – 214 120 120 120 120 200 Adult Total (including 429 269 335 297 296 399 midwifery and other specialty courses)

A Nurse Productivity Group (NPG) has been in place at the UHB for the last five years chaired by the Director of Nursing and latterly joint chaired by the Interim Workforce and OD Director. The work plan of this group going forward is being reviewed and the nurse establishment plan as outlined above will be monitored by the NPG on a monthly basis.

Assessing Nursing and Midwifery - Chief Nursing Officer, Delivering Safe Care, Compassionate Care Cardiff and Vale UHB have now undertaken three acuity and dependency audits across 33 wards within the Medicine and Surgery Clinical Boards. Changes were made in May 2015 in response to user requests to reduce the burden of data collection. Actual staffing hours as well as the funded establishments are now recorded in addition to daily admissions, discharges, transfers and deaths. Across the Clinical Boards the results continue to show a pattern of both over and under establishment. Taken in isolation it remains difficult to come to any reliable conclusions as to the significance of this and the Health Board is working with the

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1000 lives team to determine how best to present the information in a meaningful way to ward teams and clinical boards. The audit is of value in building up an evidence base and our understanding of acuity and dependency across clinical boards. It is important to emphasise that the tool provides just one aspect of information required to assist in the determination of optimal nurse staffing levels and should not be viewed in isolation. How best to triangulate this data with workforce, flow data and nurse sensitive quality indicators is being tested locally and discussions are being held at an All Wales level. The experience of triangulation thus far has suggested that this process does have the potential overtime to raise early „red flags‟ of concern. Information was submitted to Welsh Government in August 2015 detailing compliance details with the staffing principles. At this time the medicine clinical board highlighted registered nurse (RN) vacancies of 42.75 whole time equivalents (WTE) and 2.29 WTE health care support workers (HCSW); the surgery clinical board 16.70 WTE vacancies for RNs and 5.46 WTE vacancies for HCSWs. Both clinical boards reported progress in achieving compliance with staffing standards where they were appropriate, with recruitment plans in place and of a high priority. Work continues on the development and testing of additional acuity tools for use in Mental Health settings, Community Nursing and Health Visiting.

Recruitment Difficulties A summary of recruitment difficulties across the UHB is supplied within the appended templates, „C22 - Recruitment Difficulties‟. During 2015 the Heads of Workforce and OD undertook an analysis across the Clinical Boards of the recruitment challenges and hard to fill roles. A number of strategies were developed to improve the short, medium and long term recruitment availability of Speech and Language Therapists, Sonographers, Radiologists, Cardiac Scrub Nurses, Paediatric Anaesthetists, Recovery Practitioners, Anaesthetics Clinical Fellows, Clinical Perfusionists, GP Sessions in Out of Hours, Sexual Health Medical Staff, Community Directors, Qualified Mechanical and Electrical tradesmen, Consultants and Middle Grade Doctors in Emergency Medicine and a number of other sub-speciality posts.

A further action plan is under development identifying specific and bespoke actions and initiatives into 2016/17.

Education Commissioning A draft set of UHB education commissioning numbers is being developed for the draft January 2016 IMTP submission and will be contained in the 2016/17 appendix templates, „C23 – Educational Commissioning Information‟.

In 2015/16 we made the following significant changes to our education commissioning numbers: • General Nursing numbers increased from 120 to 200; • B.Sc. (Hons) Healthcare Science - Biomedical Science - Blood, Infection, Cellular and Genetics increased by 100% from 3 to 6 places; • Increase in several advanced practice courses requested; e.g. Neonatal Nurses, EU and Mental Health Occupational Therapy • New commissioned places include Respiratory Physiology, Bio-infomatics, - (Genomics and Genetics)

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In 2015/16 work began, to better understand the commissioning requirements for new entrants in Independent Sector and Nursing homes.

KPI 3and4 Sickness Absence and PADR

Sickness Absence Management The UHB considers reducing sickness absence as the number one workforce priority and has set sickness targets as follows:

Year 1 2015/16 = 5% (0.75% reduction) Year 2 2016/17 = 4.5% (0.5.% reduction) Year 3 2017/18 = 4% (0.5% reduction)

It is noted that the Welsh demographic matches NW England where sickness is higher so achieving these targets will still remain a challenge, setting the above plan for 3 years is considered more realistic and more achievable however still challenging.

Sickness targets remain a high priority within workforce KPIs at performance reviews. During 2015 the programme of health and wellbeing work has been lead by the Interim Director of Workforce and OD with a Maximising Attendance Group with the focus: to enable members of staff to get back to work and keep our staff healthy and well by:

• Empowering managers to consistently manage absence using an approach which supports employees to return to work / stay healthy as well; • Ensuring sufficient support is in place for staff (including taking personal responsibility); and • Therefore enabling achievement of a sickness absence reduction from 5.75% to 5%.

The September 2015 12-month cumulative figure of 5.48% is the best performance position for the UHB in the last three and a half years. There has now been a reduction for 8 months in a row in 2015 resulting in a £0.8 million direct cost reduction in this period (and a proportion of the indirect costs which are approximately £4m p.a.). This is the most significant reduction in sickness compared with the last 5 years of sickness rates at the UHB. The table below shows the improvement against 2014/15 performance and in relation to the revised target.

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Table: UHB Sickness absence monthly sickness rates 2015/16 compared to 5% target and 2014/15 uHB Sickness Performance Against Target 6.50% 6.00% 5.50% 5.00% 4.50% 4.00% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 5.0% Target 4.96% 4.52% 4.57% 4.74% 4.83% 4.99% 5.35% 5.21% 5.42% 5.44% 5.12% 4.83% 2014-15 Actual 5.67% 5.23% 5.26% 5.44% 5.54% 5.70% 6.06% 5.92% 6.13% 6.14% 5.83% 5.53% 2015-16 Actual 5.19% 4.97% 5.08% 5.14% 4.94% 4.89%

5.0% Target 2014-15 Actual 2015-16 Actual

The information in the following table provides benchmarking against organisations within NHS Wales. Table: NHS Wales Benchmarking

NHS iView - data at 31-Aug-2015 (Jul-2015 for Sickness) 12-Month 12-Month Contracted Headcount Turnover Cumulative FTE Rate Absence Rate Abertawe Bro Morgannwg 15,450 13,460 9.05% 5.64% Uni LHB Aneurin Bevan LHB 12,700 10,855 9.01% 5.57% Betsi Cadwaladr Uni LHB 16,535 14,250 8.11% 5.07% Cardiff & Vale Uni LHB 13,865 12,180 10.37% 5.64% Cwm Taf LHB 7,855 6,900 9.68% 6.02% Hywel Dda LHB 8,650 7,455 9.40% 5.66% Powys Teach LHB 1,740 1,380 8.58% 4.17% Public Health Wales 1,480 1,305 8.96% 3.81% Velindre 3,280 2,995 9.06% 4.06% Welsh Ambulance 2,995 2,830 9.47% 7.77% Services NHS Wales 84,420 73,610 6.86% 5.51%

[Note: the figures above differ to those included in local data in the table in section 14.4.3 as the benchmarking comparison is available for a different period i.e. August 2015 and July 2015 for sickness).

The Maximizing Attendance Group continues to meet and a range of initiatives are being delivered throughout 2015/16 and beyond:

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• A newly formed UHB Health and Wellbeing Advisory Board consists of key influencers from the UHB to deliver a newly formed action plan, based on the Health and Wellbeing route map vision, which will be monitored, in order to encourage, enable and endorse a culture of health and wellbeing for staff and public health. • A Health and Wellbeing „communication sub group‟ has been formed to ensure that Health and Wellbeing is continually promoted within the UHB and a plan is to be presented to the Health and Wellbeing Advisory Group. • The 12-month pilot of an Employee Assistance Programme (EAP) has been awarded to „CiC – Supporting Organisations‟ and wentlive from November 2015. A communication plan is in place to ensure that the EAP is promoted throughout the UHB. • The new Health and Wellbeing internet pages wentlive in December 2015. Information and support will be available to managers and staff on the OH Department, Seasonal Flu, Health and Wellbeing, Sickness Advisory Team, Employee Wellbeing Service and OH Physiotherapy. • Discussions are taking place with regards to introducing Occupational Health Physiotherapy Service group intervention for staff with low back pain, in order to reduce waiting times for a physiotherapy appointment. • An outdoor exercise area is now in place within the Lakeside grounds, University Hospital of Wales which is open to patients, staff and the general public.

Personal Appraisal Development Review (PADR) The organisation recognises the importance of annual appraisals for all staff and has measures in place to monitor Personal Appraisal Development Review (PADR) compliance on a weekly basis. The UHB has a target of 85% for annual compliance and as can be seen in section 14.4.3, compliance as at 31st October 2015, is 58.29%. Since 2011 the UHB compliance levels have made steady increased from 6% to around 55-60%. The national staff survey respondents have indicated that 67% of staff have had a PADR in the last twelve months which compares to a national average on the survey of 55%.

In recognition of the role that effective appraisal plays in staff engagement, wellbeing and delivering safe and effective services the UHB process has been redesigned to ensure it is aligned to the organisational goals. The team PADR process will embed objective setting at every level of the organisation and ensure that the annual cycle links these objectives through all services. This will also introduce a more varied approach where individual and team based appraisals are used in appropriate situations.

To improve the UHB Statutory and Mandatory training compliance an action plan has been developed and progressed and continues reviewing the themes of i) data quality, transparency and access, ii) provision of smarter and more accessible training , and iii) strong communication and performance management, project managed by LED. A new system “Wired” has been procured and will be implemented in the coming few months to improve real time accessible data on PADR and statutory and mandatory training compliance for managers.

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KPI 5 and6 Pay Bill and Variable Pay ? lead in sentence or paragraph

Table: Workforce Whole Time Equivalent (WTE) against Budget

Forecasted Workforce Reductions over the three year Plan The financial framework savings opportunity is identified within section 12.2. The UHB workforce savings requirement for 16/17 is still being calculated; the delivery of which continues to be worked through by Clinical Boards and Corporate areas. The common themes emerging include a continued focus on reducing agency expenditure through strengthening nursing establishments and delivering a reduction in sickness absence, and continued efforts to streamline administrative processes to deliver greater efficiency; as well as service restructuring opportunities. The prudent healthcare, pathways and integration opportunities is also expected to impact on workforce saving. The table below provides the latest workforce WTE plan forecast by Clinical Board, but remains a work in progress.

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Table: TBC - will need to correspond to final 2016/17 templates summary

Workforce @ Planned WTE @ Planned Change 2015/16 Profiled Workforce at end of each Quarter Planned Change 31/12/2014 31/03/2015 1/1 to 31/3/15 30/06/2015 30/09/2015 31/12/2015 31/03/2016 1/4/15 to 31/3/16 WTE WTE WTE WTE WTE WTE WTE WTE Children & Women's 1516.86 1602.31 85.45 1607.57 1599.22 1599.22 1599.22 -3.09 CDT 1802.21 1852.11 49.90 1853.11 1853.11 1853.11 1853.11 1.00 Dental 379.88 412.46 32.58 413.07 413.07 413.07 411.07 -1.39 Execs 669.55 676.85 7.30 671.28 665.71 664.71 664.71 -12.14 Medicine 0.00 0.00 Mental Health 1118.01 1217.74 99.73 1231.26 1231.26 1231.26 1231.05 13.31 PCIC 633.50 697.28 63.78 689.15 689.15 689.15 689.15 -8.13 Planning 976.24 971.52 -4.72 970.02 966.02 960.02 960.02 -11.50 Specialist Services 1468.03 1517.46 49.43 1522.26 1522.26 1522.26 1522.26 4.80 Surgical Services 1677.84 1792.20 114.36 1758.23 1758.23 1758.23 1758.23 -33.97

Total 10242.12 10739.93 497.81 10715.95 10698.03 10691.03 10688.82 -51.11

Reducing Workforce Variable Pay Cost The table below provides information on variable pay expenditure during 2014/15 and the 6-month period to September 2015. The overall total expenditure for 2014/15 was 6.95% compared to 4.68% for the full year 2013/14, covering all staff groups; showing an increase in trend for the first 6 months of 2015/16.

Workforce Variable Pay Full Year 6 month period 2014-15 Apr - Sep 2015 Pay Bill - Agency £5,571,151 £4,253,575 Pay Bill - Bank £11,484,769 £5,926,753 Pay Bill - Extra Sessions £1,351,327 £588,330 Pay Bill - Internal Locum £957,276 £995,694 Pay Bill - Locum £6,738,380 £2,303,782 Pay Bill - On-Call £2,119,274 £1,024,096 Pay Bill - Overtime £3,824,654 £2,268,686 Staff Flow £1,265,064 Temp Work Payment £8,661 £11,932 Pay Bill - Waiting List Initiatives £2,372,167 £1,053,459 Pay Bill Total Variable £34,427,660 £19,691,372 Variable Pay Bill as % of Fixed Pay Bill 6.95% 8.52%

The majority of spend is associated with nurse and medical cover. Overtime is used to flex staffing resources to meet capacity requirements i.e. RTT targets.

Nurse Workforce The Nurse Sustainability Action Plan consists of target dates for the eradication of „off-contract‟ agency spend and the 98% establishment of Band 5 registered nurses in 2016 so that there is a reduction in nurse agency spend. The UHB‟s target dates are complimented by the work of the all Wales group on Temporary Nurse Staffing

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Capacity of which the Interim Director of the UHB co-chairs and the UHB Director of Nursing attends. This group meets on a monthly basis and tracks costs and progress against off/on contract agency usage. Examples of actions included in the UHB‟s local plan include: Targeted recruitment campaigns at particular times of the year and overseas campaigns; Training needs analysis, induction and preceptor buddy for each individual; Analysing exit interviews in order to retain staff and apply learning outcomes; Review agency staff authorisation process; Introduce more innovative ways for staff to fill bank shifts, e.g. social media, mobile App, website functionality, self-rostering; and Ensure rosters are compliant, audited and maximum shift utilisation.

Medical Workforce Expenditure on temporary medical staff accounts for approximately 4.92% of the total pay bill for medical staff and is directly linked to sickness and vacancy rates and waiting list initiative payments required to deliver RTT. The Medical Director established a Medical Workforce Productivity Group and part of this group is a focus on variable pay to contain temporary medical staffing expenditure and improve controls for the future. The group also reinforces: • The introduction of tighter controls on the authorisation and usage of NHS and Agency Locums; • Limited agency usage to those companies within the existing framework and the price agreed with the agency should not exceed contract rates; and • The development of an electronic authorisation and payment process for NHS Locums facilitating greater visibility and control over NHS locum expenditure and payment arrangements.

The UHB Medical Workforce Productivity Group aims to: • Support Clinical Boards to derive maximum benefit in service delivery terms from the NHS Wales Consultant Contract; • Ensure robust and high quality Job Plans for the Clinical workforce, matched to patient activity which deliver productivity requirements to a high standard; • Revise and develop current processes to support job planning process; and • Improve process so that it is considered equitable and transparent.

Key actions to date include: • The establishment of a central shared folder which holds details of job plans and can be readily accessed for relevant parties and recording of job plans on ESR; • The delivery of BIS/CHKS Training for Directorate management teams on using the CHKS data for job planning purposes; and • The development of Data Productivity Packs that reflect the KPIs relevant to the areas of clinical performance and the issuing of these to directorates.

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Medical Locums – Implementation and Maximisation of PwC‟s “STAFFflow” and Medacs‟ “Vantage” Projects

Working with Price Waterhouse Coopers (PwC) and Liaison Financial Services (LFS), in 2014, the UHB introduced a model that provides the UHB with a cost efficient means of engaging and controlling locum medical staff expenditure. This model is known as “STAFFflow”. The UHB has also engaged with MEDACS, as the primary supplier of medical locums to the UHB, over their “Vantage” solution. Through Vantage, MEDACS provide expert, in-house support to analyse and manage the UHB‟s demand profile for agency spend, and work closely with us to reduce this spend, and develop alternative internal solutions, such as an internal locum bank.

We have been successful in bringing MEDACS and PwC together to work to support us to maximise the use of medical locums in a more cost efficient way, and are the first Health Board / Trust in the UK to do so. This is bringing us a number of benefits, which include: better management information and improved controls over agency spend. The savings for 2014/15 amounted to £410k and savings to date for 2015/16 amount to £217k. Savings continue to be monitored through the Clinical Boards.

The UHB is currently considering a proposal for a Managed Service Staff Bank. The vision for the Staff Bank will incorporate “demand management” into the model to ensure that requests are challenged, authorised through the correct process and demand is analysed. This work is ongoing through to 2016/17. A full benefits analysis will be available.

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The actions set out in this section are intended to make a measurable improvement to:

Strategic Theme – Our Culture

8. Be a great place to work and learn

NHS Outcome NHS Delivery Framework Measure Results of actions from the staff survey to improve the 7.3 Quality trained staff who are organisations staff engagement fully engaged in delivering Percentage of staff undertaking performance appraisal excellent care and support to me development review and my family Percentage of medical staff undertaking a performance appraisal

9. Work better together with partners to deliver care and support across care sectors, making best use of our people and technology NHS Outcome NHS Delivery Framework Measure

10. Excel at teaching, research, innovation and improvement and provide an environment where innovation thrives NHS Outcome NHS Delivery Framework Measure Number of NISCHR clinical research portfolio studies and 3.3 Interventions to improve my commercial sponsored studies health are based on good quality Number of audits the organisation is participating in against and timely research the national clinical audit programme

13. Building Capability and Delivery

13.1 Strategic Organisational Development

Organisational Development is defined as a planned and systemic approach to enabling sustained organisation performance through the alignment of strategy, people, process and culture.

The UHB strategic context and vision is outlined in Chapter 3, including an ambition to be a leading integrated health and care organisation. Fundamental to achieving this ambition is the culture and sustainability of our workforce. By reinforcing our values we aim to be a great place to work and learn and one in which we invest in leadership and management development to enable us to deliver the best service and change to Empower the Person: Staff, Patient and Citizen. It is the

Page | 180 responsibility of all within the UHB to achieve this, and specifically the role of the Workforce and Organisational Development Directorate (WOD), amongst others, to create the framework and provide the support to enable it. The WOD Directorate therefore structures its activity under the following objectives.

Specifically we aim to: Grow and develop new and existing clinical leaders who will take us forward; Train, develop and recruit the best managers; Reconnect with our staff so we feel we are one team together; Help staff develop improvement skills and do improvement work; Support and further develop an ambition for excellence; Work more successfully with our partners; Find a way to implement technology to help us do a better job; and Create the climate for innovation to flourish.

In doing this we expect to see: A more productive and efficient workforce; An improvement in patient safety / patient outcomes; More effective integrated working; Cost reduction; Reduced sickness absence; Reduction in grievances; and Increased staff engagement.

In 2016/17 we will develop this by taking the following actions:

Year 1 – Positioning of organisational development and investment to build capability and capacity Identify existing OD resources and skills;

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Create community of practitioners to share current practice and identify development needs; Run accredited OD programme to create interventionists who can service tactical need; Establish clear relationship with improvement team; Establish scale of OD interventions required; Development of leadership framework aligned with OD methodologies; Identify an early opportunity to support activity and build a narrative about OD – exemplars; and Establish clear arrangements for commissioning, identifying and prioritising OD activity.

Year 2 – Full integration of OD into UHB strategic activity Development of strategic OD activity to ensure coherence in ways of working across the UHB; and Clear and evidenced links with system and service improvement – OD activity as integral part of all improvement activity.

13.2 Engaging Leaders and Culture Change

13.2.1 Staff engagement – valuing and caring for our staff

Improving levels of employee engagement is proven to improve performance and outcomes, including: mortality rate; health and wellbeing; absenteeism; patient satisfaction; quality of services; and financial management (NHS Employers, 2013). To support this, the results of the 2013 National Staff Survey and November 2013 Engagement Pulse Survey and the UHB Local Survey in 2015 are being used to develop the focus of Clinical Boards and the nature of the actions they prioritise. The Local Staff Survey undertaken in August 2015 saw a significant increase in response rate since 2013 (22% in 2015 compared with 8% in 2013) and the survey focused specifically on engagement. Across all aspects of engagement there was a marked improvement from an overall score of 51% in 2013 to 60% in 2015. Heads of Workforce and OD are facilitating further improvement plans in each Clinical Board. Individual Clinical Boards also undertake their own local Pulse surveys to assist in understanding morale and engagement across and within service areas.

The next All Wales NHS Staff Survey will be run in the summer of 2016, presenting an opportunity to monitor progress across the areas of: overall job satisfaction and engagement; focus on quality and patient care; creating positive work climates; supporting staff through positive human resource management practices; ensuring effective team working; and building trust. Recognising the importance of staff engagement, a specific survey will be run with medical staff – the Medical Engagement Scale – to enable a deep and rich understanding of current experience and areas for the UHB to address.

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During 2015 we placed great emphasis on further developing a set of UHB Values with staff that would help positively influence behaviours. The Francis and Andrew Reports highlighted the impact of negative culture on organisational performance and patient outcomes and we recognise the impact the same culture can have on staff morale and engagement within the UHB. To further embed UHB values, many Clinical Boards are now introducing discussions on organisational values into their selection processes, and also PADRs with staff. UHB job descriptions also now incorporate detail of the UHB values and we have incorporated the values into the questions we ask at Consultant Panel Interviews. The UHB has produced Management Guidance to support the embedding of UHB Values and Behaviour into every day practice. In our recent 2015 Local Staff Survey we asked an additional question to establish views about values and behaviours. Findings indicate increasing awareness of values.

During 2016/17 we will be further developing this work as we engage with staff to describe the behaviours that we would expect to see if we were living our values, and to integrate this into ways of working across the UHB.

Gofal Parch Uniondeb

Care Respect Integrity Cyfrifoldeb Ymddiriedaet Personol Caredigrwydd h Personal Kindness Trust Responsibilit y

Ein Gwerthoedd Our Values

13.2.2 Equality, Diversity and Human Rights

The Workforce and OD Department lead on the development of the Equality, Diversity, Human Rights and Welsh Language strategic plans for the UHB, supported by the Independent Member of the Board for Equality and delivery through Clinical Board Plans. The UHB recognises the impact Equality, Diversity and Human Rights has on culture and a detailed section is included within Chapter 6, Addressing Health Inequalities and Access.

13.2.3 Coaching for Performance

The UHB two day Coaching for Performance Programme was re-launched in November 2015 and will be running every 2-4 months in 2016. Day 1 of the

Page | 183 programme is a key element of the UHB‟s „Being a Leader‟ and Senior Leadership programmes. This training helps managers to develop a coaching style of leadership culture and management and empowers them to use coaching skills in their everyday work. The UHB also offers more comprehensive training in Level 7 Executive Coaching and has a number of trained coaches in place.

13.2.4 Workplace Mediation

The UHB Mediation Service is provided by the Learning Education and Development (LED) Department and provides confidential, impartial support to two or more people in dispute to attempt to reach an agreement.

The UHB is committed to Mediation as a culture and way of dealing with conflict and dignity at work issues, which helps individuals and teams in dispute explore and understand their differences so they can find their own solution. Mediators are Cardiff and Vale UHB employees who are trained and accredited through ACAS and act as internal mediators in addition to their day jobs.

13.3 Flexible and Sustainable Future Workforce

13.3.1 Corporate Health Standard (Platinum)

During 2014, the UHB achieved the Platinum Corporate Health Standard which is the highest level of the Standard, and recognises the organisation‟s sustainable development and corporate social responsibility work, in addition to continued efforts to improve the health and well-being of our employees. This Award runs until 2017 and the Health and Wellbeing Group continue to monitor against the standard achieved.

As part of the six criteria within the standard, the Health Board presented a case study on its „Work Ready‟ programme, which enables people from disadvantaged groups to develop the skills and knowledge required in support worker roles. The programme enables the UHB to work with a range of partner organisations, and has also supported candidates through its dyslexia assessment service. A further 90 individuals are expected to have been supported through the programme in 2015. This programme also supports the NHS Wales/Public sector LIFT programme commitment to provide education and training opportunities for people living in workless households by the end of 2017.

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Opportunity Steps to Employment

Interested in Caring for people or Administration? We will gladly interview you! Successful completion Job Opportunities Facilitator and Mentor Support 6 month course, 25 hours per week, Comprehensive Induction package Cardiff and Vale UHB In partnership with A4E

13.3.2 Workforce Transformation

Future Workforce Transformation is necessary to underpin the achievement of the ten-year vision for the UHB Shaping our Future Wellbeing.

The longer term Workforce Transformation Plan is set within the context of the UHB Strategic and Financial Framework and a number of strategic drivers including Shaping our Future Wellbeing, Mental Health Services Review, Setting the Direction and Service Transformation, Together for Health, South Wales Programme, Working Differently – Working Together.

There are four themes to the UHB‟s longer term Workforce Transformation Plan:

Role redesign and Workforce modernisation to transformation which support service impacts across the UHB change

PATIENT

Planning the shape of the future Modernisation workforce and the driven within tools and enablers Professional staff to get us there groups

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Themes 1 and 2: Workforce and Role Redesign to Support Service and Transformational Change

The UHB has numerous examples of implementing and continuing to drive workforce redesign to support service improvement for patients and service users, which are outlined throughout Chapters 6-11. Examples include:

Operational Services (link to Chapter 7) Modernising and integration of portering roles with site specific service models across the UHB in order to utilise resources more effectively e.g. porter/cleaner at CRI; site and reception cover at Barry Hospital. Increasing the availability of Fire Fighter and Rescue staff and flexibility of security staff to support the business case for 24 hour Helipad service to meet the demands of night lands.

Prevention (link to Chapter 8) Developing roles to support the public health impact of primary care. Developing a workforce plan to support Stroke prevention and deliver stroke care bundles.

Planned Care (link to Chapter 9) Improving theatre capacity through changes to infrastructure and staff and specifically middle grade staffing to prevent risk to delivering level of surgical service required. Nurse led community based post operative cataract follow up service. Priority targeted action in 2016/17 include developing a sustainable medical workforce model for Paediatric surgery.

Unplanned Care (link to Chapter 10) Enhance medical assessment capacity at UHW and continue to develop acute physician led model. Key priority in 2016/17 is to develop new and innovative clinical roles within Primary Care out of Hours to include Advanced Nurse Practitioners. Further develop the memory team‟s role to provide early support for people with suspected dementia and further develop Dementia Champions in each cluster.

Quality, Sustainability and Efficiency Award 2015 presented to the All Wales Cystic Fibrosis Multidisciplinary team as they are commended for achievement in quality and embracing changing times, new technology and patient desires to lead normal lives whilst living with chronic life limiting conditions.

Awarded by Margaret McLaughlin, Independent Member

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Primary Care Workforce During 2014 the UHB undertook a high level analysis of the workforce data available of the GP workforce in Primary Care. At October 2013, there were 69 practices, across Cardiff and the Vale, and the high level data is identified in the following table:

Summary of GP workforce within GP practices across Cardiff and Vale Whole Time Equivalent Headcount (WTE) GP Partners 278 205.33 Salaried GP's 40 40 Registrars 32 25.53 Retainer 7 4.33 Practice Nurse 178 116.36 Health Care Support Worker 53 21.89 Practice Managers 79 69.72 Practice Receptionists 664 451.2 Totals 1331 934.36

Against a backdrop of change across all clinical/service areas, the workforce priorities for Primary Care for 2014/2015 were: An engaged workforce (increase staff voice, improve engagement index, involve staff in organisational and cultural change); A transformed workforce (integrated working along pathways, role redesign); A skilled and flexible workforce (skills, development and training to meet service needs); and A productive and efficient workforce (achieve tier 1 targets for PADR and sickness absence, maximise use of technology).

Against each of the headings significant progress has been achieved including: Organisational Health review and development of a values based Staff Charter in Primary Care Out of Hours service. Active engagement of staff enabling successful delivery of a number of change schemes including: Transforming District Nursing, Integrating Health and Social Care in the Vale of Glamorgan and the development of the Integrated Mental Health Team in the Prison. Major workforce changes across the three CRTs involving the devolvement of Therapy staff to PCIC, Integrated Health and Social care working in the Vale of Glamorgan and the co-location of Health and Social Care staff across the CRTs in Cardiff.

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Changes to the Clinical Leadership infrastructure across the Clinical Board including the introduction of Lead Community Directors, Community Director for Primary Care and Dental Advisor role. Team based objectives agreed for Prison, Out of Hours and District Nursing Teams.

Primary and Community Care Workforce Priorities for 2016

Looking ahead to 2016 the scope and opportunities for workforce development and change continues to be significant across Primary and Community Care. The challenges and complexity staff face are significant, and their part in population health and helping the UHB to deliver against the top priorities and Integration agenda is crucial.

Key to developing the workforce plans and underpinning the Welsh Government Primary Care Workforce Plan, will be the application of the principles of prudent healthcare and in particular the principle “only do what only you can do”. In doing so the UHB will consider how roles work together across the health and social care system to ensure rigid demarcation is avoided and that patients receive their care from teams that work well together across clinical pathways. The UHB sought engagement with the public at the UHB‟s AGM on the question: “Does it matter who you see as long as the person is skilled and competent to do the job”. The feedback received indicated an appetite to explore new models of working in Primary Care moving away from traditional ways of working and developing different models of care.

Collaboration with staff and stakeholders, including patients, is key to the success of the Clinical Board and will underpin a number of key strategies to support the transformation agenda moving forward. The development of strong, trusting relationships that enable to co-creation of shared aims and visions will facilitate the identification of new solutions to existing problems.

Given the workforce profile and transformation agenda the primary and community Workforce Priorities for 2016/17 are:

Primary Care – Independent Contractors Whilst GP recruitment is not an issue in Cardiff and Vale, the sustainability of GMS is becoming a pressure; exploring economies of scale within and across clusters and skill mix and will be a key priority and using the practice development plans to undertake a baseline assessment for use in workforce planning. We will use some of the learning to support core GMS e.g. use of prescribing advisors. Role definition and recruitment to pharmacy support dedicated to practices (intelligence suggests ability to recruit locally). Extend this learning to other primary care contractors.

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Primary Care – Out of Hours Embed the use of different roles in Primary Care Out of Hours and explore further opportunities. Embed and sustain the culture change in the Prison and Primary Care Out of Hours through agreed projects to empower the staff and support the use of the Staff Charter to reinforce behaviour change.

Cluster Development Cluster development has been at a variable pace per cluster but can be described as storming in year one for all nine clusters and moving to norming (for some clusters) and performing (for some clusters). The Clinical leadership model to support the development of clusters in the planning of services needs further consideration and an OD programme for primary care, cluster leads and locality management is required.

Building the Community Resilience Significant workforce issues specifically for the CRT as follows: o Recruitment to increased capacity to meet existing demand; o Progress workforce developments to support 7 day working; o Consider extended roles and advanced practice (e.g. CRT Therapies); o Opportunities for care co-ordination roles to support and signpost to patients along the pathway. Further explore existing roles elsewhere such as Community Health Officers, Community Wellbeing Officers or Health and Wellbeing Co-ordinators. Explore how community nursing fits within this model in the future. Work up role of cluster/practice based public health champions. OD requirements to support the embedding of Making Every Contact Count. Build on the „Roadmap to Integration‟ strategic workforce planning process with partners to redesign and develop an integrated workforce with a flexible skill set that is able to deliver care based on population needs and to understand the impact of the workforce that is not directly employed e.g. Primary Care, Voluntary Sector; Carers: Patients. Maximise the opportunities to move away from historical models of care and explore the use of different roles delivering care closer to home (e.g. Optometry). Undertake training needs assessment in community services and deliver joint training with partner organisations to develop flexible skill sets and culture change.

Asylum Seeker Service Build on the learning in Primary Care Out of Hours to review and increase skill mix/capacity in Asylum Seeker service to meet service demand.

Sexual Health Service Role redesign to support changes in the pathway across multi professions in primary and community services, exploring the use of more generic roles.

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The UHB is currently advertising two fixed term appointments for Organisational Development and Workforce Planning leads to support the implementation of the Workforce Primary Care Plan.

Theme 3: Shape of the Future Workforce As part of the UHB strategic workforce planning objectives, during 2015/16, the organisation reviewed the challenges and opportunities to influence the future workforce. Engagement was undertaken with Executive Directors, Assistant Directors and Senior Clinical Professional Leads to gain a collective view of what the workforce vision should look like. This multi-professional dialogue focused on patient, citizen and population need. The emerging themes outline a vision whereby our workforce: Respond to Patient, Citizen and Population need; Are highly motivated, capable and hold the values we aspire to; Are skilled in caring for patients, especially the frail and elderly who may not need care but do need support to remain independent in their own homes; Work in partnership with patients taking joint decisions and holding joint responsibility; Achieves the right balance between specialist and generalist skills to care for patients holistically; Has expertise held by a much broader range of workers and providers than clinicians, alongside a growing role for “advocates”; Support people living longer and the wellness model and help people live with chronic illness; Are comfortable working within a multiplicity of providers in health, social care, independent contractors and voluntary sector; and May be working longer and therefore may take many different routes within their own long term careers and many job changes.

This work is now being integrated within the UHB Strategy Shaping Our Future Wellbeing.

South Wales Programme/Acute Care Alliances (ACA)

As previously set out the South Wales Programme is designed to reconfigure services across South Wales in four specialist services: - Obstetrics, Paediatric and Neonatal Services, Accident and Emergency. The workforce implications of these changes will be significant and will help address a number of shortfalls and recruitment issues in terms of the medical workforce; as well as providing opportunities for new ways of working and extended roles. The Workforce Group recently established for the South Central ACA will be supporting the implementation of the service models and short term workforce solutions.

One of the key drivers within the South Wales Programme Consultation was and is to strengthen services to provide high quality timely care for patients in the most appropriate place. Evidence shows the potential of 24/7 services to deliver improved

Page | 190 outcomes for patients and service users (source: Centre of Workforce Intelligence Reports). This will almost certainly mean a move forward to ensure working hours are responsive to this need and underpin services being available seven days a week.

Examples of SWP/ACA progress during 2015 includes: Development of an agreed set of Workforce Principles for the South Central Acute Care Alliance. Joint recruitment in Midwifery with Cwm Taf. UHB Neonatal business case approved and workforce planning undertaken. SWP Neonatal business case in progress – workforce group convenes regularly. UHB leading the ENT progress across ACA. Major Trauma Centre group established for workforce planning. PCIC £3.3 million investment – creating Workforce Planning Manager and OD and Transformation Manager posts to directly support 67 GP practices/out of hospital agenda. Delivery of a 7-day rehabilitation service on Stroke Rehabilitation Centre via the introduction of integrated Rehabilitation Health Care Support Worker roles:

o Progress to date: The project runs from July 2015-March 2016. We are currently advertising for 10 x Band 3 Rehab HCSWs and are developing an education and training plan for their induction and development.

Examples of Collaborations and Partnerships: Ongoing commitment and development of UHB Trade Union Partnership working, which is recognised as a key enabler to workforce change, transformation and workforce well-being agenda. Further development of an integrated training and development programme with health and social care to support the Community Resource Teams (CRTs), Further expansion to CRTs – longer working day. Introduction and embedding of 111Single Point of Access Contact Centre. Development of Integrated Locality Model in Cardiff Roll out of Community Optometry Service and potential roll out of Community Pulmonary Rehabilitation service for COPD patients. Develop Community Phlebotomy Service. All Wales Pathology Collaborative including work streams on: o Cellular Pathology and Mortuary Services o Microbiology o Andrology o Immunology o Transport

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Theme4: Modernisation driven within Professions and Staff Groups

Advanced Practice The UHB has a significant number of staff who evidence working at the Advanced Practice (AP) level and a recent exercise was undertaken to review the baseline number of staff and the areas in which they work. The Electronic Staff Record (ESR) has also been developed recently to enable more accurate data collection and comparison across Wales. There are several examples of AP good practice within the UHB, one of which is the introduction of an Advanced Physiotherapist Practitioner for Multiple Sclerosis and Neurology. The role has provided an additional facet to the clinical care of this patient group and led to the transformation of the patient pathway. The Advanced Practitioner triages patients in clinic, leads care where the patient‟s problems are physical and liaises with the consultant as required. In addition the Advanced Practitioner‟s expertise facilitates patient reviews in their homes, which was not previously possible. A range of benefits are being realised including reduced referrals to secondary care and release of Consultant time to meet RTT.

Physicians Associates The UHB is currently undertaking a review of the organisation need and opportunity for Physician Associate roles. It is likely that we will be introducing these roles in Medicine, Primary Care and Hospital at Night service areas in 2016. The Assistant Director of Therapies and Health Science and Assistant Medical Director are already strategically linked into the All Wales work being undertaken to develop these roles and education programmes in Wales.

Modernising Pharmacy Careers The UHB is embracing the complex modernising pharmacy careers programme designed to ensure the pharmacy workforce have the knowledge, skills and competencies to deliver the future services required by patients, the public and the health service. The programme also embraces the development of career pathways for pharmacists, pharmacy technicians and pharmacy support staff. The planned first intake for the new programme is 2018 and work placements will begin in September 2018. The UHB is putting plans in place to manage the transitional changes starting in 2016. Graduates from the new programme will enter the service in August 2023 as foundation prescribers. This means they will be able to undertake basic prescribing duties but the area has yet to be determined. The pilot prescribing programme will be started in 2021.

Modernising Scientific Careers The UHB continues to develop and implement service and workforce plans in Cellular Pathology, Laboratory Genetics and Radiology. This has resulted in new structures and skill mix to support 7 day working and change in service pathways. Discussions continue with commissioners to work collaboratively with the All Wales Medical Genetics Laboratory Service to progress proposals for an integrated All Wales Medical Genetics service (link to Chapter 9). This work will also support the development of a national translational genomic medicine service aligned to the precision medicine catapult.

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The UHB is well placed to drive forward healthcare science workforce modernisation as the Assistant Director of Therapies and Health Science jointly chairs the All Wales Strategic Healthcare Science Workforce Group.

Workforce Planning and OD to specifically support GP Practices Dedicated appointment of a Workforce Planning Manager and Organisational Development Manager to work with the core Sustainability Team to support GP practices. Support the development of 67 Practices producing Workforce Plans; and support the delivery of the Plans and new ways of working. Support the skill mixing and develop further the ethos of integrated teams - GPs, nurses, pharmacists, midwives, health visitors, dentists, optometrists, physiotherapists, podiatrists, healthcare support workers, social workers and others. Skills Development to enable the workforce shift from secondary to primary care, focusing on the role of clusters, significant service change and supporting an engaged, motivated and empowered workforce. Understand the workforce demographics and ageing workforce in terms of succession planning. Leadership Development for GPs and Clinical Community Directors. Specific OD - Working between Teams – Localities, Primary Care and Medicines Management.

13.4 Productive, Efficient and High Performing Workforce

Link to Chapter 12.4, Resources, which covers this objective in more detail.

Revalidation From 2012/13, all licensed doctors have been required to undergo revalidation by the General Medical Council (GMC) at 5-yearly intervals. Progress to date in the UHB identifies 546 doctors have revalidated, with 65 deferred. Since October 2012 the UHB has trained approx 177 (AQMAR trained) doctors as Appraisers in the Non GP system and delivered 70 MARS (Medical Appraisal Revalidation System) training sessions.

Reporting into the Deputy Nurse Director, the UHB has appointed a Project Manager to implement the Nursing & Midwifery Council (NMC) Revalidation. Good progress is being made to engage with staff, trade unions and partners in this work and ensure that training and guidance is provided so that the Revalidation process is embedded.

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Maximising the Use of Workforce Technology The key priorities which form the Workforce Information Strategy are to implement roll out plans and benefits realisation for: a. ESR Managers Self Service/ Employee Self Service (MSS/ESS). b. E-Expenses. c. Rosterpro Central.

During 2015 the UHB has set a goal and plan to reach the NHS WfIS target of 80% implementation of MSS/ESS by the end of December 2015. Given the number of competing priorities of the team and limited resource available this is a challenging plan in the timescale, however, the UHB has made a considerable improvement from 17% in 2014 to 60% of current areas with self service functionality. To date manager and employee self service has been implemented in the following Clinical Boards: Dental, Mental Health, Clinical Diagnostics and Therapeutics and Primary Community Intermediate Care. It has also been implemented in the corporate areas of Planning, Workforce and OD, Finance and IM&T. Current work is focussed to complete within Specialist Services and the latter phases will be Children and Women, Medicine and Surgery.

Further development work has been undertaken in 2015/16 to include all Job Plans now recorded on ESR. Current developments also include the interface with Occupational Health system.

13.5 Building Capacity and Capability

Developing Leaders and Managers Threaded throughout the IMTP there are references to building the capacity and capability of our staff to deliver high quality services. For example, investment in Health Care Support Workers which will reap rewards across all the pathways as evidenced in service specific issues identified through Chapters 9 and 10; and investment in the leadership and management skills of our staff to ensure our workforce are led in such a way that they achieve their highest potential.

In 2015 the UHB delivered a range of Leadership Development programmes and activity through its in-house Learning, Education and Development (LED) team, complemented by external providers such as Academi Wales.

Examples of delivery in 2015 include: Six Advisory Board Leadership Workshop Sessions run to date in 2015/16. A suite of leadership and management courses made available for all staff. Apprenticeship modules commissioned through ACT and talk training. All leadership programmes run twice a year apart from the Empowering Ward Sister programme which runs four times a year. IHI 2-day Senior Clinical Leadership Programme (Nov 2015) Management Training Needs Analysis undertaken – revised leadership framework in development.

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As the needs of the UHB develop our Leadership Development activity will continue to evolve, including placing engagement at the heart of leadership activity. Recognising that leadership development is only one, albeit fundamental, part of a leadership framework, we continue to develop our approaches to talent identification and management; mentoring; coaching; 360 feedback; appraisal; promotion / development (career pathways); and values based performance management. The ambition is for the UHB during the lifetime of this IMTP is to have its own „centre of excellence‟ for leadership and quality improvement.

In 2016-17 the UHB will focus on refining and delivering a suite of leadership programmes that are open and accessible to all staff groups. In order to achieve this we will: Commission a workshop by Academi Wales to quality assure current programmes and facilitate development / refinement of in-house programmes; Establish the evidence-base of both content and models of delivery for leadership programmes; Establish a clear evaluation programme to ensure ongoing refinement of programmes; Deliver on policy development and in the areas of: talent identification and management; mentoring; coaching; 360 feedback; appraisal; promotion / development (career pathways); and performance management. This will also include the graduate trainee scheme; and Develop a costed plan for the delivery of a „centre of excellence‟.

In addition to leadership and management development, the UHB has invested and will continue to invest in its staff to ensure: a focus on patient safety (link to Chapter 7); staff are skilled in identifying ways in which services can be improved; that new advances and understanding are shared with staff (e.g. dementia training for all staff); new staff arriving into the UHB are fully aware of the strategic plan, their responsibilities around statutory and mandatory training, and that they are familiar with key policies and working practices; a clear Advanced Practice pathway; effectiveness in clinical skills; and a focus on effective communication.

Examples include: Improvement and education programmes delivered in 2015 o IQT training: 200 staff – Bronze; over 250 staff – Silver Foundation and 40 Silver Practitioners (through a combination of LIPS, Silver Practitioner; Junior doctor QI programme and the Senior Leaders‟ Programme). The organisation currently has c.1800 staff who have IQT accreditation at Bronze, Silver Foundation and c.200 at Silver Practitioner level Advance Practice Pathway o The UHB received 12 full pathways for the MSc and an additional 25 modules to enable Nurses and Allied Health Professionals to gain the qualification necessary for advanced practice. Level 4 programme for Health Care Support Workers

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o This is a two-year programme facilitated by the University of South Wales. Thirty staff began in 2015/16. Training the UHB trainer o To improve and accredit the training skills of staff within the UHB who deliver and assess training programmes. Health Care Support Workers o Funding from WEDS for four places to enable those HCSW with a level 4 qualification to apply for Registered Nurse training. o Induction programme with 25 new starters per month in 2015, to be expanded in line with the HCSW framework. Dementia training o Training in line with the Welsh Dementia Care Framework. Over 200 staff have been trained and this training continues at a pace. A suite of „Communicating with Dignity and Respect‟ Programmes o Enhanced communication skills, including „difficult conversations‟ for Registered Staff and managers. o Communicating with dignity and respect for unregistered and administrative staff. o Conflict management for managers who want to resolve conflict effectively through the use of mediation. Patient stories o Training staff in the methodology of gathering stories from a client, patient, carer or staff member.

13.6 Continuous Service Improvement

To deliver the organisational change required in Chapters 6 - 11, best practice will be applied from the disciplines of change management, continuous service improvement and lean approaches as well as programme management. Our Change Management approach depends on the collaboration of many corporate functions to support Clinical Boards to deliver the required strategy outlined in the Continuous Service Improvement organogram on the next page.

The work of the continuous service improvement (CSI) and programme management (PMO) teams underpins our improvement and transformational change agenda such that we achieve and sustain system improvement. The approach builds on the Model for Improvement Logic Model, the backbone of IQT, and employs a number of improvement tools and techniques to reduce unwarranted harm, waste and variation and as such is acutely aligned to the Prudent Healthcare agenda.

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In 2015/16, the organisation implemented a „Big Room‟ approach to targeting improvements on originally five and now seven key organisation challenges to include: Tier 1 targets: RTT; Cancer pathway with a particular focus on urology, gastroenterology and dermatology; Patient Flow to include A&E and WAST targets, Stroke pathway and Delayed Transfers of Care; IP&C; and Finance. Adopting a quality improvement approach to include run chart and PDSA reporting, the organisation has demonstrated step and sustained improvements in its RTT and IP&C programmes with smaller gains noted in the other programmes. In order to sustain and accelerate the pace of change the organisation has employed an external agency who will support the local improvement teams in delivering sustainable gains in Stroke; Patient Flow (focus on in-patient and DTOC population); Cancer pathways and Outpatients. Importantly the improvement approach being adopted is synergistic with IQT methodology.

The combined CSI and PMO work programme will continue to underpin our transformation priorities planned to improve patient pathways through the use of lean and other improvement and project methodologies as appropriate. The work will support our transformation programmes for unscheduled and planned care, for example continuing to progress our patient flow programme and stroke pathway, improving our discharge communication, fully automated booking and e-referral

Page | 197 process with GPs, ensure the efficient use of our theatres and the emerging Day of Surgery Admission plan, and streamlining cancer pathways (particularly urology where demand has risen) to support the delivery of cancer diagnostic and treatment access times. (Refer to Improving Systems on the Organogram).

13.7 Accelerating Innovation and Improvement

Building on the approaches described earlier in section 13, the UHB in collaboration with Cardiff University recognise the importance of innovation, continuous service improvement and transformational change. Indeed we consider clinical innovation to be a broach church encompassing quality improvement through to novel clinical ideas as demonstrated in the framework on the below.

Building on the foundation of the UHB‟s approach to service improvement has been the establishment of the Quality Improvement Faculty. The NHS Award winning Faculty signalled our intent to create a dynamic environment that contributes to the health and wellbeing of our patients and citizens. The Faculty is the engine to drive discussion, generate enthusiasm and action for transformational change. Importantly it also supports and develops collaborative relationships with partner organizations, locally, nationally and internationally to ensure vitality, creativity and sustainability.

The focus for 2016/17 is based on 3 primary drivers: Increase the quality, reliability and effectiveness of care by focussing efforts on programmes that tackle the reduction of harm, waste and variation (aligned

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to Shaping Our Future Wellbeing and prudent healthcare principles as per the Continuous Service Improvement and Leaner and Fitter work programmes; see section 13.6 above); Develop a culture of sustainable continuous improvement to support capacity and capability in healthcare improvement methodology and delivery, at the coal face and in educational settings (embedding IQT through LIPS, Silver Practitioner, Clinical Leadership and the C21 education and training programmes; support for the Bevan Clinical Fellows); and Build and maximize collaborative relationships with partnership organisations that seek to advance and promote innovations in promoting and delivering healthcare (Public Health Wales; Bevan Commission; Academy Wales; NHS Award applications; IHI, Boston; and support for the Welsh Wound Innovation Centre as well as the pursuit of excellence in grant applications to the Health Foundation and NISCHR).

The Faculty meets on a quarterly basis currently with plans to move to bi-monthly meetings in 2016 owing to its success. The meeting serves to celebrate success, unlock barriers and importantly create networking opportunities. In developing the „ideas‟ pipeline to encompass service improvement and clinical innovation we aim to establish a physical home for the Faculty in the Clinical Innovation Centre.

13.7.1 Clinical Innovation

As a teaching University Health Board, we already have strong and interdependent relationships with Cardiff University, Cardiff Metropolitan University and the South Wales University. We will be building on the work initiated with Cardiff University to strengthening our approach to clinical innovation, as one of the key drivers for improving how we treat and care for patients as aligned to our Strategy and the framework set out in section 13.7.

Acknowledging the challenges we are facing1, we recognise the importance of searching for and applying innovative approaches to delivering healthcare, and that this must become an integral part of the way we do business. As one of the biggest employers in the region, and a large consumer of goods and services, we also have a major role as an investor and wealth creator in South Wales. We know that our success in adopting clinical innovation helps support growth in the life sciences industries, of which there are many within the region, which in turn leads to investment in developing the technology and other products by us and the NHS more widely. Cardiff University has a proven track record in developing successful small and medium sized enterprises, (SME‟s) and in partnership with the UHB we believe that we can accelerate the pace of change and broaden the opportunities for NHS Wales as well as the more local economy through effective collaboration with industry, social sciences, other HEI‟s, University Health Boards and Third Sector and voluntary agencies alike. The success of the Welsh Institute for Minimal Access Therapy (WIMAT), based in the Medicentre, as a world leading training centre and

1 Innovation Health and Wealth, Accelerating Adoption and Diffusion in the NHS, 2011

Page | 199 incubator for ideas (resulting in several spin off companies) is our clinical innovation exemplar demonstrating what can be achieved in aligning academics, clinicians, scientists and industry together. There are other notable developments within the UHB to include St. Mary‟s Pharmaceutical Unit and also the Rehabilitation Engineering unit, who as part of their service remit are required to be at the forefront of product development/service innovation. Further, in developing a clinical innovation eco-system we are also building our links with primary care and public health to ensure that the focus is not just on improving hospital based care. We are encouraging and promoting ideas and knowledge from the medical school, the wider Bio and Life Sciences College, the Business School, engineering, mathematics and computer science disciplines. For example we are engaged in the work of the Cardiff Innovation Academy, housed in Cardiff Business School. The Academy is a University-wide initiative and sits at the heart of the School‟s Public Value Strategy: to place social improvement as well as economic development at the heart of its teaching, research and engagement. At its core, is „learning by doing‟ and the links to NHS are vitally important for this as evidenced in the recent Welsh Government sponsored BSc and MBA student placement schemes.

The Clinical Innovation Partnership has set itself ambitious goals related to the number of ideas generated, income generated and impact on job creation. The first phase of this collaboration will focus on: Engaging and inspiring the students and workforce to create a knowledge transfer and translation culture which improves patient care; Creating a physical environment to pursue discovery without boundaries; Collaborating creatively to advance clinical innovation, research, science, education and training; Developing future workforce capacity and capability; and Accelerating translation for health and wealth and job creation.

Our 4 key pillars encompass Culture; Facilities; Partnership and Focus.

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Culture: encourage and nurture clinical innovation and improvement; develop a Multidisciplinary Team to support idea development/exploitation/translation;

Facilities: a physical infrastructure enabling a single point of access and home for the Faculty of Quality Improvement ensuring the a „collision space‟ to bridge the gap between improvement and innovation;

Partnership: working with Health Innovation Cymru; South Eeast Wales Academic Health Science Partnership (SEWAHSP); neighbouring Higher Education Institutes and University Health Boards; Industry and other stakeholder organisations to foster a learning and collaborative environment;

Focus: development of a joint Intellectual Property policy; a directory to identify Innovation funding opportunities; link with Health Innovation Cymru e-platform to capture ideas and communication to include a launch at Bio-Wales in 2016.

13.7.2 Clinical Innovation – Progress to Date

Culture: Recognising the opportunities that we have as a teaching University Health Board, delivering a broad spectrum of services from primary care to very specialist tertiary services, in collaboration with Cardiff University we are actively seeking ideas for service and technology improvements and innovations generated by our combined workforce.

Clinical Innovation structure Under the leadership of the UHB‟s Executive Director for Clinical Innovation, Mrs. Abigail Harris and the Pro Vice Chancellor, Professor Hywel Thomas, we have established a clinical innovation structure following consultation within the University and Cardiff and Vale University Health Board. This development forms one strand of the joint working arrangements between the 2 organisations and it is based on the premise of partnership working, joint investment and shared strategy and objectives. As a result, both organisations have committed to installing a small senior team comprising a Dean of Clinical Innovation, Professor Keith Harding; an Associate Dean, Professor Ian Weeks; an Assistant Medical Director, Mr. Jared Torkington and an Assistant Director of Innovation and Improvement, Maureen Fallon. This team are collectively responsible for creating a better climate for innovation across the two organisations in keeping with each organisation‟s strategy (See structure below).

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Clinical Innovation Structure

Clinical Innovation activity will be reported via the structure detailed in below to the joint University /UHB Steering group. The terms of reference for the Steering Group and Operations Group have been agreed and meetings are in place.

Broadly the function of each group in relation to Clinical Innovation is as follows: University /UHW Steering Group – meets annually. Chaired by the VC/CEO considers and approves high level strategy. Operations Group – meets bi annually, Chaired by the DVC/ Medical Director receives reports from all sub groups including the Clinical Innovation Joint Board and approves programmes of work as well as escalating relevant issues to the Steering Group.

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Clinical Innovation Joint Board- meets monthly initially and will move to quarterly meetings in the future. This Board is chaired by the PVCR/Director of Planning UHB. Membership includes senior members of both organisations and the 3 Colleges of the University. The group will develop /confirm the innovation strategy. Ensure contribution to the health and wealth of Wales, link all parties to provide transformational change of healthcare practice and delivery and ensure a focus on patient care and safety. Clinical Innovation Leadership/Management Group – meets monthly. Chaired by the Dean of Clinical Innovation. Membership includes the management team and key operational contacts. The group will develop clinical innovation engagement agenda, promote the benefits of the Clinical Innovation Centre, project manage key initiatives and oversee the work programme.

In recognition of these key ingredients, the Clinical Innovation Team has established a multidisciplinary team in October 2015. Building on the work of the Quality Improvement Faculty, this new collaboration brings a co-ordinated approach to the acquirement of specialised, high quality support by bringing together academics, scientists, and researchers from different disciplines, clinicians, managers and students to create, develop and test ideas.

The purpose therefore of the Clinical Innovation Multidisciplinary Team (MDT) is to be a comprehensive, inclusive and cross-sectional decision-making forum for the development/progression of the research and clinical innovation ideas/service improvements in line with the overarching principles focussed on developing, translating and deploying evidence for patient and societal benefit, illustrated in below. The MDT membership comprises Academic Professors from the schools of Engineering; Business, Biosciences and Clinical Practice as well as Independent members; Intellectual Property Professionals and NHS clinicians and managers all who have some experience of SME‟s and business/clinical service developments. The group meets monthly and it is chaired by the Assistant Medical Director and serves as a supportive entity to staff, researchers and students working at/engaged in an undergraduate or postgraduate educational programme in either institution.

Idea/Innovation/Improvem ent for patient /person benefit

Academia, Translational Prototype Education, Clinical Product Clinical Service Clinical practice Innovation

Adoption Translation Implementation

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The MDT reports to the Executive Steering Group for Clinical Innovation and its core objectives are as follows: 1. To build a learning and delivery network to accelerate the adoption and spread of clinical innovation and service improvement to benefit the patient, student and citizen experience. 2. To build a culture of partnership and collaboration that support and incentivises the development/exploitation/translation of a clinical idea/ service improvement at pace. 3. To co-create solutions and partner with local industry where appropriate to optimise and test techniques, products, and prototypes within an agreed governance framework. 4. To capture and report the activities, evaluation and outcomes of the MDT to the Executive Steering Group. 5. To develop and disseminate an awards/funding registry to inform translation opportunities. 6. Recognition and celebration of innovation and innovators that make a difference to both organisation‟s reputation, standing and financial wellbeing. 7. Strengthen the academic and clinical community by creating a vibrant and exciting clinical innovation environment, which will help to recruit and retain the very best professionals.

Since October to December; 4 clinicians to include 2 Specialist Registrars and 1 academic scientist have presented to the MDT. At each meeting a record of the agreed supportive actions are recorded and are followed-up at the following meeting. All those that have attended have found the MDT advice as supportive and productive and importantly have served to accelerate exploitation and development opportunities. Considering that we have not formally launched the Clinical Innovation Centre and Strategy yet, albeit it is planned for March 2015, the success of the MDT has resulted in the request to extend the meetings such that 3-4 staff/students/industry partners can attend rather than the current portfolio of 2 per meeting.

Facilities:

The importance of having a physical presence has been identified as a critical enabler for clinical innovation, and a physical space; the Medicentre will be established as the single point of access and incubator for clinical innovation. Further, the acquisition of this space will importantly serve as a „collision space‟ for innovation and improvement and provide a home for the Faculty.

In creating the clinical innovation centre both organisations have developed a single entry point for people to take ideas and enable them to progress the idea through the most appropriate route. This proposal is closely aligned to The Way Forward and the Cardiff and Vale University Health Board‟s Shaping Our Future Wellbeing. Our ambition over the next 2-5 years is to deliver against key performance indicators (KPI‟s) including: Grow research income by 10%p.a. Grow industry funding by 10% p.a.

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Additionally, the Clinical Innovation Centre furthers the organisation‟s ambitions for research and innovation, including to: Undertake externally funded research leading to impact; Increased economic, health and social impact; Increase in innovation and numbers of translational projects.

The clinical innovation centre will contribute to the delivery of these KPIs by building on the core competencies of both organisations, providing a single point of contact for clinicians, academics, industry and other collaborators to develop, test and translate, at pace, tangible ideas into clinical practice. The patient management and problem solving skills of the clinicians and the research produced by academics at the University will be turned into tangible benefits for patients and their health. The Centre will offer opportunities for outreach and engagement with patients, local and national government and industry. It should be considered as phase 1 of the Clinical Innovation presence on the Heath Campus, focusing on activities, which require close proximity to patients. This will not be to the exclusion of other initiatives that may be taking place at School/College level, but rather enhancing and complementing them by providing a University/Health Board-wide infrastructure to act as a catalyst and foster growth and consolidation.

The vision for this facility is closely aligned with Welsh Government priority areas highlighted in the smart specialisation agenda of Innovation Wales, as well as those of the UK and EU, through the promotion of: Investment in innovation, skills and infrastructure that will drive prosperity, economic and social improvement; Greater innovation from the research base through better engagement between social, physical, biomedical and life scientists, clinicians and with external stakeholders; The maximisation of local spill-over benefits and knowledge exchange; Excellent research that has an impact on growth, prosperity and wellbeing, contributing to the health and wealth of Wales; Translational research capability that is both world-class and closely linked to commercial and social opportunities.

Further, the proposal fits in with the vision for the Welsh Health and Wealth System outlined in the document produced by the Health and Wellbeing Best Practice and Innovation Board, established by the Welsh Government to accelerate the adoption of innovation and the dissemination of best practice.2 Indeed, Innovate UK has recently established a Precision Medicine Catapult in Cambridge, focused on making the UK the most compelling location in the world for the development and delivery of this new targeted approach. It has recently been announced (28 October 2015) that Cardiff will host one of the regional centres of excellence – the first catapult in Wales. The Clinical Innovation Centre located at Medicentre is seen as an ideal location to

2 Health and Wellbeing Best Practice and Innovation Board, NHS Social Care and Business Workstream, Recommendations on Health and Wealth in Wales http://www.wales.nhs.uk/sitesplus/documents/888

Page | 205 house the Precision Medicine Catapult due to the synergy with the Clinical Innovation Strategy.

The figure below illustrates the themes under which the work will be taken forward, and the activities that will be progressed at a micro (green); meso (red) and macro (blue) level.

Partnership:

Our partnership approach builds on Welsh Government‟s focus on clinical innovation as a means of delivering prudent healthcare and strengthening economic growth in Wales. Spurred by our links with the Welsh Wound Innovation Centre, which we see as a template for a replicable model for clinical innovation across Wales, and our Chief Executive‟s, Professor Adam Cairns role as NHS Wales lead for clinical innovation, we are progressing shared value through working in partnership with external partners, including industry, social services, the Third Sector and the Department of Defence. With over 100,000 employees and an annual expenditure of close to £10 billion3, the healthcare sector in Wales has many valuable assets and opportunities with which to make a much greater contribution to economic growth and wealth creation. The Health Board, in collaboration with other Health Boards, NHS Trusts and Universities in Wales will ensure that the developments we are taking forward with Cardiff University form part of a coherent network of innovation activities designed to realise more of the potential in Wales. To this end our Chief Executive is taking personal responsibility for leading the work across Wales and with Welsh Government colleagues a business case for investment to support this work has been developed, Health Innovation Cymru was launched in the Autumn.

3 Health and Wellbeing Best Practice and Innovation Board, NHS Social Care and Business Workstream, Recommendations on Health and Wealth in Wales. 3 State of Innovation – Welsh Public Services and the Challenge of Change, Matthew Gatehouse and Adam Price, NESTA

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It is fair to say that our efforts thus far have concentrated on the development of our local strategy and importantly securing Executive sign-off to include the commissioning of a team and procurement of a dedicated facility for our activities. Our focus therefore is described as a small test of change to see what does and doesn‟t work before entering the national arena. As we approach the official launch at BioWales our partnership efforts will focus more on our external stakeholders. We are building our networks with SEWAHSP; local HEI‟s and MediWales as well as the Life Science Hub and the Institute for Healthcare Improvement and the Mayo Clinic. Further the Assistant Director for Innovation at Cwm Taf has set up a South Wales network with the inaugural meeting being held in January. We actively engage in National events to include Health Innovation Cymru and SEWAHSP meetings and are active contributors to the Health Technology Challenge (HTC); INVENT and more recent Bevan Technology challenges.

Focus:

As part of our small test of change approach to clinical innovation we recognise that there are 2 key enablers to effecting transformational change, seed corn funding and intellectual property. We are seeking to develop a small fund to enable translation, prototype development and patent searches to be completed. Further, whilst each organisation has its own intellectual property policy, the MDT considers that a joint policy would better serve the interests of the collaboration going forward. There are opportunities to develop this policy that will better describe the benefits for the developer and organisations as well as other partners that may contribute to the IP development.

Aligned to Health Innovation Cymru we are seeking to support population of the Beta E-Platform, pending the sign off of any related non-disclosure agreements.

Finally, our efforts in the January – March period are centred on the development of an operational plan and importantly our communication strategy which will serve to underpin our official launch of Clinical Innovation Cardiff at the BioWales event, March 1st 2016.

13.8 Expanding Research and Development (R&D)

Nationally, a coordinated approach to Government policies has placed research in the life science sector at the centre of the programme for economic renewal. The All Wales R&D budget has been increased in recent years to enhance Wales‟ competitiveness in R&D (£43m in 2013-4), with the UHB receiving £5.575.m in 2014/15.

The UHB shares and is fully engaged with Welsh Government R&D ambitions to bring patient and economic benefit to Wales through increasing R&D activity. Through its strategic objectives, the UHB has described a desire for “an environment where innovation thrives”. Further more an expansion in R&D within the UHB

Page | 207 supports services priorities in “delivering the improvement in population health our citizens are entitled to expect” whilst improving the sustainability by “joining up what we do for the people we serve and striving for operational excellence so we make the best use of the resources we have”. In turn this will help foster a culture where the UHB is considered “a great place to work and learn”

During 2015 the UHB approved a 3-year R&D plan. Align to the UHB strategic themes its aims are: For Our Population: Improve the health and well-being of patients and the wider population by promoting and supporting innovation and research translation for the better understanding of diseases and human behaviours; and improved treatments, healthcare provision, and preventative programmes. Our Service Priorities Building research capacity and strategically align research and service planning and delivery; Assist Clinical Boards and individual Directorates with their own R&D strategies and delivery; Improve the capacity of the Clinical Research Facility to undertake complex specialist studies e.g. Cardiac, Ophthalmology, Gastroenterology etc; and Development of Paediatric Clinical Research Facility for Wales. Sustainability Comply with NISCHR WG metrics including use of its ABF allocation for research delivery; Build a skilled workforce capable of advancing high quality multidisciplinary research which is population and people centred and leads to quality improvements in healthcare and public health; Increase commercial income from its present level of ~£1m per annum towards the UK average for a UHB of £6m over the next 5 years with the aim of increasing research capacity; Contribute to economic prosperity, by developing existing and new partnerships with industry in the pharmaceutical and technical sectors to grow the commercial research portfolio; and Ensure patient safety by compliance with all Regulatory and Clinical Governance requirements. Culture Create a culture and research environment to develop and sustain the reputation of the UHB for research excellence in clinical and translational medicine; and Add value and enhance impacts by creating new synergies between the UHB and HEI organisations especially Cardiff University with the aim of increasing innovative development with possible commercial exploitation.

Tangible progress has been made during 2015/16 on delivering closer collaboration with our main academic collaborator, Cardiff University. Through joint funding, a research Endoscopy suite was opened in the UHBs Clinical Research Facility in January 2016 - only the 2nd such facility in the UK. Building on its worldwide

Page | 208 reputation for brain research and following the securing of £44m by the University for a new Cardiff University Brain Research Imaging Centre (CUBRIC), agreement has been reached to extend studies into clinical areas in partnership with the UHB. This work has lead to the development of one of the 2016/17 Bold Improvement Goals (BIG) see section 3.3.1: Dementia Innovation - building on the priorities set out in the Dementia Plan and working with Cardiff Universities and Dementia Plan partners, establish a „centre of excellence‟ for dementia research and development, innovation and excellence in care and support. Performance metrics include – those set out in the Dementia Plan.

As part of the Welsh Government National Institute for Social Care and Health Research (NISCHR) Academic Health Science Collaboration (AHSC) Performance Metrics, targets have been set in relation to number of research studies undertaken by the UHB, (these are now included in the NHS Wales Delivery Framework): Increase of 10% per annum of the number of NISCHR Clinical Research Portfolio (CRP) studies being undertaken within the UHB; Increase of 5% per annum of the number of commercially sponsored studies being undertaken within the UHB; Increase of 10% per annum of the number of patients recruited into NISCHR Clinical Research Portfolio studies being undertaken within the UHB; and Increase of 5% per annum of the number of patients recruited into commercially sponsored studies being undertaken within the UHB.

Funding from NISCHR is received by the UHB in accordance with an activity based funding model. Funding is retrospective, based on the previous year‟s activity. However, the assumption that an increase in activity – both in terms of number of studies or recruitment to each study – will necessarily result in an increase of income to the UHB is complicated by the fact that the total NISCHR budget is unlikely to increase and other NHS organisations in Wales also have to deliver against the same performance metrics.

Overall research activity in Wales has fallen with the UHB performance for non- commercial studies in line with other NHS organisations however performance in commercial studies is above average, with increase set up and participant activity. The R&D Office surveyed its R&D Leads and the most common reasons for reduced activity were – service pressures, lack of supporting staff and increasing stratification of medicine leading reduced numbers of available patients for studies. The Health Care Research Wales (HCRW) workforce has been particularly depleted in south east Wales following the restructuring of NISCHR into DSCHR, reducing the nurses available to the UHB for research purposes.

13.8.2 Challenges and Priorities for 2016/17

Clinical research is not easy and requires a combination of the right qualified/skilled staff with protected time and a supporting network to enable successful completion of research projects. As outlined above the pressures on staff with increasing service commitments is ongoing and protecting time to enable research activities is an

Page | 209 ongoing issue. The fall in availability of the HCRW workforce to assist with research activities will be ongoing probably until the autumn of 2016 when its internal review should be complete and new appointments made to make up the large fall in staff in the last year or two. Commercial research continues to be difficult due to increasing demands from industry for more stratified patients, quicker set up times, competitive recruitment, more clinical time for unpaid activities e.g. serious adverse event reporting etc. This will be compounded by the proposed changes in the Health Research Authority approvals process in England, which will make Wales a less attractive place to undertake commercial research.

The priorities for the Research and Development Department during 2016/17 and beyond are to: Continue to develop a closer working relationship with the R&D functions of the UHB‟s main academic partner, Cardiff University, with the expected outcome of an improved service to the research community including investigators, grant funding bodies and industry. Build on the aim of developing a joint R and D Office between the two organisations to speed up contract approvals and ultimately study set up times; Continue to streamline processes for setting up and delivering recruitment to commercial studies in order to gain a reputation UK and worldwide as a centre of excellence for the placement of commercial studies, enhancing the opportunities for Clinical Boards to maximise opportunities for patients to participate in high quality studies as well as generating additional revenue; Complete the role out of the new R&D database management system (EDGE), finalising the move to an organisation wide accessible database to assist research teams in their collection of patient related (unidentifiable) data; Improve Directorate Level Management of Research Funding – identify activity based funding (ABF) and commercial funding at directorate level on monthly directorate finance reports, allowing a great ability to manage income and expenditure Further develop the physical build of the CRF to make it normal volunteer, cancer and non-cancer patient appropriate Take the next steps in developing a Paediatric Clinical Research Facility Devise a suitable structure/staffing/ governance processes akin to a UHB “Clinical Trials Unit” to enable investigator led „Clinical Trial of an Investigational Medicinal Product‟ (CTIMP) studies to be undertaken at the UHB.

13.9 Transforming Information Management and Technology

The UHB has a 3-year IM&T plan in place, which sets out the changes the UHB needs to make to enable service improvement, and support the implementation of Shaping Our Future Wellbeing. This includes a commitment to progress the implementation of national programmes for IT jointly with NWIS. The IMTP is aligned with the newly published “Informed Health and Care – A Digital Health and Social Care Strategy for Wales”. This programme of priorities can be flexible in their

Page | 210 delivery reflecting the current exercise in the UHB to produce a Strategic Outline Programme (SOP) and the availability of National and local Capital and Revenue funding. All the specific projects to support service change highlighted in Chapters 6-12 are included in the IM&T IMTP, however the overarching priorities for 2016/17 are:

Keeping the Lights On - Standardisation and Resilience Infrastructure upgrades and system support (80% of resources) Addressing End of Life Hardware and Software New Intranet site Data quality – Attribution and Accuracy Access and training to the UHB‟s Business Intelligence System for clinicians Coding Emergency and Assessment Unit data

Service Intelligence Primary care data and reports Community Resource Team data and reports Community reports Cancer – developing links with the All Wales Cancer Information system (CANISC) and building reports from the system, Developing further understanding on the demand for Child and Adolescent Mental Health services and the capacity available to provide timely access to the service Ambulatory Care Analysis Patient facing information

Automation and Intelligent Systems Intelligent flow – prescriptive capacity management system Development of the fully automated booking system to incorporate the dynamic scheduling of new and follow up appointments Auto validation of elective care pathways via text mining and machine based learning approaches

Big Data and Outcomes Capturing, reporting and evaluating patient reported outcome and experience measures via an electronic web based platform Capturing, reporting and evaluating condition specific outcomes Complications report Community deaths Development of the Stage 2 electronic mortality audit tool Nursing dashboard Incorporating Test results from radiology and pathology in the analysis of pathways and outcomes

Mobile and Transactional Solutions Delivery Welsh Clinical Communications Gateway Phase 2 e-Clinical Letters National Patient Flow Project

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Local Patient Flow Project e-Advice Welsh Clinical Portal - Medicines Transcribing and e-Discharge Module Welsh Clinical Portal - Welsh Patient Referral System Module Fully Automated Booking Clinicians‟ Office Module/Follow up Development Delivering Shared Well (Citizen-Driven Health) Patient Self Checking In System Increased uptake of “Bring your own devices”

E- Clinical Records Development and Implementation National Laboratory Information Management System – Histology and Blood Transfusion Modules - including POCT interconnectivity and a new Laboratory Genetics National Fuji Picture Archiving and Communication System (PACS) and PACS Image Sharing Mandate Ward Clinical Workstation Real Time Bed Management System Digital Health Record GP Test Requesting Welsh Community Care Information System Implementation Emergency Department Clinical Information Management System Migration to Welsh Clinical Portal from Cardiff Clinical Portal Welsh Clinical Portal - Test Requesting and Results Reporting Module Welsh Clinical Portal - Welsh Care Records Service Module

13.10 Good Communications Matters

The importance and value of communication and engagement to the UHB continues to rise.

The last twelve months has seen the introduction of a new structure and system with each of the Clinical Boards and corporate departments being assigned their own communications lead. This has seen benefits for both parties and resulted in better collaboration and more proactive positive news being shared across the UHB, with partners and the public. Work will continue to strengthen and develop this model allowing the development of new improved systems for sharing information and greater efficiency through reduced duplication of messages and improved engagement.

Improvements to how the UHB engages with staff and the public will also continue. Regular evaluation and monitoring will help to improve CAV You Heard?, the weekly staff newsletter, and the Your Health Board News, the monthly e-bulletin to stakeholders and the public. Both these tools will be enhanced with greater information on how the UHB is doing and its plans for the future.

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The communications team will continue to explore and develop new and existing channels. A project to evolve the UHB‟s display screen network into a multi-channel tool offering tailored local messaging at UHB sites will be undertaken. In addition to expanding the number and effectiveness of the UHB‟s channels, work will also be carried out to expand the reach of key messages utilising the networks of partners such as the local councils and universities along with new partnerships with local transport companies and major employers.

Our communication objectives for the 2015/18 period, as detailed in our Communication Strategy and Action Plan, are to: Communicate our revised vision and strategy effectively so that a person‟s chance of leading a healthy life is the same wherever they live and whoever they are; Increase the avenues for promoting our goal of improving health and wellbeing and reducing health inequalities; Provide a professional communications input into transformation programmes and service priorities. Development of a robust stakeholder engagement programme to inspire confidence in the care its offers and services provided; Improve staff communication and engagement across the health board and provide support for work to recruit and retain the best staff and initiatives to reduce the sickness absence level, measured through HR performance metrics and staff surveys; Support the quality and safety agenda by championing the sharing of information, learning, best practice and celebration of success across the UHB; Enhance our reputation as a highly trusted, expert and competent organisation by providing a professional, highly skilled, resilient corporate communications support, with increased positive media coverage of our work; Showcase our work in leading research and innovation locally, across the UK and on the global stage; and be innovative and creative in the deployment of health-related communications – using all forms of communication, to help achieve our goals.

13.10.1 Continuous Engagement on Shaping Our Future Wellbeing

This plan sets out a programme of change on which we are engaging with stakeholders, including those who use our services (or who may do in the future). Some of the changes may require us to undertake more formal engagement and consultation in line with good practice and Welsh Government expectations and requirements. Across the organisation, efforts are being made to strengthen our approach to continuous engagement with citizens and stakeholders based on the principles of co-production.

During 2014/15 the UHB invested in working with colleagues, the public and partners in developing the Shaping Our Future Wellbeing Strategy (SOFW). Successfully

Page | 213 sharing and embedding this vision will be critical in achieving the UHB‟s mission and strategic objectives.

Our Chair and Vice Chair are leading a programme of engagement events - conversations - with local community and third sector organisations. These involve discussing the challenges and choices facing the UHB and exploring issues of interest or concern about local health services. This includes sessions facilitated by third sector colleagues who work with people from diverse backgrounds whose voices may be seldom heard but whose views are of key importance in ensuring we understand and respond to the full range of needs in our communities. A recent addition to the programme is to combine these conversations with input from a public health specialist who leads a discussion about our major public health challenges and provides an interactive opportunity to explore how we can collectively tackle some key topics including obesity and smoking.

We recognise that it has never been more important for us to work closely with partners to deal with serious health challenges facing our population and to work together to develop solutions. Third sector organisations in Cardiff and the Vale of Glamorgan are some of our key partners and our relationships with them are many and varied. They are a source of volunteers, information, advice and expertise; they assist us in engaging with geographical communities and communities of interest; and we commission them to deliver range of services to some of our most vulnerable citizens on our behalf. Our engagement work on the development of Shaping Our Future Wellbeing and development work on the emerging models of care has had good input from a range of third sector organisations, reflecting the very important contribution that the voluntary sector plays in delivery patient care and supporting people in the community.

The UHB Stakeholder Reference Group (SRG) is growing in influence and confidence with a consistent membership from a diverse set of partner organisations and sectors. The SRG is a way for us to engage with an informed group of stakeholders and use their input to help shape future plans and service models. The group has been regularly updated on the development of the IMTP and has provided advice on key messages to share with the public and partners. It has also provided advice and helped shape the content of the UHB Annual Quality Statement and Quality, Safety and Experience Framework, and shared ideas on how to set up a Citizen Panel as required under the Social Services and Wellbeing (Wales) Act.

Examples of activities to directly support our engagement events and raise awareness of SOFW and the key messages within can be seen on the next page:

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14. Stewardship and Governance

14.1 IMTP Development Process

The integrated planning approach that the UHB has used to prepare its Plan, builds on the strengthened processes introduced over the last two years. An internal audit conducted in December 2015 found:

The level of assurance given as to the effectiveness of the system of internal control in place to manage the risks associated with IMTP is Reasonable Assurance. The overall assurance rating is reflective of the arrangements to develop the IMTP.

14.2 Governing Delivery

In addition to the programme management approach described in Chapters 12 and 13 which is designed to ensure that we are able to deliver the service transformation programme through a number of cross cutting themes as set out in our Strategy, we have strengthened our performance management arrangements.

In November 2013, the UHB agreed and published its Performance Management Framework, with the stated purpose being to document the arrangements that the UHB had put in place to monitor the delivery of the three year Integrated Medium Term Plan (IMTP), annual operating and financial plans. Subsequently, revised performance management arrangements were agreed for Clinical Boards in April to May 2015. As the Framework is wider than purely Clinical Board performance a full review is being completed. The revised Performance Management Framework will be approved in March 2016.

The performance arrangements will consist of up to 8 operational performance reviews per annum which are Clinical Board specific and are led by the Chief Operating Officer. The reviews will cover three key standing agenda items: Performance review against delivery of Welsh Government NHS delivery measures (Tier 1 targets); key issues and risks; and Clinical Board developments. Performance dashboards have been developed for each Clinical Board and are used to inform the first agenda item.

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In addition to this there will be quarterly strategic reviews focussing on the delivery of the IMTP, cross cutting themes and progress with embedding the UHB strategy. These IMTP/cross cutting performance reviews will be led by the Director of Planning and the Director of Public Health and will involve all Clinical Boards. They will be structured in a way that enables meaningful assessment and accountability on strategic delivery and outcome delivery with a further more open discussion on clinical service change, improvement and leadership.

In addition to the formal Performance Management Reviews there is also an opportunity for real time discussions on a weekly basis in the “Big Room”.

14.3 Corporate Governance

Our governance and assurance arrangements are reviewed annually as part of the Wales Audit Offices Annual Structured Assessment. Last year‟s assessment confirmed that there were sound governance arrangements in place overall and also highlighted where further improvements could be made – which have been reflected in strengthened programme and performance management arrangements, and the working arrangements of the committees.

Each Committee is chaired by an Independent Member of the Board, and has an annual work plan agreed by the Board. At each meeting the Committee will, if required consider matters for more detailed scrutiny referred from the Board. They will also flag up issues to be referred to the Board for consideration or action. Independent Members form the membership of the Committees, with lead Executive Directors in attendance.

There are a number of groups operating below the Board Committees which report into the Committees on a regular basis, but which may also report into the Management Executive. For example, the Capital Management Group is currently chaired by the Chief Executive because of the level of risk associated with the estate, is attended by the Independent Member with an interest in capital, and reports on a regular basis into the People, Planning and Performance (PPP) Committee.

Clinical Boards are asked to present regularly to Board Committees either on a particular topic of interest, or through the Chief Operating Officer, account for an area of performance under scrutiny.

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The Board Committee Structure is detailed below.

The system of internal control is supported by annual internal audit programme agreed with our Internal Auditors, and which reflects the risks identified in the Corporate Risk and Assurance Framework. The Board and Committee work plan will reflect the risks identified through the development of the IMTP and the on -going risk assessment processes.

The annual clinical audit programme also supports our system of internal control, and is agreed annually by the Quality, Safety and Experience Committee, with key audit outcomes being reported to the Committee. In addition to our own internal clinical audit programme, we participate in a number of national peer audits, the outcome of which is used to inform where we need to make improvements.

14.4 Managing Risk

We have a well establish Corporate Risk and Assurance Framework (CRAF) which enables us to understand the key risks racing the organisation and ensure that appropriate action is being taken to manage the risks identified. Our approach to risk management is detailed in our Risk Management Policy and our Risk Assessment and Risk Register Procedure, the objectives of which are to: Define what we mean by a risk assessment, risk register and other associated terms commonly used;

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Clarify who is responsible throughout the process from identification to resolution; Specify how risks will be considered, prioritised and managed within the UHB; Provides a mechanism to identify if a risk is tolerable taking into account the risk rating and the actions being taken to deal with the risk; Provides guidance to ensure consistent scoring when used by staff from a variety of roles and professions; and Ensures capability for assessing a wide range of risks including clinical, health and safety, financial and reputational.

We are adopting the four „Ts‟ approach to how we manage the risks we identify. The risk management approach taken by the UHB is captured in brief below.

The CRAF identifies where further action is required to manage/mitigate a risk, what that action will look like, how the Board will know that the action taken is effective (how it is assured), any gaps that require closing and any further action being taken. It is constantly reviewed and Committee receive an update regarding the management of these risks at regular intervals. In preparation for the 2016/17 assurance cycle the annual Audit Committee sponsored workshop, which took place in August 2015 provided the opportunity for the UHB Board to focus on the extreme risks within the CRAF and satisfy itself that the IMTP had adequately responded to these risks. It also allowed it to ensure that it was sighted regarding the potential risks of non-delivery of any aspect of the IMTP. This exercise will be repeated during 2016/17, together with a number of other mechanisms for ensuring that the CRAF is kept up to date. The Board and Committee work plans are also agreed with a view to ensuring that they receive adequate assurance during the year.

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The following have been identified as extreme risks (those scoring 20 and 25):

Risk Risk Descriptor Risk Sections of Lead Ref Score IMTP which Committee demonstrate mitigation of risk 5.3.4 Bone Marrow Transplantation - 25 9.8.3 People, unacceptable waiting times 13.3.2 Planning and leading to the potential relapse Performance or death. 6.4 Plan, resource and implement 25 12.3 People, safe and adequate estate Planning and Performance 6.4.1 Meet statutory compliance in 25 12.3.3 People, respect of estates Planning and maintenance Performance 6.7 Failure to deliver financial 25 12.2 Board balance and savings programmes

6.4.12 Risks to neonates and high 25 12.3.2 Quality, risk mothers a) as a result of Safety and providing on-going care to Experience neonates in a clinically unsuitable environment and b) as a result of current closure of Neonatal Intensive Care Unit (NICU)

New redefined risk relating to current issues

2.1 Failure to embed a 20 5.1 People, commissioning approach to Planning and ensure services are based on Performance evidence and population need 5.1.1 Failure to recognise 20 7.2 Quality, deteriorating patients resulting Safety and in avoidable harm Experience 5.1.11 Sufficient critical care capacity 20 9.8.1 People, and workforce to meet need 9.9.5 Planning and 10.10.1 Performance 5.6.1 Identify clinical failures and 20 7.4 Quality, patterns from information and 13.9 Safety and data sources Experience

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6.8 Plan, fund and maintain 20 12.3.4 People, effective and resilient IM&T Planning and systems to support service Performance delivery 6.9.1 Laboratory Information 20 13.9 People, Management System (LIMS) – Planning and Risk of clinical governance and Performance / information governance Information concerns as LIMS goes live Governance into additional laboratory areas due to the level of fobustness of the system. 8.2.3 Comply with relevant, up to 20 14 Audit date and accessible policies, procedures and other control documents

Total 12

14.5 Financial Governance - Controls to Support Delivery of the Financial Plan

Overall financial performance against the plan is managed via monthly Executive Director led performance reviews with Clinical Board teams. These reviews consider year to date and forecast financial performance, key financial performance indicators and actions to mitigate against risks. Performance against the key savings plan themes are managed via the Leaner and Fitter project structure where programme management arrangements and dedicated support will be provided to the key savings opportunities.

Financial controls to support the delivery of the plan include the following: Dedicated Clinical Board finance teams to provide financial advice, reporting, analysis and support to assist financial delivery; All vacancy replacements to be authorised as affordable and within budgeted establishment; Enhanced non pay controls over committing expenditure with a tight scheme of delegation ; Enhanced and standardised monthly workforce scorecard including variance to WTE budget and sickness; Contracts framework with identified Clinical Board leads; Consultant business case scrutiny; Further developing the internal framework to manage demand on support services; Issuing an accountability letter to all Clinical Boards which they will then cascade to budget holders;

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Strict protocols regarding LTA variations and changes; and All investments to be prioritised and subject to scrutiny with clearly set out benefits that will be monitored to ensure best value is delivered.

Financial performance is core Health Board business and this will be reported and considered at all Health Board meetings with supplementary discussion at development sessions as necessary. The Board will have early notice of any risks to deliver with options presented as to mitigating actions for it to consider.

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Appendix. Overview of health and wellbeing needs for Cardiff and the Vale of Glamorgan 2016/17-2018/19

Summary of health and wellbeing needs in Cardiff and the Vale of Glamorgan The boxes below summarise a detailed assessment, updated in January 2016, which follows. The information was collated at GP cluster and locality level wherever available, and locality profiles developed in summer 2015 to aid local planning.

Population size and composition The population of Cardiff is growing rapidly in size, projected to increase by 13% between 2015- 25, significantly higher than the average growth across Wales and the rest of the UK. An extra 46,000 people will live in and require access to health and wellbeing services The Cardiff population is relatively young compared with the rest of Wales, with the proportion of infants (0-4 yrs) and young working age population (20-39yrs) significantly higher than the Wales average. This reflects in part a significant number of students who study in Cardiff. There will be significant increases in particular in people aged 5-16 and the over 65s The population age structure of the Vale of Glamorgan is very similar to the Wales average, with the exception of a slightly lower number of young adults (20-24yrs). The population of the Vale will increase modestly over the next 10 years, by around 3% or 4,000 people. However, this masks significant growth in the over 65s and over 85s categories The population of South Cardiff is ethnically very diverse, particularly compared with much of the rest of Wales, with a wide range of cultural backgrounds and languages spoken. Arabic, Polish, Chinese and Bengali are the four most common languages spoken after English and Welsh. Cardiff is an initial accommodation and dispersal centre for asylum seekers

Risk factors for disease Unhealthy behaviours which increase the risk of disease are endemic among adults in Cardiff and the Vale o Nearly half drink above alcohol guidelines (44% Cardiff, 43% Vale) o Around two thirds don‟t eat sufficient fruit and vegetables (66% Cardiff, 67% Vale) o Over half are overweight or obese (55% Cardiff, 54% Vale) o Around three quarters don‟t get enough physical activity (74% Cardiff, 73% Vale) o Around one in five smoke (21% Cardiff, 18% Vale) There is considerable variation in rates of unhealthy behaviours within Cardiff and the Vale o Smoking rates vary between 14% and 33% across Cardiff, and between 17% and 29% across the Vale o Similar patterns are seen for other behavioural risk factors for disease Many children in Cardiff and Vale are also developing unhealthy behaviours o Two thirds (67%) of under 16s don‟t get enough physical activity o Over a third (34%) of under 16s are overweight or obese Air pollution is a significant cause of illness and deaths o It is estimated 143 deaths each year in Cardiff and 53 each year in the Vale among over 25s are due to man-made air pollution. The burden and impact of environmental air pollution is worse with increased deprivation, and Cardiff has the worst air pollution measured by PM2.5 levels in Wales o It is estimated that long-term exposure to man-made air pollution is responsible for 5.1% of all deaths in Cardiff and Vale

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Equity, inequalities and wider determinants of health There are stark inequalities in health outcomes in Cardiff and Vale o Life expectancy for men is nearly 12 years lower in the most-deprived areas compared with those in the least-deprived areas o The number of years of healthy life varies even more, with a gap of 22 years between the most- and least-deprived areas o Premature death rates are nearly three times higher among the most-deprived areas compared with the least deprived There are also significant inequalities in the „wider determinants‟ of health, such as housing, household income and education o For example, the percentage of people living without central heating varies by area in Cardiff and Vale from one in a hundred (1%) to one in eight (13%) There are inequalities in how and when people access healthcare o For example, immunisation uptake varies considerably, with uptake of infant vaccines ranging from 89% to 98% across Cardiff and Vale In addition to health needs, each community has „assets‟, such as social capital, community groups or community buildings

Ill health and service use The disease profile in Cardiff and Vale is changing o The number of people with two or more chronic illnesses in Cardiff and Vale has increased by around 5,000 in the last decade, and this trend is set to continue o Around 1 in 7 (15%) people consider their day-to-day activities are limited by a long-term health problem or disability o Many people with chronic conditions are not diagnosed and do not appear on official registers o Due to changes in the age profile of the population and risk factors for disease, new diagnoses for conditions such as diabetes and dementia are increasing significantly Around 1 in 5 adults have visited their GP within a 2 week period; and nearly three quarters visit a pharmacy over a year period The highest rates of attendance at the Emergency Department are from people living in more deprived areas of Cardiff and Vale Rates of delayed transfer of care for social care reasons are nearly twice as high in Cardiff and Vale than the Wales average Heart disease, lung cancer and cerebrovascular disease are the leading causes of death in men and women Preventable illness and deaths o Many (but not all) of the most common chronic conditions and causes of death may be avoided by making changes in health-related behaviours

Working in partnership with our local residents There are a number of consistent themes from local residents and health professionals about how they would like services to look in future These include: o Helping people stay healthy and independent for as long as possible o Early diagnosis of disease and receiving the best treatment available, wherever an individual lives o Co-ordinated and convenient care, as close to home or work as possible

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1. Population size and composition

Population size and composition The population of Cardiff is growing rapidly in size, projected to increase by 13% between 2015-25, significantly higher than the average growth across Wales and the rest of the UK. An extra 46,000 people will live in and require access to health and wellbeing services The Cardiff population is relatively young compared with the rest of Wales, with the proportion of infants (0-4 yrs) and young working age population (20-39yrs) significantly higher than the Wales average. This reflects in part a significant number of students who study in Cardiff. There will be significant increases in particular in people aged 5-16 and the over 65s The population age structure of the Vale of Glamorgan is very similar to the Wales average, with the exception of a slightly lower number of young adults (20-24yrs). The population of the Vale will increase modestly over the next 10 years, by around 3% or 4,000 people. However, this masks significant growth in the over 65s and over 85s categories The population of South Cardiff is ethnically very diverse, particularly compared with much of the rest of Wales, with a wide range of cultural backgrounds and languages spoken. Arabic, Polish, Chinese and Bengali are the four most common languages spoken after English and Welsh. Cardiff is an initial accommodation and dispersal centre for asylum seekers

(i) Population size, structure and projected change Table 1. Population projections for Cardiff and Vale by broad age group, 2015-2025. Source: StatsWales (2014) Year Additional people Area Age group 2015 2018 2020 2025 2015-25 Cardiff 0-4 24,013 24,800 25,180 26,017 2,004 5-16 46,269 49,439 52,142 57,210 10,941 17-64 242,384 249,072 253,036 263,948 21,564 65-84 42,250 44,500 46,164 51,450 9,200 >84 7,427 7,928 8,326 9,495 2,068 All 362,343 375,739 384,848 408,120 45,777

Vale 0-4 7,146 7,148 7,073 6,816 -330 5-16 17,874 17,889 18,199 18,184 310 17-64 77,347 76,876 76,291 75,063 -2,284 65-84 22,548 23,979 24,890 27,116 4,568 >84 3,583 3,909 4,150 5,085 1,502 All 128,498 129,801 130,603 132,264 3,766

C&V 0-4 31,159 31,948 32,253 32,833 1,674 5-16 64,143 67,328 70,341 75,394 11,251 17-64 319,731 325,948 329,327 339,011 19,280 65-84 64,798 68,479 71,054 78,566 13,768 >84 11,010 11,837 12,476 14,580 3,570 All 490,841 505,540 515,451 540,384 49,543

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Table 2. Projected percentage increase in population of (a) Cardiff and Vale; (b) Cardiff; and (c) the Vale of Glamorgan, by broad age group, over 3, 5 and 10 years from 2015. Source: StatsWales (2014) (a) Cardiff and Vale Projection year Age 2018 2020 2025 group 0-4 2.5% 3.5% 5.4% 5-16 5.0% 9.7% 17.5% 17-64 1.9% 3.0% 6.0% 65-84 5.7% 9.7% 21.2% >84 7.5% 13.3% 32.4% All 3.0% 5.0% 10.1%

(b) Cardiff Projection year Age 2018 2020 2025 group 0-4 3.3% 4.9% 8.3% 5-16 6.9% 12.7% 23.6% 17-64 2.8% 4.4% 8.9% 65-84 5.3% 9.3% 21.8% >84 6.7% 12.1% 27.8% All 3.7% 6.2% 12.6%

(c) Vale of Glamorgan Projection year Age 2018 2020 2025 group 0-4 0.0% -1.0% -4.6% 5-16 0.1% 1.8% 1.7% 17-64 -0.6% -1.4% -3.0% 65-84 6.3% 10.4% 20.3% >84 9.1% 15.8% 41.9% All 1.0% 1.6% 2.9%

The Cardiff population is relatively young compared with the rest of Wales, with the proportion of infants (0-4 yrs) and young working age population (20-39yrs) significantly higher than the Wales average. A large student population of around 60,000 contributes to this. Cardiff also has a remand prison with around 800 male inmates, slightly above the average UK prison size.

The population of Cardiff is projected to increase in all age groups, with the highest increase seen in the 5-16 (23.6% increase over 10 years) and 65-84 and over 84s (21.8% and 27.8% increase over 10 years respectively). This is in contrast to the national Wales projections, which predict contraction among 0-4 year olds and 17-64 year olds, and lower growth for children aged 5-16. The overall increase in the

Page | 227 population is over three times the overall Wales increase, at 12.6% for Cardiff 2015- 2025 compared with 4.1% for Wales as a whole.

The projected 10 year growth in the Cardiff population (12.6%) is higher than the England average (7.0%) and that of the nine regions within England, including London as a whole (11.9%) and the South East (7.7%). The likely reasons for this are discussed below.

On the assumption that the health needs of the additional people projected to reside in Cardiff in the future due to population growth are similar to those of the existing population, this would translate into a 1.2% year-on-year growth in service demand in Cardiff (3.7% over 3 years), considerably higher for services for some age groups (e.g. 6.9% growth for 5-16 year olds, and 6.7% for over 84 year olds, both over 3 years).

While the population of the Vale is projected to increase only marginally overall, at 2.9% compared with an all-Wales projection of 4.1%, this masks significant changes in the age make-up of the population. The 65-84 and over 84s age groups will see marked increases (20.3% and 41.9% over 10 years respectively). These increases are in excess of the Wales averages for these age groups of 13.9% and 39.4% respectively. In contrast, there is a projected contraction of 4.6% among infants aged 0-4 years.

On the assumption that the health needs of the additional people projected to reside in the Vale in the future due to population growth are similar to those of the existing population, this would translate into a 2.1% year-on-year growth in service demand for 65-84 year olds in the Vale (6.3% over 3 years), and 2.9% annual growth in demand for the over 84 age group (9.1% over 3 years).

Figure 1. Proportion of population by age and sex, (a) Cardiff and (b) Vale of Glamorgan compared with Wales using ONS Midyear population estimates, 2014 (Public Health Wales, 2015)

(a) Cardiff

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Wales Males Cardiff Males Wales Females Cardiff Females

90+ 85-89 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 8 6 4 2 0 2 4 6 8

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(b) Vale of Glamorgan

Wales Males Vale of Glamorgan Males Wales Females Vale of Glamorgan Females

90+ 85-89 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 8 6 4 2 0 2 4 6 8 Table 3. Proportion of population by age and sex, (a) Cardiff and (b) the Vale of Glamorgan, compared with Wales using ONS Midyear population estimates, 2014 (Public Health Wales, 2015)

(a) Cardiff

Proportion of population by age and sex, Cardiff and Count of population by age and sex, Cardiff and Wales, Wales, 2014 2014 Cardiff Wales Cardiff Wales Age group % Males % Females % Males % Females Age group Males Females Males Females 00-04 3.4 3.1 2.9 2.8 00-04 11,947 11,077 91,079 86,596 05-09 2.9 2.9 2.9 2.8 05-09 10,435 10,383 90,296 86,028 10-14 2.6 2.4 2.7 2.6 10-14 9,100 8,601 84,933 80,158 15-19 3.3 3.4 3.1 3.0 15-19 11,587 11,958 97,095 91,352 20-24 5.7 6.0 3.6 3.4 20-24 20,116 21,213 112,027 105,551 25-29 4.4 4.1 3.2 3.1 25-29 15,547 14,484 97,544 94,557 30-34 3.9 3.7 2.9 2.9 30-34 13,821 13,258 90,870 91,202 35-39 3.2 3.1 2.7 2.7 35-39 11,268 11,108 83,293 84,454 40-44 3.1 3.0 3.1 3.2 40-44 10,951 10,585 96,215 100,341 45-49 3.0 3.2 3.4 3.6 45-49 10,652 11,164 106,600 111,213 50-54 2.9 3.1 3.4 3.6 50-54 10,390 11,015 105,862 109,796 55-59 2.6 2.6 3.0 3.2 55-59 9,207 9,292 94,304 98,390 60-64 2.3 2.3 3.0 3.1 60-64 8,080 8,266 91,683 95,850 65-69 2.0 2.1 3.1 3.2 65-69 7,110 7,463 94,316 98,517 70-74 1.4 1.6 2.3 2.4 70-74 4,923 5,762 70,022 75,593 75-79 1.1 1.5 1.7 2.0 75-79 3,947 5,292 53,177 61,432 80-84 0.8 1.2 1.1 1.5 80-84 2,845 4,312 35,321 47,503 85-89 0.4 0.8 0.6 1.0 85-89 1,594 2,874 18,707 31,334 90+ 0.2 0.5 0.3 0.7 90+ 758 1,909 7,971 20,854

Produced by Public Health Wales Observatory, using 2014 Mid Year Produced by Public Health Wales Observatory, using 2014 Mid Year Population Estimates (ONS) Population Estimates (ONS)

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(b) Vale of Glamorgan Proportion of population by age and sex, Vale of Count of population by age and sex, Vale of Glamorgan Glamorgan and Wales, 2014 and Wales, 2014 Vale of Glamorgan Wales Vale of Glamorgan Wales Age group % Males % Females % Males % Females Age group Males Females Males Females 00-04 2.9 2.8 2.9 2.8 00-04 3,681 3,539 91,079 86,596 05-09 3.0 2.9 2.9 2.8 05-09 3,889 3,738 90,296 86,028 10-14 2.9 2.8 2.7 2.6 10-14 3,709 3,525 84,933 80,158 15-19 3.1 3.0 3.1 3.0 15-19 4,000 3,819 97,095 91,352 20-24 2.8 2.6 3.6 3.4 20-24 3,627 3,298 112,027 105,551 25-29 2.9 2.6 3.2 3.1 25-29 3,678 3,364 97,544 94,557 30-34 2.9 2.8 2.9 2.9 30-34 3,665 3,593 90,870 91,202 35-39 2.9 2.9 2.7 2.7 35-39 3,704 3,763 83,293 84,454 40-44 3.2 3.5 3.1 3.2 40-44 4,076 4,518 96,215 100,341 45-49 3.4 3.8 3.4 3.6 45-49 4,335 4,811 106,600 111,213 50-54 3.6 3.8 3.4 3.6 50-54 4,583 4,876 105,862 109,796 55-59 3.1 3.5 3.0 3.2 55-59 4,009 4,454 94,304 98,390 60-64 3.0 3.2 3.0 3.1 60-64 3,807 4,078 91,683 95,850 65-69 3.0 3.3 3.1 3.2 65-69 3,784 4,252 94,316 98,517 70-74 2.2 2.5 2.3 2.4 70-74 2,848 3,182 70,022 75,593 75-79 1.7 2.0 1.7 2.0 75-79 2,123 2,577 53,177 61,432 80-84 1.2 1.5 1.1 1.5 80-84 1,489 1,948 35,321 47,503 85-89 0.6 1.1 0.6 1.0 85-89 761 1,341 18,707 31,334 90+ 0.2 0.7 0.3 0.7 90+ 302 939 7,971 20,854

Produced by Public Health Wales Observatory, using 2014 Mid Year Produced by Public Health Wales Observatory, using 2014 Mid Year Population Estimates (ONS) Population Estimates (ONS)

Table 4. Current and projected population age structure, (a) Cardiff and Vale; (b) Cardiff; and (c) the Vale of Glamorgan, and Wales, 2015-2025. Source: StatsWales (2014) (a) Cardiff and Vale Proportion of population 2015 2025 (projected) Age (yrs) All Wales C&V All Wales C&V 0-4 5.9% 6.3% 5.4% 6.1% 5-16 13.2% 13.1% 13.7% 14.0% 17-64 60.8% 65.1% 58.3% 62.7% 65-84 17.5% 13.2% 19.1% 14.5% >85 2.6% 2.2% 3.5% 2.7%

(b) Cardiff

Proportion of population 2015 2025 (projected) Age (yrs) All Wales Cardiff All Wales Cardiff 0-4 5.9% 6.6% 5.4% 6.4% 5-16 13.2% 12.8% 13.7% 14.0% 17-64 60.8% 66.9% 58.3% 64.7% 65-84 17.5% 11.7% 19.1% 12.6% >85 2.6% 2.0% 3.5% 2.3%

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Proportion of population 2015 2025 (projected) Age (yrs) All Wales Vale All Wales Vale 0-4 5.9% 5.6% 5.4% 5.2% 5-16 13.2% 13.9% 13.7% 13.7% 17-64 60.8% 60.2% 58.3% 56.8% 65-84 17.5% 17.5% 19.1% 20.5% >85 2.6% 2.8% 3.5% 3.8%

The increase in the older population is significant from a healthcare resource perspective, because hospital use and costs rapidly increase with age in this group (Figure 2).

Figure 2. Annual hospital cost in Wales by age and sex, excluding maternity. (Graph courtesy of Nuffield Trust, taken from Roberts, A and Charlesworth, A. 2014. A decade of austerity in Wales).

Across Wales, the increase in population alone is projected to contribute to an increase in spend on acute care by 1.2% each year in the period 2010-2025 (Nuffield Trust).

The Cardiff local authority area is almost entirely an urban one with a high population density. Based on draft local development plans (LDP), for Cardiff the predicted housing growth is 41,100 new homes between 2006 and 2026. The Vale of Glamorgan is predominantly rural, with five small urban centres and a large number of villages and hamlets. In the Vale, the predicted housing growth is 9,960 new homes between 2006 and 2026.

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The LDP takes into account projected population growth so should not be a driver itself of additional growth.

In the 2011 Census 43,071 people identified themselves as full-time students in Cardiff, 37,043 of whom were aged 16-24. A higher proportion of 16-24 year old students (70%) considered themselves in „very good health‟ compared with the general population of 16-24 year olds (66%).

6,369 people identified themselves as full-time students in the Vale, 5,575 of whom were aged 16-24. A higher proportion of 16-24 year old students (74%) considered themselves in „very good health‟ compared with the general population of 16-24 year olds (68%).

(ii) Birth and in-migration rates The significant increase in the size of the population in Cardiff is driven principally by a birth rate which exceeds the death rate, contributing to around 0.6% growth each year, and net in-migration, which contributes around 0.3% growth annually. In- migration rates have over recent years declined slightly in Cardiff.

In contrast, the Vale has a relatively stable population size which reflects a low net migration rate, and roughly equal birth and death rates.

Table 5. Historic migration, births and natural change in (a) Cardiff and (b) the Vale, 2006-2014 Source: StatsWales (2015)

(a) Cardiff Annual figure (rolling 3 year average) Natural Net Net migration Natural change* Year migration % Births change* % 2006 2437 0.8% 3865 1070 0.3% 2007 2375 0.7% 4074 1324 0.4% 2008 2334 0.7% 4315 1595 0.5% 2009 2877 0.9% 4473 1753 0.5% 2010 2529 0.8% 4579 1873 0.6% 2011 2224 0.7% 4677 1993 0.6% 2012 1512 0.4% 4753 2100 0.6% 2013 1399 0.4% 4742 2037 0.6% 2014 971 0.3% 4671 1979 0.6% * natural change = births-deaths

(b) Vale of Glamorgan Annual figure (rolling 3 year average) Natural Net Net migration Natural change* Year migration % Births change* % 2006 849 0.7% 1302 38 0.0%

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2007 779 0.6% 1327 98 0.1% 2008 798 0.6% 1388 147 0.1% 2009 623 0.5% 1437 217 0.2% 2010 294 0.2% 1485 274 0.2% 2011 40 0.0% 1452 282 0.2% 2012 -69 -0.1% 1450 292 0.2% 2013 29 0.0% 1390 213 0.2% 2014 181 0.1% 1357 154 0.1% * natural change = births-deaths

Cardiff is a both an initial accommodation centre and dispersal centre for UK asylum seekers. In this capacity, around 100-180 individuals seeking asylum in the UK enter Cardiff each month, and around 6 in 10 of those dispersed in the South West and Wales area live in Cardiff. The number of new asylum seekers is expected to grow between 8-15% per annum. There are thought to be around 900 asylum seekers living in Cardiff at any one time. Many asylum seekers have complex health and social care needs. Pregnant women, unaccompanied children, those with significant mental health problems, and those who have experienced traumatic events such as rape or torture, are likely to be particularly vulnerable.

Asylum seekers are located across Cardiff but historically more in the „southern arc‟.

Figure 3. Geographical spread of asylum seeker households in Cardiff (Courtesy of CRC, 2014)

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(iii) Ethnicity and languages spoken Table 6. Ethnicity, (a) Cardiff and Wales and (b) the Vale and Wales. Source: Nomis (2015) from Census 2011

(a) Cardiff Cardiff Wales

Ethnicity Persons % Persons %

All 346,090 100.0% 3,063,456 100.0% White British 277,798 80.3% 2,855,450 93.2% White Other 12,248 3.5% 55,932 1.8% Indian 7,886 2.3% 17,256 0.6% Pakistani 6,354 1.8% 12,229 0.4% Black African 5,213 1.5% 11,887 0.4% Bangladeshi 4,838 1.4% 10,687 0.3% Arab 4,707 1.4% 9,615 0.3% Asian Other 4,639 1.3% 16,318 0.5% Chinese 4,168 1.2% 13,638 0.4% Mixed White/Black 3,641 1.1% 11,099 0.4% Caribbean White Irish 2,547 0.7% 14,086 0.5% Mixed White/Asian 2,459 0.7% 9,019 0.3% Mixed Other 2,189 0.6% 6,979 0.2% Other 2,152 0.6% 5,663 0.2% Mixed White/Black African 1,742 0.5% 4,424 0.1% Black Other 1,666 0.5% 2,580 0.1% Black Caribbean 1,322 0.4% 3,809 0.1% White Gypsy or Irish 521 0.2% 2,785 0.1% Traveller

(b) Vale of Glamorgan Vale Wales

Ethnicity Persons % Persons %

All 126,336 100.0% 3,063,456 100.0% White British 119,212 94.4% 2,855,450 93.2% White Irish 1,966 1.6% 55,932 1.8% White Gypsy or Irish 639 0.5% 14,086 0.5% Traveller White Other 629 0.5% 11,099 0.4% Mixed White/Black 610 0.5% 16,318 0.5% Caribbean Mixed White/Black African 566 0.4% 17,256 0.6% Mixed White/Asian 454 0.4% 13,638 0.4% Mixed Other 431 0.3% 9,019 0.3% Indian 388 0.3% 6,979 0.2% Pakistani 252 0.2% 3,809 0.1% Bangladeshi 247 0.2% 4,424 0.1%

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Chinese 216 0.2% 12,229 0.4% Asian Other 174 0.1% 9,615 0.3% Black African 173 0.1% 5,663 0.2% Black Caribbean 165 0.1% 11,887 0.4% Black Other 121 0.1% 10,687 0.3% Arab 72 0.1% 2,580 0.1% Other 21 0.0% 2,785 0.1%

Table 7(a). Most common main language spoken in Cardiff, over 3s. Source: Nomis (2015) from Census 2011 Main language spoken Cardiff % English/Welsh 304,729 91.7% Other European (EU) 3,973 1.2% Arabic 3,561 1.1% Polish 2,650 0.8% Bengali (with Sylheti and Chatgaya) 2,431 0.7% Chinese 2,321 0.7% African language 2,048 0.6% West/Central Asian language 1,927 0.6% Other South Asian 1,640 0.5% Other East Asian 1,365 0.4% Urdu 1,214 0.4% French 766 0.2% Portuguese 682 0.2% Panjabi 643 0.2% Other European (non EU) 638 0.2% Gujurati 610 0.2% Spanish 597 0.2% Tamil 325 0.1% Other language 153 0.0%

Table 7(b). Most common non-English, non-Welsh main languages spoken in Cardiff by age group. Source: Nomis (2015) from Census 2011 3 to 15 yrs 16-64 yrs >65 yrs Arabic Other European language Other European language Bengali (with Sylheti and Chatgaya) Arabic African language Other European language Polish Bengali (with Sylheti and Chatgaya) African language Chinese Urdu Polish Bengali (with Sylheti and Chatgaya) Gujarati

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Table 7(c). Most common main language spoken in Vale, over 3s. Source: Nomis (2015) from Census 2011 Main language spoken Vale % English/Welsh 120,026 98.4% Other European (EU) 482 0.4% Other East Asian 264 0.2% Chinese 213 0.2% Polish 199 0.2% Other European (non EU) 140 0.1% French 93 0.1% Other South Asian 93 0.1% Arabic 83 0.1% Spanish 82 0.1% West/Central Asian language 55 0.0% African language 47 0.0% Bengali (with Sylheti and Chatgaya) 46 0.0% Gujurati 39 0.0% Other language 38 0.0% Panjabi 37 0.0% Portuguese 32 0.0% Urdu 29 0.0% Tamil 20 0.0%

Around 1 in 10 (8%) of people in Cardiff and Vale can read, write and speak Welsh, significantly below the rate in the rest of Wales (15%) (Census 2011).

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2. Risk factors for disease Risk factors for disease Unhealthy behaviours which increase the risk of disease are endemic among adults in Cardiff and the Vale o Nearly half drink above alcohol guidelines (44% Cardiff, 43% Vale) o Around two thirds don‟t eat sufficient fruit and vegetables (66% Cardiff, 67% Vale) o Over half are overweight or obese (55% Cardiff, 54% Vale) o Around three quarters don‟t get enough physical activity (74% Cardiff, 73% Vale) o Around one in five smoke (21% Cardiff, 18% Vale) There is considerable variation in rates of unhealthy behaviours within Cardiff and the Vale o Smoking rates vary between 14% and 33% across Cardiff, and between 17% and 29% across the Vale o Similar patterns are seen for other behavioural risk factors for disease Many children in Cardiff and Vale are also developing unhealthy behaviours o Two thirds (67%) of under 16s don‟t get enough physical activity o Over a third (34%) of under 16s are overweight or obese Air pollution is a significant cause of illness and deaths o It is estimated 143 deaths each year in Cardiff and 53 each year in the Vale among over 25s are due to man-made air pollution. The burden and impact of environmental air pollution is worse with increased deprivation, and Cardiff has the worst air pollution measured by PM2.5 levels in Wales o It is estimated that long-term exposure to man-made air pollution is responsible for 5.1% of all deaths in Cardiff and Vale.

(i) Self-reported behaviours and USOA maps for reference Note that information from the Welsh Health Survey is currently reported by Upper Super Output Area (USOA) which is not directly co-terminous with cluster boundaries. Therefore information is presented here by USOA rather than cluster. Figure 4. Upper Super Output Area (USOA) boundaries, (a) Cardiff and (b) the Vale of Glamorgan (a) Cardiff

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(b) Vale of Glamorgan

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Table 8. Age-standardised percentage of adults with particular lifestyle characteristics, Cardiff and Vale, 2013-14. Source: Welsh Health Survey (2015).27 Area Lifestyle characteristic Cardiff Vale Wales Smoker 21 18 21 Consumption of alcohol: above guidelines 44 43 41 Consumption of alcohol: binge drinking 26 24 25 Consumption of fruit and vegetables: meets guidelines 34 33 33 Exercise or physical activity done: meets guidelines 26 27 30 Overweight or obese 55 54 58 Obese 21 18 22

Table 9. Percentage of 0-15 year olds with particular lifestyle characteristics, Cardiff and the Vale of Glamorgan. Source: Welsh Health Survey (2013).

Self-rated health status Lifestyle characteristic Good / Very Limiting Physically good Long- long- active on Physically general standing standing 5 or more active on Overweight Area health illness illness days 7 days or obese Obese Cardiff 94 17 5 48 33 34 20 The Vale of Glamorgan 95 21 5 54 36 26 14 Wales 94 19 6 52 36 35 19

(ii) Specific risk factors

Table 10. Self-reported smoking status in (a) Cardiff and (b) the Vale (a) Cardiff

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Adults who reported being a current smoker (age- standardised), 2008-13

Lower Upper Confidence Confidence Smoker Interval Interval Unweighted USOA % % % Base (c) W03000085 14 - 11 18 644 W03000086 19 - 15 22 564 W03000087 13 - 10 16 717 W03000088 30 + 26 34 723 W03000089 21 17 25 539 W03000090 21 17 25 541 W03000091 23 19 28 493 W03000092 33 + 29 37 715 W03000093 17 - 14 21 689 W03000094 29 + 25 32 801

Wales 23 22 23 92,081 Source: Welsh Health Survey: 2008-2013

(a) Values significantly higher than Wales denoted by '+', values significantly lower than Wales denoted by '-'. (c) Bases vary, those shown are for the whole sample.

(b) Vale of Glamorgan

Adults who reported being a current smoker (age-standardised), 2008-2013 Lower Upper Confidence Confidence Smoker Interval Interval Unweighted USOA % % % Base (c)

The Vale of Glamorgan W03000055 17 - 15 20 1,022 W03000056 18 - 15 21 867 W03000057 29 + 26 32 1,037 W03000058 17 - 14 20 804

Wales 23 22 23 92,081 Source: Welsh Health Survey: 2008-2013

(a) Values significantly higher than Wales denoted by '+', values significantly lower than Wales denoted by '-'. (c) Bases vary, those shown are for the whole sample.

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Table 11. Self-reported physical activity in (a) Cardiff and (b) the Vale (a) Cardiff Adults who reported being physically active on 5 or more days in the past week (age-standardised), 2008-2013 Physically active on 5 or more days in Lower Upper the previous Confidence Confidence week Interval Interval Unweighted USOA % % % Base (c) W03000085 24 - 21 28 644 W03000086 25 22 29 564 W03000087 23 - 20 26 717 W03000088 24 - 21 28 723 W03000089 25 21 29 539 W03000090 25 - 21 29 541 W03000091 26 22 31 493 W03000092 29 25 32 715 W03000093 20 - 17 24 689 W03000094 26 23 30 801

Wales 29 29 30 92,081 Source: Welsh Health Survey: 2008-2013

(a) Values significantly higher than Wales denoted by '+', values significantly lower than Wales denoted by '-'. (c) Bases vary, those shown are for the whole sample.

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(b) Vale of Glamorgan Adults who reported being physically active on 5 or more days in the past week (age-standardised), 2008-2013

Physically active on 5 or more days in Lower Upper the previous Confidence Confidence week Interval Interval Unweighted USOA % % % Base (c)

The Vale of Glamorgan W03000055 31 27 34 1,022 W03000056 28 25 32 867 W03000057 29 26 32 1,037 W03000058 26 23 30 804

Wales 29 29 30 92,081 Source: Welsh Health Survey: 2008-2013

(a) Values significantly higher than Wales denoted by '+', values significantly lower than Wales denoted by '-'. (c) Bases vary, those shown are for the whole sample.

Table 12. Obesity and overweight in (a) Cardiff and (b) the Vale

(a) Cardiff Adults who were overweight or obese (age-standardised), 2008-2013 Body Mass Index: Lower Upper Overweight Confidence Confidence or obese Interval Interval Unweighted USOA % % % Base (c) W03000085 50 - 46 54 644 W03000086 54 49 58 564 W03000087 53 - 48 57 717 W03000088 62 58 66 723 W03000089 53 48 58 539 W03000090 48 - 43 53 541 W03000091 50 - 45 55 493 W03000092 59 55 63 715 W03000093 55 51 59 689 W03000094 59 55 62 801

Wales 58 58 58 92,081 Source: Welsh Health Survey: 2008-2013

(a) Values significantly higher than Wales denoted by '+', values significantly lower than Wales denoted by '-'. (c) Bases vary, those shown are for the whole sample.

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(b) Vale of Glamorgan

Adults who were overweight or obese (age-standardised), 2008- 2013

Body Mass Index: Lower Upper Overweight Confidence Confidence or obese Interval Interval Unweighted USOA % % % Base (c)

The Vale of Glamorgan W03000055 53 - 50 57 1,022 W03000056 56 53 60 867 W03000057 61 57 64 1,037 W03000058 51 - 47 55 804

Wales 58 58 58 92,081 Source: Welsh Health Survey: 2008-2013

(a) Values significantly higher than Wales denoted by '+', values significantly lower than Wales denoted by '-'. (c) Bases vary, those shown are for the whole sample.

There are an estimated 8,000 people aged 16 and over in Cardiff and Vale with a BMI over 40 (1.9%), including 800 with a BMI over 50 (0.2%).

Among children and young people, overweight and obesity is also a problem (Table 9). The child measurement programme has found that over a fifth of children in reception year in Cardiff (22.6%) and the Vale (21%) are overweight or obese (Child Measurement Programme for Wales, 2013/14). While both these rates appear comparatively low, it is possible firstly that bias in which schools participated in the programme locally has artificially reduced the reported rate; and secondly, in absolute terms the rates are still higher than they should be to protect the health of future generations.

Figure 5. Proportion of children who are overweight or obese, 4 to 5 years

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Proportion of children aged 4 to 5 years who are overweight or obese, Wales and local authorities Produced by Public Health Wales Observatory, using CMP data (NWIS)

Figure 6. Proportion of children who are overweight or obese, 3 years combined data, 2011/12-2013/14, Children aged 4 to 5 years, Cardiff and Vale UHB

In the Cardiff South, East and City Locality the highest percentages of children who are overweight and obese live in the Grangetown, Butetown, Splott, St Mellons and the Llanrummey/Rumney areas. In the Vale, the highest percentages of children who are overweight and obese live in the Gibbonsdown and Barry areas of the Vale.

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Table 13. Fruit and vegetable consumption in (a) Cardiff and (b) the Vale

(a) Cardiff Adults who reported eating five or more portions of fruit and vegetables the previous day (age-standardised), 2008-2013 Consumption of fruit and vegetables: Lower Upper Meets Confidence Confidence guidelines Interval Interval Unweighted USOA % % % Base (c) W03000085 39 34 43 644 W03000086 37 33 42 564 W03000087 38 34 42 717 W03000088 29 - 25 33 723 W03000089 39 34 44 539 W03000090 38 33 43 541 W03000091 32 27 37 493 W03000092 30 - 26 33 715 W03000093 36 32 41 689 W03000094 39 + 35 43 801

Wales 34 34 35 92,081 Source: Welsh Health Survey: 2008-2013

(a) Values significantly higher than Wales denoted by '+', values significantly lower than Wales denoted by '-'. (c) Bases vary, those shown are for the whole sample.

(b) Vale of Glamorgan

Adults who reported eating five or more portions of fruit and vegetables the previous day (age-standardised), 2008-2013

Consumption of fruit and vegetables: Lower Upper Meets Confidence Confidence guidelines Interval Interval Unweighted USOA % % % Base (c)

The Vale of Glamorgan W03000055 36 33 40 1,022 W03000056 34 30 38 867 W03000057 28 - 24 31 1,037 W03000058 37 33 40 804

Wales 34 34 35 92,081 Source: Welsh Health Survey: 2008-2013

(a) Values significantly higher than Wales denoted by '+', values significantly lower than Wales denoted by '-'. (c) Bases vary, those shown are for the whole sample.

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(iii) Air pollution It is estimated 143 deaths each year in Cardiff and 53 each year in the Vale among over 25s are due to man-made air pollution. (Source: Estimating local mortality burdens associated with particulate air pollution, Public Health England, 2014) Anthropogenic particular matter (PM2.5) pollution is higher in the Cardiff and Vale area, at 9.0 µg m-3, than all other LHBs in Wales, with Cardiff having the highest single LA level in Wales at 9.5 µg m-3. This level is slightly below the mean for England (9.9 µg m-3), but above that of Scotland (6.8) and Northern Ireland (6.6).

It is estimated 2100 life years are lost each year in Cardiff and Vale alone due to anthropogenic air pollution, with long-term exposure to air pollution responsible for 5.1% of all deaths in Cardiff and Vale.

Positive, significant associations have been found between air pollution and all- cause and respiratory mortality, and cardiovascular and respiratory hospital admissions (Environmental Public Health Annual Review 2014-15, PHW) The burden and impact of environmental air pollution is worse with increased deprivation.

Figure. NO2 pollution and deprivation in Wales (Source: Brunt H et al, Epidemiology of NO2, PM10 and PM2.5 in Wales)

Carbon emissions such as those released through the use of fossil fuels in transport and heating, and in generating electricity from fossil fuel sources, are responsible for climate change. The earliest impacts of climate change are already being felt in

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vulnerable developing countries, but over time negative effects will be felt locally, including more frequent extreme weather events such as flooding (Climate Change Risk Assessment for Wales, 2012). Without concerted global action future effects in the UK may also include threats to food security (Haines, Lancet, 2014) In the UK the least deprived quintile generates one fifth of all pollution from car emissions, with the most deprived quintile generating one twentieth (Centre for Sustainable Energy, 2013).

3. Equity, inequalities and wider determinants of health Equity, inequalities and wider determinants of health There are stark inequalities in health outcomes in Cardiff and Vale o Life expectancy for men is nearly 12 years lower in the most-deprived areas compared with those in the least-deprived areas o The number of years of healthy life varies even more, with a gap of 22 years between the most- and least-deprived areas o Premature death rates are nearly three times higher among the most- deprived areas compared with the least deprived There are also significant inequalities in the „wider determinants‟ of health, such as housing, household income and education o For example, the percentage of people living without central heating varies by area in Cardiff and Vale from one in a hundred (1%) to one in eight (13%) There are inequalities in how and when people access healthcare o Immunisation uptake varies considerably, with uptake of infant vaccines ranging from 89% to 98% across Cardiff and Vale In addition to health needs, each community has „assets‟, such as social capital, community groups or community buildings

(i) Health equity and inequalities Life expectancy for men is nearly 12 years lower in the most-deprived areas compared with those in the least-deprived areas. The number of years of healthy life varies even more, with a gap of 22 years between the most- and least-deprived areas. Figure 7. Life expectancy in years, in Cardiff and Vale. Source: Public Health Wales Observatory (2011).1

Page | 248 Comparison of life expectancy, healthy life expectancy and disability-free life expectancy at birth, Cardiff 2001-05 and 2005-09 Produced by Public Health Wales Observatory, using ADDE/MYE (ONS), WIMD/WHS (WG)

2001-05 2005-09 95% confidence Inequalitygap interval (SII in years)

Males Life 75.9 12.9 expectancy 76.9 12.8 Comparison of life expectancy, healthy life expectancy and disability-free life expectancy at birth, Wrexham 2001-05 and 2005-09Healthylife 63.0 22.5 63.7 22.7 Produced by Public Health Wales Observatory, usingexpectancy ADDE/MYE (ONS), WIMDWIMD/WHS(WG) 2008 (WAG)

Disability-free life 59.2 17.2 59.8 expectancy 2001-05 2005-09 17.1 Males Females Comparison of life expectancy, healthy life expectancy and disability-free life 75.9 Life expectancy expectancyLife at birth, Cardiff and80.6 Vale UHB 2001-05 and 2005-09 8.8 77.3 Producedexpectancy by Public Health Wales Observatory,81.7 using ADDE/MYE (ONS), WIMD/WHS (WG) 10.0 63.9 Healthy life expectancy Life expectancy with 95% Inequality gap 64.7 2001-05 200565.4-09 21.0 Healthylife confidence interval (SII in years) 60.8Males expectancy 65.9 22.0 Disability-free life expectancy 61.5 76.1 11.6 Life expectancy 62.1 Disability-free life 77.3 12.3 11.8 Females expectancy 62.5 12.9

79.9 Healthy life 63.4 22.5 Life expectancy 81.0 expectancy 64.2 22.7

65.5 Healthy life expectancy 66.1 Disability-free life 59.6 16.7 expectancy 62.0 60.1 16.7 Disability-free life expectancy 62.5 Females 0 10 20 30 40 50 60 70 80 90 Life expectancy 80.7 8.5 81.8 9.9

Healthy life 65.7 20.2 expectancy 66.3 21.3

Disability-free life 62.1 12.3 expectancy 62.5 12.9

Key: SII, Slope Index of Inequality. The Slope Index of Inequality (SII) measures the absolute gap in years of life expectancy between the most and least deprived, taking into account the pattern across all fifths of deprivation within the Local Authority FigureAll-cause 8. mortality,Premature under mortality 75, males, in males European in Cardiff age-standardised and Vale rateby deprivation (EASR) per 100,000, fifths. Cardiff Eurandopean Vale UHB age and-standardised Wales, 2001 -rates09 (EASR) per 100,000 population (Source: Public HealthProduced Wales by Public Observatory Health Wales Observatory, 2013) using ADDE/MYE (ONS), WIMD 2008 (WG) Most deprived within Cardiff and Vale (95% CI) Wales EASR Least deprived within Cardiff and Vale Cardiff and Vale overall 900 800 700 600 500 400 300 200 Rate Ratio - most deprived divided by least deprived 100 2.6 2.5 2.4 2.5 2.8 2.9 2.8 0 2001-03 2002-04 2003-05 2004-06 2005-07 2006-08 2007-09 Risk factors and mortality for many common conditions is also adversely affected by deprivation, with a significant inequality „gap‟ between those in the most- and least- deprived communities.

Figure 9. Obesity in Cardiff and Vale by deprivation fifth (Public Health Wales, 2014)

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Percentage of adults reporting to be obese, by deprivation fifth, all persons, Cardiff and Vale UHB Produced by Public Health Wales Observatory, using Welsh Health Survey (WG) 2004/05 - 2008 95% confidence interval 2009 - 2012

24 Most deprived 28

21 Next most deprived 24

15 Middle 20

14 Next least deprived 17

13 Least deprived 15

Figure 10. Uptake of the 5 in 1 primary in Health Board resident children reaching one year of age during 01/07/2013 to 30/06/2014, by MSOA of residence

Source: Public Health Wales Vaccine Preventable Disease Programme (2015) Uptake of childhood vaccinations varies considerably across Cardiff and Vale. In Cardiff South, East and City Locality, uptake of the 5 in 1 vaccine by age 1 is low, in particular in City and South Cardiff. A similar pattern is seen for MMR2 by age 4, where uptake is low throughout the locality, but especially in City and South. There is an association between black ethnicity and lower immunisation uptake in Cardiff. In Cardiff North, West and South West Locality, uptake of the 5 in 1 vaccine by age 1 varies significantly, being low in Cardiff South West but above the 95% WHO target in Cardiff North and Cardiff West. For MMR2 by age 4, all areas are lower than the 95% threshold required to achieve a good level of population protection against, for

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example, a measles outbreak. Again, Cardiff South West has the lowest uptake in the locality area. In the Vale, uptake of vaccines is generally good, with uptake across the locality for the 5 in 1 at age 1 above 95%. However, uptake of MMR2 by age 4 is lower than the 95% target, particularly in Central Vale. Figure 11. Percentage of children with completed 5 in 1 primary course by age 1, Cardiff and Vale clusters (2015)

Figure 12. Percentage of children with completed MMR course (2 doses) by age 4, Cardiff and Vale of Glamorgan (2015)

(ii) Deprivation and wider determinants of health Areas of deprivation in Cardiff are mainly in the southern arc, with around one in six of Cardiff‟s neighbourhoods within the 10% most deprived in Wales. Most deprivation

Page | 251 in the Vale is around Barry, and around 1 in 15 neighbourhoods in the Vale are in the 10% most deprived in Wales. The „wider determinants‟ of health including income, quality and availability of housing, employment, education and community safety show large variation across Cardiff and Vale and, in particular, within Cardiff. Two examples are given below. Figure 13. Areas of deprivation in Cardiff and Vale, based on the Welsh Index of Multiple Deprivation (WIMD) 2014. Source: Public Health Wales Observatory (2015, revised)

Figure 14. Percentage of people living in households with no central heating. Source: Public Health Wales Observatory (2012) from Census 2001 data.

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Further data is available in a Public Health Wales Observatory report (2012) on wider determinants.

(iii) Community assets An overview of some assets in each USOA is available using the Public Health Wales Observatory health assets reporting tool, available at http://howis.wales.nhs.uk/sitesplus/922/page/63326.

4. Ill health and service use in Cardiff Ill health and service use The disease profile in Cardiff and Vale is changing o The number of people with two or more chronic illnesses in Cardiff and Vale has increased by around 5,000 in the last decade, and this trend is set to continue o Around 1 in 7 (15%) people consider their day-to-day activities are limited by a long-term health problem or disability o Many people with chronic conditions are not diagnosed and do not appear on official registers o Due to changes in the age profile of the population and risk factors for disease, new diagnoses for conditions such as diabetes and dementia are increasing significantly Around 1 in 5 adults have visited their GP within a 2 week period; and nearly three quarters visit a pharmacy over a year period The highest rates of attendance at the Emergency Department are from people living in more deprived areas of Cardiff and Vale Rates of delayed transfer of care for social care reasons are nearly twice as high in Cardiff and Vale than the Wales average Heart disease, lung cancer and cerebrovascular disease are the leading causes of death in men and women Preventable illness and deaths o Many (but not all) of the most common chronic conditions and causes of death may be avoided by making changes in health-related behaviours

(i) Self-reported ill health Over 30,000 people in Cardiff and Vale classified themselves in 'bad' or 'very bad' health, a rate of 6.4%.

At the LSOA level within Cardiff the proportion of residents reporting bad or very bad health ranged from 1.2% in the Cathays area (Cardiff LSOA 032C) to 15% in the Rumney area (Cardiff LSOA 016A). However these are crude percentages only and do not take into account the age structure of the population. The areas with the highest percentages are found in the Rumney and Llanrumney areas of Cardiff.

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Within the Vale of Glamorgan the areas with the highest proportion of people reporting bad or very bad health are found in the Cadoc and Buttrills areas.

Figure 15 . Self-reported general health status, Cardiff and Vale, 2011

This compares with the Wales average of 7.6%. Across Cardiff and Vale, the broad ethnic group with the most people rating themselves in „bad‟ or „very bad‟ health is white, at 6.7%; all other ethnic groups are below the average of 6.4%, with Asian/British Asian ranking the lowest, with 3.7% rating their health as bad.

The proportion of people who self report „bad‟ or „very bad‟ health is lower in Cardiff and Vale among people who can read, write and speak Welsh (1.9%) compared with people without Welsh language skills (7.4%) (Census 2011).

Around 1 in 7 (15%) of the adult population in Cardiff and Vale considered their day- to-day activities were limited a lot by a long-term health problem or disability. A third (32%) had a limitation of any sort. These rates are slightly lower than the Wales average of 16% and 34% respectively.

(ii) Burden of disease across GP clusters Table 14. Age-standardised percentage of patients on selected chronic condition registers, (a) Cardiff and (b) the Vale, 2014, to indicate the relative burden of recorded disease across GP clusters having taken age into account. Source: Public Health Wales Observatory, using Audit+ (NWIS) (2015) (a) Cardiff

Chronic condition Area Asthma Hypertension CHD COPD Diabetes Epilepsy Heart Failure Cardiff East 6.6 17.3 4.3 2.5 7.4 1.0 1.0

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Cardiff South East 6.1 16.0 4.0 2.7 7.5 0.8 1.0 City & Cardiff South 6.6 17.2 4.0 2.2 9.3 0.8 1.0 Cardiff and Vale UHB 6.7 15.6 3.8 1.9 6.5 0.8 0.9 Wales 6.8 15.7 4.0 2.2 6.7 0.9 1.0

Key: COPD, chronic obstructive pulmonary disease; CHD, coronary heart disease

(b) Vale of Glamorgan

Chronic condition Area Asthma Hypertension CHD COPD Diabetes Epilepsy Heart Failure Central Vale 7.2 17.0 4.0 2.2 6.9 1.0 0.8 Eastern Vale 6.7 14.1 3.4 1.4 5.6 0.8 0.7 Western Vale 6.5 13.4 3.4 1.3 5.0 0.8 1.2 Cardiff and Vale UHB 6.7 15.6 3.8 1.9 6.5 0.8 0.9 Wales 6.8 15.7 4.0 2.2 6.7 0.9 1.0

Key: COPD, chronic obstructive pulmonary disease; CHD, coronary heart disease

(iii) Service use Nearly 1 in 5 adults (18%) in Cardiff and Vale visit their GP each fortnight, and over the period of a year around one third of adults (34%) visit an outpatient department. Self-reported attendance at a community pharmacy within the last year is higher in Cardiff and Vale (74%) than Wales as a whole (70%). Table 15. Age-standardised percentage of adults using NHS services in Cardiff and Vale and Wales in the prior 2 weeks to 1 year (Welsh Health Survey 2012-13) NHS service C&V Wales Family doctor (GP) (past 2 weeks) 18 17 Attended casualty (past 12 months) 16 17 Outpatients (past 12 months) 34 32 In hospital as an inpatient (past 12 months) 9 9 Pharmacist (past 12 months) 74 70 Dentist (past 12 months) 69 70 Optician (past 12 months) 52 50

Attendance at major Emergency Departments is higher than the Wales average (240 per 1,000 per year) for residents in Cardiff (270) (Public Health Wales Observatory, 2013/14). In contrast, emergency admission rates are lower for Cardiff (87 per 1,000) than the Wales average (112). Attendance at major Emergency Departments is below the Wales average (240 per 1,000 per year) for residents in the Vale (188) (Public Health Wales Observatory, 2013/14). Similarly, emergency admission rates are lower for the Vale (103) than the Wales average (112).

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During 2013, there were 101,270 new attendances across all ages at University Hospital Wales (UHW), putting substantial pressure on secondary care systems. There are many factors that can affect service utilisation including underlying population need, provision of services (including elective, emergency, community and primary care services), as well as patient and parental behaviour in seeking health care. The figure below shows the crude rate per 1,000 population of emergency unit attendances at UHW in 2013 for Cardiff and Vale residents at MSOA level and it is evident from the map that the highest rates of EU attendances are from residents who live in the most deprived areas of Cardiff. For example the association with deprivation is clear when looking at Butetown. Figure 16 shows that higher rates are seen in the dark area to left of Lloyd George Avenue compared to the lighter area to the right (Atlantic Wharf). Figure 16. Emergency Unit attendances, UHW, C&V residents (2013)

Llanedeyrn / Rumney / Llanishen estate Pentwyn Trowbridge Mynachdy / Llandaff North

Splott / Tremorfa

Butetown

Grangetown / Riverside

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Figure 17. Emergency Unit attendances at UHW by deprivation fifth for Cardiff and Vale residents combined using WIMD 2011 (2015) Emergency Unit attendances, University Hospital of Wales, crude and European age-standardised rate per 1,000, Cardiff and Vale residents by deprivation fifth, 2013 Produced by Public Health Wales Observatory, using WIMD (WG), MYE (ONS) and UHW EU dataset (Cardiff & Vale UHB Information Dept.) Crude rate Age-standardised rate 300

250

200

150

100

0 Least deprived Next least Middle Next most Most deprived deprived deprived

Rates of delayed transfer of care for social care reasons are nearly twice as high in Cardiff and Vale than the Wales average (Cardiff 8.6 per 1,000; Vale 8.2 per 1,000; Wales 4.7 per 1,000). The long-term impacts of significant reductions in local authority funding are still emerging but could adversely affect general and tailored support for vulnerable individuals in the community. This may result in an increase in hospital admissions where families or individuals are unable to cope, and place further pressure on resources in the community to support patients being discharged from hospital. Around one in five people locally die in their home, and around six in ten in hospital. Table 16. Percentage of deaths by place of occurrence, (a) Cardiff and (b) the Vale, deaths registered in 2013 (Source: Office for National Statistics) (a) Cardiff Other communal establishmen Home Hospital Care home t Elsewhere Male 23.0 57.9 10.1 6.8 2.3 Female 14.9 55.6 20.9 7.6 1.0 Persons 18.9 56.7 15.6 7.2 1.6

(b) Vale of Glamorgan Other communal establishmen Home Hospital Care home t Elsewhere

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Male 22.9 57.5 8.9 8.6 2.2 Female 13.6 55.8 19.6 9.5 1.5 Persons 18.0 56.6 14.6 9.1 1.8

Note. Deaths at home are those at the usual residence of the deceased (according to the informant)‚ where this is not a communal establishment. Care homes includes homes for the chronic sick; nursing homes; homes for people with mental health problems and non-NHS multi function sites. Other Communal Establishments include hospices; schools for people with learning disabilities; holiday homes and hotels; common lodging houses; aged persons‟ accommodation; assessment centres; schools; convents and monasteries; nurses‟ homes; university and college halls of residence; young offender institutions; secure training centres; detention centres; prisons and remand homes. Elsewhere includes all places not covered above such as deaths on a motorway; at the beach; climbing a mountain; walking down the street; at the cinema; at a football match; while out shopping; or in someone else's home. This category also includes people who are pronounced dead on arrival at hospital.

(iv) Change in disease profile The proportion of people with chronic illness rises with age (Figure 18). While this pattern has not altered significantly over the past 10 years, because the population is getting older on average this manifests as a trend of an increasing average number of illnesses per individual in the population (Figure 19). Over the past 10 years there have been around 13,000 additional individuals in Cardiff and Vale with one chronic illness and 5,000 with two or more chronic illnesses. This trend is set to continue. Figure 18. Percentage of individuals in Wales with 1, 2 or more illnesses by age group (Welsh Health Survey, 2013) 100 90 80 70 60 50 40 2 or more 30 1 chronic illnesses chronic 20 10 0

Percentage of people with 1, 1, with people of morePercentageor 2 16-24 25-34 35-44 45-54 55-64 65-74 75+ Age (yrs)

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Figure 19. Percentage of individuals in Wales with 1, 2 or more illnesses by year (Welsh Health Survey, 2003-2013) 100 90 80 70 60 50 40 2 or more

30 1 chronic illnesses chronic 20 10

% People aged 16+ moreor 2 16+ People aged 1, with % 0 2003 2008 2013 Year

The profile of disease in Cardiff and the Vale is changing. Examples are given for two common diseases – diabetes and dementia – which affect many people, including their families, friends and carers. In both cases many (but not all) instances of the disease could be prevented by modifying behaviours such as diet and physical activity. Diabetes It is thought that the number of people who have been diagnosed with diabetes and appear on the GP registers, 22,181, is lower than the number who actually have the disease, in particular for type 2 diabetes. It has been estimated that there are actually 29,000 adults in Cardiff and Vale with diabetes, around 8% of the population. This suggests there is a shortfall in diagnosis of around 7,000 adults, or over a quarter of predicted cases. The percentage of people reporting being treated for diabetes has been rising steadily over the last ten years across Wales. Current projections are for the adult population with diabetes in Cardiff and Vale to increase from around 29,000 to around 40,000 by 2025, an increase of nearly 40%. Recorded prevalence of diabetes varies significantly within areas of Cardiff with higher black and minority ethnic (BME) population. The age adjusted burden of prevalence ranges from 7.4% to 9.3% in Cardiff South, East and City locality.

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Figure 20. Prevalence of diabetes, persons aged 17 and over, Cardiff and Vale UHB residents, 2013/14

Dementia The number of people living with dementia is also projected to rise significantly. The driver for this is mostly the increase in the over 85 population (see above). There is evidence that the risk of developing dementia at any given age is actually starting to fall, but this decline does not sufficiently offset the rise in the population size. Similarly to diabetes, there are thought to be many people currently living with dementia whose condition has not yet been diagnosed.

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Table 17. Estimated number of people with dementia in Cardiff and Vale, 2015 to 2025 (Source: Daffodil Cymru)

Year Age group 2015 2020 2025 30-64 yrs (early onset dementia) 109 116 121 65-69 yrs 282 269 291 70-74 yrs 465 576 554 75-79 yrs 813 894 1,110 80-84 yrs 1,262 1,375 1,540 85 yrs and over 2,565 2,875 3,355 65 yrs and over (total) 5,387 5,988 6,849

Figure 21. People with dementia on GP registers in Cardiff and Vale; and estimated total number of people with dementia, including those currently undiagnosed. Source: Public Health Wales Observatory (2013)

Mental health 4,111 people are on the primary care register for serious mental illness (including schizophrenia, bipolar disorder and other psychoses), around 0.8% of the GP list size in Cardiff and Vale. In general, people with a psychotic illness have fewer qualifications and are more likely to have left school before the age of 16 with no qualifications, compared with other groups. The percentage of Year 11 school leavers who were known to be not in education, employment or training (NEET) in 2013 in Wales was 3.7%, with a local rate of 4.9% in Cardiff and 3.8% in the Vale. 43% of people accessing homelessness projects in England had a mental illness. The number of households who were deemed to be eligible, unintentionally homeless and in priority need was 195 in the Vale and 690 in Cardiff in 2013/14.

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The standardised rate for suicide among women in Cardiff (5.8 per 100,000) is above the Wales average of 5.3, with rates for men below the Wales average. The rates for men and women in the Vale are below the Wales average.

(v) Cancer incidence Table 18. Incidence of top 3 newly diagnosed cancers in males in South Wales, 2007-2011. European age-standardised rate per 100,000 population. Source: Welsh Cancer Intelligence and Surveillance Unit (WCISU). Year Cancer site 2007 2008 2009 2010 2011 Prostate 125.5 118.7 106.9 110.1 104.8 Trachea, bronchus and lung 64.6 65.8 58.9 59.6 62.7 Colorectal 61.5 61.6 66.2 67.8 57.7 All excluding NMSC 471.5 465.2 440.2 448.2 444.9

Key: NMSC, non-melanoma skin cancer Table 19. Incidence of top 3 newly diagnosed cancers in females in South Wales, 2007-2011. European age-standardised rate per 100,000 population. Source: Welsh Cancer Intelligence and Surveillance Unit (WCISU). Year Cancer site 2007 2008 2009 2010 2011 Breast 122.2 126.1 128.7 131.4 116.9 Trachea, bronchus and lung 40.5 43.9 38.1 40.6 41.1 Colorectal 39.4 37.5 39.3 34.9 39.8 All excluding NMSC 379 384 390 390.8 382.1

Key: NMSC, non-melanoma skin cancer (vi) Causes of death Table 20. Top 5 causes of death in men, England and Wales 2012 Cause of death EASR per million Ischaemic heart disease 954 Trachea, bronchus and lung cancer 442 Cerebrovascular disease 341 Bronchitis, COPD 327 Pneumonia 260

Key: EASR, European age-standardised rate Table 21. Top 5 causes of death in women, England and Wales 2012 Cause of death EASR per million Ischaemic heart disease 426 Cerebrovascular disease 327 Trachea, bronchus and lung cancer 298 Breast cancer 239 Bronchitis, COPD 224

Key: EASR, European age-standardised rate

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In Cardiff and Vale, although death rates from cancer, respiratory disease and heart disease overall are gradually decreasing, for some other conditions such as liver disease, mortality is increasing. Figure 22. Changes in mortality rates for liver disease, cancer, respiratory disease and circulatory disease (Source: Public Health Wales Observatory, 2011)

Under 65 European age standardised mortality rates for various diseases, Wales, percentage change from 1996 baseline Produced by Public Health Wales Observatory, using ADDE/MYE (ONS)

220% 200% 180% 160% liver 140% malignant cancers 120% respiratory 100% circulatory 80% 60% 40%

% change in EASR sincechange EASR 1996% in 20%

1996 1997 1998 1999 2004 2005 2006 2007 2008 2009 2000 2001 2002 2003

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5. Working in partnership with our local residents Working in partnership with our local residents There are a number of consistent themes from local residents and health professionals about how they would like services to look in future These include: o Helping people stay healthy and independent for as long as possible o Early diagnosis of disease and receiving the best treatment available, wherever an individual lives o Co-ordinated and convenient care, as close to home or work as possible

Rapid access to services which can diagnose my disease at an early stage

Easy access to high quality advice. This could be via helplines or websites but, when I have a complex problem, I want to be able to talk to people who know me and understand my disease and its treatment

To have ownership of how and where my care is delivered at the end of my life

To stay close to my community and family

Rapid access to knowledgeable healthcare professionals who can advice me when my health deteriorates, allowing treatment alterations that allow me to stay at home as much as possible

Care which is delivered close to where I live and work, so that I can continue to lead as normal a life as possible, whilst still working closely with clinical teams to ensure the best outcomes for me

To maintain independence and have the best quality of life possible during my care

To die with dignity in a place of my choosing

A co-ordinated service, including out of hours, so I don‟t repeat the same story

To always be offered the best, most effective treatments, regardless of where I live and which health professional I see

Decisions regarding my care to be made by experienced clinicians who have an understanding of my condition, whatever time of day or night

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To receive holistic care from a range of health professionals, who communicate effectively with each other and work as a team

6. Needs highlighted in GP cluster plans The 2015/16 plans in the nine GP clusters in Cardiff and the Vale include the following needs and demands, set out in the context of the UHB‟s strategic priorities, and by locality. Understand the needs of the population (in addition to information provided in this document) o Cardiff South, East and City clusters . Reduce unhealthy behaviours in population including improving levels of smoking quit rates, and improving access to obesity services . Reduce teenage pregnancy rates . Increase uptake of childhood immunisations and seasonal flu vaccine . Drug dealing and misuse is an issue in the area . Improve uptake of bowel and cervical screening o Cardiff North, West and South West clusters . Reduce number of people with adverse lifestyle behaviours, particularly alcohol use . Significant number of young families requiring multi-disciplinary support . Improve screening uptake rates, particularly among minority ethnic communities . Significant levels of dementia in locality Increase staff training to support needs of patients with dementia . Ensure equitable levels of proactive support to people in care homes . Improve uptake of flu immunisation among under 65s in at-risk groups and over 65s . Improve childhood immunisation uptake . Significant student population . Needs of asylum seekers, including language issues . High population of elderly vulnerable in own homes; isolation; morbidity from falls . Significant number of planned housing developments in the locality . Increasing practice list size

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. Large number of people in sheltered accommodation (older people and those with learning disabilities) o Vale of Glamorgan clusters . Cater for an increasing population size . Improved communication for patients with English as a second language . Improve uptake of vaccines for Western Vale . Increase flu immunisation „at risk‟ uptake . Improve alcohol awareness . Increase engagement with smoking cessation pathway . Improve access to primary care mental health services, CAMHS, optometry . Improve healthcare provision to housebound elderly . Patients with early mental health issues not meeting criteria for mental health services Ensure the sustainability of GP services o Cardiff South, East and City clusters . Improve access to GP services . Ensure sufficient access to services in light of new housing developments o Cardiff North, West and South West clusters . Ensure patients with diverse backgrounds and languages fully aware of services they can access o Vale of Glamorgan clusters . Reduce number of „did not attends‟ . Reduce number of inappropriate frequent attendees at out-of- hours and emergency services . Improve access to primary care Urgent care o Cardiff North, West and South West clusters . Ensure patients access right care, right time, right place for dental and eye services . Improve access arrangements for people in crisis with dementia and mental health in older people o Vale of Glamorgan clusters . High emergency admissions Central Vale Planned care o Cardiff South, East and City clusters . Ensure adequate provision and choice of contraceptive options . Improve communication and management for people with diabetes . Improve access to sexual health screening and contraception

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. Ensure adequate access to care in nursing homes . Improve understanding of dementia needs in area . Improve access to trauma, urology, neurology and gastroenterology . Improve access to diabetes, heart failure specialist advice, pulmonary rehabilitation . Improve diagnosis of hypertension and skin lesions o Cardiff North, West and South West clusters . Increase availability and equity of access for contraception . Improve sexual health provision for students . Provide sufficient counselling capacity within practices to meet demand . Improve diabetes management o Vale of Glamorgan clusters . Reduce unnecessary hospital admissions . Improve access and equity of access to planned care including cardiology, dermatology, family planning, minor surgery, dermatology, ENT, paediatric services . Improve care of patients with chronic health problems . Improve management of patients with AF End of life care o Cardiff South, East and City clusters . Variation in approach to end of life care – need for improved consistency o Vale of Glamorgan clusters . Improve patient choice over place of death and to ensure as comfortable as possible . Ensure needs of patients in nursing homes are met . Identify needs of patients on dementia register Cancer o Cardiff South, East and City clusters . Improve early diagnosis of cancer o Cardiff North, West and South West clusters . Improve prevention and early detection of cancer o Vale of Glamorgan clusters . Improve rates of early detection and treatment . Increase awareness of national screening programmes Locality issues o Cardiff South, East and City clusters . Varied access to multilingual communication available . Reduce inequalities in health, including smoking, alcohol, obesity, heart disease, diabetes and COPD

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o Cardiff North, West and South West clusters . Reduce variation in management e.g. prescribing, lab testing, radiology referrals o Vale of Glamorgan clusters . Reduce incidence of flu cases

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