Hywel Dda University Health Board Annual Report and Accounts 2015-16

Hywel Dda University Health Board Annual Report and Accounts 2015-16 What will this annual report tell you? Our annual report is part of a suite of documents that will tell you about our organisation, the care we provide and what we do to plan, deliver and improve healthcare for you to meet changing demands and future challenges. It will provide information about how we have performed this year, what we have achieved in 2015/16 and how we will improve further next year. It will also explain how important it is for us to work with you and listen to you in order to deliver better services that meet your needs as close to you as possible. Our priorities are shaped by our Integrated Medium Term Plan which sets out our objectives and plans until 2019. You can read this and find out more about us at www.hywelddahb.wales.nhs.uk. Our annual report for 2015/16 includes: • Our accountability report which details our key accountability requirements under the Companies Act 2006 and The Large and Medium-sized Companies and Groups (Accounts and Reports) Regulations 2008. • Our annual governance statement (AGS) which provides information about how we manage and control our resources and risks and comply with our own governance arrangements. • Our performance report which details how we have performed against our targets and actions planned to maintain or improve our performance. • Our summarised financial statements which details how we have spent our money and met our obligations under The National Health Service Finance (Wales) Act 2014. • Our annual quality statement (AQS) which provides details on actions we have taken to improve the quality of our services and is available here http://www.wales.nhs.uk/sitesplus/862/page/75118 If you require any of these publications in printed or alternative formats and/or languages please contact us using the details below. Hywel Dda University Health Board, Corporate Offices, Ystwyth Building, Hafan Derwen, St David’s Park, Jobswell Road, Carmarthen, SA31 3BB. Telephone: 01267 239554 Email: [email protected] Website: www.hywelddahb.wales.nhs.uk Twitter: @HywelDdaHB Facebook: www.Facebook.com/HywelDdaHealthBoard

2 Contents

1. Welcome from the Chair and Chief Executive 4 2. About Us 6 3. Key Achievements and Developments 9 4. Improving Patient Care and Services 17 5. Improving Health and Wellbeing 29 6. Involving Local People, Partners and Communities 33 7. Valuing Our Staff 36 8. Investing In Our Estates and Services 39 9. Our Performance Report 46 10. Our Accountability Report 80 11. Our Financial Statements 173

3 1. Welcome from the Chair and Chief Executive

This year has signalled a profound change for Hywel Dda University Health Board. We have set ourselves a goal to become a population health organisation focused on keeping you well, helping you to manage your health and co-ordinating your care in a holistic way. This goes beyond being merely a provider of services to becoming a partner in your health and wellbeing. To achieve our ambition, our objectives in 2015/16 were to first ensure we were getting the basics right with a real focus on supporting and developing our workforce, delivering existing services to high quality and halting the decline in our performance. Beyond this, we have been planning how we wish to move forward over the coming three years and set out our thinking on this in our Integrated Medium Term Plan. For the first time, this plan sets out the top ten priorities we think we need to tackle to meet the needs of local people, not just today but over the next 10 years. We cannot do everything at once so these priorities will guide our efforts over the coming years. The plan also describes in broad terms how we intend to tackle our challenging financial position and meet national targets. These are significant issues which require more thinking and development and so we were pleased recently when the Welsh Government announced they would provide us with targeted intervention to help us develop this plan to get it to the position where it is formally approved, and the organisation is on a more sound financial footing. In the meantime we continue to develop the set of actions which will deliver on our strategic ambitions, making further improvements in our performance, particularly in terms of the length of time patients are waiting to access services, and focusing on stabilising our financial position. We ended 2015/16 having improved or sustained performance in the majority of our indicators, which marks a turning point for us but we also recognise that on 27 out of the 66 against which we are measured our performance has not improved. 2016/17 will see further improvement on this result. This annual report showcases our many innovative and award-winning successes. In 2015/16, we invested £13.4m in improving our hospital and our community services. It also shows you where we have performed less well and how we will address this through £80m of improvements in the next three years. These are not cuts to services, rather they are taking the necessary steps to ensure we get the most out of our current systems to provide better care in more efficient ways, embracing the principles of Prudent Healthcare. Key to this is our workforce. We are very proud of our staff who always do their very best to provide the highest standards of care. We value their dedication so, in 2015/16, we introduced a new staff recognition scheme and received more than 100 entries in our Best of Health staff awards. We developed our organisational values with staff and invested in education and training. The quality of our staff is evidenced in this report by numerous national awards and recognition, both for exceptional services and individual employees. For this commitment, often at difficult times, we thank each and every member of our team. Our recruitment challenges are ongoing and to address this, we focused on innovative HR solutions with key successes in medical and nurse appointments and modernising staff roles. Thanks to the hard work of our staff in 2015/16, we provided more primary and community services closer to your home, using technology to reduce calls to emergency services. We saw more GP appointments, locality services and pharmacies offering triage and treat; new routine dental access, emergency supply of medication and eye care services; a walk-in pilot at Tenby Hospital; and many developments to transform our mental health services in consultation with patients and public. We were shortlisted for six NHS Wales awards, with a top accolade won by our mental health

4 team who also twinned with one of the best mental health services in the world – the first UHB in Wales to do so. Our public health team has worked to increase community and in-hospital stop smoking services, staff flu vaccinations and new obesity services. We now have a lead doctor, nurse and manager in all four hospitals and, in the next 12 months, our clinical leaders and teams, working with local people, will define a strategy for each, building on our desire to provide 24/7 urgent and emergency services across our three counties. We could not have done this without our staff, or without the support of the communities we serve. These are your health services and we value your opinion. We want to work with you to improve your services. This year, we listened and talked to more people than ever before. We held 24 Sgwrs Iach – Let’s Talk Health community engagement events; grew to more than 1000 members in Siarad Iechyd/Talking Health; and our patient experience services gained national recognition. We recruited 123 more health volunteers and increased our Investors in Carers scheme, with 98% of all GP surgeries, plus many pharmacies and health settings, at bronze level. We did all of this working in partnership with you, our key stakeholders and collaboratives across mid and west Wales. For this, we say a heartfelt thank you. There is no doubt that the past 12 months has been challenging and that there is more challenge ahead. We are now seeing the first fruits of our endeavours and are even more determined to tackle the issues we face. We are not daunted by this task and look forward to working more closely in partnership with the Welsh Government in the next year. Our Board strongly believes that your NHS, the services you know and love, are worth fighting for and, with your help, that is exactly what we will do.

Bernardine Rees OBE Steve Moore Chair Chief Executive Hywel Dda University Hywel Dda University Health Board Health Board

5 2. About Us

Hywel Dda University Health Board (UHB) is the planner and provider of all NHS healthcare services for people in Carmarthenshire, Ceredigion, Pembrokeshire and its bordering counties. Our 9,871 members of staff provide primary, community, in-hospital, mental health and learning disabilities services for around 384,000 people across a quarter of the landmass of Wales. We do this in partnership with our three local authorities and colleagues from the public, private and third sectors, including 377 volunteers, through: • Our four main hospitals: Bronglais in Aberystwyth, Glangwili in Carmarthen, Prince Philip in Llanelli and Withybush in Haverfordwest. • Our seven community hospitals: Amman Valley and Llandovery in Carmarthenshire; Tregaron, Aberaeron and Cardigan in Ceredigion; and Tenby and South Pembrokeshire Hospital Health and Social Care Resource Centre in Pembrokeshire. • 54 general practices, 48 dental practices, 99 community pharmacies, 56 opticians and 11 health centres. • Numerous locations from which mental health, learning disabilities and related services are provided. • Highly specialised and tertiary services commissioned for us by the Welsh Health Specialised Services Committee. This is a joint committee with representation from all seven health boards across Wales. Our aim is to prevent ill health and deliver high quality healthcare for the people we serve. This means providing the right care, in the right place, at the right time, every time and is the basis of our vision to deliver a world class health care system of the highest quality with improved outcomes for the people of Hywel Dda. We have agreed that the difference we intend to make for people in Hywel Dda is: • We will prevent ill health and intervene in the early years. This is key to our long term mission to provide the best health care to our population. • We will be proactive in our support for local people, particularly those living with health issues and the carers who support them. • We will put rapid diagnosis in place so that, if you think you have a health problem, you can get the treatment you need. If you do not need treatment, you can move on with your day-today life. • We will be an efficient organisation that does not expect you to travel unduly or wait unreasonably; is consistent, safe and of high quality; and with a culture of transparency and learning when things go wrong.

6 For this reason, in 2015/16, we set ourselves 10 strategic objectives, as follows: 1 To encourage and support people to make healthier choices for themselves and their children and reduce the number of people who engage in risk taking behaviours. 2 To reduce overweight and obesity in our local population. 3 To improve the prevention, detection and management of cardiovascular disease in the local population. To increase survival rates for cancer through prevention, screening, earlier diagnosis, 4 faster access to treatment and improved survivorship programmes. To improve the early identification and management of patients with diabetes, improve 5 long term wellbeing and reduce complications. To improve the support for people with established respiratory illness, reduce acute 6 exacerbations and the need for hospital based care. 7 To improve the mental health and wellbeing of our local population through improved promotion, prevention and timely access to appropriate interventions. To improve early detection and care of frail people accessing our services including those 8 with dementia specifically aimed at maintaining wellbeing and independence. 9 To improve the productivity and quality of our services using the principles of prudent health care and the opportunities to innovate and work with partners. 10 To deliver, as a minimum requirement, Outcome and Delivery Framework targets and specifically eliminate the need for unnecessary travel and waiting times, as well as return the organisation to a sound financial footing over the lifetime of this plan.

How will we do this? ‘Our Health, Our Future’ Each year, as part of the NHS Wales Planning Framework, we are required to have an Integrated Hywel Dda Interim Integrated Medium Term Plan Medium Term Plan (IMTP) which sets out our strategic Summary vision, aims and objectives for the next three years. 2016/17 to 2018/19 ‘Our Health, Our Future’ is updated yearly. In our 2016/7 to 2018/19 plan, we set ten strategic objectives listed above and the values which will guide us in their delivery. Strategic objectives 1 to 8 are the goals we have set to meet what local people need now and over the next ten years. Strategic objectives 9 and 10 focus ! on our financial position, national performance targets and the quality and safety of our services.

7 Our financial strategy sets out the steps to return to financial balance. To do this, we need to deliver almost £80m of improvements over the next 3 years. These are not service cuts. This is about getting the most out of our systems to provide care now and into the future. We forecast in our IMTP that we would stabilise and improve our deficit for the first time in 2016/17. Key to this is solving our staffing challenges, becoming more efficient and reducing our service demand, particularly for emergency care. The answer lies in delivering more primary care and community services closer to, and sometimes in your own homes, increasingly using the opportunities afforded by better use of technology. Our plan also sets out the vision for our four hospitals. Over the next 12 months, our clinical leaders and teams, working with patients and the public, will define the strategy for each hospital, building from our desire to ensure 24/7 urgent and emergency services continue to be delivered across our three counties. The plan has been approved in principle by our Board but does not yet achieve financial balance and is therefore unapproved by Welsh Government. We approved an operational plan for 2015/16, supported by a number of enabling plans, to ensure improvements across the NHS Wales Delivery Framework and set milestones for the 2016/17 plan. Our Board and How It Governs Details of our Board, Executive Directors, Independent Members and information about how we manage and control our own resources and risks and comply with, monitor and evaluate our own governance arrangements can be found in our Accountability Report and Annual Governance Statement which are available here: http://www.wales.nhs.uk/sitesplus/862/page/75118

8 3. Key Achievements and Developments

Bronglais Hospital Front of House This year, our £38m investment in Bronglais Hospital’s Front of House in Aberystwyth continued with the construction of a new antenatal and paediatric clinic and a link corridor to the new building. The pathology department also moved into new purpose-built, state of the art facility which is the first of its type in Wales. The biochemistry and haematology laboratories merged to provide a single blood sciences facility which, together with the adjacent Public Health Wales microbiology laboratory, creates a single specimen reception area to serve all laboratories and reduce duplication. The departments are co- located adjacent to the CT scanner. This new facility will ensure Bronglais Hospital continues to provide these vital services to patients, staff and the mid Wales community and continues to take part in valuable medical research studies. Refurbishment works to outpatient department flooring is due to be completed in early June 2016 and further work to refurbish the main theatre 2 is due to commence in Autumn 2016. Blood Sciences at Withybush and Prince Philip Hospitals In 2015/16, £4.7m of Welsh Government funding was spent on the final phase of blood sciences (pathology) at Withybush and Prince Philip Hospitals. This included the upgrade of a range of laboratory facilities to bring together services and provide modern diagnostic and testing equipment in appropriate accommodation. Prince Philip Hospital Front of House Prince Philip Hospital’s £1.4m Front of House and Minor Injuries Unit will ensure modern and sustainable emergency and minor injury services for the people of Llanelli. Emergency patients are now treated in a purpose- built 16 bed Acute Medical Assessment Unit with a resuscitation unit, two resuscitation bays, a fast positive stroke bed, six ambulatory care chairs, an assessment area, a six-bed step-down area for monitoring patients and a reception and lobby. Patients arrive through a new ambulance entrance and senior doctors and nurses treat patients with a wide range of problems, including strokes and chest conditions. Patients go straight to the medical team so the sickest patients are treated in the shortest possible time.

9 The new Minor Injuries Unit is run by GPs and Emergency Nurse Practitioners and can treat patients with a range of problems from muscle and joint injuries to burns and scalds, minor head injuries, minor eye injuries and more. This project includes a new frailty area, improved assessment facilities and space for community teams to support discharges, plus significant investment in new equipment such as an electronic system to improve links between care providers. Glangwili Hospital Women and Children’s Services

In 2015/16, we took action to improve women and children’s services in Withybush and Glangwili hospitals. This followed an independent review by the Royal College of Paediatrics and Child Health of service changes made in Pembrokeshire and Carmarthenshire in 2014 which resulted in 54 recommendations to further improve these services. The review concluded that the changes were safe and sustainable and has led to improved outcomes for our patients. Phase 1 concentrated on consultant-led maternity care and inpatient paediatric care in Glangwili Hospital with a new midwife-led maternity service and 12-hour paediatric assessment unit established at Withybush Hospital in Haverfordwest. We also provided dedicated paediatric high dependency beds at Glangwili Hospital and are continuing to work towards level two status for our neonatal service. Phase 2 focuses on upgrading patient and family accommodation at Glangwili Hospital. Funding of £0.63 million has recently been approved by Welsh Government to proceed to outline business case in Autumn 2016, with a full business case planned for May 2017. In total, £3m of Welsh Government funding for 2016/17 has been granted, subject to approval of our business case plans.

10 Our Chief Executive led the project group developing the business plan and actions taken this year, including setting up an interim waiting room for fathers in Glangwili Hospital; scheduling daytime sessions on the Special Care Baby Unit for out-of-hour consultants; progressing with plans to move the Paediatric Assessment Unit closer to the Emergency Department at Withybush Hospital; providing new transport options for parents and families and an organisational development programme for staff across all sites. The dedicated ambulance vehicle for women and children’s services was extended to 2016/17 and one of our Independent Members was appointed as Children’s Champion for Women and Children’s issues. We worked directly with women and children’s staff and staff user groups who developed initial accommodation plans. Engagement is also taking place with wider staff, mothers and families to inform the design and business case for submission to Welsh Government in 2016/17. Withybush Hospital Cancer Services In 2015/16, planning began to build a new £950,000 Chemotherapy Day Unit and extensively refurbish the palliative care, oncology and haematology area in Ward 10, Withybush Hospital. This state-of-the- art unit will include consulting rooms for haematology, oncology, research-led clinics and specialist treatments, video-conferencing for telemedicine clinics with off-site specialists, a meeting room for multidisciplinary staff, a dedicated counselling/quiet room, a reception point with separate waiting areas for outpatients and day patients, clinical nurse specialist and improved staff facilities. The facilities in the Ward 10 area will have inpatient beds, isolation facilities, en-suite facilities, a day room and space for relatives. This work has been made possible thanks to the support of Pembrokeshire charitable fundraisers. Adam’s Bucketful of Hope, Withybush Hospital CDU Appeal and the Health Board’s Pembrokeshire Cancer Services Fund have raised more than £670, 000 and more than £312,000 has been raised by the University Health Board’s Pembrokeshire Cancer Services Funds and Elly’s Ward 10 Flag Appeal. The plans have been drawn up in discussions and engagement events with staff nurses, doctors and healthcare professionals, service users, their families and carers and key stakeholders to ensure the best environment and patient experience. Work to deliver these important projects will continue this year and it is hoped that the Chemotherapy Day Unit will open towards the end of 2016.

11 Withybush Hospital Recruitment Drive In August 2015, Withybush Hospital was facing a shortage of staff in key medical specialties, nursing and therapies and in GP surgeries. Loss of junior medical staff in core training grades led to direct recruitment across the UK and internationally. We took the following action to ensure the hospital continued to provide as many core services as possible, including 24/7 medical and emergency care: • Formed a clinician-led implementation group to develop sustainable services. • Temporarily closed 15 beds at Withybush and sent small numbers of emergency medical patients from east Hywel Dda to Glangwili, with Prince Philip Hospital accepting more Carmarthen east patients. On average, this affected three patients per day. • Implementing an innovative UK and overseas recruitment programme using social media to pro-actively recruit to vacant posts. • Developing our own two year training programme, the first of its type in Wales, to mirror the medical training scheme for UK junior doctors. As part of this scheme, we provided an e-portfolio for each doctor to build competencies and achieve trainee doctor qualifications. In 2015/16,13 clinical fellows have been directly employed in medicine, A&E and anaesthetics to support the junior doctor rota. • Appointing new consultants, including an orthogeriatrician, a care of the elderly physician and an anaesthetist and giving approval to increase the consultant medical physicians from 8 to 12 to improve the stability of the acute general medical service. • Funding additional beds in local nursing homes for patients fit for rehabilitation and an additional ambulance for 16 hours per day to minimise pressure on the Welsh Ambulance Services NHS Trust. • Working with staff across our area and health and social care partners to plan early discharge, avoid admission where appropriate, increase uptake of re- ablement services and return residents to local services.

12 Cardigan Integrated Care Centre

In 2015/16, our plans for a new £20m integrated care centre in Cardigan were approved by Welsh Government. These proposals for the state-of-the-art centre on the Bathhouse site were also unanimously approved by Ceredigion County Council. This modern, fit for purpose facility will enable health and social care professionals to provide care closer to people’s homes and in the community. It will include a GP practice and out-of-hours service, specialist and nurse-led clinics, a rehabilitation day unit, services for dementia sufferers and carers, a minor injury service, radiology and diagnostics, a phlebotomy service and point-of-care testing, an outpatient suite with consulting rooms, clinical treatment facilities for pre-assessment and a telemedicine suite to access specialists. These services will be delivered jointly with the third sector, local authority and partner organisations. The centre will also provide a base for the community resource nurses delivering services in South Ceredigion, North Pembrokeshire and the Teifi Valley and help to reduce inappropriate admissions to hospital and nursing and care homes. Together with the enhanced community nursing service in Cardigan, this will increase our capacity to deliver a wider range of community services across Ceredigion. The full business case will be submitted to Welsh Government in 2016. Cylch Caron Community Resource Centre In 2015/16, we invested £5.8m of Welsh Government funding in our Cylch Caron project in Tregaron, Ceredigion. This funding will enable the business case for this £8.1m project to be developed and allow the partners to engage a registered social landlord for the final design stage. This flagship project includes a range of integrated services including a GP surgery, community pharmacy, outpatient clinics, community nursing services, long-term nursing care and day care. Plans include 34 flats for people who require support to remain at home and six integrated health and social care places for people in hospital who require support to return home. The Cylch Caron development, led by Ceredigion Local Service Board, will bring together health, housing and social services under one roof, closer to those who need them, and will focus on helping older people to stay well and live active and independent lives. It will replace the existing Tregaron Community Hospital, Bryntirion nursing home and GP surgery.

13 Award-Winning Staff and Services In 2015/16, a number of our staff and teams won national and international awards for their outstanding care and work in improving our services for patients. This is a selection of them and you will find other examples throughout our annual report. National Endorsement for Withybush’s Endoscopy Unit

In 2015/16, Withybush Hospital’s Endoscopy Unit was awarded accreditation from the Joint Advisory Group (JAG) on GI Endoscopy, joining Glangwili and Bronglais and becoming the fourth accredited endoscopy unit in Wales. This accreditation is recognition that endoscopy services can deliver against targets in the endoscopy global rating scale standards. To meet the strict criteria for this prestigious award, both the facilities and procedures were upgraded to enhance the patient experience. Patients visiting the unit now have a relaxing waiting room, male and female changing areas and access to a private room. The JAG report praised the endoscopy staff as ‘a model for others to follow and learn from’ and said the unit provides an ‘excellent environment for trainees’. Consultant Gastroenterologist and Physician and Clinical Lead for Endoscopy, Dr Faiz Ali, was also commended for his highly effective leadership, robust governance and a highly competent workforce. In 2016, we plan to submit a capital bid to Welsh Government to ensure Prince Philip Hospitals’ Endoscopy Unit gains accreditation, an achievement that would make us the first JAG accredited UHB in the country. Welsh Government has agreed to a capital bid submission via business case processes. Award-Winning Spasticity Clinic at Prince Philip Hospital In 2015/16, an award-winning service aimed at helping people with long-term neurological conditions like stroke, multiple sclerosis, spinal injury and cerebral palsy opened in Llanelli’s Prince Philip Hospital. The service manages muscle tightness and spasms caused by neurological conditions through medical and physical treatments, such as splints, physiotherapy, tablets or Botox injections.

14 The service has already achieved a number of awards for its treatment at Glangwili Hospital, Carmarthen. This second clinic in Llanelli means that people can access treatment locally rather than travelling to Glangwili, one of the first places in the world where physiotherapists were able to independently prescribe medicines and inject Botox. This model has been showcased around the UK and in Australia to illustrate how physiotherapy-led services can help rural communities. The new service compliments the stroke unit already at Prince Philip Hospital and also provides some treatments for people in their own homes when they are unable to travel to hospital for an appointment. Bronglais is Best in Wales In 2015/16, Bronglais Hospital was named as the best in Wales for patients undergoing an emergency laparotomy, according to the results of the National Emergency Laparotomy Audit. It showed high scores for the number of patients whose care needs were met in processes pre-operation. Psychiatrist is Simply the BEST In 2015/16, a psychiatrist who uses medical speciality techniques to add value to professional appraisals won a BEST award in recognition of his innovation. This prestigious award is presented by the Wales Deanery to recognise high standards in the education and training of doctors and dentists. Dr Anand Ganesan, a specialist doctor in Adult Mental Health in Carmarthen and lead mental health appraiser, was winner in the Innovation in Education category. He provides support for a number of learning and development schemes, including appraisals and mentoring and has an honorary teaching role with Cardiff University. Dr Ganesan sees appraisals as a performance enhancement tool and uses skills, techniques and inspirations from his various medical and teaching roles to add value in an appraisal setting. Doctor Appointed as Chair of Respiratory Medicine In 2015/16, one of our consultants was appointed as the first practising Clinical Chair in Respiratory Medicine in Wales. Professor Keir Lewis, a consultant in respiratory and general medicine, was chosen by Swansea University and our UHB for this key health and academic role which aims to improve care and outcomes for patients with respiratory disease. By working more closely with local universities and research and commercial institutions throughout the world, patients will get better access to state-of-the- art treatments, cutting-edge research and staff training and partnerships. The post is being hosted at Swansea University’s Medical School, one of the fastest growing medical schools in the UK, and Professor Lewis will work as part of the respiratory team of consultants that are all already impacting on national and international policy and researching the prevention, diagnosis and treatment of respiratory illness. This appointment helps to improve training opportunities, carry out teaching and undertake research with evidence of specific outcomes.

15 Award-Winning Nurses In 2015/16, one of our Macmillan Specialist Nurses Tracey Lloyd was named as Learning Disabilities Nurse of the Year in the national Royal College of Nursing Awards in recognition of her excellent work on the Check4Change Programme. This programme provides cancer information and support to people with learning disabilities.

Runners-up in these prestigious awards were Community Psychiatric Nurse Lisa Kinsella, Advanced Nurse Practitioner in Mental Health Services Richard Jones, Ward Sister Lisa Marshall and Mental Capacity Act Lead Chris Sayer.

A Lifetime Achievement Award was awarded to school health nurse Brenda Scourfield at the Royal College of Nursing Awards in recognition of decades of service in Carmarthenshire.

16 4. Improving Patient Care and Services

Primary and Community: More Care Closer To Home In 2015/16, we have been successful in providing more care closer to your home and in your local communities, as follows: More GP Appointments In 2015/16, 41% of GP practices made positive improvements to their appointment and opening hours. A large proportion of the population find it difficult to attend a GP appointment during working hours, so offering early morning and evening appointments has been encouraged. In 2016, we have seen a significant improvement in GP practices offering more flexible appointment times. An example of this is that in May 2015 only 3.7% of GP practices offered appointments before 8.30am but, by the end of March 2016, this increased to 37%. New Locality Services These continue to develop and introduce new services. In 2015/16, successful results included: • Multi-disciplinary team working in Carmarthenshire has significantly contributed to a reduction in unplanned hospital admissions from 102 per 1000 patients to 98. • In Ceredigion, 709 people at risk of developing diabetes have been identified for proactive management with 19 completing a ‘Foodwise’ programme. • Pharmacists and chronic disease nurses undertook targeted care home reviews in Ceredigion, reducing the risk of admission and improving prescribing safety. • Collaborative working with Paul Sartori in Pembrokeshire is improving advanced care planning for end of life patients. Improving Primary Care Premises To deliver integrated community care, high quality, equipped and modern estate is essential. In 2015/16 we invested in premises improvement grants for nine GP practices, increasing the number of clinical rooms, improving patient waiting areas and access. Primary Care Support Team This team was developed to provide support to GP practices with recruitment difficulties and to test how new professionals could support patient care. The team includes GPs, occupational therapists, clinical pharmacists and advanced paramedic practitioners. In 2015/16, four GP practices were supported with home visits, telephone consultations and rapid access to occupational therapists, reducing GP demand and avoiding hospital admissions.

17 New Routine Dental Access Service In 2015/16, a new routine access service was introduced to deliver courses of treatment to people who cannot access regular high street dental services and do not have an immediate or urgent clinical need. All patients on the central waiting list have been offered this service and 50% have used it while they await allocation to a long term practice. This service provides an important source of treatment for those who do not have access to an NHS dentist or do not want regular NHS dental care. More Children in Design to Smile This is an oral health education programme delivered to children in targeted settings. In 2015/16, the tooth brushing programme supported 9,797 children and the fluoride varnish application programme was delivered in 21 schools, with the majority of eligible children having two applications per year. Eighty schools have also been screened as part of the national five year-old epidemiology survey. It is hoped this programme will reduce the need for paediatric general anaesthetics for tooth extraction. More Pharmacies Offer Triage and Treat In 2015/16, new triage and treat services were made available at pharmacies in south and north Pembrokeshire and Ceredigion. These services help patients with low level injuries and prevent unnecessary visits to a doctor or A&E. They are provided by a pharmacist or a pharmacy team member with special training and can be used by visitors, holiday makers and local residents, especially when the GP practice is closed. They also provide general advice about different health conditions. 47% of patients seen said that they would have gone to A&E if the service was not available and a further 38% would have gone to the GP practice. New Emergency Supply of Medication Service In March 2016, an emergency supply of medication service was set up in 27 pharmacies in our area. This service provides urgently required medication to patients when they are unable to obtain a prescription before they need to take their next dose. This relieves pressure on GP out- of-hours services, A&E departments and GP appointments from visitors to the area. Initial patient and pharmacy feedback is very positive and this service will be further developed in 2016/17. New Eye Care Services Forty-two of our practices are Eye Health Examination Wales accredited to provide enhanced eye examinations. In 2015/16, we: • Introduced new evening and weekend hospital slots to address cataract waiting lists. • Sent some hospital patients to external providers while new capacity is developed. • Developed glaucoma suspect and ocular hypertensive services and cataract post-operative discharge service.

18 • Undertook feasibility work in Ceredigion to move services into better accommodation in Bronglais by November 2016. • Provided a new community Acute Macular Degeneration (Wet AMD) service in Tenby and Cardigan to reduce the 100 mile journey time for patients in Pembrokeshire and south Ceredigion who were travelling to Amman Valley or Bronglais Hospital to access services. Tenby Hospital’s New ‘Walk-In’ Service In 2015/16, we piloted a new ‘walk-in’ nurse-led service for residents and visitors in Tenby Hospital. The service was run over Easter by a team of advanced nurse practitioners and healthcare assistants who provided a range of treatments for minor illnesses and injuries. The first aid service was successfully provided over previous Easter and summer holidays by the British Red Cross Service. South Pembrokeshire Hospital, Health and Social Care Resource Centre In 2015/16, in conjunction with Pembrokeshire County Council, we began a review of services at South Pembrokeshire Hospital, Health and Social Care Resource Centre to ensure it is meeting current needs and continues to meet patient needs in the future. Staff, patients, partners and key stakeholders are involved in this review. Staff Integration at Aberaeron Hospital In 2016, staff from Aberaeron Hospital relocated into a modern, integrated health and social care facility in Felinfach to create an improved working environment. Clinical services continue to be provided at the hospital until alternative facilities are identified. This co-location strengthens links between health and social care staff and supports the continued growth of clinical and community services in Aberaeron. Royal Assent for New X-Ray Service at Llandovery Hospital In 2015/16, we welcomed HRH The Prince of Wales to Llandovery Hospital to officially unveil a new state-of-the-art X-Ray machine funded with the support of the local community by the Llandovery Hospital League of Friends. His Royal Highness met with Llandovery Hospital staff and patients before unveiling the new X-Ray machine. An appeal by the League of Friends raised £225,000 to purchase and install the new X-Ray machine. Increase in Patient Participation Groups In 2015/16, the three original groups increased to five with plans for at least a further three within the next six months. A patient participation network has been set up to support the development of these groups and provide them with an opportunity to share best practice. These open group discussions are a good way to develop better understanding between primary care services and the population they serve and are an essential part of improving primary care services.

19 Health and Care Standards: Fundamentals of Care

We are working to improve our performance against the Fundamentals of Care identified in the Health and Care Standards. In 2015/16, a comprehensive audit of care provision across all our services concluded that for all of the audited standards, we achieved at least, if not greater than, the target standard. Next year, we plan to focus on further improvements including pressure sore prevention, eating and drinking, rest and sleep, foot care, oral hygiene and continence care. Patient audit feedback shows that we mostly get things right for you. Your feedback tells us where we provide excellent standards and, if we do not, where to focus and re-double our efforts to continually improve care. Staff audit feedback tells us that there is an increase in the percentage of staff feeling valued as a member of our organisation, that they are treated with dignity and respect and have a sense of belonging. Next year, the launch of our organisational values will provide a platform to further strengthen the way in which we ensure that staff who deliver your care also feel cared for themselves. This is a critical ingredient in improving the quality of the care you receive. Transforming Mental Health Services In 2015/16, we launched a consultation to transform mental health services. Our vision is for a modern, community based mental health service available 24 hours a day with Transforming Mental Health Services no waiting lists and more care delivered at home and in the community by health, social care and the third sector. We spoke to staff, service users and partners about how to provide better, more accessible services in Carmarthenshire, Ceredigion and Pembrokeshire. A multi-agency project group was set up to consider your views about mental health needs across services, age groups and sectors. Engagement events were held for staff, key stakeholders and partners, the third sector and health interest groups. Meetings were held with a range of organisations, including the three local authorities, town and community councils and public information leaflets were placed at key locations. Following an evaluation of the many comments received, options for the future service are being developed.

20 New Pembrokeshire Mental Health Facility In 2015/16, a new mental health facility in Pembrokeshire was opened to improve the experience of assessments. The new facility on St Caradog Ward at Bro Cerwyn in Haverfordwest provides a discreet area to protect dignity and confidentiality during a mental health assessment. It was a joint project with Dyfed Powys Police.

Six Projects Shortlisted at NHS Wales Awards! In 2015/16, we were shortlisted in six categories in the NHS Wales Awards and won an award for a partnership project with Dyfed Powys Police aimed at improving support at incidents for people experiencing mental distress. The ‘Working Seamlessly Across Organisations’ award recognised the way our two organisations work together to ensure vulnerable people get the assessments and assistance they need as early as possible. The project was launched to address an increase in people detained under the Mental Health Act, high use of police cells as places of safety and delays in carrying out assessments. A mental health clinician and police officer were brought together to triage 999 calls and respond to people with mental health needs to get the right help and avoid detentions. The project has now been expanded into a year-long trial working with a number of organisations, including three local authorities, the Welsh Ambulance Service NHS Trust, mental health experts, substance misuse services and the University of South Wales. Mental Health Nurse Wins National Champion Award In 2015/16, Mental Health Nurse Lisa Kinsella CPN won the National Champion Award for dedication to her vulnerable client group and contributing to mental health research. The award was presented at the Perinatal Mental Health Conference and attended by over 200 delegates. The conference provides up-to-date clinical evidence to address mental health issues that commonly occur following child birth.

21 Wales’ First Mental Health International Twinning Agreement

In 2015/16, we became one of the first UHB’s in Wales to sign a Mental Health International Twinning Agreement with Trieste Mental Health Services, one of the best in the world. Supported by the International Mental Health Collaborating Network, the agreement aims to develop quality community mental health services, share best practice and bring knowledge and skills to Wales. The event at Trinity St David University in Carmarthen also promoted opportunities for international collaboration in mental health services and hosted the first meeting of the Trieste and Hywel Dda Twinning Steering Group. Leaders and key professionals from across Wales attended the event. The mental health services in Trieste are widely recognised for their pioneering efforts in community based mental health. Improvements to Bryngolau Ward, Llanelli In 2015/16, we refurbished an older adult mental health assessment ward to improve the flow of the ward in line with best practice in dementia friendly wards. Additional Funding Received In 2015/16, additional funding enabled us to recruit dementia link and support staff to work with GP cluster groups and to increase occupational therapy time within older adult inpatient services. This development, together with a new perinatal mental health service, will improve interagency team working, maximise efficiencies and reduce variation in provision. A new mental health liaison service is being created and recruitment will take place over the next few months. Six new staff have been employed to improve access to low intensity psychological therapies and a senior clinician is also being recruited to reduce waiting times for more complex cases.

22 Perinatal Systemic Art Therapy Group This pilot service encourages expectant mothers to use art and music for positive emotional and mental health and reduce negative impact on the developing child. Extra Clinics and Nurses Improve Cancer Care In 2015/16, we improved cancer care by providing extra weekend and weekday clinics, more MacMillan clinical nurse specialists and improving partnership working with other UHBs. These actions are part of our 100-day plan which builds upon our recent achievements in improving survival rates for cancer. Its objectives include improving the number of first outpatient appointments within 10 working days, completing diagnosis and agreeing the decision to treat within 31 days, filling medical staff vacancies and appointing additional clinical nurse specialists. The appointment of new MacMillan clinical nurse specialists has been very successful in supporting patients along their individual care pathway and positive progress has also been made across a range of tumour pathways due to additional clinical nurse specialists in other specialities. We are also working in partnership with Abertawe Bro Morgannwg University Health Board and other organisations to further improve capacity for surgical and oncology treatments. In 2016, work will continue to address ongoing recruitment challenges in key specialities and to further refine complex diagnostic waiting times which involve travel across Wales for specialist investigations not available locally. New Scanner Secures Men’s Cancer Care

In 2015/16, urology consultants at Llanelli’s Prince Philip Hospital commissioned a £117,000 state-of- the-art scanner that will put our male cancer services at the top of the class. The Hitachi Hi Vision Preirius Urology scanner was purchased with funds raised by the local community. It will allow consultants to use imaging and perform targeted biopsies that have not previously been possible. The fundraising campaign was supported by Prince Philip’s League of Friends and local charities and businesses pledged their support, including Glangwili Hospital’s League of Friends, the West Wales Prostate Cancer Support Group, British Steel Pensions, Burry Port Male Voice Choir and rotary and golf clubs across the region. We also contributed £40,000. The scanner is already allowing consultants to target smaller lesions and also allows for various modules to be added, for example to perform biopsies for other urological cancers. Fundraising continues into 2016.

23 Stroke Ambassadors Act FAST In 2015/16, 20 volunteers in the ‘Act FAST, Be Stroke Aware Project’ have helped to educate people and create awareness of stroke prevention and detection across Carmarthenshire, Ceredigion and Pembrokeshire. Stroke is the fourth single largest cause of death in the UK and up to 80% are preventable. This project, jointly funded by Hywel Dda Charitable Funds, the Stroke Association and the Millennium Stadium Charitable Fund, provided a unique opportunity for a dedicated resource to recruit, train and manage volunteers into a ‘Stroke Ambassador’ role. In total, 20 people volunteered as ambassadors, some of whom have also been trained to take blood pressure measurements. With the support of a Stroke Association coordinator, the Stroke Ambassadors have helped to provide stroke information, awareness and prevention messages and give free blood pressure checks through the ‘Ask First, Know Your Blood Pressure’ and FAST Campaigns. The project has also helped local people to be more aware of the symptoms and risk factors of stroke and actions they can take. Its successes include helping the Stroke Association at 37 events providing information, lifestyle guidance and recruiting volunteers; engaging with 2,901 local people; taking 652 blood pressure measurements; encouraging 450 people to make at least one change toward a healthier lifestyle through awareness talks; and assisting the Life After Stroke Services staff with groups and events. New ‘One-Stop’ Contact Centre Reduces Waiting Times In 2015/16, we launched a new central contact centre for patients to reduce waiting times for hospital appointments and give greater choice and equality. We merged our contact centres at Glangwili, Withybush and Bronglais Hospitals into one centralised contact centre at Prince Phillip Hospital in Llanelli. The new centre will ensure that outpatient appointments can be arranged at the earliest opportunity, particularly for people with life-threatening conditions or where time is critical. By using a single dedicated telephone number, service users can arrange appointments with ease, ensuring that all outpatient clinics are fully utilised. This will increase efficiency and reduce wasted staff time and resources. In addition, patients can request a free ‘call back’ option to avoid queuing on the phone. This will speed up appointment times for people willing to travel, standardise working practices, reduce inequality and help us to meet our referral to treatment time targets. Good Progress on United4Heath United4Health is a pan-European research project which assesses the feasibility of large scale implementation of telehealth devices. We are involved in two of the three chronic disease areas, Type 2 diabetes and chronic obstructive pulmonary disease. In 2015/16, we finished recruitment and the results are being analysed so that lessons can be understood locally. This links to our strategic objectives by: • Providing a funding stream to support the deployment of telehealth as part of providing more care closer to home. • Enabling us to learn about telehealth and how to embed it into care pathways and service delivery. • Helping to rebalance the care system using clinical expertise in all care settings. • Supporting the evaluation of service redesign.

24 New Transport Services In January 2015, we created a central transport unit (CTU) to manage and coordinate internal transport bookings and non-emergency patient transport requests. This has reduced the number of taxi journeys from 2,063 to 1,796. It has also enabled more robust monitoring of internal transport, non-emergency patient transport, business mileage, video conferencing usage, bunkered fuel usage and park and ride services. The CTU has introduced a number of service improvements in 2015/16, including: • The creation of a 25 space cycle compound at Glangwili Hospital. • The introduction of a pool car scheme for staff. • The development of Glangwili Hospital park and ride service in partnership with Carmarthenshire County Council. • The implementation of the volunteer drivers scheme for both internal transport and non emergency patient transport. • The extension of the Blood Bikes Wales service to cover both Withybush and Bronglais Hospitals. • The completion of site travel plans for all acute and community hospital sites. It has also taken the lead for car parking across our UHB with a specific focus on traffic flow and parking capacity at Glangwili and Bronglais Hospitals to improve site access for patients, visitors and staff. Award-Winning Patient Experience Project In 2015/16, we continued to integrate patient stories into everything we do to ensure that patient voices inform what we do. Our Patient Experience Manager, Anna Tee, won the Patient Experience Manager of the Year award from a national network. The Big Thank You scheme was also a finalist in the Kate Granger Compassionate Care Awards. This scheme makes it easy for patients to give feedback to staff who have made a difference to their experience by using our website, WiFi homepages and postcards at hospital receptions. Staff also receive a personal thank you letter from our Director of Nursing and Patient Experience. We have further developed our online feedback pages and the principles of appreciative inquiry, which explore how to feed back to staff in a balanced way so that they can learn from best practice, have been included as a Bevan Commission Exemplar project. We have also had agreement to pilot the Friends and Family Test.

25 Hywel Dda Health Charities Hywel Dda Health Charities is a registered charity which supports patients, staff and services across our UHB. It makes a difference to the thousands of people we care for across Carmarthenshire, Ceredigion, Pembrokeshire and beyond each year. The continued generosity of patients, their families and our local communities enables us to direct our charitable donations to support a wide range of services and activities, above what the NHS can provide, for the benefit of our patients.

Our Income The total income in 2015/16 was £947,873:

Investment Income £211,298

Donations £510,243

Legacies £226,332

Our Expenditure Hywel Dda Health Charities is principally a grant making body, providing grants to our UHB as a contribution to the cost of providing healthcare and adding value to what the NHS provides. By working closely with us, they are able to use generous donations to provide invaluable support on patient focused expenditure. During 2015/16, expenditure on charitable activities was £889,749, supporting a wide range of charitable and health related activities across our UHB:

Patient Staff Building & Education Education Refurbishment & Welfare & Welfare £55,066 £23,124 £7,521

Miscellaneous £73,066

Office & Medical & Computer Surgical Equipment Equipment £73,839 £560,975 Support Costs £96,158

Full details of the charity’s activities are available in the Hywel Dda Health Charities Annual Report and Accounts 2015/16 which is available here: http://www.hywelddahealthcharities.org.uk/publications

26 Welsh Language We believe in treating Welsh and English languages on the basis of equality. We work to provide services that satisfy the needs of Welsh speakers so they can receive the care that meets their needs in their own language. We work with staff so that they consider the Welsh language as a core component of care, not an optional extra. We aim to comply with our own Welsh Language Scheme which will soon be replaced by the Welsh Language Standards. Key developments in 2015/16 include: • Welsh language awareness training is a key part of the induction programme so all new staff are aware of their responsibilities with Welsh language. • Bilingual Costa coffee shops at our hospital sites – the first of its kind in Wales. Key priorities for the coming year are: • To continue to progress the four stages of the bilingual skills strategy and ensure that more departments implement it. • To continue to implement, monitor and report on the Welsh Government’s strategic framework ‘More Than Just Words’ and build ownership so that Welsh language officers are not solely responsible for its delivery. • To improve further by delivering the active offer concept so that the public do not need to ask for Welsh services and they are automatically provided. • To play a proactive role in implementing the recommendations of the Welsh Language Commissioner’s primary care report. • To prepare for the new Welsh Language Standards so that we continue to provide the best possible service to our bilingual population. Welsh Language Winners In 2015/16, we won two awards in the Welsh Language in Health Care Awards which acknowledges innovative Welsh language services. Our Children and Adolescent Mental Health Service won an award for an innovative project called ‘Getting the Lowdown Wales: An Emotional Wellbeing Resource’ which is unique to our UHB. The project provides education and health teachers and college facilitators with tools to educate young people about mental health and emotional well being. It includes a bilingual DVD with materials to use with young people from 5-18 years old. Teifi GP Surgery in Llandysul also won an award for their innovative practice responding to patients’ need for a bilingual service. To build on their Welsh language provision, they record patients’ language choice and send all patient correspondence in their language of choice.

27 Equality, Diversity and Human Rights We recognise that people’s individual experience of equality varies. We believe that people should not be disadvantaged because of their age, disability, religion/belief, gender, race, sexual orientation, gender reassignment status, by being married or in a civil partnership, being pregnant or raising a family and aim to be accessible and inclusive for all. During 2015/16, we continued working towards delivering patient-centred care and providing more inclusive environments for both staff and service users. Examples are in our Equality and Diversity Annual Report 2016: http://www.wales.nhs.uk/sitesplus/862/page/61233. Our report covering April 2015 to March 2016 will be published by March 2017. This year we undertook a joint multi-agency public and staff engagement exercise across Dyfed Powys to find out what should be our focus over the next four years in seeking to better meet the needs of our increasingly diverse communities, both as a service provider and employer. Our Strategic Equality Objectives for 2016-2020 can be found here: http://www.wales.nhs.uk/sitesplus/862/page/61233 Increasing collaborative work with partner organisation across all sectors, further engagement with staff and service users and expert advice from specialist organisations continue to be key to achieving our aims of celebrating diversity and embracing inclusivity.

28 5. Improving Health and Wellbeing

Tobacco Control During 2015-16, we expanded the in-hospital smoking cessation service provided in Carmarthenshire hospital sites to Withybush and Bronglais Hospitals. The pharmacy level 3 smoking cessation scheme also expanded, with a 50% increase in the number of providers compared to the same period last year. We also implemented a smoking in pregnancy improvement programme which includes brief advice and carbon monoxide training to the opt- out referral pathway for pregnant women who smoke. To support our smoke free sites policy, a ‘Push the Button’ scheme has been launched. This involves a PA announcement system that plays messages recorded by local children to anyone seen smoking near hospital entrances to remind them that hospitals are smoke free and ask them to extinguish their cigarette. The system is activated by a red push button located just inside the hospital entrance, enabling anyone who has just walked past a smoker to press the button anonymously. Immunisations and Vaccinations In 2015/16, flu vaccination rates amongst healthcare staff increased significantly due to a significant effort from a range of teams including occupational health, infection prevention and public health. Whilst vaccination rates at age 1 have fallen slightly compared with last year, the uptake remains above the Welsh Government’s target of 95%. New delivery models developed through a pilot of a team of part-time immunisation staff and the commitments of the Healthy Child Wales and Flying Start Programmes should improve uptake further. Overweight and Obesity The Child Measurement Programme official statistics released in May 2016 show that over the last three years, there appears to have been a significant increase in overweight or obesity in reception years from 26.4% in 2012/13 to 30.1% in 2014/15. Midwife training in ‘Making Every Contact Count – Eating for 1: Healthy for 2’ increases staff competency, skills, knowledge and confidence to support behaviour change in pregnant women and their families to improve their health and wellbeing. Working with the three local authorities, we have funded, developed and agreed a service delivery model and specification for a new National Exercise Referral Service (NERS) in Pregnancy Service – ‘Baby Let’s Move’. Increasing the Uptake of Bowel Screening In 2015/16, our Public Health team carried out a patient engagement project to explore barriers to, and increase uptake of, bowel screening invitations. This was conducted with the three local authorities’ health and well-being managers, the over-50 fora, the unity gypsy and traveller programme, the three county voluntary councils and third sector agencies that have daily contact with the target population. Conversations were held with 638 individuals to collect views about the bowel screening kit process and to discuss ideas to improve uptake. We reported recommendations for improving the programme to Bowel Screening Wales.

29 New Quit Smoking Initiative In 2015/16, we launched a new initiative to help people quit smoking. Local community pharmacies across Ceredigion, Carmarthenshire and Pembrokeshire took part in ‘iQUIT’, a service offering support to help people stop smoking. It also provides advice on how to deal with cravings, change habits and offers nicotine replacement therapy. This scheme adds to the range of support already available. The iQUIT service will contribute towards our targets to reduce smoking rates across our area. Award-Winning Beat Flu Campaign In 2015/16, we won the third annual national Flu Fighter Cymru awards which reward individuals and teams who reach the highest flu vaccination uptake of frontline healthcare staff in Wales. Our staff won the most innovative campaign after creating bespoke materials using real life flu advocates, along with powerful and emotive images. The campaign raised awareness by using messages that appealed to staff professionalism and focused on patient protection and infection prevention. Innovative Weight Management Service In 2015/16, a new weight management service was set up in Ceredigion to help people to reduce their weight. The service is run by our dietetics department and uses a behaviour change technique called motivational interviewing and patient-centred counselling to encourage people to change their behaviour. Identical services are also delivered in Carmarthenshire and Pembrokeshire. This specialist service provides weekly one-to-one clinics in Cardigan, Aberystwyth, Aberaeron and Tregaron, with specialist weight management groups held alongside the ‘Foodwise for Life’ groups, an eight week structured programme designed to reduce weight. The sessions provide basic nutritional knowledge to help patients to make informed choices about eating to aid weight loss. They also help people with musculo-skeletal problems such as arthritis or other weight health issues.

30 National Award for Diabetes Programme

In 2015/16, we won a national award for improving the quality of life of people living with Type 2 diabetes. We achieved first place for the best average rate of diabetes programme completers at the prestigious X-PERT Health National Audit Awards. X-PERT is a programme which increases knowledge, skills and understanding of diabetes and helps individuals to make choices to manage their blood glucose levels. This award recognised the number of programmes we delivered, the attendance and the number of participants per session. We also won second place in the highest participant empowerment and satisfaction category, evidence that we are leading the way in high- quality programmes for people living with diabetes. Our Consultant Becomes UK Diabetes Champion In 2015/16, one of our consultants became one of only 20 diabetes champions in the UK after a national search for experts by charity Diabetes UK. Dr Sam Rice, Consultant Physician and Endocrinologist in Glangwili and Prince Philip Hospitals, was chosen as a Local Clinical Champion to improve diabetes care nationally and locally. He is working with healthcare commissioners and providers at all levels to improve the quality and consistency of diabetes services. His role will enhance work already taking place including integrating services, educating patients, sharing good practice and networking locally and nationally. Public Health Annual Report Our Public Health Annual Report 2015/16 provides further detail on the actions we have taken to improve the health and wellbeing of our local communities and is available here: http://www.wales.nhs.uk/sitesplus/862/page/62040

31 Other Achievements • A new, integrated breathe easy group was set up Ceredigion to help people to manage long term lung conditions. Working with the British Lung Foundation Wales, this group provides support, advice and information to maintain health. • Our Paediatric Diabetes teams became part of the Children and Young People’s Wales Diabetes Network (and Brecon Group) to improve care for children and young people diagnosed with diabetes. This will play a key role in the implementation of the Welsh Government’s diabetes delivery plan. • Our staff played a key role in developing an educational programme to help children and young people understand their condition and how best to manage it. The programme will be tested across Wales later this year. • Dementia patients across Pembrokeshire benefitted from tactile cushions sewn by the Women’s Institute to provide exercise for their hands. The cushions offer sensory stimulation which alleviates agitation, improves sleep quality and prompts happy memories. • In 2015/16, the children’s flu vaccine programme was extended to include five and six year olds so all children between two and six years- old are now eligible.

32 6. Involving Local People, Partners and Communities

Sgwrs Iach – Let’s Talk Health We have a statutory duty to continuously engage and consult around any changes to health services. In 2015/16, we improved our engagement processes with Sgwrs Iach – Let’s Talk Health, regular engagement events delivered in partnership with the Community Health Council. Twenty-four Let’s Talk Health events took place and provided individuals and local communities with an interest in their local NHS with opportunities to have their say, find out how our services currently work and what changes we propose to improve these services. Updates, future meeting dates and feedback are available online at www.hywelddahb.wales.nhs.uk/letstalkhealth Co-production Public and patient engagement focuses on how we engage, involve, inform and communicate with our stakeholders, including local people, staff, statutory agencies, Hywel Dda Community Health Council, the third sector and others. Integral to any engagement work is the commitment to equality, diversity and the Welsh Language. We are committed to co-production and participatory decision making, underpinned by an ethos of openness, honesty and clear communication. The Transforming Mental Health Services engagement work offers an example of best practice. Siarad Iechyd/Talking Health Siarad Iechyd The Siarad Iechyd/Talking Health involvement and engagement scheme continues to provide Siarad. Gwrando. Gwneud. members with up-to-date information and opportunities to shape health services. We have Talking Health over 1,000 members and are keen to recruit more. For further information, or to join up, Speak. Listen. Act. please visit www.talkinghealth.wales.nhs.uk, telephone 01554 899056 or write to Freepost, Hywel Dda University Health Board. Success for Health Volunteers Our Volunteering for Health service aims to improve healthcare experiences for our patients. Our volunteers act mainly as patient friends on wards and meet and greeters at hospital receptions but we do have interesting roles on children and maternity wards, in A&E, intensive care, stroke rehabilitation and pharmacy, as diabetes education meet and greeters and some administration volunteers. In 2015/16, we developed additional roles such as outpatient guides in Glangwili hospital and worked with other departments, such as the chaplaincy department and central transport unit, to develop volunteer roles. This year, 123 volunteers started with us. Of these, we employed 12, six went on to university to study medicine, 12 to study nursing, two to study midwifery, seven to study other courses and 11 moved on to other employment.

33 We also worked with third sector organisations to help recruit hospital volunteers for roles with MacMillan Cancer Information Service, Royal Voluntary Service and some hospital radio stations. Volunteering is a great way for people to experience a career in health and can enable people to give something back. If you are interested in being a volunteer or would like to find out more, please contact: Volunteering for Health Service, Hywel Dda University Health Board, 1 Penlan Road, Carmarthenshire SA16 OBB. Support for our Carers We have over 40,000 carers who provide an invaluable contribution to health and social care services. The delivery of a wide range of support for our carers is part of a partnership approach with the three local authorities, third sector organisations and carers groups. Welsh Government also contributes funding to this work. In 2015/16, our successes include the delivery of information and advice services to nearly 10,000 registered carers in our area allowing us to provide assistance specific to their needs and the Investors in Carers programme within primary care. One of our challenges is the ‘hidden’ carer population and we are working closely with our partners to address this through events such as Carers’ Awareness Week. Another challenge is changing from the Carers’ Measure to the new Social Services and Wellbeing (Wales) Act 2014 and work has started on a population needs assessment. Increase in Investors in Carers The Investors in Carers scheme continues to be applied by all our GP surgeries and other health settings in our region. In 2015/16, we are pleased to report that: • 98% of our surgeries have gained the Bronze level standard. There is clear evidence all are supporting carers in a number of different ways. • Three surgeries have achieved the more advanced Silver level and a number of GP surgeries are working towards it. This level requires new and more in-depth ways of supporting carers. • Nine community pharmacies have gained their Bronze level with a further 10 engaging with the scheme. • South Pembrokeshire Hospital Health and Social Care Resource Centre has achieved Bronze level with Cardigan Hospital outpatients and Tregaron Hospital engaging with the scheme. • All areas in older adult mental health are either at the Bronze level or working towards it. Other areas in mental Health, including S-CAMHS, are also working on the scheme. • The scheme has been developed for secondary schools with three achieving Bronze level and others engaging in the scheme. • The scheme has been developed for other settings such as the ‘Team around the Family’ in Pembrokeshire, a community project and a voluntary community organisation.

34 Our Strategic Partnerships and Collaboratives In order to develop joint services, we have a number of key strategic partnerships and collaborations that support the involvement of local communities and people: • Public Service Boards, created as part of the Wellbeing of Future Generations (Wales) Act 2015, in Carmarthenshire, Pembrokeshire and Ceredigion. They aim to improve economic, social and environmental well-being in line with sustainable development principles and will undertake an assessment of local well-being and develop a well-being plan. • The University Partnership Board comprises us, Aberystwyth and Swansea Universities and the University of Wales Trinity St David. Our three year agreement aims to improve the health and well-being of local people by working together and pooling resources and ideas in areas of mutual benefit to achieve the highest standards of care, innovation, education and training. We hope this will become a national and international collaboration exemplar and it will help us to retain our University status. • The West Wales Regional Partnership Board was set up in April 2016 to implement the requirements of the Social Services and Well-being (Wales) Act 2014. Its membership is us, Pembrokeshire County Council, Carmarthenshire County Council and Ceredigion County Council and includes third sector organisations care providers, carers and people with care needs. • The Mid and West Wales Health and Social Care Collaborative has strategic responsibility for delivering health and social care integration across the region including older people’s services, modernising learning disability services, regional complex needs and transition service and regional adult safeguarding. • The South West Wales Acute Care Alliance was formed to develop the South Wales plan along with Abertawe Bro Morgannwg University Health Board, Welsh Ambulance Services Trust and Powys Teaching Health Board. • A Regional Collaboration for Health (ARCH) is health, education and science working together to improve the health, wealth, skills and wellbeing of the people of south west Wales. It is a partnership between us, Abertawe Bro Morgannwg University Health Board and Swansea University covering six local authority areas and working with social care, voluntary and other public bodies. It aims to improve healthcare through research, innovation and skills across the region and its key projects include a £60m Llanelli Wellness and Life Sciences Village, a regional specialist centre, the Swansea Bay city region/city deal proposal, a ‘Talent Bank’ further education programme for 16-18 year olds and personalised wellbeing. • Hywel Dda Community Health Council through our Executive team and the Community Health Council Strategy and Planning Committee at which strategic issues are discussed.

35 7. Valuing Our Staff

Our Organisational Values During 2015/16, we continued to develop our core values. They are due to be launched in July 2016. Staff Benefits and Rewards We offer a range of staff benefits to all staff which includes several salary sacrifice schemes plus discounts from a number of organisations. Staff Wellbeing Services We continue to support our staff through comprehensive occupational health and staff psychological wellbeing services. Support is provided to both individuals and managers. Best of Health Staff Awards

Our Best of Health Staff awards are held every year to recognise our staff who go the extra mile in delivering and developing excellent care and services. In 2015/16, we received more than 100 entries in ten categories. The overall winner at this year’s awards was the Transfer of Care and Advice Liaison Service (TOCALS) which won the Chief Executive’s Award for Overall Best Entry. To see all our winners, please visit: www.hywelddahb.wales.nhs.uk/bestofhealth Staff Recognition Scheme In January 2016, we launched our new staff recognition scheme. Monthly award certificates are presented by our Chair to say thank you to staff and teams who have been nominated by others for their outstanding and exemplary service. Between January and March 2016, we have awarded 11 certificates to valued employees.

36 Apprentices In Health

In 2015/16, our first Apprentices in Health were recognised at a celebration event to mark Adult Learner’s Week. Twenty-six of our healthcare support workers enrolled on the course. Medical Education and Training As well as commissioning and delivering services, we are a local education provider. Training and education is a central element of our function and clinical governance strategy. Appropriately trained and developed staff are needed to deliver high quality healthcare for local people. Staff are individuals with aspirations and personal development needs to provide optimum performance. Our aims are to: • Create an educational environment that nurtures and develops future doctors. • Deliver quality training standards by harmonising service and training to maximise educational opportunities within the clinical setting. • Develop a culture of educators, supporting and developing doctors as trainers. • Support the continual professional development of all doctors and dentists. Our achievements in 2015/16 include: • The implementation of the GMC accreditation process for educational supervisors and named clinical supervisors. • Introduction of the clinical fellows programme at Withybush Hospital. • Hosting the only Wales Royal College of Physician PACES examinations which test the clinical knowledge and skills of middle grade doctors training to become consultant physicians. Candidates from across the UK attended examinations with our consultant physicians involved as examiners.

37 • Refurbishing the medical education centre in Glangwili Hospital and the development of a clinical skills training area. • Introducing senior medical staff input into our clinical skills training programmes in Glangwili, Prince Philip and Bronglais Hospitals. • Withybush Hospital won the inaugural Cardiff University Paul Bradley prize for excellence in clinical skills teaching. • Improvements to the medical student accommodation in Glangwili Hospital and a move towards student only flats in Withybush Hospital. Library and Knowledge Services The Library and Knowledge Service provides a multidisciplinary service function, supporting patient care, education, research and lifelong learning. In 2015/16, they: • Successfully trialled the ClinicalKey product. • Redecorated the hospital library in Glangwili General Hospital. • Systematically reviewed and scoped telemedicine for the Mid-Wales Healthcare Collaborative. Charitable Support for Wales4Africa In December 2015, our Charitable Funds Committee created a new fund under Hywel Dda Health Charities to establish health links with sub-Saharan Africa and manage charitable donations and grant funding for this work. One of its goals is to promote and protect good health in Africa and Wales by setting up partnerships between health workers in these countries. This work addresses Millennium Development goals by harnessing NHS expertise in Wales and in sub-Saharan Africa with benefits for the NHS and staff involved. Our three projects are: • A Woman’s Journey Programme, Chongwe, Zambia looks at educational, health and environmental issues affecting a girl throughout her life course. Our immunisation and vaccination coordinator Buddug Nelson and Dr Charles Msiska, Director of Chongwe Medical Office, Chongwe, Zambia, will firstly focus on cervical cancer as the area has the third highest incidence in the world. Work is needed to educate staff, invest in screening equipment, find ways to identify and treat women and to promote HPV vaccinations to grade 4 girls in primary schools. • Health Needs Assessment, Nkhata, Malawi: We have been working with Dr. Walapu, a retired consultant in communicable disease control and formerly with Public Health Wales, to explore health service support in Nkhata, Bay South in Malawi. Malawi is a former British colony in East Southern Africa and one of the poorest countries in the world. It does not routinely collate and publish local population health data but extrapolates it from ten year census and national surveys every five to ten years. The plan is to gather, collate and analyse health and population data to build a health profile, establish a baseline for priorities and a plan for health support services. Umoyo.org, a no-profit organisation chaired by Dr. Walapu, has a grant from Hub Cymru Africa to take this forward with the University of Malawi and the District Health Management Team. • New Maternity Unit, Kachumbala Health Centre, North East Uganda: Our Head of Midwifery in Carmarthen, Julie Jenkins, and our Midwifery department continue to work with the Engineers for Overseas Development South West Wales on a project to enhance maternity facilities at the Kachumbala Health Centre in North East Uganda. Our health professionals are advising on the design and equipping of a maternity unit to be built adjacent the health centre.

38 8. Investing In Our Estates and Services

Our total capital investment in 2015/16 was £13.4m. In addition to the projects highlighted in our key achievements and developments chapter, investments from Welsh Government central funding included: • Provision of additional bed capacity at Glangwili and Bronglais Hospitals (£630,000). • Funding for Phase 2 of the replacement programme for infusion pumps (£281,000). • Funding to provide local wet acute macular degeneration clinic facilities in Pembrokeshire (£30,000). • Equipment to improve community cardiology provision (£100,000). • Additional Welsh Government funding of £0.75 million including the replacement of the mobile image intensifier at Withybush Hospital (£70,000) and early pregnancy clinic ultrasound (£84,000). • Information technology investment funding (£211,000). The key elements of the expenditure from our discretionary capital programme are:-

Carmarthenshire Replace Endoscopy Washers HSDU £520,000 Replace Neonatal Ultrasounds, Glangwili and Prince Philip Hospital £118,000 Replace Interventional Ultrasound, Glangwili Hospital £87,000 Replace Endoscopy Stack & Scopes, Glangwili Hospital £271,000 Replace Cardiology Echo Machine, Glangwili Hospital £87,000 Replace Paediatric Cardiology Echo Machine, Glangwili Hospital £87,000 Replace Hysteroscopy OPD Stack, Glangwili Hospital £60,000 Replace ENT Stack, Glangwili Hospital £78,000 Replace Oscar Theatre System, Prince Philip Hospital £51,000 Ceredigion Replace Patient Food Trolleys £16,000 Replace Catering Equipment £11,000 Pembrokeshire Replace Neonatal Ultrasounds £59,000 Replace Syringe and Infusion Pumps £66,000 Replace Catering Ovens £20,000 Additional Bariatric Bed £18,000 Upgrade of Aseptic Pharmacy £19,000 Upgrade of Sunderland Ward Kitchen SPH £80,000 Mental Health Provision of ultralow beds for Mental Health sites £79,000 Upgrade of Bryngolau Ward, Prince Philip Hospital £92,000 Community Therapy Trainer Equipment, EWC £25,000

39 Future Projects In addition to the ongoing projects highlighted in our key achievements and developments chapter, future projects include the Energy Efficiency Phase 2. Following the success of the Phase I Energy Performance Contract, we are now developing plans to further exploit energy efficiency opportunities to achieve circa £180, 000 of energy savings and circa 800 tonnes of carbon reduction per annum. The business case submission to Welsh Government is planned for August 2017.

Discretionary/Capital Projects Refurbishment & Alteration Schemes: • Gorwellion refurbishment work at Bronglais Hospital. • Disability W/C improvement works at Ferryside Health Centre. • Radiology reporting scheme at X-Ray, Prince Philip Hospital (MRI project). • Hospital sterilisation and decontamination unit centralisation at Glangwili Hospital. • Bryngolau ward improvements. • Sunderland and Glangwili Hospital ward kitchen refurbishments. • 40 space car park at Glangwili Hospital. • Additional parking at Cardigan. Charitable Funded Schemes: • Llandovery X-Ray facility and support rooms. Welsh Government Funded Schemes: • Unscheduled Care Project Phase 1, Prince Philip Hospital. • Withybush work transfer project at Glangwili Hospital. • Proposed 12 bed ward facility at Afallon, Bronglais Hospital. • Helipad sites at Glangwili and Bronglais Hospitals and in Haverfordwest. • Pharmacy aseptic works at Glangwili Hospital. • Primary care premises improvement grant at Amman Valley Hospital. • Service Increment for Teaching projects at Glangwili postgraduate, library and nurses residences. • Additional energy saving measures/street lighting at Prince Philip Hospital.

40 Property Performance Summary

Key Facts Average running cost for facilities management services is circa £151 per square metre per annum. Current backlog maintenance within the estate is £52 million (high and significant backlog maintenance totals £25 million). 61% of our estate is over 30 years old and this contains circa 80% of our overall backlog maintenance. Rationalisation programme in 2015/16 reduced the estate by 828m2 which equated to circa £96,000 capital receipts and a facilities revenue reduction of circa £60,000. Achieved a 10% reduction in carbon emissions through the Phase I energy scheme and reduced energy spend by just over £800,000 (17%).

The Estate Our estate covers circa 50 hectares across the counties of Pembrokeshire, Ceredigion and Carmarthenshire, a landmass covering a quarter of Wales. Healthcare services are provided via 55 freehold and leasehold properties which equates to a total gross floor area of 189,552m2. Estate Rationalisation Programme We continue to rationalise the estate and have achieved a reduction in estate floor area from 2012 of over 9,000m2. This has produced capital receipts totalling circa £1.4m, a reduction in rental charges of circa £325,000 and savings in facilities costs of circa £400,000. In 2015/16, the rationalisation programme delivered an estate reduction of 828 m2 which delivered circa £96,000 capital receipts and a revenue reduction of circa £60,000. Estate Compliance In 2015/16, we continued to address prioritised, high risk and significant backlog, which currently total £2,409,577 and £22,696,222 respectively, via investment from Welsh Government and discretionary capital programme funding. This was used to upgrade patient environments, replace prioritised equipment (medical and non-medical), on high risk statutory health and safety backlog, engineering, building and information technology infrastructure and supporting service developments, including the delivery of the estate rationalisation programme. A summary of discretionary capital estate allocation over the last 3 years is provided below:

Funding £000 2015/16 2014/15 2013/14 Statutory H&S 780 596 600 Refurbishment & Minor Works 655 1,146 495

To demonstrate that we are prioritising our investments in areas of greatest risk, well developed risk register and prioritisation processes are in place which support our annual application for funding from the discretionary programme.

41 Estate Performance Indicators The chart below shows our average performance against Welsh Government’s All Wales Estates Performance Indicators, as reported via the Estates, Facilities and Performance Measurement System. Overall, we are closely aligned to the all-Wales average position although we continue to target statutory compliance, physical condition and energy performance.

Estate Performance Targets 2015/16 87% 88% 92% 92% 99% 78% 100

90 Target 90% 80 70 60 50 40 30 20 10 0 Physical Statutory Fire Safety Functional Space Energy Condition and Safety Suitability Utilisation

Estate Operating Costs Comprehensive and accurate information is vital to monitor and manage the performance of our estate. Cleaning, catering and energy management represent the most significant spends. There has been a reduction in the overall facilities average premise running cost across the estate in recent years. The reduction in-year mostly reflects the saving made on energy costs. • 2015/16 – £151/m2. • 2013/14 – £156m2. • 2014/15 – £153/m2. • 2012/13 – £167m2. Operational Facilities Management Our new management structure has been in place for a year and key priorities are: • Improving the patient experience. • Ensuring the built environment is fit for purpose. • Combining all hard and soft facilities management issues within one area of responsibility. • Implementing cleanliness monitoring across the UHB in line with the National Standards for Cleaning in NHS Wales. We have developed a number of initiatives to support nursing teams to deliver improved patient experience. National Standards of Cleaning in NHS Wales utilises a monitoring system of ‘credits for cleaning’. We have invested in new technology for improved data capture which is scrutinised at local and UHB infection, prevention and control committee meetings. Stakeholders have accurate and timely information regarding the cleanliness of environments in all the patient areas. Our

42 facilities managers are represented on the national framework ensuring best current practice is delivered and introduced consistently. Microfibre technology cleaning systems have been introduced to enhance the cleanliness of the built environment and, working closely with infection, prevention and control, this approach has been standardised across all our sites. The integration of hard and soft facilities management operational staff has been built on to enhance ward cleanliness through the creation of a team approach. All staff work closely with the ward nursing team to provide a fast response to basic issues. Closer working relationships and operational practices have been implemented between mental health and hospital sites in areas of cleaning, maintenance and food service provision. Significant investment has been made in the main entrance public toilets on all our hospital sites. This has resulted in considerable environmental improvements in entrance foyers. New no smoking messages are announced at main entrances to discourage patients and visitors smoking in these areas. The use of ‘rapid-response teams’ continue to assist nurses to ensure prompt bed turnaround to minimise down time of beds. Catering Services Food Hygiene Inspections/FSA Ratings The most recent round of food hygiene inspections have been undertaken by the Department of Environmental Health in accordance with the revised Food Standards Agency Food Hygiene Rating Scheme. All of our premises have received the highest rating of 5, with the exception of Bronglais Hospital who received a score of 4. All Wales Menu Significant progress has been made with All Wales Menu Framework compliance, with three out of our four hospitals now fully compliant with in-house patient menus. Estates and Facilities Performance Management System During 2015/16, the average cost of a patient meal reduced by 25p per meal, from £4.11 per meal to £3.86 per meal. There was an overall increase of £27,000 to the non-patient catering subsidy which now stands at £315,000 per annum. Work has commenced to introduce a revised pricing structure for non-patient catering service and plans are underway to upgrade some of the staff catering facilities. Food Wastage Significant improvements have been made in terms of capturing, monitoring and reporting wastage levels. These reports are currently being scrutinised at the menu planning group and the county nutrition groups. An invitation has been received to attend a workshop on food waste management with WRAP Cymru and to work collaboratively with them to minimise food wastage. Service Developments and Service Initiatives The closure of the central production unit at Bryntirion saw a major change in the provision of patient meals at Prince Philip Hospital with the introduction of bought-in cook frozen meals from Cwm Taf University Health Board. This service change was necessary due to concerns in relation to the building infrastructure which left no option but to move off the site. The menu planning group is currently exploring ways of improving the quality of information offered to patients in regard to catering and nutrition, including the possible introduction of an electronic patient meal ordering system which will significantly reduce the time between ordering and actually receiving the meal. Additional benefits such as greater flexibility and reduced wastage levels are also anticipated from this system.

43 Quality Improvements: Hospital Sterilisation and Decontamination Unit £520,000 was invested to centralise the endoscope decontamination facility at the hospital sterilisation and decontamination unit at Glangwili Hospital. This state of the art facility can now decontaminate all flexible endoscopes and surgical instruments. Work is ongoing for this facility to become accredited to the Medical Devices Directive for the reprocessing of flexible endoscopes, which will make it the second facility to achieve this prestigious award alongside Prince Philip Hospital. A business case has also been developed to centralise endoscopy to the hospital sterilisation and decontamination unit at Withybush Hospital. This will allow the endoscopy unit to have another procedure room and all endoscopes from all areas will be processed in one area, as recommended by the Welsh Government Endoscope Audit. Welsh Government Endoscope Audit Following the Welsh Government audit of flexible endoscopes in 2014, the Health Minister requested a follow up audit to review progress made in decontamination of flexible endoscopes throughout Wales. Our audit took place in July 2016 and further significant improvements were identified in all four units. Hospital sterilisation and decontamination unit management were praised for their work in obtaining and supporting accreditation for both surgical instruments and flexible endoscopes. Medical Devices Directive 93/42 EEC All four of our hospital sterilisation and decontamination units are accredited to the above directive and undergo annual external audits by SGS UK Limited who have been supportive in highlighting areas for continual improvement as well as identifying positive achievements. In addition, the endoscope decontamination unit at Prince Philip Hospital has managed to maintain its accreditation to the Medical Devices Directive and continues to be the only unit in Wales to have achieved this. Plans are now underway to achieve compliance for the remaining three hospitals. Organisational Changes in Decontamination Structures Following an organisational change process, decontamination management structures have been reviewed and an east and west structure developed. This has resulted in significant efficiency savings allowing substantial reinvestment into quality improvement measures in this service. Health and Safety and Security Following our corporate governance review, responsibility for health and safety and security management have been transferred from the Executive Director of Nursing, Quality and Patient Experience to the Deputy Chief Executive/Director of Operations. Since October 2015, line management arrangements for health and safety and security have come under the Director of Estates, Facilities and Capital Management.

44 Health and Safety and Emergency Planning Sub Committee The above sub-committee has been established to provide assurance about compliance with health and safety and security management. It reports to the Business Planning and Performance Assurance Committee. Its purpose is to provide assurance for the health, safety, welfare and security of all employees and of those who may be affected by work-related activities, such as patients, members of the public, volunteers and contractors. The health and safety and security team have developed a priority action plan that highlights significant health and safety risks covering eight strategic topics, namely health and safety management arrangements, violence and aggression, manual handling, health issues, environment safety and patient health and safety issues, fire safety management, health and safety estates management and sharps safety. Each of these areas has individual work activity aimed at reducing the risk of harm to staff and others. The Health and Safety and Emergency Planning Sub-Committee scrutinises progress. Case Management Violence and aggression towards staff continues to be a concern with incidents increasing year on year. Staff are supported by the security and case manager and health and safety managers when incidents do occur. This has resulted in the team providing assistance when having to speak directly to aggressive patients or family members who have assaulted our staff. Collaboration and improved partnership working with Dyfed Powys Police has taken place during the year and this will be continued throughout 2016 with the establishment of regional liaison meetings. Prevent Strategy In relation to the Government’s strategy on counter terrorism, the health and safety team have represented us at local authority CONTEST and Channel Panel meetings. This will be strengthened during 2016 with colleagues from mental health and learning disabilities and safeguarding taking an active role in ensuring we discharge our duties effectively.

45 9. Our Performance Report

Performance Overview The NHS Finance (Wales) Act 2014 requires us to prepare a plan which sets out our strategy for complying with the three year financial duty to breakeven. Our Integrated Medium Term Plan (IMTP) cannot yet evidence financial balance and must therefore be considered in terms of the strategic direction it signals and as an interim position pending further work locally and with Welsh Government to bridge the financial gap. During 2015/16, in the absence of a Welsh Government approved IMTP and as advised by them, we worked to a Board approved Operational Plan. In the main, our Operational Plan for 2015/16 was drawn from the Integrated Medium Term Plan 2015/16 to 2017/18 already approved by the Board in terms of our strategic path of travel, albeit as interim as it was unapproved by Welsh Government. The Operational Plan 2015/16 reflected the strategic direction established in the Integrated Medium Term Plan, in particular the work which has continued since its production, namely:- • Planning for workforce stabilisation. • Integrated performance reporting. • Capital planning. • Prioritisation of ministerial allocation to community and primary care initiatives. In addition, we have also been supported by the Welsh Government Delivery Unit to achieve robust demand and capacity plans which are reflected in our quarterly activity performance projections for the referral to treatment Tier 1 Ministerial targets. Progress was constantly monitored through the Business Planning and Performance Assurance Committee and the Board via the Integrated Performance Report which is in the public domain and accessible on our website. The draft IMTP for 2016/17 – 2018/19, approved at the January 2016 Board meeting, was submitted to Welsh Government as required with scrutiny and discussions ongoing since the submission. The plan has been strengthened as intended and also informed through feedback and dialogue with Welsh Government. Welsh Government has acknowledged the work undertaken to strengthen the plan across performance, workforce and finance including ambitious savings targets. It is now more action focused including more detailed work programmes and ambition for our ten strategic objectives and the key challenges we face. Although feedback noted the increased confidence in our recruitment strategies, concern remains regarding the challenges within the primary care workforce. The feedback also remarked on further work required to develop the plan including working with Welsh Government to establish clear timelines for stabilising and redesigning our systems to produce a sustainable model for the future. On this basis, it was agreed the plan submitted to Welsh Government by the 31st March 2016 would be a work in progress and therefore an interim rather than a formally approved plan, pending further work with Welsh Government, particularly regarding the financial trajectories over the period of this plan.

46 Performance Outcomes The NHS Outcome Framework, launched in April 2015, aims to ensure that the health and wellbeing of people living in Wales is improved. The framework provides an annual view of the impact health services are having on improving population outcomes and is supported by a delivery framework. The Outcomes Framework seven domains are listed below.

The Outcomes Framework’s Seven Domains

Staying Healthy People in Wales are well informed and supported to manage their own health.

Safe Care People in Wales are protected from harm and protect themselves from known harm.

Effective Care People in Wales receive the right care and support as locally as possible and are enabled to contribute to making that care successful.

Dignified Care People in Wales are treated with dignity and respect and treat others the same.

Timely Care People in Wales have timely access to services based on clinical need and are actively involved in decisions about their care.

Individual Care People in Wales are treated as individuals with their own needs and responsibilities.

Our Staff and Resources People in Wales can find information about how their NHS is resourced and make careful use of them.

47 Detailed performance reports are reported routinely to every Board meeting and are also available on the Board’s website. The following table demonstrates performance overall has improved:

Improved Sustained Decline in TARGET performance performance performance SUMMARY

STAYING HEALTHY – I am well informed and supported to manage 9 measures 0 measures 10 measures my own physical and mental health.

SAFE CARE – I am protected from harm and protect myself from 6 measures 2 measures 3 measures known harm.

EFFECTIVE CARE – I am receive the right care and support as locally as 6 measures 0 measures 3 measure possible and I contribute to making that care successful.

DIGNIFIED CARE – I am treated with dignity and respect and treat 0 measures 0 measures 1 measures others the same.

TIMELY CARE – I have timely access to services based on clinical need 9 measures 1 measure 7 measures and am actively involved in decisions about my care.

INDIVIDUAL CARE – I am treated as an individual, with my own needs 2 measures 1 measure 2 measures and responsibilities.

OUR STAFF AND RESOURCES – I am can find information about how their NHS is open and transparent on 3 measures 0 measures 1 measure use of resources and I can make careful use of them.

SUMMARY 35 measures 4 measures 27 measures

Within the Staying Healthy domain, we have achieved the required reduction in readmissions for the basket of eight chronic conditions and witnessed an improving trend for residents making a smoking quit attempt. We are aiming however to improve our influenza uptake and childhood vaccination rates for one and two year olds. For Safe Care, we have witnessed an improving trend for non-mental health delayed transfers of care but not for mental health patients. Demand for older adult mental health is impacting upon the increase in delays and work to strengthen the specialist care home sector is ongoing. Also during the year, there was an increase in the rate of Clostridium difficile infection and a reduction in the rate of MRSA blood stream infections. In order to improve, we are reinforcing health promotion and infection prevention in the community and primary care.

48 Within Effective Care, clinical coding of consultant episodes has been a challenge due to vacancies. However, performance for both mortality metrics has improved. Performance has deteriorated for short notice procedure postponements which are reported within the domain of Dignified Care; however an improvement plan is now in place. Whilst not achieving all the required targets that sit within the Timely Care domain, there have been successes. We met our eight week diagnostic target along with the red call ambulance response rate to life threatening conditions. Whilst not achieving the ambulance handover and A&E targets, the Board has developed an unscheduled care programme to review all aspects of the emergency care pathway from primary care and ambulance arrivals through to discharge. At the end of March 2016, there were a number of patients who were not treated within the Welsh Government’s 36 week target and the majority of these patients were in orthopaedics. The Board has witnessed an improving performance trend for the 62 day urgent suspected cancer waiting time target. Performance remains below the 95% target but was affected by a variety of capacity pressures. Non urgent suspected cancer performance has deteriorated slightly over the year. However the 98% target was achieved on four months and narrowly missed on a further five occasions. The Board’s performance against the Welsh Government stroke quality improvement measures has shown an improving trend for three of the four measures. A stroke delivery plan is now in place which details actions required to deliver further improvements. Two of the five mental health measures noted within Individual Care have shown an improvement trend over the 12 month period and one has remained static. As a result of a significant recruitment campaign we are already witnessing improvements in all areas. Workforce and sickness absence measures noted within Staff and Resources have shown an improving trend over the year along with new and follow up outpatient DNA rates. Early indications are that during 2015/16 the noted performance appraisal downward trend has reversed. Our Delivery against Finance and Workforce Plans We continued to experience significant financial challenges in 2015/16. Our year end deficit was £31.199m. This was more than was planned for in the Integrated Medium Term Plan (IMTP) of £25.569m but an improvement on the mid-year forecast of £41m. The forecast reflected the unprecedented pressures seen during the year in unscheduled care, particularly in Withybush Hospital and staff recruitment challenges. The £31.199m deficit was achieved after Welsh Government allocations in support of Withybush Hospital contingency measures (£5.690m), contributions to achieve waiting time performance targets (£3.5m) and full additional mental health funding (£1.3m) for 2015/16. We experienced significant workforce recruitment pressures during 2015/16 which resulted in considerable variable pay costs. This was exacerbated by the medical staffing pressures in Withybush Hospital seen after the Wales Deanery was unable to allocate core medical trainees for the August 2015 start. We put alternative solutions in place to ensure that the number of medical beds at Withybush Hospital reflected the number of doctors available, whilst also keeping the medical intake and doors to the Emergency and Urgent Care Centre open. This led to an unplanned service position not accounted for in the IMTP, so that other hospitals in Hywel Dda have needed to open medical bed capacity in order to receive acute medical patients from Pembrokeshire, where capacity reduced. We kept Welsh Government fully informed of the exceptional pressures we have been experiencing and, in acknowledgement of these issues, Welsh Government provided additional financial support. As well as the medical staffing pressures, we also saw significant nursing challenges both for registered and non registered nurses. In headline terms, average monthly variable pay (classified as

49 agency, locum, bank and overtime) increased from £1.195m per month in 2013/14 to £1.844m in 2014/15. On average in 2015/16, this increased to £3.260m per month, with the March 2016 costs being £5.203m. Our total variable pay bill last year was £39.121m (£17m more than the previous year; 11.1% of the total pay bill). The biggest element of this increase related to nurses required to cover both substantive vacancies and sicker patients requiring one to one nursing ratios including in our mental health service. The substantial increase in cost reflected both the increased usage but also our inability to obtain services from agencies on an approved procurement agreement, leading us to use more expensive off-contract agencies in order to maintain our required staffing complement. These workforce pressures severely hampered our ability to deliver savings in 2015/16 with actual achievement of £8.571m against a target of £24.5m. Consequently, developing innovative recruitment measures remains one of our key objectives for 2016/17. We are innovating recruitment techniques by focusing on the different components i.e. nursing/ agency spend and systems improvement, medical and recruitment. We have offered over 170 nursing posts to overseas staff together with appointing newly qualified nurses and our normal recruitment levels. There is a lead in time for the overseas nurses, most expected to take up post in the autumn/winter. In the meantime, the focus is on increasing our use of on-contract agencies and reducing, ideally eliminating, our use of non-registered nurse agency by bank recruitment. Whilst this will take time, we are confident that we will see a significant reduction in nursing variable pay in 2016/17. Medical recruitment is more challenging as we try to recruit to specialties where there are national shortages but we are looking at alternatives to the traditional routes taken e.g. by developing links with overseas universities and promoting Hywel Dda as an employer of choice. During the year, we invested in services to achieve performance targets but much of the investment in 2015/16 was directed at addressing the unscheduled care pressures, both in the short term and by developing more sustainable service models for the future. This also included a significant element of the £13.3m capital investment in 2015/16 that supported both the Front of House Schemes in Bronglais and Prince Philip hospitals. We are projecting a deficit of £38.3m for 2016/17. As was the case in 2015/16, we have not reflected the £7.475m 2014/15 deficit and £31.199m 2015/16 deficit repayment, pending agreement with Welsh Government on the impact and timing of this on the remaining year of the three year rolling breakeven duty. We continue to work with Welsh Government to agree the steps required to achieve the aim for Hywel Dda to ultimately have an approved three year plan. Our 2016/17 draft annual Operational Plan was agreed by the Board on 2 June 2016 subject to the sign off of the interim IMTP.

50 Our Performance Analysis Domain 1: Staying Healthy

Chronic Conditions

Staying Healthy Trend Jul-15 Target Oct-15 Apr-15 Jan-16 Mar-15 Jun-15 Feb-16 Sep-15 Dec-15 Nov-15 Aug-15 May-15

Rate of emergency hospital admissions within a year for a basket of 8 chronic 1259 1277 1273 1273 1276 1288 1275 1268 1248 1219 1203 1184 conditions per 100,000 of the population. Reduce over 12 Rate of emergency month hospital Trend readmissions within a year for a basket 256 254 252 252 254 258 257 252 243 239 233 231 of 8 chronic conditions per 100,000 of the population

How are we doing? Both chronic condition measures have shown an improvement trend over the 12 month period.

Uptake of National Influenza Vaccine

Target 2013/14 2014/15 Staying Healthy Trend

65.5 64.9 Over 65 years of age 75

Under 65 years of 47.5 46.2 % uptake of 75 the national age in at risk groups influenza for the following 39.7 42.9 groups Pregnant women 75

41.2 34.8 Healthcare workers 50

*Validated 2015/16 influenza vaccination data not yet released

How are we doing? We are making similar progress to date compared to the previous year’s vaccine uptake in the over 65 age group and the under 65’s in our area. Uptake rates in pregnant women have improved. Flu vaccination uptake amongst staff requires further improvement.

How will we deliver? Our seasonal influenza plans have been updated based on the recommendations from flu debriefing meetings. The focus is on increasing vaccination rates with healthcare staff through robust monitoring of data flow and bespoke communication materials with renewed emphasis on recruitment and deployment of flu champions within the workforce.

When will we deliver? We are striving to improve our performance for the 2015/16 campaign.

Uptake of National Childhood Scheduled Vaccinations

Q1 Q2 Q3 Q4 Staying Healthy Target (2015/16) (2015/16) (2015/16) (2015/16) Trend

% uptake of 5 in 1 vaccine 95% 96.5 95.5 97.3 95.5 at age 1

% uptake of MenC vaccine 95% 97.7 97.2 98.1 96.6 at age 1

% uptake of MMR1 vaccine 95% 94.4 93.5 93.6 93.5 at age 2

% uptake of PCV vaccine 95% 95.1 94.0 94.3 94.0 at age 2

% uptake of HibMenC 95% 93.8 93.9 93.6 93.6 booster vaccine at age 2 * MenC - Meningococcal C conjugate vaccine; MMR -Measles, Mumps and Rubella Vaccine; PCV – Pneumococcal Conjugate Vaccine; Hib/MenC – Haemophilus Influenzae Type B/Meningococcal Serogroup C Vaccine

How are we doing? Vaccination rates for 1 year-olds has fallen slightly in 2015/16 although the uptake remains above the Welsh Government’s target of 95%.

How will we deliver? We will increase access to clinics for service users through a targeted communication plan, explore new models of immunisation through the ‘Healthy Child

Wales’ and ‘Flying Start’ programmes and implement a primary care immunisation plan.

When will we deliver? We will work with our local immunisation leads to improve uptake annually.

% of Reception Class Children age 4/5 as Overweight or Obese

2013/14 2014/15 Staying Healthy Target Trend % % of reception class children age 4/5 as Reduce over 12 28.3 30.1 overweight or obese (annual measure) month trend

How are we doing? The Child Measurement Programme official statistics released in May 2016 show that across the last three years there has been a significant increase in the prevalence of overweight or obesity in reception year in Hywel Dda UHB.

How will we deliver? We will fund, monitor and evaluate the National Exercise on Referral Scheme for the obese pregnant women ‘Baby Let’s Move’ service. The Beaufort Research will be used to develop training resources for primary care professionals and support the Healthy Schools and Pre-School Schemes, Flying Start and Communities First.

When will we deliver? We will see a reduction over the next three to five year period.

Smoking Cessation Services

2014/15 2015/16 Trend Staying Healthy Target (Q1-Q3) (Q1-Q3)

% % of estimated LHB smoking population 5% 1.1% 1.5% treated by NHS smoking cessation services. % of smokers treated by NHS smoking cessation services who are CO-validated as 40% 48.6% 49.8% successful.

How are we doing? We have improved our performance compared to last year for both measures.

My Health Online

Staying Healthy Jul-15 Oct-15 Oct-15 Apr-15 Apr-15 Jan-16 Jun-15 Jun-15 Feb-16 Mar-16 Sep-15 Sep-15 Dec-15 Nov-15 Nov-15 May-15 May-15 Aug-15 Trend Target Target % Of those Practices set up to use MHOL, % who are 14.8 14.8 14.8 14.8 22.2 22.2 22.2 24.1 31.5 31.5 35.2 35.2 offering appointment bookings Improve Of those practices set up to use MHOL, % who are 29.6 29.6 29.6 29.6 44.4 44.4 44.4 51.9 55.6 55.6 59.3 59.3 offering repeat prescriptions

How are we doing? We see an increasing level of service offered to local people through GP practices.

Helplines

Staying Q1 Q2 Q3 Q4 Target Trend Healthy 2015/16 2015/16 2015/16 2015/16

Number of mental health 648 799 803 626 calls to the 'CALL' helpline Number of calls relating to dementia to 8 15 13 10 the 'Dementia' Improve helpline Number of calls relating to drugs and 97 113 77 115 alcohol to the 'DAN 24/7' helpline

How are we doing? In 2015-16, 2,876 contacts were made to the CALL helpline from our area. There was a fall in the number of contacts in quarter four.

How will we deliver? We will identify opportunities to promote relevant helplines.

When will we deliver? An increase in contacts to call lines should be realised from quarter three in 2016 onwards.

Domain 2: Safe Care

Delayed Transfers of Care: Non- Mental Health

Safe Care Trend Trend Jul-15 Jul-15 Target Target Oct-15 Oct-15 Apr-15 Apr-15 Jan-16 Jun-15 Jun-15 Feb-16 Mar-16 Sep-15 Sep-15 Dec-15 Nov-15 Nov-15 May-15 May-15 Aug-15

DTOC per 10,000 LHB population - Reduce non mental health over 12 61.0 57.7 56.9 59.2 57.7 54.9 49.9 51.9 53.7 56.9 58.7 63.5 (aged 75+) - month rolling 12 month trend period

How are we doing? Non-mental health delayed transfers of care have shown an improvement trend over the 12 month period.

Delayed Transfers of Care: Mental Health

Safe Care Trend Trend Jul-15 Jul-15 Target Target Oct-15 Oct-15 Apr-15 Apr-15 Jan-16 Jun-15 Jun-15 Feb-16 Mar-16 Sep-15 Sep-15 Dec-15 Nov-15 Nov-15 May-15 May-15 Aug-15

Rate of mental health delayed Reduce transfers of care over 12 per 10,000 of 3.8 3.7 3.7 3.6 3.8 3.8 3.8 3.8 3.9 3.9 3.9 4.2 month Local Authority trend population (all ages)

How are we doing? Mental health delayed transfers of care performance has deteriorated over the year.

How will we deliver? An issue in relation to availability of medium secure beds has been escalated to Welsh Government and Welsh Health Specialised Services Committee. Further work is underway to improve the private sector provision for people with a learning disability and behaviours that challenge.

When will we deliver? The continued high level of delayed transfers of care for older adult mental health patients is driving this trend and work to strengthen the specialist care home sector is ongoing.

Healthcare Acquired Infections: Clostridium Difficile and MRSA

Safe Care Trend Jul-15 Oct-15 Apr-15 Jan-16 Jun-15 Feb-16 Mar-16 Sep-15 Dec-15 Nov-15 Aug-15 May-15

Rate of C difficile infection per 100,000 54.01 49.19 47.66 70.72 46.12 47.66 49.19 6.35 15.37 21.52 19.72 43.05 population

Rate of MRSA blood stream infection per 6.35 3.07 3.18 3.07 3.07 0.00 0.00 0.00 3.07 6.15 6.57 6.15 100,000 population

How are we doing? During the year, there was an increase in the rate of Clostridium difficile infection and a reduction in the rate of MRSA blood stream infections.

How will we deliver? In addition to identifying the avoidable infections that arise in hospital, we are also reinforcing health promotion and infection prevention in the community and primary care. The root cause of Clostridium difficile infection is antibiotic usage thus our focus is implementing the Antimicrobial Delivery Plan for Wales to eliminate inappropriate antibiotic use.

When will we deliver? The infection reduction expectation for UHBs in Wales has now been revised with a retained focus on Clostridium difficile and expansion of the Staphylococcus aureus (S.aureus) blood stream infections to include Meticillin Sensitive S. aureus (MSSA).

Pressure Sores

Safe Care Trend Jul-15 Target Oct-15 Apr-15 Jan-16 Jun-15 Feb-16 Mar-16 Sep-15 Dec-15 Nov-15 Aug-15 May-15

Number of healthcare Reduce 10 16 11 9 14 12 18 15 14 14 16 20 acquired pressure ulcers

How are we doing? During the period April 2015 to March 2016, we saw a 6% reduction on the overall number of hospital acquired pressure ulcers. However, our performance in the second half of the period showed an increase in the number of pressure ulcers being reported each month.

How will we deliver? In 2016/17, our aim is to achieve a further 2.5% reduction against the 2015/16 total number of pressure ulcers developed in hospital, with a monthly target of no more than 16 incidents during April to September 2016, reducing to no more than 15 incidents per month from October 2016.

Work to improve pressure damage prevention has been ongoing and will continue to be prioritised over the next 12 months, particularly in view of the increase in incidence during the second half of 2015/16. Specifically, we will:

• Introduce and embed different ways of working in hospital wards which ensures that frail patients have their skin looked at and cared for on an even more regular basis • Provide a rolling programme of training to UHB staff on the most effective approaches to prevent, manage and record information relating to pressure damage. This will be provided by the UHB’s specialist tissue viability team • Pilot a range of pressure relieving equipment including a hybrid mattress and heel protectors aimed at targeting the prevention of particular types of pressure damage e.g. heel or sacral damage • Establish a task and finish group to undertake an option appraisal on the supply, maintenance and storage of pressure relieving equipment • Maintain a high level of scrutiny on every incident of hospital acquired pressure ulcer and, where pressure damage is deemed avoidable, ensure detailed analysis is taken to determine whether any lessons can be learnt to prevent any re-occurrence • Establish mechanisms for the same level of scrutiny for patients cared for in the community • Work co-operatively across several of the UHB’s key teams to ensure that any significant pressure damage (Grade 3 or 4) are transparently reported as a serious incident and that they receive an even more detailed level of investigation, analysis and learning. • Play a key role in the all-Wales task group which is reviewing the way in which we report on pressure ulcers nationally, in order to ensure that the information provided to our public and patients is as meaningful as possible

Patient Safety Solutions

Q1 Q2 Q3 Q4 Safe Care Target (2015/16) (2015/16) (2015/16) (2015/16) Trend

% compliance with National Patient Safety Agency 100% 100.00 100.00 100.00 100.00 Alerts issued prior to Apr- 14 % compliance with National Patient Safety Agency 100% 97.37 97.37 97.37 97.40 Rapid Response Reports issued prior to Apr-14

% compliance with Patient Safety Solutions Wales 100% 100.00 100.00 100.00 100.00

Alerts issued after Apr-14

% compliance with Patient Safety Solutions Wales 100% 91.67 83.33 89.47 92.00 Notices issued after Apr-14

How are we doing? • We are complaint with all NPSA Safety Alerts and NPSA Rapid Response reports issued prior to April 2014 • We are compliant with all issued Patient Safety Solutions (Wales) Alerts issued after 1st April 2014 and Patient Safety Solutions (Wales) • All the non-compliant notices are under consideration and, with the exception of one notice, all have been issued with two months of the year end

How will we deliver? • There are outstanding Rapid Response reports relating to glaucoma which have been subject to regular reporting and review throughout this year at the Quality, Safety and Experience Assurance Committee. We are producing an updated action plan which will be the subject of ongoing scrutiny until we can evidence compliance • All non-compliant alerts are reviewed at the Quality, Safety and Experience Assurance Committee and are subject to ongoing scrutiny to ensure progress is made. Our level of compliance is consistent with the best performing UHBs across Wales

When will we deliver? All patient safety solution agency alerts, reports and notices are monitored by the Quality, Safety and Equality Assurance Committee on a bi-monthly basis to track progress and delivery.

Serious Incidents and Never Events

Safe Care Jul-15 Oct-15 Apr-15 Jan-16 Jun-15 Feb-16 Mar-16 Sep-15 Dec-15 Nov-15 Aug-15 May-15 Trend Target % Of the Serious Incidents due for assurance within 90% 0.0 30.0 20.0 25.0 28.6 25.0 37.5 40.0 25.0 0.0 12.5 60.0 the month, % which assured in agreed timescale

Number of new Reduce 0 0 1 0 0 0 0 0 0 0 0 0 Never Events

How are we doing? Serious incidents due for assurance have shown an improvement trend over the 12 month period. Never events are serious patient safety incidents which should never occur if preventable measures are in place properly. This target was delivered for 11 out of the 12 months, with one never event being reported in 2015/16.

Domain 3: Effective Care

Mortality Indicators

Effective Care Trend Trend Jul-15 Jul-15 Target Target Oct-15 Oct-15 Apr-15 Apr-15 Jan-16 Jun-15 Jun-15 Feb-16 Mar-16 Sep-15 Sep-15 Dec-15 Nov-15 Nov-15 May-15 May-15 Aug-15

Risk Adjusted Mortality Reduce (12 Index: RAMI 116 116 117 116 116 116 116 114 115 116 - - month 2014 (rolling trend) 12 months) Crude Reduce mortality (12 1.94 1.93 1.94 1.93 1.94 1.94 1.92 1.89 1.87 1.83 1.82 1.83 (rolling 12 month % % % % % % % % % % % % months) trend)

How are we doing? Performance for both metrics has improved over the last 12 months. What we now understand from the report by Professor Stephen Palmer is that a number of measures need to be brought together to achieve a comprehensive view. Palmer concluded that Risk Adjusted Mortality Index as a single measure was not particularly useful or accurate. His report recommended that to obtain a more accurate view of the quality and safety of services, a range of indicators need to be

considered. We have now established a Quality Indicators Group, chaired by the Medical Director, with the specific remit of reducing harm and variation. This group looks at the four areas identified by Palmer, specifically findings from clinical audit, condition specific mortality statistics, case note reviews and ensuring accurate and in depth coding.

Clinical Coding Quality

Effective Care Jul-15 Target Oct-15 Apr-15 Jan-16 Mar-15 Jun-15 Feb-16 Sep-15 Dec-15 Nov-15 Aug-15 May-15 Trend

% % valid principle diagnosis code 3 95 100 100 100 100 99.9 99.5 98.4 96.9 94.6 91.6 84.9 74.9 months after episode end date - monthly % valid principle diagnosis code 3 months after episode 98 100 100 100 100 100 99.9 99.8 99.5 99.1 98.4 97.1 95.1 end date - rolling 12 months

How are we doing? We have seen the trend for both targets deteriorate over the year. However there are plans in place to clear the backlog of patients which will result in a significant improvement when the end of financial year submission is made at the end of June 2016, with both targets being achieved. Please note that coding compliance will always be analysed 3 months in arrears due to the department having up to 12 weeks to clinically code all episodes, so performance will improve month by month as episodes are coded.

How will we deliver? Vacancies have been appointed to and processes are being reviewed across the UHB to ensure a more efficient clinical coding process with the support of health records and other key areas.

GP Records

2013/14 2014/15 Effective Care Target Trend % % of people aged 50+ who have a GP record of blood pressure Improve 87.3 90.7 measurement in the preceding 5 years (40+ in 2013/14.

How are we doing? The total percentage of our population having a record of blood pressure measurement in the last five years has improved this year.

Health and Care Research Wales

Target Q1-Q3 Q1-Q3 Trend Safe Care 2014/15 2015/16 Number of Health & Care Research Wales Clinical 38 39 Research Portfolio Studies. Number of commercially 6 5 sponsored studies Improve Number of patients recruited into NISCHR Clinical Research 767 907 Portfolio Studies Number of patients recruited into 3 15 commercially sponsored studies.

How are we doing? We continue to support our research activities and strive to continuously increase the number of patients recruited into research studies. We are working increasingly closer with our local universities and medical schools to develop our research activity. We are restructuring our Research and Development Department and this, together with the amalgamation with the Health and Care Research Wales workforce, will provide additional resources and a closer working partnership. This should lead to increased numbers of research studies and patients recruited.

Domain 4: Dignified Care

Postponed Admitted Procedures

Dignified Care Jul-15 Oct-15 Apr-15 Jan-16 Jun-15 Feb-16 Mar-16 Sep-15 Dec-15 Nov-15 Aug-15 May-15 Trend Target % % procedures postponed on more than 1occasion, for non-clinical reasons with less than 8 days 73.3 57.1 64.3 100 62.5 37.5 57.1 60.0 38.5 46.2 45.0 46.7 notice that are % % % % % % % % % % % % subsequently carried out within 14 days or month trend at the patients Improveover12 earliest convenience

How are we doing? As a result of deterioration in performance, a review of postponements was undertaken. Results of which have been reported to our Quality Safety and Experience Assurance Committee. An action plan is now in place and sets out measures to ensure we significantly improve.

How will we deliver? We are committed to addressing the longstanding and complex issues that impact on the successful delivery of timely care to our patients. We need to continue to reduce cancelled operations and deliver further improvement to ensure patients waiting for elective surgery receive the best possible experience and outcomes.

When will we deliver? A theatre improvement plan has set the following targets for this financial year end:

• A 20% reduction in cancellation on the day of surgery due to patient being unfit for the procedure • A 50% reduction in cancellations on the day before surgery due to appointment being inconvenient • A 50% reduction in administration errors leading to cancellation • A year-on-year improvement for cancellation due to lack of ward beds • A year-on-year improvement for cancellations due to unavailability of clinical staff

We are working with the all-Wales Patient Communication Group and Welsh Government to identify better ways to ensure that correct information is available to our patients throughout the referral-to-treatment pathway about self cancellation, ill health and fitness for surgery and prioritising to ensure that the most vulnerable patients are accommodated wherever possible.

Domain 5: Timely Care

GP Practices

2014 2015 Timely Care Target Trend

% GP practices offering appointments between 97% 98.1 98.1 17:00 and 18:30 at least 2

days a week. % of GP practices open during daily core hours or 80% 66.7 64.8 within 1 hour of the daily core hours

How are we doing? Sustainability and workforce challenges within General Medical Services are having a significant impact on the ability of practices to remain open and offer appointments throughout core hours. Improvements have been made in extending the range of appointments before 8.30am and after 5.30pm.

How will we deliver? In the last quarter of 2015-16, a rapid access improvement project was established to support practices to improve opening hours and the variety of appointment times offered. This support aimed to improve a deteriorating position due to sustainability concerns. During 2016-17, a working group will be established to focus on prudent access, continuity of care and quality improvements in a whole integrated primary healthcare system.

All Wales HDUHB HDUHB Change 2015 report 2015 Report 31/3/2016 Practices open within 1 hour of daily core opening 82% 65% 68% (different from our 47.5 hours) Weekly opening hours – 95% of total 67% 48% 54% (49.9 hours) Weekly opening hours – all core 45% 22% 30% hours (52.5 hours) Appointments before 8.30am on 2 days 16% 11% 38% per week Appointments offered up to 6pm at 64% 57% 70% least 2 days

When will we deliver? There are no contractual requirements for General Medical Services to deliver on these access targets and we are working with them to consider appropriate improvements.

Referral to Treatment Times

Timely Care Jul-15 Oct-15 Apr-15 Jan-16 Jun-15 Feb-16 Mar-16 Sep-15 Dec-15 Nov-15 Aug-15 May-15 Trend Target % % of patients waiting less than 95 79.9 78.9 79.5 79.1 78.2 77.6 78.8 80.4 79.2 79.4 81.4 82.6 26 weeks for % treatment – all specialties* Number of referral to treatment 36 0 5180 5729 6167 6665 7023 6721 6202 5789 5768 5584 4992 4281 week breaches – all specialties* *Please note: Trend arrows (up, down or static) reflect overall performance as a result of adding a linear trend line to the figures quoted in the time period above.

How are we doing? Both referral to treatment measures have shown a declining trend over the 12 month period.

How will we deliver? We are working with the Welsh Government Delivery Unit to refine our plan and target trajectory for 2016/17.

Diagnostic Waits

Jul-15 Oct-15 Apr-15 Jan-16

Timely Care Jun-15 Feb-16 Mar-16 Sep-15 Dec-15 Nov-15 Aug-15 May-15 Trend Target % % of patients waiting less than 8 100 94.0 95.2 97.9 97.3 94.8 94.1 97.6 98.5 98.9 99.3 100 100 weeks for specific diagnostics

How are we doing? The percentage of patients waiting less than eight weeks for diagnostics has shown an improvement trend over the 12 month period. The target was met in the last two months of the financial year.

4 and 12 Hour waits in A&E

Oc t- Timely Care Jul-15 Jul-15 Apr-15 Apr-15 Jan-16 Jun-15 Jun-15 Feb-16 Mar-16 Sep-15 Sep-15 Dec-15 15 Nov-15 May-15 May-15 Aug-15 Trend Trend Target Target % % of new patients to 95 spend no 84.5 83.3 87.4 85.3 87.4 86.4 84.5 86.2 83.8 81.4 82.2 83.8 % longer than 4 hours in A&E Number of patients spending 12 0 242 244 229 97 146 178 255 335 183 326 390 476 hours or more in A&E

How are we doing? Both accident and emergency measures have shown a declining trend over the 12 month period resulting in both targets not being met.

How will we deliver? An unscheduled care plan has been developed looking at key areas with clear actions and timescales which should improve performance.

When will we deliver?

4 Hour Target: As a minimum, we aim to achieve 85% performance at Withybush Hospital by the end of 2016-17, 90% at Glangwili Hospital and sustain 95% at Bronglais and Prince Philip Hospitals.

12 Hour Target: Our aim is to significantly reduce the number of patients waiting more than 12 hours during this financial year. This will be dependent upon delivering the unscheduled care plan.

Ambulance Red Call Responses – Within 8 Minutes

Timely Care Target Target Oct-15 Oct-15 Jan-16 Jan-16 Feb-16 Feb-16 Mar-16 Dec-15 Dec-15 Nov-15 Nov-15 Trend % % of emergency responses to red calls arriving within 65 57.6 63.2 63.8 67.4 63.0 61.8 (up to and including) 8 minutes *Please note: Trend arrows (up, down or static) reflect overall performance as a result of adding a linear trend line to the figures quoted in the time period above.

How are we doing? In October 2015, a new clinical response model was introduced to ensure the most critical or seriously ill patients received the quickest and most appropriate response. Since October 2015, performance has shown an improvement trend.

Ambulance Handovers – 1 Hour

Timely Care Trend Trend Jul-15 Jul-15 Target Target Oct-15 Oct-15 Apr-15 Apr-15 Jan-16 Jun-15 Jun-15 Feb-16 Mar-16 Sep-15 Sep-15 Dec-15 Nov-15 Nov-15 May-15 May-15 Aug-15

Number of Ambulance 0 110 104 102 32 42 38 94 108 84 106 166 166 handovers over 1 hour

How are we doing? Ambulance handover delays over one hour have shown a declining trend over the 12 month period.

How will we deliver? We now have the ‘Front of House’ model in place in Prince Philip Hospital and this has resulted in a reduction in ambulance delays. Medical patients are seen on an Adult Medical Assessment Unit and flow has improved through timely assessment and treatment of patients. There is also an unscheduled care programme, chaired by our Director of Operations, which reviews all aspects of the emergency care pathway from primary care and ambulance arrivals through to discharge. A key aspect to ensuring timely ambulance offload is sufficient bed availability by time of day so that A&E does not become blocked with patients waiting inpatient beds. This is dependent on the discharge pathway from hospital and ensuring patients have clear discharge plans and appropriate community support. Meetings take place between the Welsh Ambulance Service Trust and our acute hospitals to improve the timeliness of ambulance handover and the red release policy, with underlying actions being implemented on all our hospitals sites.

When will we deliver? As a minimum, we aim to achieve zero handover delays at Bronglais and Withybush Hospitals by the end of 2016-17 and reduce our number significantly at Glangwili Hospital to five.

Urgent and Non-Urgent Suspected Cancer Waiting Times

Timely Care Jul-15 Target Oct-15 Apr-15 Jan-16 Jun-15 Feb-16 Mar-16 Sep-15 Dec-15 Nov-15 Aug-15 May-15 Trend

% Urgent Suspected Cancer: % patients referred 95 87.6 87.0 75.0 91.8 85.2 88.6 81.7 92.9 88.2 90.9 80.2 83.8 via the urgent cancer route seen within 62 days Non Urgent Suspected Cancer: % patients referred 98 95.3 100 95.1 98.4 99.1 97.5 97.7 97.4 99.1 93.6 97.2 97.9 not via the urgent cancer route seen within 31 days

Urgent Suspected Cancer

How are we doing? Performance in respect of urgent suspected cancer shows an improving trend in performance. However, the target is not being met.

Non-Urgent Suspected Cancer

How are we doing? Performance in respect of non-urgent suspected cancer shows a declining trend in performance. However, the target was met on four occasions. Where performance fell below target levels, this was predominantly due to delays for specialist tertiary centre treatments.

How will we deliver? We have published an operational plan to support delivery of both urgent and non- urgent suspected cancer targets during 2016/17.

When will we deliver? We are aiming to continue to meet the 98% target in 2016/17.

Stroke

Timely Care Jul-15 Target Oct-15 Apr-15 Jan-16 Jun-15 Feb-16 Mar-16 Sep-15 Dec-15 Nov-15 Aug-15 May-15 Trend

% % compliance with stroke QIMS* (<4 hours = Direct 95 31.8 30.6 44.1 45.3 49.2 44.6 48.3 38.5 50.0 39.4 48.6 32.4 admission to Acute Stroke Unit)

% compliance with stroke QIMS* (<12 95 100 96.6 95.7 98.2 95.6 96.8 93.0 96.6 95.7 100 97.6 98.8 hours = CT Scan)

% compliance with stroke QIMS* (<24 95 87.8 87.9 92.8 98.2 86.8 85.7 80.3 91.5 87.0 91.4 91.7 85.7 hours = Assessed by a Stroke Nurse) % compliance with stroke QIMS* (<72 hours = Formal 95 86.2 86.7 95.7 89.5 90.0 100 92.3 100 84.6 95.0 100 84.6 Swallow Assessment) *QIMS – Quality Improvement Measures

How are we doing? Three of the four stroke measures have shown an improvement trend over the 12 month period.

How will we deliver? Our stroke delivery plan is now in place. This details the actions required to deliver improved performance. Key areas for investment are clinical nurse specialists and therapies to deliver improvements to the assessment and treatment of patients.

When will we deliver? Structures are in place to support the continuous delivery of improving stroke services across our UHB. Acute hospital sites hold weekly stroke service improvement meetings which feed into monthly UHB stroke service improvement meetings. These facilitate an analysis of stroke care provided and support the continuous drive for service improvement on a patient by patient basis. The stroke delivery plan 2015/16 sets out a timetable of actions to support the delivery of pathway efficiencies and highlights the investments required across the UHB to improve stroke services.

Dentists

Mar-15 Jun-15 Sep-15 Dec-15 Timely Care Target Trend

Patients treated by an NHS dentist in the last 24 Improve 45.4 45.3 45.2 45.3 months as % of population

How are we doing? Patients treated by an NHS dentist have shown a declining trend over the 24 month period. However, there has been a marginal increase in the percentage of the growing population receiving NHS dental care within the last 2 years. There has also been an increase in activity in the community dental service during this period.

How will we deliver? This improving trend is positive. However, accessibility of General Dental Services is still below the levels that we would wish to deliver. A longer term future strategy for delivering improved access has been drafted for consideration. A routine and urgent access service will continue to be supported for those people without access to an NHS general dental practitioner.

Delayed Follow-Up Appointments

Timely Care Trend Jul-15 Target Oct-15 Apr-15 Jan-16 Jun-15 Feb-16 Mar-16 Sep-15 Dec-15 Nov-15 Aug-15 May-15

Total patients waiting for a follow up appointment Reduce delayed past 12 month 38676 39883 31989 34558 36247 35261 33926 31423 31193 30599 30231 31281 target date - trend booked & not booked

How are we doing? The total number of patients delayed waiting for a follow-up appointment has shown an improvement trend over the 12 month period.

Domain 6: Individual Care

Mental Health (Wales) Measure

Individual Care Jul-15 Target Oct-15 Apr-15 Jan-16 Jun-15 Feb-16 Mar-16 Sep-15 Dec-15 Nov-15 Aug-15 May-15 Trend

% LPMHSS assessments within 80 82.7 82.7 83.9 82.8 83.0 84.7 88.6 91.2 84.9 72.0 90.9 84.2 28 days from referral

% therapeutic interventions within 80 83.2 81.5 87.4 94.3 95.1 86.8 93.3 90.9 88.5 86.0 86.6 77.1 28 days following an assessment % LHB residents in receipt of secondary mental health 90 97.6 96.0 95.3 95.4 96.1 95.5 96.0 96.4 94.9 95.6 95.7 93.0 services have a valid care and treatment plan % LHB residents sent their outcome assessment report 90 100 90.9 100 80.0 100 100 80.0 88.9 100 90.9 100 100 within 10 working days of assessment

Mar Mar Target Individual Care 15 16 Trend % % of hospitals in HB which have arrangements in place to 100 100 100 ensure advocacy is available for all qualifying patients

How are we doing? Two of the five Mental Health (Wales) measures have shown an improvement trend over the 12 month period and one has remained static.

How will we deliver? A significant recruitment campaign has commenced and early results are being seen. This will produce improvement in all areas towards October 2016. As a short term measure, waiting list initiatives are being undertaken to bring about earlier improvement in the LPMHSS measures. Further funding is anticipated to support waiting times in LPMHSS, as there are national pressures related to continued high demand for the service. To ensure we continue to send outcome assessment reports within 10 working days, we have put monthly performance monitoring in place. In 2016/17, an audit of the quality and content of the plans is scheduled to ensure the effect of the measure is being seen in practice.

When will we deliver? We expect full improvement to be seen by December 2016.

Domain 7: Our Staff and Resources

Workforce and Sickness Absence

Our Staff and Jul-15 Target Oct-15 Apr-15 Jan-16 Jun-15 Feb-16 Mar-16 Sep-15 Dec-15 Nov-15 Aug-15 Resources May-15 Trend

% sickness absence 4.79 5.5 5.6 5.6 5.7 5.7 5.6 5.7 5.7 5.6 5.6 5.6 5.6 (rolling 12 months)*

*Please note: Trend arrows (up, down or static) reflect overall performance as a result of adding a linear trend line to the figures quoted in the time period above.

How are we doing? Sickness absence has shown an improvement trend over this 12 month period and we will work to improve this in future years, as per the replacement reduction target in 2016/17.

Performance Appraisal of Medical Staff

Target 2013/4 2014/5 Trend Our Staff and Resources % % of total medical staff undertaking performance 85 93 80 appraisals

How are we doing? Whilst older data shows deterioration, early indications in 2015/16 are that performance has improved.

New and Follow-Up Outpatient DNA Rates Staff

Our Staff and Jul-15 Jul-15 Oct-15 Oct-15 Apr-15 Apr-15 Jan-16 Jun-15 Jun-15 Feb-16 Mar-16 Sep-15 Sep-15 Dec-15 Nov-15 Nov-15 Resources May-15 Aug-15 Trend Trend Target Target % New outpatient DNA rates for Reduce 8.4 8.0 9.8 9.7 9.8 10.2 9.1 8.5 8.3 8.6 8.4 8.6 selected specialties* Follow up DNA rates for Reduce 8.3 8.1 8.8 8.2 9.1 8.7 8.5 8.2 8.7 8.6 7.8 8.2 selected specialties* *Please note: Trend arrows (up, down or static) reflect overall performance as a result of adding a linear trend line to the figures quoted in the time period above.

How are we doing? Both do-not-attend measures have shown an improvement trend over the 12 month period.

Our Sustainability Performance Report Sustainable Development is a central organising principle of Welsh Government. Although not directly applicable to devolved governments, Welsh Government request public bodies in Wales who report under the Financial Government Reporting Manual (FReM) to produce a Sustainability Report. Accordingly, this section of our annual report covers the environmental performance of the organisation, written in line with public sector requirements set out in the FReM and supplementary Her Majesty and Customs Guidance ‘Sustainability Reporting in the Public Sector’.

Description of Organisation Hywel Dda UHB has an estate covering circa 50 hectares containing 65 freehold and leasehold premises totalling circa 190,000m2. This includes four acute hospitals, seven community hospitals and administration, health centre and clinic, mental health and accommodation facilities.

Environmental Management Governance Board assurance on environmental and sustainability performance is provided via the Business Planning and Performance Assurance Committee, with work coordinated by the Estates, Capital and Information Management and Technology sub committee. Action is delivered in line with the international environmental management standard ISO 14001. A monitoring system is in place to gather the data required for sustainability reporting. This system is audited annually by the NHS Wales Shared Services Partnership Audit and Assurance Services and periodically as part of external ISO 14001 audits.

Summary of Performance In 2015/16, we successfully completed Year 1 of our Energy Performance Contract (EPC), the first of its kind in the Welsh public sector. Dedicating significant operational and monitoring resource from our maintenance and environment teams, alongside those of our partner British Gas, we ensured that the contract is guaranteed to save £600,000 + VAT. From this solid start, we hope to better this position in future years through continued partnership working. As well as delivering this important project, we continued to maintain our Environmental Management System (EMS) to the international ISO 14001 standard, retained our 33% recycling rate and delivered a range of transport strategy initiatives. We are committed to our continual environmental improvement in all areas, particularly in light of the Environment (Wales) Act.

Greenhouse Gas Emissions The benefit of our EPC can be seen in our reduction in carbon emissions. The project over-performed in this area, delivering an actual reduction of 4,571 tonnes of CO2 in 2015/16.

This is mainly due to our biomass boiler, avoiding oil as a primary fuel source, and the Combined Heat and Power units which use gas to generate electricity and heat on site, so we consume less electricity from the grid. Overall, we have reduced our carbon emissions by 10% in 2015/16.

Greenhouse Gas Emissions 2013-14 2014-15 2015-16 Non Financial Total Gross 27.218 26.182 23.818 Indicators Emissions (1000 tCO e)† 2 Gross 13.522 14.126 14.838 Emissions Scope 1 from Gas and Oil Gross 13.696 12.056 8.980 Emissions Scope 2 & 3 from electricity and business mileage

Related Electricity: Non 22.84 20.17* 14.42* Energy Renewable Consumption Electricity: 0 0.0079 0.016 (million KWh) Renewable Gas 47.74 51.9* 62.14* LPG 0.0428 0.202 0.228 Oil 17.74 16.80 12.56 Biomass 0 0.395 6.79

Financial Expenditure on £5,331,248 £4,896,655* £4,088,359* Indicators Energy CRC License 0 £319,129 £319,591 Expenditure Expenditure on £3,267,205 £2,848,813 £2,751,059 official business travel *these figures include estimated data for a small number of sites due to national difficulties with the provision of invoices by British Gas Business †use DEFRA ‘Greenhouse Gas Emissions for Company Reporting’ calculations for carbon emissions

The table above illustrates a decisive move in the right direction for our emissions, reducing by 10%, while our energy spending reduced by over £800,000 (17%). Renewable energy increased significantly during the first full year of generation from solar PV and woodchip. Biomass boiler efficiency improved as operating practices developed, supporting further improvement in 2016/17. Although our reduction in spend is mainly due to the EPC, we also benefited from low fuel oil rates and favourable weather conditions, which will change in future years.

The Central Transport Unit has helped reduce emissions through improvements identified in our Transport Strategy. This included the development and delivery of a pool car system, commencing early 2016/17, with 10 fleet vehicles across four sites. The telematics system installed on the vehicles will monitor driver behaviour and

74 identify where driver training and awareness could improve fuel efficiency. Subject to effectiveness, there is potential to install telematics across our fleet. We continue to update our sustainable transport infrastructure, installing a 24 bay cycle shelter at Glangwili Hospital in March 2016 to facilitate and encourage staff cycling to work. Additionally, taxi use has reduced substantially from 2063 to 1796 journeys in 2015/16 through better co-ordinated deliveries and ensuring multiple packages can be transported by the most appropriate providers. Patient transport processes have also enhanced through increased scrutiny and improved control.

Waste Management In a year when energy management has been a primary focus, we have endeavoured to maintain a recycling rate of 33%, diverting 408 tonnes of waste from landfill. A key improvement has been the introduction of food waste recycling in catering departments at our Glangwili and Prince Philip Hospitals, so that all four acute hospital sites now recycling food waste.

Waste 2013-14 2014-15 2015-16 Non Total Waste 2064 2126 2,155 Financial Indicators Landfill (Black Bag) 885 825 835 (tonnes) Reused/Recycled 291 374 356 Composted* 15 32 52 Landfill (Hygiene 307 304 287 Bag) Alternative 440 458 490 Treatment (Clinical) Incinerated with energy recovery** 125 133 136 Incinerated without 0 0 0 energy recovery

Financial Total Disposal Cost £699,150 £668,615 £697,551 Indicators Landfill (Black Bag) £196,315 £145,774 £150,991 Reused/Recycled £55,284 £61,739 £63,209 Composted* £366 £1,073 £4,433 Landfill (Hygiene £105,242 £104,986 £100,979 Bag) Alternative £233,083 £240,742 £253,122 Treatment (Clinical) Incinerated with energy recovery** £108,860 £114,304 £116,920 Incinerated without 0 0 0 energy recovery *includes Anaerobic Digestion **provides steam to a nearby facility

Total waste disposal increased by 1.3%, mainly due to the diversion of food waste from drainage via macerators. We have reduced this increase by 50% since last year and work will continue to ensure waste does not go up in future. Resource efficiency and improvements to our reuse and recycling schemes will be a focus moving forward. The greatest change can be seen in our clinical waste disposal. Non- infectious hygiene waste disposal decreased by 17 tonnes but infectious clinical waste volumes increased by double this amount. The latter is expensive to treat and this is shown (along with the impact of rising rates) in our total disposal cost increasing by circa £28,000 (4%) this year.

Use of Resources Water consumption has remained steady, although 2015/16 shows the lowest consumption and expenditure in recent years due to good housekeeping measures, identifying and investigating leaks. Our borehole at Withybush is also back in use following a year when the water table was disrupted due to nearby development.

Finite Resource Consumption 2013-14 2014-15 2015-16

Non Water Supplied 237,177 228,395 234,453 Financial Consumptio Indicators n (Office)* Abstracted 11,735 0 11,178 (m3) Per FTE** 33.12 30.53 31.81

Water Supplied 29,994 31,311 29,436 Consumptio n (Non - Office)*** Abstracted 0 0 0

Financial Water Supply Costs Indicators £316,339 £313,784 £304,009 (Office)*

Sewerage Costs (Office)* £378,051 £329,611 £356,593

Water Supply Costs (Non - £28,251 £30,301 £26,174 Office)***

Sewerage (Non -Office)*** £30,186 £31,937 £32,064

*All estate with the exception of the main laundry at Glangwili and the Bryntirion Central Production Unit ** WTE Staff *** Main laundry at Glangwili and the Bryntirion Central Production Unit only

Environmental Management System (EMS) Implementation We continue to be externally audited and maintain compliance with the requirements of the international standard for Environmental Management Systems ISO 14001. As this has been in use since 2012, the environment team have this year prioritised embedding system processes. This will allow operational activity and improvements in performance to become the focus for support provided by the team.

Performance against Local Issues During 2015/16, we had a number of reviews by external organisations such as Wales Audit Office, Health Inspectorate Wales, Hywel Dda Community Health Council (CHC) and the Delivery Unit from Welsh Government. Examples of these are included in our Annual Quality Statement and Accountability Report (Annual Governance Statement) which are available here: http://www.wales.nhs.uk/sitesplus/862/page/75118.

Quality Care: Our Annual Quality Statement A significant amount of work has taken place in 2015/16 to improve the quality, safety, outcomes and experiences of care for our patients. This is detailed in our Annual Quality Statement which describes, in an open and honest way, how and what we have been doing to improve the quality of our services. It includes information for young children, young people, adults and older adults and what we have done to support our staff and volunteers in the following areas:

• Staying Healthy - so you can manage your own health and wellbeing • Safe Care – to protect you, and help you protect yourself, from harm • Effective Care – so that you get the right care as locally as possible and can contribute to make your care successful • Dignified Care – so you are treated with dignity and respect and treat others the same • Timely Care – so you have timely access to services you need and are involved in decisions about your care • Individual Care – so you are treated as an individual with your own needs and responsibilities • Our Staff and Resources – so you get the information about NHS resources and careful use of them

Our Annual Quality Statement includes a commitment to work to improve the quality of our services next year and is available to read in full at http://www.wales.nhs.uk/sitesplus/862/page/75118.

Putting Things Right: Our Principles for Remedy We recognise the value of listening to our patients and making improvements based on what you tell us. Our patient support team manages all patient complaints and provide support during an investigation. If we believe care has failed, a consideration for redress is made. This year, we made good progress in responding to concerns in a more timely manner but we still have a long way to go.

We continue to implement the NHS Concerns, Complaints and Redress Arrangements (Wales) Regulations 2011. In 2015/16, these arrangements were subject to a review called ‘Using the Gift of Complaints’ across NHS Wales. Some regulatory changes will be made next year as a result of this review. We are currently developing a new structure for responding to concerns which will involve strengthening our service and providing better ways for patients and the public to feed back on their service experiences.

The Public Services Ombudsman for Wales ‘Principles for Remedy’ set out six principles that represent best practice and are directly applicable to NHS procedures. In summary the principles, which we have fully adopted, are:

• Getting it right - quickly acknowledging and putting right cases of maladministration or poor service that have led to injustice or hardship • Being customer focused - apologising for and explaining maladministration or poor service, including managing and understanding people’s expectations and needs • Being open and accountable - being open and clear about how remedies are decided upon. Operating a proper system of accountability and delegation in providing remedies and keeping clear records • Acting fairly and proportionately – offering remedies that are fair and proportionate to the complainants injustice or hardship • Putting things right - considering fully or forms of remedy including financial redress • Seeking continuous improvement – using lessons learned from complaints to ensure that poor service is not repeated. Recording and using information on the outcome of complaints to improve services

The Board receives regular reports on the themes identified and these reports are also published on our website. Under the NHS Concerns, Complaints and Redress Arrangements (Wales) Regulations 2011, we have a duty to produce a ‘Putting Things Right’ annual report to be published as part of this statement. This can be found on our website at www.hywelddahb.wales.nhs.uk and provides further detail about the types of concerns received and the lessons learned.

Emergency Preparedness We have a major incident plan, reviewed and approved by the Board annually, which covers the three counties of Carmarthenshire, Ceredigion and Pembrokeshire. This plan, together with our other associated emergency plans, detail our response to a variety of situations and how we will meet the statutory duties placed upon us by the Civil Contingencies Act 2004. Within the Act, we are classified as a Category One responder to emergencies. This means that in partnership with the Local Authority, Emergency Services, Natural Resources Wales and other Health Bodies (e.g. Public Health Wales), we are the first line of response in any emergency affecting our population.

Consistent progress has been made in ensuring our compliance with the Act and in working with our partners in the Local Resilience Forum to ensure preparedness for emergency situations.

In order to prepare us for such events, we assess local risks and use these to inform emergency planning. Key achievements in 2015/16 include:

• Multi-agency planning for Tier 1 live major incident exercise • Development of tactical level training packages • Development of trained Medical Emergency Response Incident Team (MERIT) staff to contribute to all-Wales capability • Participation in development of all-Wales mass casualty response structures

10. Our Accountability Report

Our Corporate Governance Report

Statement of Chief Executive’s Responsibilities

The Welsh Ministers have directed that the Chief Executive should be the Accountable Officer to the LHB. The relevant responsibilities of Accountable Officers, including their responsibility for the propriety and regularity of the public finances for which they are answerable, and for the keeping of proper records, are set out in the Accountable Officer's Memorandum issued by the Welsh Government. To the best of my knowledge and belief, I have properly discharged the responsibilities set out in my letter of appointment as an Accountable Officer.

Date…………………2016 …………………………………………… Chief Executive

The Director’s Report

Table 1: Detailed information in relation to the composition of the Board including Executive Directors, Independent Members, Advisory Board Members and those who have authority or responsibility for directing or controlling the major activities of Hywel Dda University Health Board during the financial year 2015/2016.

Name Date Appointment Position on Board/Board Appointed Term Champion Bernardine Rees 01.07.2014 31.07.2018 Chairman Champion for Carers Sian-Marie James 03.10.2011 30.09.2019 Vice Chairman Champion for Mental Health, Counter Fraud Adam Morgan 01.04.2016 31.03.2018 Independent Member David Powell 01.12.2011 30.04.2018 Independent Member/ Champion for IT systems and services Don Thomas 01.10.2009 31.03.2017 Independent Member John Gammon 31.07.2014 31.07.2017 Independent Member (Professor) Judith Hardisty 01.04.2016 31.03.2018 Independent Member Julie James 01.05.2010 30.04.2018 Independent Member Champion for Concerns, Third Sector and HR

Margaret Rees- 01.10.2009 31.03.2017 Independent Member Hughes Champion for Welsh Language and Cleaning, Hygiene & Infection Management, Unscheduled Care Mike Ponton 01.06.2012 31.12.2016 Independent Member Champion for Children's Services & Armed Forces & Veterans Simon Hancock 01.08.2013 31.07.2016 Independent Member (Local Authority) Champion for Equalities and Older People Eifion Griffiths 01.10.2009 31.03.2016 Independent Member/Board Champion for Estates, Sustainable Development and Security Management Neil Sandford 01.01.2010 31.12.2015 Independent Member Champion for Violence & Aggression Steve Moore 05.01.2015 Chief Executive Joe Teape 07.09.2015 Deputy Chief Executive/Director of Operations Caroline Oakley 01.10.2009 Director of Nursing, Quality and Patient Experience Karen Miles 16.09.2009 Director of Finance, Planning & Performance Kathryn Davies 01.03.2010 Director of Commissioning, Primary Care & Therapies & Health Scientists Lisa Gostling 09.01.2015 Director of Workforce & OD Philip Kloer 01.10.2011 Medical Director/Director of Clinical Strategy Sarah Jennings 01.06.2010 Director of Governance, Communication & Engagement Teresa Owen 03.09.2012 Director Public Health Joanne Wilson 01.12.2014 Board Secretary Paul Hawkins 12.08.2013 25.05.2015 Chief Operating Officer Jake Morgan 01.11.2014 Associate Member Paula Martyn 01.06.2014 Associate Member Phil Parry 01.06.2014 Associate Member

Table 2: Details of company directorships and other significant interests held by members of the Board which may conflict with the responsibilities as Board members.

Name Committee Directorships Ownership/part Majority or Position of Connection Member of any Interests relating to Membership held ownership of controlling authority in a with a other public spouse/partner or (inc non private shareholding in charity/ voluntary or bodies close family member executive held companies or an organisation voluntary body other body including those that may relate to the conduct of NHS in private consultancies likely or in the field of contracting for unconnected business companies/plc) likely or possibly health and NHS Services with the health possibly seeking to do social care service seeking to do business with business with the NHS NHS Bernardine Health Board No No No No No No Husband is Rees (Chair) Independent Member of Shalom House, Remuneration Pembrokeshire Committee (Chair)

Sian-Marie Health Board No No No No but a WHSCC No but Chair for Daughter remains a James (Vice-Chair) Member of the Membership the South West Bank Healthcare National Wales Branch of Support Worker but Mental Health Association for the Chartered resides in Ireland

Legislation Crohn's & Colitis Institute of Legal Brother is Chair of the Assurance (NACC) Executives Abertawe Bro Committee Morgannwg University (Chair) Health Board’s Cancer Patient Forum and a Primary Care Member of Welsh Applications Government’s Committee National Strategic (Chair) Advisory Group: Patient Forum

Audit & Risk Assurance Committee

Charitable Funds

University Partnership Board

Primary Care & Community Services Quality, Safety & Experience Sub Committee

Hospital Managers Powers of Discharge Sub- Committee Adam Morgan Hospital Managers Powers of Discharge Sub- Committee

Charitable Funds Committee

Mental Health Legislation Assurance Committee

Quality, Safety & Experience Assurance Committee

Workforce & OD Sub-Committee

Mental Health & Learning Disabilities Services Quality, Safety & Experience Sub- Committee

Name Committee Directorships Ownership/part Majority or Position of Connection Member of any Interests relating to Membership held ownership of controlling authority in a with a other public spouse/partner or (inc non private shareholding in charity/ voluntary or bodies close family member executive held companies or an organisation voluntary body other body including those that may relate to the conduct of NHS in private consultancies likely or in the field of contracting for unconnected business companies/plc) likely or possibly health and NHS Services with the health possibly seeking to do social care service seeking to do business with business with the NHS NHS David Powell Health Board No Independent No No No No Sister works in Charitable Consultant Cardiology Funds providing IT Department, PPH, Committee consultancy Llanelli

(Chair) services to Son works as a English NHS General Manager in a Business organisations London Hospital Planning & Performance Assurance Committee (Vice-Chair)

Hospital Managers Powers of Discharge Sub- Committee

Audit & Risk Assurance Committee

Capital, Estates & IM&T Sub- Committee (April 2016 onwards)

Don Thomas Health Board Welsh Lamb & No No No Castell Howell Member of Daughter is a Audit & Risk Beef Producers Foods Ltd Advisory Board Foundation 2 Doctor Assurance Ltd (Managing Celtic Pride Ltd of School of from July 2015 Committee Director) Management (Chair) and Business Quality Welsh Aberystwyth Remuneration Food University Committee (Vice Chair) Certification Ltd (Executive Director)

WFS Border Ltd (Non Executive Director)

Border Distribution (2000) Ltd (Non Executive Director)

Farm Assured Welsh Livestock Ltd (Executive

Border Distribution Ltd (Non Executive Director)

Welsh Agricultural Org Soc Ltd (Managing Director)

Welsh Farmers Ltd (Non Executive Director)

Chair of Quality Welsh Foods Certification Ltd

Director of Celtic Pride Ltd (an associated company of Castell Howell Foods Ltd)

Director & Company Secretary of Welsh Livestock Ltd

Director of Iechyd Da (Gwledig) Ltd

Member of Advisory Board of School of Mgmt & Business, Aberystwyth University

Director of Aberystwyth Animal Health Laboratory Ltd

Name Committee Directorships Ownership/part Majority or Position of Connection Member of any Interests relating to Membership held ownership of controlling authority in a with a other public spouse/partner or (inc non private shareholding in charity/ voluntary or bodies close family member executive held companies or an organisation voluntary body other body including those that may relate to the conduct of NHS in private consultancies likely or in the field of contracting for unconnected business companies/plc) likely or possibly health and NHS Services with the health possibly seeking to do social care service seeking to do business with business with the NHS NHS John Gammon Health Board No No No No No No No (Professor) University Partnership Board (Chair)

Quality, Safety & Experience Assurance Committee (Vice Chair)

Mental Health Legislation Assurance Committee (Vice Chair)

Acute Services Quality Safety & Experience Sub- Committee

Hospital Managers Powers of Discharge Sub- Committee

Name Committee Directorships Ownership/part Majority or Position of Connection Member of any Interests relating to Membership held ownership of controlling authority in a with a other public spouse/partner or (inc non private shareholding in charity/ voluntary or bodies close family member executive held companies or an organisation voluntary body other body including those that may relate to the conduct of NHS in private consultancies likely or in the field of contracting for unconnected business companies/plc) likely or possibly health and NHS Services with the health possibly seeking to do social care service seeking to do business with business with the NHS NHS Judith Hardisty Hospital Managers Powers of Discharge Sub- Committee

Emergency Planning, Health & Safety Sub- Committee

Charitable Funds Committee

Business Planning & Performance Assurance Committee

Julie James Audit and Risk No No No No Member of the Trustee, Brecon Assurance Marie Curie Beacons Trust Committee Cancer Care (Vice-Chair) Advisory Board Health Assessor for Wales for the WG Hospital Health and Managers Wellbeing at Powers of Work Corporate

Name Committee Directorships Ownership/part Majority or Position of Connection Member of any Interests relating to Membership held ownership of controlling authority in a with a other public spouse/partner or (inc non private shareholding in charity/ voluntary or bodies close family member executive held companies or an organisation voluntary body other body including those that may relate to the conduct of NHS in private consultancies likely or in the field of contracting for unconnected business companies/plc) likely or possibly health and NHS Services with the health possibly seeking to do social care service seeking to do business with business with the NHS NHS Discharge Sub- Standard Committee Independent Quality, Safety & Member Audit Experience Committee Assurance Committee Local Delivery Boundary Improving Commission Experience Sub- Wales Committee Trustee of the Workforce & OD National Sub-Committee Botanical Garden of Wales Primary Care Applications Member of Court Committee Swansea University

Member of Court University of Luton

Non-Exec Director of WG Dept for Education and Local

Non-Exec Director of Local Government Public Service Programme Board

Margaret Rees- Health Board No No No No Member of the No Son works in the Hughes Quality, Safety & Patient Oncology Department Experience Participation at Singleton Hospital, Assurance Group at Bridge ABMU LHB Committee Street Surgery, (Chair) Penygroes

Audit & Risk Assurance Committee

Charitable Funds Committee

Mental Health Legislation

Hospital Managers Powers of Discharge Sub- Committee

Infection Prevention & Control Group

Business Planning & Performance Assurance Group

Mike Ponton Business Trustee, Age No No Trustee, Age Trustee, Age No No Planning & Cymru - Term Cymru Cymru Performance ending Assurance September 2015 Committee (Chair)

Quality, Safety & Experience Assurance

Strategic Safeguarding Sub-Committee

Remuneration & Terms of Service Committee

Hospital Managers Powers of Discharge Sub- Committee

Primary Care Applications Committee

Simon Hancock Charitable No No No Treasurer, No Cabinet Brother employed at Funds Neyland Age Member, Argyle Surgery, Committee Concern Pembrokeshire Pembroke Dock (Vice-Chair) County Council Sister in Law: GP in

Newport (Retired) Hospital Magistrate, Managers Pembrokeshire- Niece: Nurse, Powers of Ceredigion Withybush Hospital Discharge Sub- Bench

Name Committee Directorships Ownership/part Majority or Position of Connection Member of any Interests relating to Membership held ownership of controlling authority in a with a other public spouse/partner or (inc non private shareholding in charity/ voluntary or bodies close family member executive held companies or an organisation voluntary body other body including those that may relate to the conduct of NHS in private consultancies likely or in the field of contracting for unconnected business companies/plc) likely or possibly health and NHS Services with the health possibly seeking to do social care service seeking to do business with business with the NHS NHS Committee Board Member, Mental Health Care Council for Legislation Wales Assurance Committee

Audit & Risk Assurance Committee

University Partnership Board (Vice Chair)

Business Planning & Performance Assurance Committee

Information Governance Sub-Committee

Research Governance

Eifion Griffiths Mental Health No No No No Board Member Council Member No Legislation of Grwp Gwalia of Trinity St Assurance and Chair of two David's Committee subsidiary University (Vice-Chair) companies Tai Gwyr Cyf and University Tai Cartrefi Cyf. Partnership It has extensive Board (Vice- and growing Chair) interests in health and social Quality, Safety & care sectors Experience Assurance Committee

Hospital Managers Powers of Discharge Sub- Committee

Capital Estates & IM&T Sub- Committee

Charitable Funds Committee Neil Sandford Health Board No No No No No No Wife is employed at Remuneration & South Pembs Hospital Terms of Service Committee

Business Planning & Performance Assurance Committee

Quality, Safety & Experience Assurance Committee

Charitable Funds Committee

Mental Health Act Legislation

Local Partnership Forum

Hospital Managers Powers of Discharge Sub- Committee

Mental Health & Learning Disabilities Services Quality, Safety & Experience Sub- Committee

Steve Moore Health Board No No No No No No Wife is an employee of and Key the North, East & West Committees Devon Clinical Commissioning Group

Joe Teape Health Board No No No No No Chartered Wife is a Director of and key Institute of Dental Practice in Committees Public Finance Newquay and Partner

Name Committee Directorships Ownership/part Majority or Position of Connection Member of any Interests relating to Membership held ownership of controlling authority in a with a other public spouse/partner or (inc non private shareholding in charity/ voluntary or bodies close family member executive held companies or an organisation voluntary body other body including those that may relate to the conduct of NHS in private consultancies likely or in the field of contracting for unconnected business companies/plc) likely or possibly health and NHS Services with the health possibly seeking to do social care service seeking to do business with business with the NHS NHS Accountancy in Dental Nurses Healthcare Training Company. No Financial connection with Welsh Management NHS

Association Caroline Oakley Health Board No No No Undertaking No No Husband is an and Key voluntary work employee of Hywel Committees with Dyfed Dda University Health Powys Crime & Board in the Physiotherapy Police Department at South Commissioner Pembrokeshire on a panel Hospital reviewing complaints Karen Miles Health Board No No No No No No Brother is a Senior and Key Lecturer, Swansea Committees Medical School & Postgrad Research Sister in law serves on R&D Committee, Lampeter University

Kathryn Davies Health Board Non-Executive No No No No No No and Key Board Member Committees (Independent) for Football Association of Wales (FAW) – unpaid

Lisa Gostling Health Board No No No No No No No and Key Committees Philip Kloer Health Board No No No No No Member of No and Key Council of St Committees John, Carmarthen Sarah Jennings Health Board No No No No No No No and Key Committees Teresa Owen Health Board No No No No No No No and key Committees

Joanne Wilson Health Board No No No No No No Husband is employed and Key by the Health Board Committees Paul Hawkins Health Board No No No No No No No and key Committees

Jake Morgan Public Board Associate Member

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Name Committee Directorships Ownership/part Majority or Position of Connection Member of any Interests relating to Membership held ownership of controlling authority in a with a other public spouse/partner or (inc non private shareholding in charity/ voluntary or bodies close family member executive held companies or an organisation voluntary body other body including those that may relate to the conduct of NHS in private consultancies likely or in the field of contracting for unconnected business companies/plc) likely or possibly health and NHS Services with the health possibly seeking to do social care service seeking to do business with business with the NHS NHS Kevin Davies Health Board WAST No No Motivation and No WAST No Learning Trust Chair Reserve (Reg: 1155810) Forces and Cadets Association Wales

Paula Martyn Stakeholder No No No No I act as an I am an No Reference independent Associate Group (Chair) advisor to Care Director (Chair Forum Wales a of Stakeholder professional Reference body which Group) with supports the Cardiff & Vales independent UHB sector Phil Parry Healthcare Professional Forum (Chair)

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Table 3: Details relating to membership of the Board level assurance committees and the Audit and Risk Assurance Committee.

Mr Don Thomas Independent Member – Finance Chair of the Audit and Risk Assurance Committee Mrs Julie James Independent Member – Third Sector Vice-Chair of the Audit and Risk Assurance Committee Mr David Powell Independent Member – Information Technology Member of the Audit and Risk Assurance Committee Mrs Margaret Rees- Independent Member – Community Member of the Audit and Risk Assurance Committee Hughes Mrs Sian-Marie James Health Board Vice Chair – Primary Community Member of the Audit and Risk Assurance Committee Services and Mental Health Services Cllr Simon Hancock Independent Member – Local Authority Member of the Audit and Risk Assurance Committee Mr Mike Ponton Independent Member – Community Member of the Audit and Risk Assurance Committee

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Information Governance Information relating to personal data related incidents and how information is managed and controlled is contained within the Annual Governance Statement.

Environmental, Social and Community Issues As a large employee and public service provider, we are cognisant of the impact we have on our environment and take steps to reduce this impact. For example, this year we have introduced biomass boiler systems at Glangwili General Hospital, a combined heat and power plant at Prince Philip Hospital and Withybush General Hospital, energy efficient lighting and improved control systems across the Health Board.

We have also encouraged staff to use different forms of transport to get to work, such as cycling, car share and public transport, introducing a park and ride scheme to Glangwili General Hospital in Carmarthen, for example.

We feel very much part of the communities we serve and have been involved in many activities that reinforce that relationship and provide a community and social focus. We have constructive relationships with key partners such as the Community Health Council, local authorities, police and fire service, as well as the third sector. We play an active role in Local Service Boards, but also work on the frontline with these partners everyday and this year have seen the fruits of some key partnership schemes. For example, we have worked with the fire service to provide literature and support for people who hoard, we have won an NHS Award for the provision of our Street Triage team that works with the police to jointly assess people in mental distress and we have also established areas in our Emergency Departments where community police officers can have a presence, as well as a technical solution for improving communications between the agencies during a mass casualty event. We are key partners in two collaborative to improve health and wellbeing, ARCH and the Mid Wales Collaborative, and we have also signed a memo of understanding this year with our local universities, which is a landmark in our joint working.

We aim to strengthen our own employees’ sense of community through a number of projects. For example, this year we have established designate local leadership in each acute hospital with a lead manager, doctor and nurse; and we continue our work to provide and live out staff values, which have been developed by our staff themselves. Our hospitals and other healthcare facilities are also host to community and social events, from hospital fundraisers to health improvement awareness events. For example, our inpatient children’s ward at Glangwili Hospital is a regular stop-off for regional ruby team the Scarlets at Christmas every year. Whilst these are often happy occasions, we also hold reflective and supportive events, for example, loved and lost babies remembrance services and this year, a coffee morning in Penparcau, Aberystwyth, during National Transplant Week, attended by the Forget-Me-Not support group for people affected by organ donation.

We also aim to support our communities with their varied and individual needs. For example, this year one of our Sisters in Withybush General Hospital, Haverfordwest, worked with Pembrokeshire Women’s Institute, whose members created beautiful and unique tactile cushions to provide warmth and exercise for dementia patients. We have also worked closely with young people through the Healthy Schools programme, as well

103 as attended student fresher fairs to raise awareness of the advantages of ‘choosing well’ when they choose which health service they need. Our work to improve awareness and uptake of support for carers has also strengthened as we have been able to provide investors in carers’ awards to GPs, community pharmacies and mental health providers in Prince Philip Hospital, Llanelli. It is also not just our immediate community that we consider but our global neighbours. We have been an active part of multi agency groups to support Syrian refuges during this year, and this work continues as we strive to welcome those people into our communities.

We want to continue this positive work into next year and believe it is a key part to improving the health and wellbeing of our population. Looking at how positive changes can make a difference to people’s lives and what can be achieved together in partnership is detailed further in our Director of Public Health’s report, which can be found here www.hywelddahb.wales.nhs.uk/publichealth. This approach aims to develop resilience and promote positive health and wellbeing, placing more power with communities and individuals.

Information relating to Sickness Absence Data is contained within the remuneration report.

The Health Board confirms it has complied with cost allocation and the charging requirements set out in HM Treasury guidance during the year.

Annual Governance Statement

Scope of Responsibility The Board is accountable for Governance, Risk Management and Internal Control. As Accountable Officer and Chief Executive of the Board, I have responsibility for maintaining appropriate governance structures and procedures as well as a sound system of internal control that supports the achievement of the organisation's policies, aims and objectives, whilst safeguarding the public funds and the organisation's assets for which I am personally responsible. These are carried out in accordance with the responsibilities assigned by the Accountable Officer of NHS Wales.

The Hywel Dda University Health Board (Health Board) has in place governance and assurance arrangements which are continually being developed and strengthened. Reiterating my initial comments last year on first taking on the role of Chief Executive of Health Board, I remain undeterred from the view that it is my role and that of the Board to support the front line to be as good as it can be for our patients. The Board recognise that our staff work incredibly hard in providing high standards of care to our local population sometimes under difficult circumstances and their effort is sincerely appreciated. In order to do this, it is essential that we have strong and effective clinical and non clinical engagement and a sound and honest relationship with all our staff and our population, sharing with them and looking for their engagement in responding to, the challenges that we face. This requires sound governance arrangements and having the best possible process for making and implementing decisions.

In recognition that most effective Boards regularly reflect on their effectiveness and the robustness of their governance arrangements, the Board, towards the later part of the

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2014/15 financial year commissioned an external review of its governance arrangements. The ensuing report sets out a challenging governance agenda for the Health Board, recognising that a period of stability with signs of a change in style and culture and a redefining of organisational expectations were already being seen. It was my clear vision at that point in time that we expedite the pace of change and this current year has therefore seen an invigorating focus on the governance arrangements within the organisation and continual implementation of the recommendations arising from the review.

Effective governance is derived from more than systems and processes; it is built on strong and enduring relationships that engender trust and cooperation between the Board, the Executive Team, staff, partners and stakeholders. The marriage of process and people creates a collegiate governance culture that:

• Provides a foundation for ensuring that the Health Board is operating effectively and delivering safe, high quality care; • Delivers assurance to the Welsh Government, key stakeholders and the public regarding organisational probity and sustainability; and • Demonstrates leadership that enables the Health Board to respond to the significant challenges it has to face, both current and in going forward.

The Board is responsible for maintaining appropriate governance arrangements to ensure that it is operating effectively and delivering safe, high quality care. The Board recognises the need to govern the organisation effectively and in doing so build public and stakeholder confidence. All Board members share corporate responsibility for formulating strategy, ensuring accountability, monitoring performance and shaping culture, together with ensuring that the Board operates as effectively as possible. The Board, which comprises individuals from a range of backgrounds, disciplines and areas of expertise, has during the year provided leadership and direction, ensuring that sound governance arrangements are in place.

Taking the above principles into account, the principal role of the Board during the year has been to exercise leadership, direction and control as shown in the following figure:

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The Board has been constituted to comply with the Local Health Boards (Constitution, Membership and Procedures) (Wales) Regulations 2009. In addition to responsibilities and accountabilities set out in terms and conditions of appointment, Board members also fulfil a number of Champion roles where they act as ambassadors for these matters. Board and Committee Membership and Champion roles during 2015-2016 were as follows:

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AREA OF BOARD COMMITTEE ATTENDANCE EXPERTISE CHAMPION NAME POSITION MEMBERSHIP/ATTENDA AT MEETINGS REPRESENTATI ROLES NCE 2015/2016 ON ROLE Bernardine Chair • (Chair) Board • 7/7 meetings • Carers Rees • (Chair) Remuneration & • 4/4 meetings Terms of Service Committee

Sian-Marie Vice Chair Mental • (Vice Chair) Board • 7/7 meetings • Mental Health James Health • Quality & Safety • 6/7 meetings • Counter Primary Experience Fraud Care Assurance Committee • 4/4 meetings Community • (Chair) Mental Services Health Legislation • 3/4 meetings Assurance • 3/4 meetings Committee • Charitable Funds • 1/2 meetings Committee • 4/4 meetings • Audit & Risk Assurance Committee • 6/7 meetings • University Partnership Board • (Chair) Primary Care Applications Committee • Business Planning Performance Assurance Committee

Julie James Independent Third • Board • 7/7 meetings • Third Sector Member Sector • Quality Safety & • 6/7 meetings • HR Experience • Concerns Assurance • 6/7 meetings Committee • • Audit & Risk 2/4 meetings • Assurance 3/3 meetings Committee • • Charitable Funds 2/2 meetings Committee • Remuneration & Terms of Service Committee • Primary Care Applications Committee

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Mike Independent Community • (Chair) Business • 4/7 meetings • Children & Ponton Member Planning & • 7/8 meetings Young Performance People‟s Assurance Committee • 5/7 meetings Services • Audit & Risk • Armed • Assurance 5/7 meetings Forces & Committee Veterans • • Quality Safety & 2/3 meetings Experience • Assurance 2/2 meetings Committee • Remuneration & Terms of Service Committee • Primary Care Applications Committee

John Independent University • Board • 7/7 meetings Gammon Member • Quality Safety & • 4/7 meetings Experience Assurance Committee • 2/2 meetings • (Chair) University Partnership Board • 1/4 meetings • Mental Health Legislation Assurance Committee Don Independent Finance • Board • 7/7 meetings Thomas Member • Audit & Risk • 7/7 meetings Assurance Committee • 3/3 meetings • Remuneration & Terms of Service Committee Eifion Independent Capital, • Board • 6/7 meetings • Estates Griffiths Member Estates & • Mental Health • 1/4 meetings • Sustainable Service Legislation Development Redesign Assurance • 4/8 meetings • Security Committee Management • Business Planning • & Performance 1/1 meetings Assurance Committee • Remuneration & Terms of Service Committee

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David Independent Information, • Board • 7/7 meetings • IT Systems & Powell Member Commun- • Audit & Risk • 7/7 meetings Services ications & Assurance technology Committee • 8/8 meetings • Business Planning & Performance Assurance • 4/4 meetings Committee • 1/2 meetings • Charitable Funds Committee • Primary Care Applications Committee

Margaret Independent Community • Board • 7/7 meetings • Cleaning Rees- Member • Mental Health • 4/4meetings Hygiene & Hughes Legislation Infection Assurance • 5/7 meetings Management Committee • Welsh • Audit & Risk • 7/8 meetings Language Assurance • Unscheduled Committee Care • • Business Planning 7/7 meetings & Performance Assurance • Committee 2/3 meetings • (Chair) Quality Safety & Experience Assurance Committee • Charitable Funds Committee

Simon Independent Local • Board • 4/7 meetings • Older Hancock Member Authority • Charitable Funds • 2/4 meetings People Committee • 4/8 meetings • Equalities • Business Planning & Performance Assurance • 6/7 meetings Committee • • Audit & Risk 0/2 meetings Assurance Committee • University Partnership Board

Neil Independent Trade • Board • 2/5 meetings Sandford Member Union • Mental Health • 0/4 meetings (Until Legislation 31/12/15) Assurance • 2/3 meetings Committee • 1/6 meetings • Charitable Funds Committee • 1/1 meetings • Quality Safety & Experience Assurance Committee • Remuneration & Terms of Service Committee 109

Paula Associate (Chair) Board • 3/7 meetings N/A Martyn Member Stakeholde r Reference Group Jake Associate Director of Board • 3/7 meetings N/A Morgan Member Social Services

Phil Parry Associate Chair Board • 2/7 meetings N/A Member (Healthcar e Profession als Forum)

Steve Chief Board • 7/7 meetings N/A Moore Executive Officer Joe Teape Deputy Chief • Board • 4/4 meetings N/A (from Executive • Mental Health • 3/3 meetings 01/10/15) Officer/ Legislation Director of Assurance • 5/5 meetings Operations Committee • Audit & Risk • 3/3 meetings Assurance Committee • 6/6 meetings • Quality Safety & Experience Assurance Committee • Business Planning & Performance Assurance Committee

Karen Miles Director of • Board • 7/7 meetings N/A Finance, • Business Planning • 8/8 meetings Planning & & Performance Performance Assurance Committee • All • NHS Wales Shared attended Services Partnership by deputy • Charitable Funds • 4/4 meetings Committee • 3/5 meetings • Quality Safety & Experience • 7/7 meetings Assurance (or via Committee deputy) • Audit & Risk Assurance Committee

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Caroline Director of • Board • 7/7 meetings • Children Oakley Nursing, • University Partnership • 2/2 meetings Quality Board • 6/8 meetings & Patient • Business Planning Experience & Performance Assurance • 5/7 meetings Committee • Quality Safety & Experience Assurance Committee Kathryn Director of • Board • 4/7 meetings • Chronic Davies Commissionin • University Partnership • 2/2 meetings Disease g, Primary Board • 4/7 meetings Management Care, • Quality Safety & • Therapies & Long Term Experience • 3/8 meetings Health Care

Scientists Assurance Committee • Business Planning • 1/4 meetings & Performance Assurance • 3/3 meetings Committee • Primary Care • 3/3 meetings Applications Committee • Welsh Health Specialised Services Committee • Emergency Ambulance Services Committee Lisa Director of • Board • 6/7 meetings N/A Gostling Workforce & • University Partnership • 2/2 meetings Organisational Board • 6/7 meetings Development • Quality Safety & Experience • 8/8 meetings Assurance Committee • Business Planning • 6/6 meetings & Performance • 4/4 meetings Assurance Committee • Staff Partnership Forum • Remuneration & Terms of Service Committee Teresa Director of • Board • 7/7 meetings N/A Owen Public Health • University Partnership • 2/2 meetings Board • 7/7 meetings • Quality Safety & Experience • 8/8 meetings Assurance Committee • Business Planning & Performance Assurance Committee

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Sarah Director of • Board • 7/7 meetings • Armed Jennings Governance, • University Partnership • 2/2 meetings Forces Commu- Board • 3/5 meetings nications • Quality Safety & & Experience • 6/7 meetings Engagement Assurance Committee • Business Planning • 6/7 meetings & Performance Assurance • 4/4 meetings Committee • 4/4 meetings • Audit & Risk Assurance Committee • Stakeholder Reference Group • Charitable Funds Committee

Joanne Board • Board • 7/7 meetings N/A Wilson Secretary • Audit & Risk • 7/7 meetings Assurance Committee Phil Kloer Medical • Board • 6/7 meetings N/A Director • University Partnership • 0/2 meetings & Director of Board • 5/7 meetings Clinical • Quality Safety & Strategy Experience • 4/8 meetings Assurance Committee • Business Planning & Performance Assurance Committee

At a local level, Health Boards in Wales must agree Standing Orders for the regulation of proceedings and business. They are designed to translate the statutory requirements set out in the LHB (Constitution, Membership and Procedures) (Wales) Regulations 2009 into day to day operating practice, and, together with the adoption of a scheme of matters reserved to the Board; a scheme of delegation to officers and others; and Standing Financial Instructions, they provide the regulatory framework for the business conduct of the University Health Board and define - its 'ways of working'. These documents, together with the range of corporate policies set by the Board make up the Governance Framework.

The following table outlines dates of Board and Committee meetings held during 2015/2016, with all meetings being quorate:

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Meeting Dates of Meeting Board 28.05.2015 03.06.2015 30.07.2015 24.09.2015 26.11.2015 28.01.2016 31.03.2016 Audit & Risk 05.05.2015 03.06.2015 11.08.2015 13.10.2015 12.01.2016 09.02.2016 08.03.2016 Assurance Charitable 29.06.2015 03.09.2015 10.12.2015 10.03.2016 Funds Quality Safety & Experience 21.04.2015 26.05.2015 01.07.2015 18.08.2015 20.10.2015 15.12.2015 16.02.2016 Assurance Mental Health Legislation 11.06.2015 10.09.2015 10.12.2015 10.03.2016 Assurance Business Planning 30.06.2015 25.08.2015 22.10.2015 24.11.2015 17.12.2015 26.01.2016 23.02.2016 29.03.2016 Performance Assurance Primary Care 13.10.2015 01.12.2015 02.02.2016 23.02.2016 Applications University Partnership 07.07.2015 16.11.2015 Board Remuneration & Terms of 28.05.2015 04.08.2015 30.09.2015 26.11.2015 Service

The UHB and its Committees The Committees of the Board, chaired by Independent Members, have key roles in relation to the Governance and Assurance Framework. On behalf of the Board, they provide scrutiny, development discussions, assessment of current risks and performance monitoring in relation to a wide spectrum of the Health Board’s functions and its roles and responsibilities.

During the year, resulting from the recommendations of the governance review, a streamlined committee structure has been introduced. The resultant strengthening of committee governance arrangements supports effective scrutiny, has reduced duplication and ensured improved coordination across committees. This has enabled the Board to actively focus on strategy, delivery and assurances, shaping a strong, cohesive culture, whilst ensuring its other responsibilities are discharged effectively. At the time of implementation it was agreed to undertake an evaluation in twelve months to review the effectiveness of the revised committee structure and this will proceed during the first part of the 2016/2017 financial year. Together with a revised Scheme of Reservation and Delegation, clarifying roles and responsibilities of Executive Portfolios, there is clarity regarding where decisions are taken and what delegated decision making powers are assigned to individual executives. In order to ensure that the objectivity of Independent Members is not impaired, there has been a realignment of chairing arrangements for both committees and sub committees.

The committees have met regularly during the year with update reports outlining key risks and highlighting areas of development being provided to the Board to contribute to its assessment of assurance. The Committees as well as reporting to the Board also work together on behalf of the Board to ensure where required that cross reporting and consideration takes place and assurance and advice is provided to the Board and the wider organisation. The Wales Audit Office (WAO) Structured Assessment 2015

113 acknowledged that important changes to the structure and operation of Board committees have strengthened overall governance and assurance although opportunities for further improvement remain. The Health Board is committed to ensuring that this work continues.

Our system of Governance and Accountability during the year is therefore demonstrated in the following diagram:

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Governance & Accountability Framework 2015/2016

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The Board In governing the business of the organisation, all Executive Directors and Independent Members are collectively and corporately accountable for the Health Board’s performance. This is fundamental to the Board’s role in pursuing performance and ensuring that the interests of patients are central and creates a culture supporting open dialogue. Governance is not a static concept and this is reflected by the increased focus on ethics, equality and diversity and the Health Board is committed to being honest and improving values and behaviours. The Board has moved to holding its meetings across the three counties with a focus on local as well as wider Health Board issues. We have placed an increased focus on risk with greater openness, transparency and honesty regarding the issues discussed. The WAO’s 2015 Structured Assessment concluded that the Board has been strengthened and is operating more effectively and is now the main decision making forum.

The Board, in working to a planned programme of work, adapted as necessary to respond to emerging events and circumstances has, during the year, discussed and considered, amongst other items, the following areas of Health Board activity:

UHB Wide Issues • Confirmed support for the on-going recruitment strategy, endorsing (Approval) the contents of the report on hospital services; • Confirmed its support for the work being undertaken by the Oncology Programme Board to develop a model for safe and sustainable oncology services; • Approved the refreshed Cancer Delivery Plan 2015/2016; • Approved the recommendations from the External Governance Review, including changes to Executive Directors portfolios, voting arrangements on the Board and revised committee structure; • Approved the revised Major Incident Plan and Civil Contingencies Strategy; • Agreed the further actions proposed to mitigate the risks highlighted in the Corporate Risk Register to provide the necessary assurance that internal control is being enacted appropriately; • Approved the monitoring report on the UHB’s Welsh Language Scheme for the Welsh Language Commissioner; • Approved the Committee’s Annual Reports and the Governance and Accountability Module; • Approved the Annual Quality Statement, Annual Governance Statement, Annual Accounts, Letter of Representation and WAO ISA 260 for submission to Welsh Government; • Approved UHB’s Annual Report; • Approved Hywel Dda Health Charities Annual report and Accounts 2014/2015; • Ratified the UHB’s involvement in the ARCH programme and the commitment to work with all partners to further develop the work programme; • Agreed, subject to some areas requiring further clarification, the Emerging Informatics Strategy; • Approved the UHB’s revised Standing Orders & Standing Financial Instructions and revised Risk Management Strategy and Policy; • Approved the UHB’s Winter Plan 2015/2016; • Approved the draft IMTP 2016/2017 to 2018/2019 and the enabling plans;

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• Approved the Strategic Equality Plan and Objectives for 2016-2020; • Approved the Together for Mental Health Annual Report; • Approved the Director of Public Health Annual Report; • Approved several recommendations in relation to funded nursing care. Health Board • Endorsed the findings and recommendations of the Oncology Service Wide Issues Review report and agreed the Oncology Implementation Plan and (Endorsement) governance arrangements; • Endorsed the establishment of a Programme Management Office drawn from a range of functions to oversee the performance assurance framework and in-year delivery of the 2015/2016 IMTP; • Discussed, at an early stage in the year, the concern to achieving the forecasted year end position and endorsed further actions to improve the position; • Endorsed the findings and recommendations of the Royal College of Paediatricians and Child Health independent review summary report and approved the ensuing action plan; • Endorsed the report presented on the UHB’s progress on Nursing & Midwifery Council Revalidation and what further action needed to occur; • Received the Women & Children’s monitoring report providing information for the first year of operation of the reconfigured service; • Supported and endorsed the UHB’s plan including the principles and actions proposed to embed Prudent Healthcare within the organisation at greater scale to achieve impact over the coming years; • Supported and endorsed the development and implementation of a new mental health service model across the Health Board; • Endorsed the development of the draft Board Assurance Framework and the further development required after approval of the UHB’s objectives for 2016/2017; • Endorsed the audit findings of the Health & Care Standards/Fundamentals of Care (2015) which provided an assurance that the care delivered within the Health Board continues to achieve a high level of satisfaction amongst patients, whilst also identifying areas of improvement. Focus on • Acknowledged the challenges faced in the delivery of services across Pembrokeshire Pembrokeshire and supported the on-going service changes to Issues ensure sustainable healthcare services for the future, included in the reports on the Focus on Healthcare in Pembrokeshire; • Approved the proposed model for services at Withybush Hospital, recognising the current position in relation to services and supporting the ongoing development of community services to ensure sustainable healthcare services for the future; • Re-confirmed the commitment to delivering the refurbishment and upgrade of cancer services at Withybush Hospital in line with the overall clinical model for the hospital and the future direction of the UHB’s model for delivery of healthcare services across the • three counties; • Approved the investment required for the CDU scheme at Withybush Hospital; • Approved the Pembrokeshire Carers Strategy 2015-2020. Focus on • Acknowledged the challenges faced in the delivery of services across Ceredigion Ceredigion and supported the on-going service changes to ensure issues sustainable healthcare services for the future, included in the reports

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on the Focus on Healthcare in Ceredigion; • Supported the work undertaken by the Mid Wales Healthcare Collaborative and to note the achievements that are being made. Focus on • Acknowledged the challenges faced in the delivery of services across Carmarthenshire Carmarthenshire and supported the on-going service changes to Issues ensure sustainable healthcare services for the future, included in the reports on the Focus on Healthcare in Carmarthenshire; • Approved the proposed actions to alleviate parking issues at Glangwili Hospital; • Received progress reports on the proposals for re-design of Unscheduled Care and Community Services in Prince Philip Hospital; • Endorsed the current approach in using data for quality improvement purposes as outlined in the report on Mortality and Harm – Using Data for Quality Improvement.

Triangulation of Information At the Hywel Dda University Health Board, there is recognition that it is important for Board and Committee members to be able to form opinions and judgements based on information assimilated from multiple sources. The inclusion of both Patient and Staff Experience stories at the start of each Board meeting followed by Board member walkabouts at the end of meetings enables triangulation of performance information/Board reports with such other sources of assurance. During the year this has helped with focusing challenge and scrutiny which ultimately support increased risk management.

Board Development Programme During the year, the Board has participated in the ongoing Board Development Programme facilitated by Academi Wales, which has clear aims and expected learning outcomes. The programme has involved separate facilitated development sessions with both Independent and Executive Team Members. Further to Academi Wales’ attendance to observe procedures at a meeting of the Board in public, several recommendations were forthcoming which captured key areas for review, discussion and action by individual Board members and the Board as a whole. These were accompanied by a number of future suggested interventions for further Board development which will be given considered during the forthcoming year. Combined with the implementation of the 58 recommendations contained in the External Governance Review, the Board is well placed to address the challenges it faces.

The above programme has been supported by locally designed initiatives and development sessions, with Board Members participating in the Health Board’s Board Development Sessions and Board Seminars, both of which have been held on a regular basis during the year. The combination of Board Organisational Development (OD) sessions and Board Seminars has provided the Board with an opportunity to receive and discuss subjects/topics which provide additional sources of information and intelligence as part of its assurance framework. This in turn assists with the Board’s ability in adequately assessing organisational performance and the quality and safety of services. In terms of governance, one of the Board OD sessions focused on the implications of the overall role of the Board and its members in gaining a common understanding and some guidance for effective governance within a governance framework. Other sessions have featured:

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• The External Review of Governance Arrangements; • Presentation on ‘Well-being of Future Generations (Wales) Act 2015’; • Presentation by Members of the Bevan Commission; • Presentation on ‘Welsh Political Landscape’; • Presentation on ‘Social Services and Well-being (Wales) Act 2014’; • Presentation on the proposed Welsh Language Standards.

From a personal perspective, the Chair and I have participated jointly in Academi Wales’ ‘Two at the Top’ programme, designed to develop the effectiveness of our relationship in providing leadership to the Health Board.

Audit and Risk Assurance Committee (ARAC) Emanating from the recommendations made in the External Review of Governance reflecting its enhanced responsibility for overseeing risk management processes across the organisation, the Audit Committee was given a revised title of ‘Audit & Risk Assurance Committee’.

The report recognised that the Committee is well organised, understands its assurance role and works hard to ensure that it covers the totality of the business whilst also retaining its focus on assuring strong financial governance across the organisation. The Audit and Risk Assurance Committee’s primary role is to ensure the system of assurance is valid and suitable for the Board’s requirements and it should review whether:

• The system of assurance is appropriate for the organisation; • The processes to seek and provide assurance are robust and relevant; • The controls in place are sound and complete; • Assurances are reliable and of good quality; and • Assurances are based on reliable, accurate and timely information and data.

In supporting the Board by critically reviewing governance and assurance processes on which reliance is placed, ARAC in its reporting to the Board has specifically commented during the year on:

• The Committee’s concerns regarding the financial position, with the matter being escalated to the Board to ensure that clear assurance is provided on how the Health Board will reach its forecast position; • The Head of Internal Audit Opinion and other opinions on the adequacy of disclosure statements for 2015-2016, including the overall adequacy and effectiveness of the organisation’s risk management, control and governance processes; • Discussed and approved for recommendation to the Board, the Health Board’s Annual Quality Statement, Annual Governance Statement, audited financial statements and Auditor General’s Opinion; • The Health Board’s assessment against various reports/reviews including the Targeted Intervention and Capital Governance reviews at BCUHB and lessons learnt from such reviews, identifying any actions to be taken; • The review of the Board’s Standing Orders, Standing Financial Instructions, Scheme of Delegation and the Committee’s own Terms of Reference, revised in

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accordance with the external governance review and recommended for approval to the Board; • The Health Board’s revised Risk Management Strategy and Policy, inclusive of the Board’s risk appetite, with recommendation for Board approval; • The Board’s risk register, with particular reference to reviewing high scoring risks remaining at the same level for six months or more with Executive Directors being held to account via discussions; • WAO performance and financial audit reports, the Health Board’s management responses and monitoring delivering of action plans. The Committee has expressed concern regarding the pace of implementation of recommendations for a number of reports and in some instances, the standard of management responses; • The Board was informed of the Committee’s concerns regarding the lack of progress made in implementing recommendations from the WAO Data Backup Review and Information Governance Follow Up reports. Concerns were expressed regarding the lack of adequate back up arrangements and the limited progress made in improvements to data quality; • Specific concerns expressed and highlighted to the Board in respect of some cyclical internal audit reports which continuously identify the same areas of learning, with the Committee challenging why learning is not being shared across the organisation; • The Committee’s concerns regarding the Health Board remaining at ‘Enhanced Monitoring’ status, and in view of this position that it should be included on the Health Board’s risk register. In view of this, I have, at the Committee’s request, attended and provided assurance on progress made and the future work planned in order for the Health Board to be de-escalated from its current position.

Any Internal Audit reports receiving less than reasonable assurance rating or if any specific area of concern were identified and were subject to increased scrutiny, in order that suitable assurances could be obtained. In addition, the Committee has requested an extraordinary meeting to be convened at the commencement of the new financial year to review all WAO reports and Health Board management responses over the last 12 months to ensure progress has been made in accordance with agreed timescales.

The Audit and Risk Assurance Committee, in accordance with best governance practice, has undertaken a self assessment and evaluation of its own performance and operation, with members being constructive in their responses, commenting on processes and procedures, with areas for development being identified. In conclusion, it was concurred that the assessment demonstrated that the Committee is effective in its performance and that the Board can take assurance from this. This was reaffirmed in the Structured Assessment with it being stated that the Audit and Risk Assurance Committee works effectively with a stronger focus on assurance and holding to account.

The Committee is therefore a key source of assurance to the Board that the organisation has effective controls in place to manage the significant risks to achieving its strategic objectives and that controls are operating effectively. In a period of rapid change where far-reaching decisions have to be made, it is vital that risk management is at the heart of the process. During the year, we have started to make progress in moving away from being an organisation where risk management was considered to be a rather bureaucratic exercise and not always used successfully to a position where it can be

120 used effectively to help achieve our objectives and improve decision making. The ARAC has a key role to play in supporting the application of good governance principles in decision making and is well placed to understand the risks to good governance faced by Health Board, such as risks arising from external factors e.g. legislative changes or risks arising from changes or initiatives within the organisation

Supporting and encouraging the effectiveness of risk management is a valuable role provided by the ARAC. A good understanding amongst ARAC members of what risk management can and should be doing has raised the profile of risk management across the organisation. By monitoring the performance of risk management and any obstacles to improvement, the ARAC has helped to ensure the adoption of good practice across the organisation. In reviewing the Health Board’s key risks it has sought assurance that the actions being undertaken are having an effect and questions from the ARAC have assisted with ensuring that the appropriate action has been taken.

In addition the ARAC held an extraordinary meeting in February 2016, whereby the Committee scrutinised the risks included in the Corporate Risk Register that had remained as extreme risks for six months or longer, as at that point in time the Board had not agreed its tolerance levels. At the specific request of the ARAC Chair, Executive Directors were in attendance to discuss these high level risks. Each individual risk was reviewed in detail and during the workshop there was collective evaluation of whether adequate controls and mitigation were evident to manage the extreme risks identified from the respective portfolios. Although Members recognised that some progress had been made, the Committee agreed that significant progress needed to be made at pace. Further guidance was provided to risk owners, with a letter from the Audit and Risk Assurance Committee Chair, setting clear expectations and timescales for completion of this work. A further extraordinary meeting will be held in May 2016 to further review these risks. This work will be taken forward within the new financial year.

In assisting the Health Board to become more open and transparent the ARAC papers are now available on our public facing website. The ARAC also provides a detailed update report to each Board meeting alongside an independent report of progress against the Committee’s work programme and associated business. Please click on link for further information: http://www.wales.nhs.uk/sitesplus/862/page/73602.

Business Planning and Performance Assurance Committee (BPPAC) Established as one of the recommendations of the external governance review and implemented with Board approved Terms of Reference, the Committee has provided one of the internal control mechanisms for providing assurance, with the following being some of the matters highlighted to Board:

• Financial Position – challenges and pressures faced by the Board noted to be of concern with more information required to be brought back to the committee to explain the reasons behind savings plans slippage; • Progress on the Health Board Operational Plan 2015/2016, developed to manage the risk of an unapproved Integrated Medium Term Plan; • Progress on the Integrated Medium Term Plan; • Approval of Together for Health Delivery Plans;

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• Approval/extension of Information Governance Policies and Corporate Written Control Documentation; • Discretionary Capital Programme – assurance provided that robust mechanisms are in place for risk assessment, prioritisation and funding of high level risks, with limited assurance with regard to the funding of backlog and statutory compliance risks and approval of management’s approach to the distribution of the capital allocations; • Performance information - through the Integrated Performance Assurance Report, with particular focus on Key Patient Flow; • Respiratory Medicine Service Provision – Outline of discussion and recommendation of preferred option to the Board; • Acute Medical On-Call Model for the four main hospital sites - the committee commended the model to the Board for inclusion in the IMTP and for as early implementation as possible; • Re-design of Unscheduled Care in PPH - the Board was provided with assurance that the development of the new service model for urgent care within Prince Philip Hospital had been overseen by the Programme Board and had been subject to the appropriate Gateway Review process by the Committee; • Update on Mid Wales Healthcare Collaborative- the Committee was assured that the work of the collaborative would complement and help the way business is delivered in Hywel Dda. However, it acknowledged the complex governance structure involved needed careful management. The detail of those matters on which BPPAC has briefed the Board regarding internal control matters during the year are included in the regular update reports, the minutes of the meetings and the Annual Report to the Board, all of which can be accessed through the following link on the Health Board’s website: Business Planning and Performance Assurance Committee: http://www.wales.nhs.uk/sitesplus/862/page/83830

Quality, Safety and Experience Committee (QSEAC) In discharging its role, the Committee has overseen and monitored activities in accordance with its Terms of Reference with some of the key highlights in the reports to Board including the following:

• The development of an action plan in place to clear the backlog of open incidents by March 2016, with monitoring the backlog of open incidents and complaints being a standing agenda item for the Committee until there was sufficient assurance of effective management enacted; • Ensuring that quality and safety issues are considered in the IMTP; • Recommendation of approval of the Annual Quality Statement by the Board; • The outline of a patient story to the Board in each update report; • Updates on medical device training relating to medical pumps; • The issues faced by the Health Board relating to Ophthalmology service challenges; • The Elective Surgery Report to be presented to the Executive Team to escalate the concerns recognised and identification of solutions; • The outcome of the Health & Care Standards/Fundamentals of Care Annual Audit 2015. This was undertaken using the new 22 Health & Care Standards as the basis, with the results remaining stable, demonstrating the excellent work

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undertaken by the nursing workforce, despite the Health Board experiencing a challenging year given the significant gaps in recruitment; • The Committee’s concerns regarding the low levels of compliance with mandatory training.

The detail of those matters on which QSEAC has briefed the Board regarding internal control matters during the year are included in the regular update reports and Annual Report to the Board, all of which can be accessed on the Health Board’s website. Further information on the detailed work undertaken by QSEAC focusing on patient care and outcomes can also be found in the Annual Quality Statement and/or by accessing the following link in the Health Board’s website: Quality, Safety and Experience Assurance Committee: http://www.wales.nhs.uk/sitesplus/862/page/72049

The Committee, as reported in the 2015 Structured Assessment, is now more strategic and focused on gaining appropriate assurances. However, it was recognised that it was not always getting the right level of assurance from its sub committees, with a better use of exception reporting required. It is my opinion that as we further embed the recommendations of the external governance review, greater clarity of reporting will be achieved.

Mental Health Legislation Assurance Committee In working to its remit agreed as part of the External Review of Governance and in respect of its provision of assurance to the Board, the following represent some of the key issues which the Committee highlighted during the year: • Quarterly Performance Reporting on the Mental Health Act 1983, providing assurance on compliance; • Update reports from the Hospital Managers Power of Discharge sub -committee; • Update reports from Mental Health Legislation Scrutiny Sub-Committee; • Update on progress made in implementing action plans following HIW announced and unannounced inspection visits with concerns raised regarding delays in progressing estates issues; • Concerns regarding the progress made in the development of equitable psychiatric liaison services across the University Health Board; • Compliance with Welsh Government targets on the use of the Mental Health Act 1983, as amended (the 1983 Act) and the Mental Health (Wales) Measure 2010; • The Board to consider identifying an Executive Lead to manage the risk associated with the use of paper case notes in Specialist Child and Adolescent Mental Health Services as this is not in line with future WG plans for a national electronic recording system (Community Care Information System (CCIS) for all mental health and primary care services. • Concerns regarding delays in agreeing the Joint Section 117 Policy (entitles individuals to receive free aftercare if they have been in hospital under Section 3, 37, 45A, 47 or 48 of the MHA 1983) with local authority partners, with the matter to be escalated within all three local authorities.

Primary Care Applications Committee The Primary Care Applications Committee determines Primary Care contractual matters on behalf of the Health Board and in accordance with NHS regulations. During the year, the Board was informed of the following key matters:

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• Premises Improvement Grant 2015/16 – Approval of £87,087 subject to a review of the proposal for investment into Health Board owned property. • Actions proposed regarding governance arrangements for managed GP practices; • Approval of GMS contract changes from Partnerships to Single Handed Practitioners; • The Committee approved the principles of supporting GMS practices to merge subject to the changes recommended to the documentation and outcome measures presented at the meeting; • Change of ownership and /or hours in Community Pharmacy; • Contract variations, including contractual activity change in General Dental Services.

Charitable Funds Committee The Charitable Funds Committee is charged with providing assurance to the Board in its role as corporate trustees of the charitable funds held and administered by the Health Board. It makes and monitors arrangements for the control and management of the Board’s Charitable Funds within the budget, priorities and spending criteria determined by the Board and consistent with the legislative framework. In discharging its duties, matters highlighted to the Board included the following:

• Updates on the performance of the charity’s investments; • Committee’s awareness of the need to manage expectations and safeguard the Health Board’s reputation in terms of charitable funds; • Recognition that there was a need for a change in the strategic direction of the charity due to the decline in charitable donations in recent years. A new structure was approved to strengthen fundraising and resilience building which should help reverse the decline in donations; • Updates on funding requests.

In addition to the Committees referred to above, the Health Board is also required to have three Advisory Groups, these being:

Stakeholder Reference Group (SRG) The Group is formed from a range of partner organisations from across the Health Board’s area and engages with and has involvement in the Health Board’s strategic direction, advises on service improvement proposals and provides feedback to the Board on the impact of its operations on the communities it serves. Meetings were convened on a regular basis with a review of the Group’s Terms of Reference undertaken during the year. Although no major changes were required, concerns were expressed regarding membership and lack of attendance in some instances with clarification to be sought on representation on the Group and these matters are being addressed.

Progress made on the development of the Integrated Medium Term Plan continued to be a significant issue of engagement and discussion with the Group. This demonstrated its co-production with colleagues, with feedback provided from the Group that the plan was too long, repetitious and contained some jargon, being taken on board. The Group was informed that the IMTP was not yet approved by the Welsh Government as there was a need to demonstrate financial balance over the period of the plan, which remained a

124 huge challenge. A further significant matter on which the Group was consulted was the redesign of adult mental health services across the Health Board, with the SRG commenting that the model with more community services would be preferable. Other key issues during the year included discussions relating to Unscheduled Care provision across the four main hospital sites with the Group being supportive of the work being undertaken, and a review of the Sgwrs Iach – Let’s Talk Health events, with workshop sessions as a development in future sessions being welcomed. A presentation was received on Prudent Healthcare, a concept of which the Group is supportive, noting that it is not about reducing costs but about individuals taking responsibility for their health by working in coproduction with professionals. The Group was also supportive of the Health and Social Care Support Workers pilot project, expressing the view that it wished to see roll out across the Health Board area. For future meetings, the Group has requested an update on the position regarding ‘A Regional Collaborative for Health’ (ARCH) and the Mid Wales Collaborative. The Board received assurance reports following each meeting but there were no matters requiring board level consideration or approval.

Local Partnership Forum The Forum is responsible for engaging with staff organisations on key issues facing the Health Board and met regularly during the year. It provides the formal mechanism through which the Health Board works together with Trade Unions and professional bodies to improve health services for the population it serves. It is the forum where key stakeholders engage with each other to inform debate and seek to agree local priorities on workforce and health service issues. During the year, significant strategic issues discussed included progress on the Integrated Medium Term Plan, Clinical Services Strategy, Withybush General Hospital Temporary Transfer of Service, Professional Nurse Staffing Standards and Escalation Plan and Transforming Mental Health Services. The forum was also provided with and discussed on a regular basis, the position regarding Glangwili General Hospital car parking, the financial position, updates on Paediatrics, Neonates and Maternity Services and the risk register. Assurance was provided to the Board that strategic workforce risks are being mitigated across the Health Board through partnership working and engagement.

Healthcare Professionals’ Forum The Forum comprises representatives from a range of clinical and healthcare professions within the Health Board and across primary care practitioners and provides advice to the Board on all professional and clinical issues it considers appropriate. Following confirmation from Welsh Government at the start of the year that no changes would be made to the advisory bodies of Health Boards’, the intention was to proceed to renew and refresh the membership in order for the Board to be supported from the functions provided by the Forum. It is disappointing to note therefore that due to constant conflicting priorities and demands on the time of the members, the forum was only able to meet once during the past twelve months. This has been recognised by the Board as a matter which now requires an invigorated approach, with measures in place to ensure that the Forum plays its full part in supporting the Board at a time of increasing challenge. At the one meeting that was held, operational delivery was discussed, focusing on reducing silo working to improve patient care and initiating a joined up approach to patient pathway design and management.

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Other Committees of the Board In addition to the above, the Welsh Health Specialised Services Committee (WHSSC) (Wales) Regulations 2009 (SI 2009 No. 3097) made provision for the constitution of a ‘Joint Committee’. This committee comprises all the Welsh Local Health Boards and is a sub-committee of each Board, with Hywel Dda University Health Board being represented by the Chief Executive. The Health Board also has representation on the NHS Wales Shared Services Partnership Committee which is considered as a sub- committee of the Board, at which the Health Board is represented by the Chief Executive’s Project Manager. The establishment of the Emergency Ambulances Services Committee at which the Health Board is represented by the Chief Executive is also a Joint Committee of the Board. The Lead Officers and/or Chairs from the joint Committees, NWIS and NWSSP have all attended a public Board meeting or a Board Seminar meeting to discuss progress made and to assure the Board the governance arrangements are being discharged appropriately and in the best interests of our population.

Governance and Accountability It is always considered good governance practice to review the Health Board’s Standing Orders (SOs) and Standing Financial Instructions (SFIs) and this year these were reviewed to reflect the changes introduced as a result of implementing the recommendations of the external governance review. These were scrutinised by the Audit Risk and Assurance Committee and approved by the Board in November 2015.

The Terms of Reference for the Health Board’s Committees (including the Advisory Committees) were reviewed at the same time with a view to strengthening the governance and reporting arrangements to provide the Board with a greater level of assurance. Although as Chief Executive I retain accountability, the Scheme of Delegation reflects the responsibilities and accountabilities delegated to Executive Directors for the delivery of the University Health Board’s objectives, whilst ensuring that high standards of public accountability, probity and performance are maintained. Since the time of writing this statement last year, I am pleased to be able to report that permanent appointments were made to several key positions on the Board, with clarity in respect of Executive portfolios. This provides the stability and expertise required in order for the Board to execute its duties effectively and means each member being clear about what their role is and the role of the other members. I also acknowledge that there will be further changes with both Executive Directors and Independent Members. As this presents a potential risk for the continuity of the Health Board, succession plans have been developed to mitigate this risk and we will work closely with Welsh Government to achieve this. The streamlined committee structure, the roles of the Committees and Advisory Groups, their relationship with the Board and a clear scheme of delegation means that we can demonstrate ‘Knowing Who Does What and Why’, in that we have crystal clear clarity and unanimity about everyone’s role and how it fits into the bigger picture.

This principle is not limited to operating within the boundaries of the Health Board as it also means being clear about how it relates to its partners and stakeholders, how it fits into the wider picture and being clear about how the various arms of Welsh Government fit into the picture. During the year we have undertaken work to strengthen partnership governance. One of the underpinning principles recognised by the Board is that

126 governance is about vision, strategy, leadership, probity and ethics as well as assurance and transparency, and should provide confidence to all stakeholders, not only to the regulators, in the delivery of objectives. However, we recognise there is more to do develop a fully robust partnership framework and to ensure the Health Board has robust governance in place in respect of the Well-being of Future Generations (Wales) Act 2015, the Social Services and Well-being (Wales) Act 2014 and the introduction of the Public Service Boards.

The Health Board regularly circulates its Stakeholder Briefing which informs both the organisation and the wider community, in particular partner organisations, of current developments and progress made across a range of subjects. These can be found on the Health Board’s website on the following link: http://www.wales.nhs.uk/sitesplus/862/page/67271.This sharing of information is further enhanced by the Health Board’s use of a range of social media channels.

The governance structure of the Health Board accords with the Welsh Government’s Governance e-manual and Citizen Centred Governance Principles in that the seven principles together with their key objectives, provide the regulatory framework for the business conduct of the Health Board and define its 'ways of working'. These arrangements support the principles included in HM Treasury’s ‘Corporate Governance in Central Government Departments: Code of good practice 2011’.

Governance in Primary Care

Primary Care Applications Committee: Following the external governance review, the Primary Care Applications Committee was established, the first meeting held in October 2015. The purpose of the Committee is to determine Primary Care contractual matters on behalf of the Health Board, and in accordance with the appropriate NHS regulations. As detailed earlier in my statement, during the 4 meetings held in 2015/16 the Committee discussed matters relating to a sustainability application by a Pembrokeshire GP practice, GP branch closure, opening hours and border change applications, Community Pharmacy opening hours and ownership applications and dental contractual changes and the issuing of remedial and breech notices. Furthermore it has been a useful forum for discussing primary care estates developments and priorities as well as broader GP sustainability issues.

A further governance review will be undertaken in 2016/17 to ensure that the strategic and non-contractual issues have an appropriate forum for discussion and development which reports appropriately to the existing Health Board committee structure.

Primary and Community Quality, Safety and Experience Sub-committee: Any issues related to governance including performance dashboards, exception reports and risk registers are presented at this Sub-Committee. Where the issues relate to information technology (IT) or delivery of the primary care elements of the IMTP, these issues are discussed at the Business Planning and Performance Assurance Committee, especially if it involves collaborative work with both primary and secondary care to resolve some of the IT and governance issues.

The Complaints and Incidents Management ‘Putting Things Right’ (PTR) Facilitator liaises with practices on Putting Things Right Regulations and where it has been

127 identified in an Ombudsman report that a practice may need further support in adhering to the PTR guidance. Practices follow this guidance when dealing with complaints and incidents and all have their own complaints procedures. The Quality and Outcomes Framework contains an annual review of complaints within the practice. All complaints concerning Primary Care received into the central hub are screened by the Quality Manager to ascertain whether it is a matter for the practice to investigate the concern or whether the Health Board needs to investigate. Case studies, action plans and lessons learned are also fed into the Improving Experience Sub Committee and in some cases the Primary Care Performers Issues Group.

Clinical Governance Primary Care Self Assessment Tool (CGPSAT): This tool is designed to encourage GP practices to reflect and assess the governance systems they have in place in order to facilitate safe and effective clinical practice, and can be mapped to Health and Care Standards in Wales. The CGPSAT may act as an assurance to other bodies such as the Health Board, the General Medical Council and Community Health Councils that such systems are in place and effective or, if not, that the practice is planning to introduce or improve such systems. The CGPSAT is now part of the Quality and Outcomes Framework (QOF) and the Health Board will be monitoring practices that have completed levels of self assessment, areas for improvement and areas identified, to be incorporated into the practice plan for development.

Risk Registers: It is recognised within Primary Care that effective risk management is integral to the achievement of all Health Board’s objectives. The Primary Care risk register highlights the current and ongoing risks in Primary Care and actions and progress are monitored and updated bi-monthly; it demonstrates that robust mitigation plans are in place wherever possible and highlights to the Health Board where there are risks but where currently no further action can be taken. Primary care performance issues are monitored and discussed at bi-monthly Performance Issues Group meetings and the recommended actions put in place. A joint Primary and Secondary care performance issues report is also produced annually and taken to the Board.

Primary Care Prescribing Leads Group: There is a robust system of prescribing monitoring in the Health Board and issues are discussed at the GP Prescribing leads group where peer review also takes place. Medicines Management technicians work with practices across the three counties to address certain areas of work and ensure that equity and quality is maintained across the whole of the Health Board. Representatives from each practice attend this meeting. Medicines Management are also linked in to cluster work with some clusters appointing Cluster Pharmacists.

Community Pharmacy Contractual and Performance Monitoring: The Community Pharmacy dashboard which monitor activity and performance. The main monitoring for Community Pharmacy is via the on-line toolkits, submission of audits, and level of complaints. Pharmacies have to complete an annual on-line Clinical Governance Self Assessment Toolkit and an Information Security & Management System (ISMS) Toolkit. Pharmacies are monitored as to whether it’s been completed by NHS Wales Informatics Service, who provide updates from the beginning of April. Toolkits have to be completed by 31st March. In the last 6 months, Post Payment Verification (PPV) have commenced visits to pharmacies for a specific enhanced service, but only a small number have been undertaken so far. The Shared Services Partnership has

128 indicated that they will be stepping up their PPV visits to Community Pharmacies over the coming year, with a particular focus on Medication Usage Reviews.

Dental Contractual and Performance Monitoring: Contract reviews, Quality Assurance system returns, Community Dental Service and Health Inspectorate Wales visits all feed into the Primary and Community Care Quality, Safety and Experience Sub Committee and Performers Issues Group. The dental dashboard captures performance information and Tier 1 target information is captured quarterly.

The Purpose of the System of Internal Control The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risks; it can therefore only provide reasonable and not absolute assurances of effectiveness.

The system of internal control is based on an ongoing process designed to identify and prioritise the risks to the achievement of the policies, aims and objectives, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically. The system of internal control has been in place for the year ended 31 March 2016 and up to the date of approval of the annual report and accounts.

The Board is accountable for maintaining a sound system of internal control that supports the achievement of the organisation's objectives and has been supported in this role by the work of the following main committees, each of which provides regular reports to the Board.

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The Health Board recognises that scrutiny has a pivotal role in promoting improvement, efficiency and collaboration across the whole range of its activities and in holding those responsible for delivering services to account. The role of scrutiny is increasingly important at this time when the Health Board is responding to the challenge of financial constraints whilst continuously seeking to maintain and improve service delivery in response to rising public expectations. With continual increasing focus on collaborative working, developing and implementing effective joint scrutiny arrangements for such arrangements remains a priority. An example of this has been the strengthened relationship with our Community Health Council, with representation at Board and Committees. Future plans include a joint visit programme between CHC members and our Independent Board members.

The Board therefore draws on assurances from a number of different sources in order to demonstrate that the system of internal control has been in place, and combined, these provide the body of evidence required to support the continuous assessment of the effectiveness of the management of risk and internal control. The structured mapping of assurances is one of the fundamental steps in building an assurance framework and the Health Board’s system of assurance, mapped to ‘Safe Care, Compassionate Care’, demonstrating how internal control has been in place for the year ended 31st March 2016, is shown below:

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Aims of Risk Management At the Health Board it is acknowledged that delivery of healthcare services carries inherent risk. We recognise that an effective risk management framework, including our Risk Management Strategy and Policy, is an essential component of successful clinical and corporate governance. We believe that by approaching the control of risk in a strategic and organised manner, risk factors can be reduced to an acceptable and manageable level. This should result in better quality and safer care for patients and residents, and a reduction in unnecessary expenditure. By adopting a risk management approach, statutory obligations can be identified and fulfilled in a positive way, rather than as a means of avoiding litigation and prosecution. Risk management is important to the successful delivery of the Health Board’s services. We operate an effective risk management system that identifies and assesses risks, decides on appropriate responses and then provides assurance that the responses are effective. At the Health Board we understand the implications of risks taken by management in pursuit of improved outcomes in addition to the potential impact of risk-taking on and by its local communities, partner organisations and other stakeholders.

Risk Management Strategy and Policy During the year we undertook a revision of our Risk Management Strategy and Policy in order to:

(i) Incorporate amendments required to reflect the Health Board’s changing regulatory framework for risk management and risk reporting; (ii) Incorporate updated guidance on effective and enhanced risk management; (iii) Incorporate recommendations from the external governance review.

The revised Risk Management Strategy and Policy subsequently approved by the Board:

• Provides a framework for managing risk both across the organisation and in working with partners/stakeholders, consistent with best practice and Welsh Government guidelines; • Outlines the Health Board’s risk management objectives, our approach to and appetite for risk and approach to risk management; • Clearly defines risk management roles and responsibilities at each level of the organisation; • Details the risk management processes and tools in place, including reference to the risk register, risk reporting arrangements, frequency of risk activities and available guidelines; • Is underpinned by a Risk Management Procedure; • Includes a clear policy statement.

Policy Statement Hywel Dda University Health Board is committed to delivering the highest level of safety for all of its patients, staff and visitors. The complexity of healthcare and the ever-growing demands to meet health care needs means that there will always be an element of risk in providing high quality, safe health care services. The management of risks is a key factor in achieving the provision of the highest quality care to our patients. Of equal importance is the legal duty to control any potential risk to staff and the general public as well as safeguarding the assets of the organisation.

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The Health Board recognises effective risk management is a key component of corporate and clinical governance and is integral to the delivery of its objectives in service provision to the citizens of the health community. There will be a holistic approach to risk management across the Health Board which embraces financial, clinical and non-clinical risks in which all parts of the organisation are involved through the integrated governance framework. The mission of the Health Board supports the effective management of risk and the role of the individual. This requires all staff to recognise that there is a responsibility to be involved in the identification and reduction of risks. The Health Board will seek to ensure that risks, untoward incidents and mistakes are identified quickly and acted upon in a positive and constructive manner so that any lessons learnt can be shared. This will ensure the continued improvement in the quality of care and the achievement of the Health Board objectives. The commitment of the Health Board is therefore to: a) Minimise harm to patients, colleagues or visitors to a level as low as reasonably practicable b) Protect everything of value to the Health Board (such as high standards of patient care, reputation, community relations, assets and resources) c) Maximise opportunity by adapting and remaining resilient to changing circumstances or events d) Assist with managing and prioritising the business/activities of the Health Board through using risk information to underpin strategy, decision-making and the allocation of resources e) To ensure that there is no unlawful or undesirable discrimination, whether direct, indirect or by way of victimisation, against its service users, carers, visitors, existing employees contractors and partners or those wishing to seek employment, or other association with the organisation

Risk Management Procedure

• Provides the framework giving detailed guidance on the risk assessment process to be undertaken across the whole organisation in order to populate the Health Board’s risk register in a consistent manner; • Includes the processes of risk analysis and evaluation and makes it clear that the level of detail in a risk assessment should be proportionate to the risk; • Risk management requires participation, commitment and collaboration from all staff and the process starts with the systematic identification of risks throughout the organisation, documented on risk registers; • Executive Directors and Senior Managers are also responsible for ensuring that staff understand and apply both the Health Board’s Strategy and Procedure in relation to risk management.

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Risk Management Process

Risk Register The Health Board manages risk within a framework that devolves responsibility and accountability throughout the organisation, discharged through a Services, County/Community and Directorate (Executive Directors portfolio) structure. This ensures:

• Operational Risk Registers are developed at service delivery level within Services, County/Community and support directorates/areas of service managed strategically across the Health Board. These are populated, reviewed and monitored within each service/ county/support directorate structure through individual Senior Management Team arrangements; • All Executive Directors take responsibility for risk identification, management and mitigation within their areas of work and practice, in line with the management and accountability arrangements of the Health Board; • The Board’s Corporate Risk Register has reverted to being populated from the highest risks identified from across the whole of the Health Board’s services, with the board being fully sighted on these risks; • An effective risk management system should also ensure that assurance is obtained over whether responses put in place to manage and control identified risks, are effective. The Audit and Risk Assurance Committee has undertaken detailed scrutiny of those risks scoring 15+ for over six months and requested assurances that these are being appropriately managed and mitigated. Executive Directors/Risk Leads were required to be present to explain and discuss the rationale for the scoring of risk, in particular those in the high or extreme category; • Training sessions have been held during the year in order to equip staff with the ability to identify and consistently score risks.

Risk Appetite A significant enhancement during the year was the further development of the Board’s risk appetite aligned to a thematic approach. A Board workshop was held at which

135 members’ concurred that risk appetite is about managing the organisation and not about developing a statement to be filed in a report or included in a strategy and is only useful if it is clear and can be implemented across the organisation.

In determining its risk appetites, the Board accepted the following principles:

• Develop risk appetite – Risk appetite is not a single, fixed concept and neither is there a ‘right’ risk appetite. There will be a range of appetites for different risks which need to align and may vary over time; • Communicate risk appetite – several common approaches are used to communicate risk appetite. The first is to create an overall statement that is both broad and descriptive enough for organisations to manage risks consistently. The second is to communicate risk appetite for each strategic objective with the third being communicating for different categories of risk; • Monitor and update risk appetite – once communicated, the risk appetite needs to be revisited and reinforced – it cannot be set once and then left alone.

Taking the above factors into account, the Health Board’s overarching risk appetite, outlines its approach to risk in relation to four key areas of the business: quality, finances, performance and reputation.

Risk Appetite Statement The core aim of the Health Board is to ensure that it delivers high quality, sustainable services to patients. In doing so, the Board recognises that it is not possible to eliminate all the potential risks which are inherent in the oversight of healthcare providers and is willing to accept a certain degree of risk where it is considered to be in the best interests of patients.

The Board has considered the level of risk that it is prepared to tolerate in relation to key aspects of the business. The following paragraphs set out its attitude to risk in respect of four key domains.

1. Quality The Board is accountable for ensuring the quality and safety of the services it provides to patients. In setting clear expectations on quality through the planning guidance and holding to account for poor performance where the quality of service to patients is severely compromised, the Health Board would have a low appetite for risk. Decision making authority is held by senior management, either clinical or non-clinical, as appropriate. The Health Board’s corporate risk register will continue to reflect material risks that may prevent the organisation in fulfilling its role to deliver clinical services which meet set recognised standards/Health Inspectorate Wales/Standards for Healthcare.

2. Finances The Board has a low appetite to financial risk in respect of the statutory financial duties, i.e. delivery of the ‘break even’ duty, maintaining expenditure within the allocated resource limit and full adherence to internal expenditure and financial controls, including the demonstration of value for money in spending decisions.

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However, in recognition of the service and workforce challenges in addition to the financial environment in which we are operating and conditional upon maintaining delivery of quality services and compliance with the Welsh Government’s NHS Planning Framework, our risk appetite will increase in that we are willing to consider all potential delivery options that ensure the delivery of sustainable, high quality services.

The Board is prepared to support investments for return and minimise the possibility of financial loss by managing associated risks to a tolerable level. Value and benefits will be considered and resources allocated in order to capitalise on opportunities.

3. Performance Our performance and delivery function is currently operating in a complex environment that recognises very challenging economic conditions, changing demographics with intense political and regulatory scrutiny.

However, the continued delivery of high quality healthcare services, working towards service sustainability, requires some moderate risk to be accepted where this results in better healthcare services for patients. Decision making authority is generally held by senior management with innovations in practice avoided unless really necessary.

Our oversight methodology and process, underpinned by a risk-based escalation rating, subject to regular review, determines how the performance and delivery function engages with the Welsh Government, including the deployment of intervention and development strategies as required.

4. Public Confidence/Reputation The Board has a moderate risk appetite for actions and decisions that, while taken in the interests of ensuring quality and sustainability of the Health Board and its patients, may affect the reputation of the Board and its employees. The tolerance for risk taking will be limited to those events where there is little chance of any significant repercussion for the Board should there be a failure. Such actions and decisions will be subject to a rigorous risk assessment and will be signed off by a member of the Executive Team

The above statement flows into more specific risk appetites for categories of risk, directed by key drivers which are detailed in the Risk Management Strategy and Policy: http://www.wales.nhs.uk/sitesplus/documents/862/156- riskmanagementstrategy%26policy-v2.pdf

Management of Risk Members of the Board recognise that risk management is an integral part of good management practice and to be most effective should become part of the Health Board’s culture. The Board is therefore committed to ensuring that risk management forms an integral part of its philosophy, practice and planning rather than viewed or practiced as a separate programme and that responsibility for implementation is accepted at all levels of the organisation. The Health Board recognises that success will depend upon the commitment of staff at all levels, and the development of a culture of openness within a learning environment will be an important factor.

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The Health Board is committed to the principle that risk must be managed, and to ensure:

• Compliance with statutory legislation; • All sources and consequences of risk are identified; • Risks are assessed and either eliminated or minimised; • Information concerning risk is shared with staff across the Health Board; • Damage and injuries are reduced, and people’s health and well-being is optimised; • Resources diverted away from patient care to fund risk reduction are minimised; • Lessons are learnt from incidents, complaints and claims in order to share best practice and prevent reoccurrence.

The Health Board Regularly seeks assurance through its Committee reporting structure that the following disciplines are in place:

• High quality services are delivered efficiently and effectively; • Equality Impact Assessment is carried out in accordance with legislation and the Health Board’s Equality Impact Assessment Policy; • Performance is regularly and rigorously monitored with effective measures implemented to tackle poor performance; • Compliance with laws and regulations; • Information used by the Health Board is relevant, accurate, reliable and timely; • Financial resources are safeguarded by being managed efficiently and effectively ; • Human and other resources are appropriately managed and safeguarded

Working with Partners and Stakeholders As an organisation, we recognise that although delivering services through partners can bring significant benefits and innovation, there is less direct control than if delivering them alone. An environment where services and projects are increasingly being delivered through partner organisations puts a premium on successful risk management. It is essential that partnership agreements are underpinned by robust governance arrangements, including appropriate reporting mechanisms and that the Health Board has a clear approach, including its associated risk appetite, to partnership working. There are already a number of specific partnerships in place which are reported to the Board and the governance arrangements of these are currently being reviewed. A significant piece of work is currently underway on the development of a partnership governance framework to provide a consistent approach across local partners and stakeholders. This will set out key principles regarding both the monitoring and managing of risks, which need to be fully integrated in day to day management, and arrangements in place to trigger intervention when appropriate. In the event of any failure, i.e. realisation of risk, an agreed contingency plan with the partner/stakeholder should be followed.

Projects and Strategic Policy Decisions It is explicit within the Risk Management Strategy and Policy that all discrete/significant projects or strategic policy decisions within the Health Board must be risk assessed using the agreed risk management procedure. Each Project Manager within the Health Board must undertake risk assessments of their designated projects at the beginning of the project with each project required to have a separate risk register. The management of

138 the project’s risk register must be a standing agenda item at all Project Board (or equivalent) meetings, where risks must be reviewed and updated as appropriate.

Where the Health Board is involved in projects which are managed through third parties who utilise a different project methodology, a clear protocol will be established which identifies how risks held in the project format or system will be escalated to the risk register. There may be projects that require formal project methodology which is fully documented within a Project Initiation Document, detailing all project risks which are known and are included in any associated Business Case. A formal project approach using or based upon a recognised project methodology will reduce the associated risks within a project.

During the year the Board has been supported to ensure development and implementation of the risk management framework and the effective identification, prioritisation and management of risks, having received training and presentations.

The Internal Audit function has a leading role to play in providing assurance over the adequacy of controls across a range of risks, whilst assurance can also be obtained from management or from other assurance functions in place.

The systems in place and activities undertaken during the year have ensured our capacity to handle risk and achievement of our main aims of risk management which are:

The risk profile of the Health Board is constantly changing, with the key risks that emerge and which can impact on the achievement of objectives including strategic, operational, and financial and compliance risks. As at 31st March 2016, the areas of highest risks, together with the management of those risks, faced by the Health Board are reflected in the following table:

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Risk Area Synopsis of Current Mitigation Workforce • Recruitment and retention issues and the age profile • Range of operational HR controls in place on a of our staff leading to shortages in certain specialities daily basis; such as Accident and Emergency, Respiratory, • Health Board recruitment strategy to be revised Oncology, Pathology, Cardiology, Radiology, to include innovative recruitment methods; Gastroenterology, Orthopaedics, Anaesthetics, • Forums established with Surgery, Ophthalmology, Paediatrics, Mental Health Deanery/trainees/middle grades/educations Services, Learning Disabilities, Medicine, and within establishments; Primary Care, including Out of Hours, with the need to • Monitoring through Health Board committee use locum and agency staff on a long term temporary structures; basis. The severity and impact are different for each • Escalation plans in place where appropriate for geographical area with consequences which could emergency closure and transfer of patients; include compromised timeliness of patient care. • Additional visiting sessions from ABMUHB. • Inability to achieve minimum nursing staffing levels for • Daily review of nurse staffing levels/skill mix and agreed bed capacity on medical, including flexible use of staffing; cardiovascular, wards across the Health Board. • Health Board recruitment strategy revised to Potential for sub-optimal patient care, unacceptable include innovative recruitment methods such as fundamental levels of care and decrease in staff overseas recruitment and development of morale. Advanced Nurse Practitioners. • Inability to release staff to attend training including • Range of HR policies and procedures in place; mandatory training and low take up of PADR. Potential • Detailed work in progress to identify additional implications for quality of care and Child Protection & mandatory requirements for specific staff groups Adult Safeguarding issues. and resource required for delivery and staff release; • Approved programme of work in place to improve compliance with PADR requirements. • Demand for some Therapy services, including • Risk assessment of patients; Dietetics, outpaces staffing available to deliver • Active caseload review routinely to support safe services leading to longer stays in hospital. practice. Quality and Safety • Failure to meet follow up waiting times targets in • Capacity and demand plans for all services in certain services including orthopaedics, general place; surgery, ophthalmology, urology having a detrimental • Clinical validation of waiting lists; effect on patient care. • Operational plans in place on a daily basis; • Contact centre created. • Lack of joined up care between acute and community • Health Board wide pathways under development; service across the three counties, leading to delayed • Consistent commissioning intentions and transfer of care and inability to deliver on care closer to process; home. • ICF proposals to establish better equity in provision with Regional collaborative monitoring. • Prolonged waits for cardiac transfers to Morriston for • Daily review of patients by medical staff with patients requiring urgent cardiac treatment, leading to updating of referral database; a risk of serious deterioration in clinical condition, • Bi-monthly operational meeting with ABMU to prolonged hospital stay and bed blocking in Coronary improve flow; Care Unit. • All patients risk scored by ABMU Cardiac team; • Health Board Cath lab development proposal approved. • Risk of medication administration errors leading to • All medication errors are now reviewed by the patient harm, organisational/professional reputation Medications Errors Review Group (MERG) to damage and litigation. establish thematic issues and ensure lessons are learnt; • Medicines Management policies, including Drug Administration Policy in place.

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• Interpretation of diagnostic results leading to a • An action plan in place which is owned by the potential increase in misdiagnosis of radiological Unscheduled Care Directorate and is being investigations and pathology tests. monitored by Quality, Safety and Experience Assurance Committee; • Sustained and continued attempt to recruit both nursing and medical staff; • Daily use of operational measures including use locums, of additional variable hours and HR policies and procedures. • The backlog of medical equipment either out of service • Prioritisation of equipment purchases through (>£4m) or in need of replacement exceeds the limited Capital Planning Group, including key funding available in the discretionary capital stakeholders; programme. This could lead to either a risk to patient • Programme of standardisation of key equipment, safety, health outcomes or business/service continuity. involving Medical Devices Group, to provide greater resilience across the Health Board; • Involvement of EBME with technical and risk assessments. • Limited investment into prevention activities in Public • Public Health investment included in the Health Health leading to an increasing burden of disease Board 2015/16 operational plan; such as cancer, diabetes, heart disease and stroke, • Support to & engagement with Primary Care which increase pressures on services and quality of clusters; life issues for our residents; • Public Health team working with a range of • Risk of continuing issues associated with obesity if partners and various county work plans adequate comprehensive evidence based • Grant opportunities explored; overweight/obesity services are not resourced, which • Action plan in place as required within All Wales could also impact on unscheduled care and planned Obesity Pathway. services across the Health Board. Primary Care • Lack of access to Primary Care Services in particular • Performance Management framework to ensure routine dental services, orthodontic treatment, with that all dental contractors deliver the best from inequality of access across the area. their existing Units of Dental Activity (UDA) and the rebasing on contracts where necessary. Commission further routine dental access services to ensure equity across 3 counties. • Urgent access service to ensure those patients without a routine dentist can get rapid access to a dentist when needed. Community Dental Service availability to ensure they can provide backup dental capacity where there is a clinical need and lack of capacity in other services. • Insufficient project or financial mechanisms in place for • The Health Board has enacted various planning transition of resources from existing services to and pathway groups to develop and monitor the primary and community care. This impacts on the position. ability to provide care closer to home, which is one of the Health Board’s main IMTP objectives. Performance • Failure to achieve targets and priorities set by WG in • Robust monitoring mechanism in place both the Delivery Framework. internally through the committee structures and externally via both internal and external audit. Finance • Non delivery of savings targets resulting in breach of • Enhanced budget monitoring and accountability; financial targets and financial duties. (Applies • Weekly monitoring of out-turn; particularly to workforce, productivity, efficiency • Monitoring through Health Board’s committee savings, Continuing Health Care, medicines structure; management and cost containment). • Quality Innovation Productivity Prudency Group. Estates •

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• Estates Infrastructure - Sustained investment required • All issues have day-to-day operational mitigation in relation to accommodation, infrastructure, facilities in place to ensure safety particular to the specific and services to prevent buildings falling into disrepair; risk identified; • Care delivery compromised due to inadequacies of • Comprehensive and prioritised discretionary accommodation for certain services throughout the capital programme to target investment around Health Board. backlog maintenance and highest risk areas; • Monitoring and assurance arrangements in place through the governance structures. • Compliance issues within the estates infrastructure in • All issues have day-to-day operational mitigation relation to a number of legislative requirements and in place to ensure safety particular to the specific statutory obligations in such areas as asbestos, boiler risk identified; plant, electrical, legionella, medical gases, • Comprehensive and prioritised discretionary formaldehyde and fire. Overall the consequences capital programme to target investment around include the potential for litigation, HSE investigation backlog maintenance; and compliance orders and a potential for patient and • Monitoring and assurance arrangements in place staff safety issues. through the governance structures. Corporate Issues • Data quality is a key component in decision-making, • Data quality arm of Information Services accurate reporting and management processes within strengthened by appointment of a Data Quality the organisation. There is a potential for invalidated Manager; data sets to be utilised within the Health Board to • Data Quality Group in place to progress matters; support decisions which could have service or financial • Additional training delivered to the 7 key consequences. information asset owners; • Data Quality programme to be developed to cover key systems . • Sub optimal IT systems across the Health Board • Operational plans in place to address high risk requiring ongoing support, upgrade and development areas through discretionary funds; in order to meet service and statutory requirements – • Tendering process in place to provide solutions; examples include Data Centre GGH, paging system at • Bids placed for discretionary capital funding. WGH, e-mail and back up/archiving systems.

• Lack of integrated records management system across • Effective management of all available storage the Health Board leading to storage capacity, retrieval facilities; and location issues and poor standard of record • Annual weeding and destruction programme keeping in some services. agreed; • Full implementation of HERS 2 full electronic referral system; • Potential for breaching enhanced requirements relating • Additional staff appointed to provide direct to Deprivation of Liberty Safeguards (DOLS). support to clinical areas and to enable assessments to take place; • Continue to identify additional Section 12 doctors available to undertake assessments.

• Lack of updated robust, tested and resilient plans • Business Continuity Management policy ratified across the organisation could lead to service and in place; disruption, impact on patient care and have financial • Training provided across the Health Board. implications for the Health Board.

The Control Framework At Hywel Dda University Health Board we are committed to putting quality at the heart of our services, providing the right care, in the right place at the right time and in the right way. Strong leadership and empowerment of front line staff is needed in order to constantly deliver the highest standards of care. Quality is also reliant on having strong, underpinning structures within the Health Board and we need to consider which existing systems and processes require improvement and whether new or extended processes should be introduced.

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Hywel Dda University Health Board, to accord with the core values for the NHS in Wales, designed to support good governance and the achievement of high standards of care (as included in the NHS e-governance manual), places significant emphasis on:

• Prioritising quality and safety • Improvement being integrated with everyday working • Focusing on prevention, health improvement and inequality • Partnership working • Investing in our staff

Detailed information on what we do to ensure that all our services are meeting local needs and reaching high standards is included in our Annual Quality Statement. From a quality perspective, however, a Health and Care Standards/Fundamentals of Care Audit was undertaken in 114 areas across the Health Board, with a subsequent report being provided as assurance to the Quality, Safety and Experience Assurance Committee. There were three elements to the audit, patient survey, staff survey and operational questions referring to patients‟ records, medication charts, food charts and fluid charts. The report provided assurance that the care delivered within the Health Board continues to achieve a high level of satisfaction amongst patients whilst also identifying areas for improvement.

At the Health Board, corporate governance is regarded as the way in which we are governed and controlled to achieve our objectives. The control environment makes an organisation reliable in achieving these objectives within a tolerable degree of risk it is the glue which holds the Health Board together in pursuit of its objectives while risk management provides the resilience.

In accordance with current guidelines appertaining to the Corporate Governance Code and its application to public bodies in Wales, the Health Board has undertaken an assessment of its compliance with the Code. The Health Board is satisfied that it is complying with the main principles of, and is conducting its business in an open and transparent manner in line with the Code. The outcome of the assessment has been reported to the Board via the Audit and Risk Assurance Committee. Although the Health Board through its scrutiny and review processes continue to identify areas for improvement, the 30 assessment against the Corporate Governance Code was clear in that the organisation has complied with and has not identified any departures from the Code during the year.

The organisation uses the Health and Care Standards for Wales as its framework for gaining assurance on its ability to fulfil its aims and objectives for the delivery of safe, high quality health services. This involves self assessment of performance against the standards across all activities and at all levels throughout the organisation, with evidence being drawn from the work undertaken across the organisation during the year. The process adopted by the Health Board has involved all the standards being reviewed in accordance with an agreed timeline, with Internal Audit reviewing a sample of standards. Further evidence of embedding the standards is that all Board and Committee papers have to demonstrate alignment with the relevant standard/s.

As part of this process, in the first year of its introduction, we have undertaken a self assessment against the Governance, Leadership and Accountability Standard (GLA),

143 which was presented to the Board for discussion and subsequent approval. The standard sets out expectations for working within a legal and regulatory framework for health bodies and asks a serious of questions to assess the organisation’s current position in terms of the following areas:

• Having a defined structure in which accountabilities, roles, responsibilities and values are clear and which upholds the standards of behaviour expected of its staff; • Having a system of governance which supports successful delivery of its objectives and partnership working. The organisation will provide leadership and direction so that it delivers effective, high quality and evidenced based services, meets patient needs at pace, with staff that are effective and appropriately trained to meet the needs of patients and carers; • Ensuring that effective systems and processes are in place to assure the organisation, service, patients, service users, carers, regulators and other stakeholders, that the organisation is providing high quality, evidenced based treatment and care through the principles of prudent healthcare and services that are patient and citizen focused.

The Health Board’s self assessment considered all the questions as set out in the Welsh Government’s supporting guidance in relation to the standard criteria and the entire assessment can be found by accessing the following link on the website: Hywel Dda Board Papers: http://www.wales.nhs.uk/sitesplus/862/page/40875.

The Governance Leadership and Accountability standard has been completed in terms of the Health Board’s current position, and cross-referenced where possible to the assessment against all other Health and Care Standards. The self assessment identified areas where reasonable progress has been made with some areas of good practice identified, with it being recognised that further development was required in other spheres.

This process has been subject to independent internal assurance by the organisation’s Head of Internal Audit, who has commented that the standards are increasingly becoming embedded in the culture of the Health Board. The narratives appeared in the main an honest self assessment of the position reached, and this was confirmed from the samples reviewed by Internal Audit.

Completion of the GLA Standard is an action within the Governance Enabling Plan underpinning the Health Board’s Integrated Medium Term Plan 2016/2017- 2018/2019.

Other Control Framework Elements Control measures are in place to ensure that all the organisation’s obligations under equality, diversity and human rights legislation are complied with. The Health Board practices a patient-centred approach to service delivery with co-production and prudent health care at the forefront of the way in which we plan, develop and deliver services. The principles of equality, diversity and human rights are embedded in the guidance to the Board on our approach to service planning and reporting mechanisms, enabling robust scrutiny of proposals, performance and actions. Equality Impact assessment forms part of the gateway process for service design, strategies, plans and policies. Our Written Controls Document Policy includes an explanatory section around Equality

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Impact Assessment and further information and guidance is available on our intranet and internet websites for staff and public consumption. Equality Impact Assessments for policies are published on our websites and Board papers are published for public scrutiny. This ensures that due regard is given to equality, diversity and human rights considerations during the development and review of all Health Board policies and the scrutiny of policies in relation to local impact on the adoption of policies developed and reviewed on an All Wales basis.

Equality and Diversity training is mandatory for all staff – ‘Treat me Fairly’ the Equality e- learning package is available to all staff as part of the Core Skills Framework, uptake is monitored and is increasing incrementally. Comprehensive information on equality, diversity and human rights (including links to external advisory bodies/organisations) is available to staff and the public on our dedicated intranet and internet web pages. Over the past year, arrangements for reporting assurance around equality, diversity and human rights have been further strengthened. An Improving Experience Sub Committee has been established, reporting to Board through the Quality, Safety and Experience Assurance Committee structure. These groups constitute wide representation across all functions, facilitating action directly targeted at improving staff and patient experience. A refreshed Strategic Equality Plan and Objectives was approved by the Board in March 2016.

As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer obligations contained within the Scheme regulations are complied with. This includes ensuring that deductions from salary, employer’s contributions and payments into the Scheme are in accordance with the Scheme rules, and that member Pension Scheme records are accurately updated in accordance with the timescales detailed in the Regulations.

The Health Board would confirm that it acts strictly in compliance with the regulations and instructions laid down by the NHS Pensions Scheme and that control measures are in place with regard to all employer obligations. This includes the deduction from salary for employees, employer contributions and the payment of monies. Records are accurately updated both by local submission (Pensions On-Line) and also from the interface with the Electronic Staff Record (ESR). Any error records reported by the NHS Pension Scheme which arise are dealt with in a timely manner in accordance with Data Cleanse requirements.

The organisation has undertaken risk assessments and Carbon Reduction Delivery Plans are in place in accordance with emergency preparedness and civil contingency requirements as based on UKCIP 2009 weather projections to ensure that the organisation’s obligation under the climate change Act and the Adaptation Reporting requirements are complied with.

The Health Board has continued to deliver on energy and transport projects that work towards reducing our carbon footprint. Good progress is being made on reducing our carbon footprint and delivering our energy efficiency plans. The Energy Performance Contract has met the year 1 target of this 10 year contract (to deliver on 4,000 tonnes of carbon reduction per annum) and performance continues to improve. In addition the Health Board has ensured continual improvement through the delivery of targeted low cost energy efficiency schemes and invested in feasibility and business case

145 development to support a second phase of large scale energy performance projects. This will ensure that the Health Board continues to be well placed to meet Government expectations regarding carbon emissions.

The Transport for All Project, introduced in March 2015 as an additional development to sustainable transport, continued during the 2015/2016 financial year. The service provides two fully wheelchair accessible 16 seat minibuses that are based in or around the Carmarthen and Llanelli area. The minibuses are available to groups and organisations, both public and voluntary providing access to essential community services which promote community activity, social inclusion, rural health, wellbeing and recovery from mental health problems. These vehicles are now well utilised and provide exceptional value for money for all organisations involved with the scheme. Most importantly, this service provides a high quality transport option for the shared benefit of local communities and public sector bodies.

The Health Board is represented on the multi-agency Dyfed Powys Local Resilience Forum, which includes a severe weather group as part of its structure. The Severe Weather Group has undertaken a robust risk assessment process based on the Local Risk Management Guidance for Civil Emergencies 2015 which identifies risks across our community and rates them according to a number of factors to give a risk score (low, medium, high, very high) and a preparedness rating. The Severe Weather Group focuses on responses to Flooding, Severe Winter Weather, Heat Wave and Drought events and the effects of climate change underpins this work. The Dyfed Powys LRF Severe Weather Arrangements Plan was first developed in 2011 and is now reviewed on a biennial basis. The group also publishes a Community Risk Register (http://www.dyfed- powys.police.uk/en/what-we-do/civil-contingencies/) which highlights the effects of climate change and informs the public about the potential risks we face and encourages them to be better prepared. We discharge our roles in terms of the management of any prospective issues which could arise through climate change, working with partners from all agencies through this group.

Integrated Medium Term Plans The NHS Finance (Wales) Act 2014 requires each Health Board to prepare a plan which sets out the Board’s strategy for complying with the three year financial duty to breakeven. The Hywel Dda University Health Board Plan cannot yet evidence financial balance and the Plan must therefore be considered in terms of the strategic direction it signals and as an interim position pending further work locally and with Welsh Government to bridge the financial gap.

During 2015/2016, in the absence of a Welsh Government approved IMTP, the Health Board, as advised by the Welsh Government, worked to a Board approved Operational Plan. The Operational Plan for 2015/2016 in the main was drawn from the Integrated Medium Term Plan 2015/2016 to 2017/2018 already approved by the Board in terms of our strategic path of travel, albeit as ‘interim’ as it was unapproved by Welsh Government. The Operational Plan 2015/2016 reflected the strategic direction established in the Integrated Medium Term Plan, in particular reflecting the work which has continued since its production to detail:

• Planning for workforce stabilisation; • Integrated performance reporting;

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• Capital Planning; • Prioritisation of ministerial allocation to community and primary care initiatives.

In addition, the Health Board has also been supported by the Welsh Government Delivery Unit to achieve robust Demand and Capacity plans which are reflected in our quarterly activity performance projections for the referral to treatment tier 1 Ministerial targets. Progress has been constantly monitored through BPPAC and the Board via the Integrated Performance Report which is in the public domain and accessible on our web site.

The Draft IMTP for 2016/2017 – 2018/2019, approved by the Health Board at the January 2016 Board meeting was submitted to Welsh Government as required, with scrutiny and discussions ongoing since the submission. The Plan has been strengthened as intended and also informed through feedback and dialogue with Welsh Government. The Welsh Government has acknowledged the work undertaken to strengthen the Plan across performance, workforce and finance including ambitious savings targets. The Plan is now more action focused including more detailed work programmes and ambition for the 10 Strategic Objectives and the key challenges facing the Health Board. Although feedback noted the increased confidence in the Health Board’s recruitment strategies concern remains regarding the challenges within the Primary Care workforce. The feedback also remarked on the further work required to develop the Plan including working with Welsh Government to establish clear timelines for stabilising and redesigning our systems to produce a sustainable model for the future. On this basis, it was agreed the Plan submitted to Welsh Government by the 31st March 2016 deadline would be a work in progress and therefore an interim rather than a formally approved Plan.

The Plan includes measurable targets for the 10 strategic objectives and a governance process to manage delivery. Strategic objectives 1 to 8 relate to the wellness and prevention approaches to care and are based on an assessment of health needs. Strategic Objectives 9 and 10 relate to efficiency and performance, setting out the University Health Board’s Quality Innovation, Productivity and Prudency Programme (QIPP) and our Scheduled and Unscheduled Care plans. The intention is to achieve clear agreed measurable aims for each Strategic Objective in order to provide assurance to the Board and our population on the achievement of the Objectives. The aims will be the subject of further review and definition in the first quarter of 2016/2017. The Plan sets out the Health Board’s approach to manage key contextual issues which impact on our ability to drive improvements in healthcare:

• The timely delivery of high quality, sustainable clinical services; • Workforce recruitment and retention; • Financial balance

The Plan evidences significant work to better understand capacity and demand for services and thereby manage improvements in access to diagnostic and treatment services over the period of the Plan. Workforce Planning has been the subject of significant strengthening and the Plan evidences the range of actions underway to first stabilise and then see the growth and development of our workforce. Our financial plans forecast that in 2016/2017 the underlying deficit will stabilise and improve which marks a significant change in the organisations finances which will be delivered through cost

147 improvement and the ten work-streams of the Quality, Innovation, Productivity and Prudency (QIPP) programme. These and other key supporting and enabling strategies are the subject of more detailed annexes to the Plan.

The status of this Plan is currently ‘interim’ and remains work-in-progress pending further work with Welsh Government colleagues particularly regarding the financial trajectories over the period of this Plan.

Ministerial Directions A number of Ministerial Directions were given during the year, this information being available by accessing the following links: http://gov.wales/legislation/subordinate/nonsi/nhswales/2015/?lang=en http://gov.wales/legislation/subordinate/nonsi/nhswales/2016/?lang=en

A schedule of the directions (11), outlining the actions required and the Health Board’s response to implementing these was presented to the Audit Committee as an integral element of the suite of documents evidencing governance of the organisation for the year. From this work it was evidenced that the Health Board was not impeded by any significant issues in implementing the actions required.

Information Governance The Health Board has a range of responsibilities in relation to the appropriate use and access to the information it holds including confidential patient information, which is guided by legislation and the Caldicott principles, the Medical Director being the Health Board’s Caldicott Guardian and the Director of Finance, Planning and Performance, the Senior Information Risk Owner. We therefore have responsibilities regarding Freedom of Information, Data Protection, Subject Access Requests and the appropriate sharing of personal identifiable information.

The Health Board has established arrangements in place to ensure that information is managed in line with relevant legislation, however recognised this as an area to be strengthened in the forthcoming financial year. The Health Board has had one incident relating to data security during the year which was self reported to the Information Commissioners Office (ICO). The incident related to a potential breach of Section 55 of the Data Protection Act and the Health Board has already undertaken its own internal investigation with the ICO investigation to commence imminently.

The Health Board has continued with enacting measures that ensure risks to data security are identified, managed and controlled. To this end, during the year we have modified our e-mail filter rules that capture any e-mails which may contain Personal Identifiable Information (PII). The filter has been escalated to ‘Inform’ which means that the sender will receive an automatic notification if the e-mail being sent has triggered the rules associated with PII. The next step will be a further escalation to ‘Enforce’, which will block e-mails that have triggered the PII rules. In addition, global e-mail ‘Hywel Dda Today’ has been a means of disseminating information regarding maintaining confidentiality and also actions to avoid when using social media. In terms of the framework the Health Board has and will continue to refresh our position against the

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Information Governance Toolkit with a further assessment already undertaken against the Caldicott Principles in Practice Assessment. The Information Governance Committee provides oversight, advice and assurance to both BPPAC and the Board with regard to Information Governance.

Data Quality and Information The WAO Structured Assessment commented that it remains unclear what assurances the Board and its committees receive on data quality. The Health Board has continued with enacting measures for improving the quality of our data which informs our performance assessments and reporting and which also informs some of the internal/external reviews undertaken. The Health Board has compiled a comprehensive response paper which provides assurance to the Board that action is being taken to implement the recommendations from all Wales Audit Office reports on ICT issues, which will result in improved reliance on data produced.

Review of Effectiveness As Accountable Officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review of the system of internal control is informed by the work of the internal auditors, and the executive officers within the organisation who have responsibility for the development and maintenance of the internal control framework, and comments made by external auditors in their audit letter and other reports.

Internal Audit Internal audit provide me as Accountable Officer and the Board through the Audit Committee with a flow of assurance on the system of internal control. I have commissioned a programme of audit work which has been delivered in accordance with public sector internal audit standards by the NHS Wales Shared Services Partnership. The scope of this work is agreed with the Audit Committee and is focussed on significant risk areas and local improvement priorities.

The overall opinion by the Head of Internal Audit on governance, risk management and control is a function of this risk based audit programme and contributes to the picture of assurance available to the Board in reviewing effectiveness and supporting our drive for continuous improvement.

The Head of Internal Audit has concluded for 2015-2016:

The previously agreed All Wales framework for expressing the overall audit opinion identified that there are eight assurance domains. The rating of each assurance domain

149 is based on the audit work performed in that area and takes account of the relative significance of the issues identified. The criteria for judgement of the overall assurance rating of the organisation is, amongst others, dependent on the ratings of the primary domains, of which there are three and where the lowest rated primary domain gives the overall assurance rating to the Health Board. However there are also the ratings of the five other domains to consider. If three or more of these domains give an assurance rating of, for example, limited, then the overall rating for the Health Board is also deemed to be limited.

In reaching this opinion the Head of Internal Audit has identified that the Board can take reasonable assurance that arrangements to secure governance, risk management and internal control, within those areas under review, are suitably designed and applied effectively. Some matters require management attention in control design or compliance with low to moderate impact on residual risk exposure until resolved. In reaching this opinion the Head of Internal Audit has considered the three primary domains which have all been rated as reasonable assurance:

• Corporate governance, risk and regulatory compliance; • Financial governance and management; and • Clinical governance, quality and safety.

The five remaining domains are:

• Operational service and functional management; • Capital and estates management; • Information governance and IT security • Workforce management; • Strategic planning, performance management and reporting.

Of the five remaining domains, four have been rated as reasonable assurance, and one, Information governance and IT security has not been rated due to insufficient work being carried out within this domain. Thus overall a reasonable assurance rating is given to the Health Board.

Internal Audit is aware of the plans and actions put in place by the Health Board in response to their recommendations, and will follow these up in the 2016/2017 year to ensure they have been enacted.

It has to be recognised that many of the reviews were directed at high risk areas, and the overarching opinion therefore needs to be read in that context. Whilst acknowledging the Head of Internal Audit Opinion, it should be noted that 82% of the Internal Audit reports achieved a rating of substantial or reasonable with only 11% of the reports receiving a limited or no assurance rating. See table below:

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Similarly for Capital and PFI it should be noted that 33% of the audit reports achieved a rating of substantial or reasonable with 17% of the reports receiving a limited or no assurance rating and a further 50% where a rating was not applicable. See table below:

During the year, Internal Audit issued the following audit reports with a conclusion of limited assurance:

Subject Issue Action

Financial Governance & Management United 4 Health Grant Agreements Individual personnel costs being Further action taken at the (1st & 2nd tranches) recharged to the project did not time resulted in a subsequent accurately reflect the actual costs audit of the third tranche being incurred by the Health Board. receiving a substantial assurance rating. Testing identified numerous instances where the actual travel & subsistence costs incurred did not correspond to the claims made.

Testing identified a number of instances where the cost of equipment and consumables had been incorrectly quoted on the submission database.

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Capital and Estates Management IMT Infrastructure The draft strategy was not in line Tender exercise to be with the required „five case model‟ undertaken to appoint external format, a condition of WG funding business case writers to requests. prepare the Programme Business Case (PBC) and The resource and timeline for subsequent Business delivering the above strategy had Justification Cases on behalf not been affirmed. of the Health Board.

No short/medium term plans to All risk registers are monitored eradicate/minimize the high risks on a monthly basis, and any identified within the risk registers new risks or mitigations are were evident with risk registers included within the latest reporting a reduced residual risk registers. despite the mitigating/ minimizing actions having not taken place.

Information Governance & Security Domain Breast Care PACS From the information available at the Due to timing of the audit time of audit, Internal Audit management responses are could not be satisfied that a) not expected until new adequate support agreements are in financial year. place; and b) arrangements exist for creating back-up copies of data programs, storing and retaining them securely, and recovering applications in the event of failure.

Strategic Planning, Performance Management and Reporting Commissioning of the Homecare Documented agreements not held Due to timing of the audit Service for all homecare medicines provided management responses are within the service. There is no not expected until new certainty that all homecare financial year. prescriptions are sent to the Pharmacy department for checking, prior to being sent off to the Homecare provider for dispensing.

Internal Audit will undertake follow up reviews of all limited audits within the first quarter of 2016/2017. Implementation of recommendations is being monitored by the relevant Health Board committee.

The Audit and Risk Assurance Committee has received progress reports against delivery of the NHS Wales Shared Services Partnership Internal Audit and Capital (Specialised Services) plans at each meeting, with individual assignment reports also being received. The findings of their work are reported to management, and action plans are agreed to address any identified weaknesses. The assessment on adequacy and application of internal control measures can range from ‘No Assurance’ through to ‘Substantial Assurance’. Where appropriate, Executive Directors or other officers of the Health Board have been requested to attend in order to be held to account and to provide assurance that remedial action is being taken. A schedule tracking the implementation of all agreed audit recommendations is also provided to the Committee.

In addition to the above, the Audit and Risk Assurance Committee has also received for assurance, a number of Internal Audit Reports appertaining to those functions delivered on its behalf by the NWSSP and which have been approved by the Velindre NHS Trust’s Audit and Risk Assurance Committee, as the host authority for the service.

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Wales Audit Office (WAO) As the Health Board’s appointed external auditor, WAO is responsible for scrutinising the Health Board’s financial systems and processes, performance management, key risk areas and the Internal Audit function. The Wales Audit Office undertake financial and performance audit work specific to the Health Board with all individual audit reviews being considered by the Audit Committee with additional assurances sought from Executive Directors and Senior Managers as appropriate. The WAO also provides information on the Auditor General’s programme of national value for money examinations which impact on the University Health Board, with best practice being shared.

During the year, WAO undertook the Structured Assessment Year 6 review of the Health Board which examined the arrangements to support good governance, effective quality assurance and the efficient, effective and economical use of resources. The progress made in addressing key issues identified in previous year’s structured assessment was also scrutinised.

The assessment concluded that the Health Board’s arrangements to support good governance continue to evolve although there remain a number of fundamental issues that need to be addressed. Achieving financial balance remains a challenge and the Health Board faces a number of significant risks and performance in some areas need to be improved.

The work undertaken as part of Structured Assessment contributed towards the WAO Annual Audit Report 2015. The key findings and conclusions emanating from the report are summarised as follows:

• Overall the Health Board has a broadly sound approach to in-year financial management although financial breakeven was not achieved in 2014/2015 and is very unlikely to be achieved in 2015/2016. A key challenge for the Health Board is to develop a clear strategic direction through the IMTP; • The Health Board has continued to strengthen its governance arrangements and has built a more open and transparent culture. However, progress on some issues has been slow and fundamental issues including agreeing a clear strategic plan and strategic objectives, establishing a Board assurance framework and improving performance have yet to be addressed; • Changes to Executive portfolios have strengthened accountability but the benefits of organisational restructure have not been fully realised across acute hospital sites and the capacity of some of the corporate and operational management functions are constrained; • The performance audit work, whilst identifying some good areas of practice and positive developments, also identified opportunities to secure better use of resources in a number of areas; • Board effectiveness, assurance and internal controls continue to be strengthened and are largely effective although there remain some important areas that need addressing.

The Board did not disagree with any of the content of the WAO Annual Report and I can confirm that progress has already been made in some of the areas outlined above. A

153 detailed management response was prepared in response to the recommendations made by Wales Audit Office with implementation of these being tracked through the Audit and Risk Assurance Committee. The management response can be viewed on the Health Board’s website.

Other Sources of External/Independent Assurance The governance structure is further supported by the work of other independent/ external bodies:

• Welsh Risk Pool The organisation continues to be assessed against the WRP Concerns and Compensation Claims Management Standard which is reviewed annually to ensure that the organisation is dealing correctly with claims that are submitted to the Welsh Risk Pool for reimbursement. An Internal Audit review of Claims Management arrangements was undertaken to ensure that the function within the organisation is operating correctly and substantial assurance was obtained.

• Healthcare Inspectorate Wales The Board is provided with independent and objective assurance on the quality, safety and effectiveness of the services it delivers through reviews undertaken by and reported on by HIW. This work is additional to the assurances emanating from embedding of and assessment against the Health and Care Standards and the completion of the Governance, Leadership and Accountability Module. Any unannounced cleanliness or dignity and respect spot checks and any special themed reviews undertaken during the year would have been reported through the appropriate committee and any matters for concern escalated accordingly. The outcomes of any such reviews and any emanating action plans are discussed in the most appropriate forum with any lessons learnt shared throughout the Health Board. This includes one specific review relating to breast cancer which was a matter of concern to the Board and improvement actions are now being monitored by the Quality, Safety and Experience Committee.

Other Review and Assurance Mechanisms

Legislative Assurance Framework

In the continuous development of the organisation’s assurance framework and in recognising that the legal obligations of the Health Board are wide ranging and complex, a legislative assurance framework has been developed. It provides the Board with assurance of compliance on those matters that present the highest risk in terms of likelihood and impact of non compliance and is a central record that captures the following three categories:

• Details of all licensed and accredited functions, responsible individuals and inspection/review activity; • Activities subject to regulation and inspection scrutiny; • Other key pieces of legislation subject to scrutiny and sub-ordinate legislation.

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Review of Economy, Efficiency and Effectiveness on the Use of Resources The Health Board’s 2015-2016 year-end financial position of £31.199m deficit reflects the on-going requirement for major service redesign in order to be able to deliver our statutory breakeven duty, which has not been achieved this year. The need for significant service change has been acknowledged by Welsh Government and Wales Audit Office, and work is continuing to progress this agenda.

However, it is also evident that the scale of redesign required remains substantial and will require a pragmatic rolling programme of service change for many years. This fact will undoubtedly be reflected in the audit opinion, and will necessitate on-going discussion with Welsh Government, our partner organisations, our key stakeholders, our staff and our residents.

Conclusion Good governance is about running things properly. It is the means by which an organisation shows it is taking decisions for the good of the people of the area in a fair, equitable and open way. It also requires standards of behaviour that support good decision making – collective and individual integrity, openness and honesty. It is the foundation for delivering good quality services that meet local needs and is fundamental to showing public money is well spent.

Achieving good governance is largely a matter of strong leadership, consistent culture and clear direction, underpinned by having robust processes in place. I firmly believe that during this last year, implementing the recommendations from the governance review being a contributory factor, the governance of the Health Board has been significantly strengthened in enacting the governance principles of:

• Knowing who does what and why; • Engaging with others; • Living Public Service Values; • Fostering Innovative delivery; • Being a learning organisation; • Achieving value for money.

Joint Escalation and Intervention Arrangements The above tri-partite arrangements involve information sharing and dialogue between the Welsh Government, the Auditor General for Wales and Health Inspectorate Wales. Under these arrangements, twice-yearly meetings are held to discuss the overall position of the Health Board (as with all other HBs and Trusts in Wales), and to agree on the best way to respond to any issues affecting service delivery, quality and safety of care and/or organisational effectiveness. Further to the most recent review in January of this year, the Health Board remains at ‘enhanced monitoring’ status, having first been escalated to and notified of this level in April 2015, in light of certain factors, not least the absence of an approvable three year IMTP. Whilst escalation to enhanced monitoring includes more regular monitoring of performance and delivery, it also enables the Health Board to access additional specialist help from the Delivery Unit established by the Welsh Government, which, in facing the current challenges, will continue to be taken advantage of. Although we remain at this enhanced level for now, there was recognition of the

155 positive stakeholder management that has emerged within recent months. This is something that I am certain, as we continue to implement the recommendations of the governance review and a revised structure for Acute Services, together with establishing the Board’s objectives, will enable us to move to a position of de-escalation.

Therefore, with reference to the period under consideration, as described within this statement, the Health Board has systems in place to control, manage, mitigate and provide assurance through our continually maturing governance structures in an open and transparent way. The IMTP 2016/2017 to 2018/2019 ‘Our Health, Our Future’, describes the actions necessary for the Health Board to achieve its strategic vision, aims and objectives for the next three years. Achieving this vision will require changes which seek to stabilise, optimise and ultimately to transform our services and it is recognised that to be successful, the Health Board will need to work in partnership with everybody affected by these changes. This means building trust with our stakeholders, to communicate, actively engage and listen. To achieve this, the Health Board has made a commitment to open and honest communication principles and standards, putting communication and engagement at the centre of all its activity and implemented a comprehensive Board approved Corporate Communications and Engagement Plan. This will involve participatory engagement, with both staff and stakeholders actively encouraged in coproduction of service design and delivery. In recognising that our staff constitutes our greatest asset, as an enabling factor a comprehensive organisational development programme will be introduced.

During the year, our risk management system has ensured that:

• Objectives are clear and understood across the organisation; • Risks to the achievement of objectives are identified; • Effective controls, understood by those expected to apply them, are in place to mitigate the risk; • The operation of controls is monitored by management with any gaps being rectified; • Management are held to account for the effective operation of controls; • Assurances are reviewed and acted on.

It is noted however that there is still a significant amount of work to be undertaken to enable the Health Board to become a risk mature organisation.

It has become evident over the last couple of months that there will be fresh challenges for the Board during 2016/2017. The constitution of the Board during this time will experience several changes due to the departure of a combination of both Independent and Executive Director Members. As an organisation we are already putting plans in place to ensure that from a governance perspective we will not be exposed in any way.

As Accountable Officer and based on the review process outlined above I have reviewed the relevant evidence and assurances in respect of internal control enacted during 2015- 2016. The Board and its Executive Directors are fully accountable in respect of the system of internal control. The Board has had in place during the year a system of providing assurance aligned to support delivery of both the policy aims and corporate objectives of the organisation.

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My review confirms that the Board has a generally sound system of internal control that supports the achievement of its policies, aims and objectives and that no significant internal control or governance issues have been identified.

Signed by Professor Steve Moore Chief Executive and Accountable Officer, Hywel Dda University Health Board Date: 1st June 2016

Our Remuneration and Staff Report Reporting bodies are required to disclose the relationship between the remuneration of the highest-paid director in their organisation and the median remuneration of the organisation’s workforce.

The banded remuneration of the highest-paid director in the LHB in the financial year 2015-2016 was £170,000 - £175,000 (2014-2015, £170,000 - £175,000). This was 7 times (2014-2015, 6) the median remuneration of the workforce, which was £26,041 (2014-2015, £28,088).

In 2015-2016, 20 (2014-2015, 11) employees received remuneration in excess of the highest-paid director. Remuneration for staff ranged from £14,434 to £272,562 (2014- 2015, £14,294 to £255,804).

2015/2016 2014/2015 Band of Highest paid 170 – 175 170 - 175 Director’s Total Remuneration £000 Median Total 26 28 Remuneration £000 Ratio 7 times 6 times

Total remuneration includes salary, non-consolidated performance-related pay, and benefits-in-kind. It does not include severance payments, employer pension contributions and the cash equivalent transfer value of pensions.

The membership of the Remuneration and Terms of Services Committee (RATS) is as follows:

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Name Title Role in RATS Mrs Bernardine Rees Chair Chair of RATS OBE Mr Don Thomas Independent Member – Vice Chair of RATS Finance & Chair of Audit and Risk Assurance Committee Mrs Julie James Independent Member- Member of RATS Third Sector Mr Mike Ponton Independent Member – Member of RATS Community

Statement on Remuneration Policy The remuneration of Senior Managers who are paid on the Very Senior Managers Pay scale is determined by Welsh Government, and the Health Board pays in accordance with these regulations. For the purpose of clarity these posts are posts which operate at Board level and hold either statutory or non statutory positions. In accordance with the regulations the Health Board is able to award incremental uplift within the pay scale and should an increase be considered outside the range a job description is submitted to Welsh Government for job evaluation. There are clear guidelines in place with regards to the awarding of additional increments and during the year the only award processed related to an additional payment for Deputy Chief Executive Responsibilities. No changes to pay have been considered by the Committee outside these arrangements. The Health Board does not have a system for performance related pay for its Very Senior Managers.

In addition to Very Senior Managers the Health Board has a number of employment policies which ensure that pay levels are fairly and objectively reviewed for all other staff. There is an All Wales Pay Progression policy which from 1st April 2016 links staff performance through their pay scale and also a local Health Board Policy for the Re- evaluation of a Post which requires individuals and their managers to submit revised job description for job matching by matching panels comprised of management and staff representatives. The Agenda for Change job matching process is utilised and all results are recorded on the Job Evaluation system. For medical and dental staff the Health Board complies with Medical & Dental terms and conditions which apply to medical remuneration.

The Health Board supports the development of its workforce and ensures opportunities are provided for career progression.

The only severance payment policy in place within the Health Board is the All Wales Voluntary Early Release scheme which is utilised to support organisational change and services undertake a robust evaluation of their service and submit evidence that this scheme is value for money and financial savings are secured from the service as a result of the change.

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Name of Role Salary Date of Expiration Notice Compen- Awards Manager (£) contract Date period sation for made Bands early within of £5k) termination year Steven Chief 170-175 5/1/2015 n/a 3 months n/a None Moore Executive Joseph Deputy Chief 140-145 7/9/2015 n/a 3 months n/a Relocation Teape Executive/ Expenses Director of Operations Caroline Director of 120-125 1/6/2015 n/a 3 months n/a Post Re- Oakley Nursing, graded on Quality & 1/6/2015 Patient Experience Karen Director of 120-125 1/6/2015 n/a 3 months n/a No Miles Finance, change to Planning & salary Performance however job title changed 1/6/2015 prior to that was Director of Finance Lisa Director of 110-115 9/1/2015 n/a 3 months n/a Nil Gostling Workforce & OD Kathryn Director of 105-110 1/6/2015 n/a 3 months n/a No Davies Commission- change to ing, Primary salary Care & however Therapies & job title Health changed Sciences 1/6/2015 prior to that was Director of Planning, Integration & Therapies & Health Sciences Sarah Director of 95-100 15/10/20 n/a 3 months n/a Prior to Jennings Governance, 15 15/10/201 Communic- 5 was ations & Director of Engagement Strategic Partnershi ps on Agenda for

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Change band Philip Medical 150-155 25/6/201 n/a 3 months n/a Prior to Kloer Director 5 this Interim Medical Director 16/3/15 – 24/6/15 no change to salary Sarah Director of 95-100 15/10/20 n/a 3 months n/a Prior to Jennings Governance, 15 15/10/201 Communic- 5 was ations & Director of Engagement Strategic Partnershi ps on Agenda for Change band

The Health Board can confirm that it has not made any payment to past directors as detailed within the guidance.

Annually the RATS Committee receives a summary report of Executive Director Performance objectives and then periodically receives an update on performance against those agreed objectives. In support of the summarised feedback completed performance appraisal documents are also available for Committee scrutiny. A more robust template will be introduced from 2016/2017 to provide assurance that all elements of performance are measured. No external comparison is made regarding performance.

No elements of remuneration are subject to continuous performance outcomes. There is no performance related pay for Very Senior Managers.

The Health Board issues all Wales Executive Director contracts which determine the terms and conditions for all Very Senior Managers. The Health Board has not deviated from this. In rare circumstances where interim arrangements are to be put in place a decision is made by the Committee with regards to the length of the interim post, whilst substantive appointments can be made.

Any termination payments would be discussed and agreed by the Committee in advance and where appropriate WG approval would be made. During the 2015/2016 year only Voluntary Early Release payments have been made and these were not connected with Senior Managers posts.

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Senior Manager previous post holders:

Name of Role Salary (£) Date of Expiration Notice Compens Awards Manager Bands of contract Date period ation for made £5k) early within terminatio year n Paul Director of 115-120 Employed n/a 3 months n/a Nil Hawkins Operations until 24/5/2015 Peter Skitt Interim 120-125 From n/a Fixed term n/a Nil Director of 2/5/2015 to Operations 6/9/2015

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Pension Benefit Disclosure Total Lump sum Cash Cash Real Real accrued at age 60 Equivalent Employer’s Real Equivalent increase in increase in pension at related to Transfer contribution increase in Transfer Cash pension age 60 at accrued Value at to pension at Value at 31 Equivalent lump sum pension at stakeholder age 60 March Transfer at aged 60 31 March 31 March 31 March pension Name and title 2016 Value 2016 2016 2015

(bands of (bands of (bands of (bands of £2,500) £2,500) £5,000) £5,000)

£000 £000 £000 £000 £000 £000 £000 £000

Mr S Moore, Chief Executive 5 – 7.5 5 – 7.5 40 – 45 120 – 125 648 577 64 0 Mr J Teape, Deputy Chief Executive / 0 – 2.5 0 – 2.5 50 – 55 145 – 150 821 748 37 0 Director of Operations (from 07/09/15)

Mrs C A Oakley, Director of Nursing and Midwifery (to 31/05/15), Director of Nursing, 2.5 – 5 12.5 – 15 45 – 50 140 – 145 949 847 92 0 Quality and Patient Experience (from 01/06/15) Mrs K Miles, Director of Finance (to 31/05/15), Director of Finance, Planning and 0 – 2.5 2.5 – 5 45 – 50 140 – 145 863 827 26 0 Performance (from 01/06/15)

Mrs L Gostling Director of Workforce and 5 – 7.5 12.5 - 15 30 – 35 90 – 95 530 422 103 0 Organisational Development Ms K Davies, Director of Planning and Integration / Therapies and Health Science (to 31/05/15), Director of Commissioning, 0 – 2.5 (7.5) – (5) 30 – 35 95 – 100 549 546 (4) 0 Therapies and Health Science (from 01/06/15)

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Mrs SL Jennings, Director of Strategic Partnerships (to 14/10/2015), Director of 2.5 – 5 0 25 – 30 0 323 292 28 0 Governance, Communications and Engagement (from 15/10/2015)

Dr P Kloer, Interim Medical Director (to 2.5 – 5 5 – 7.5 35 – 40 105 – 110 565 464 96 0 24/06/15), Medical Director (from 25/06/15)

Miss T Owen, Director of Public Health 0 – 2.5 (2.5) - 0 30 – 35 85 – 90 506 482 18 0

Mr P Hawkins, Chief Operating Officer (to 0 0 0 0 0 0 0 0 25/05/2015)

Mr Peter Skitt, Acting Director of Operations 0 – 2.5 25 – 27.5 25 - 30 75 - 80 497 412 28 0 (from 02/05/2015 to 06/09/2015)

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Severance Payments There have been no exit packages paid to senior staff during 2015-2016.

Single Total Remuneration The table is similar to that used previously, and the salary and benefits in kind elements are unchanged. The amount of pension benefits for the year which contributes to the single total figure is calculated similar to the method used to derive pension values for tax purposes, and is based on information received from the NHS BSA Pensions Agency. The value of pension benefit is calculated as follows: (real increase in pension x20) + (the real increase in any lump sum) – (contributions made by member).

The real increase in pension is not an amount which has been paid to an individual by the Health Board during the year. It is a calculation which uses information from the pension benefit table. These figures can be influenced by many factors e.g. changes in a person’s salary, whether or not they choose to make additional contributions to the pensions scheme from their pay and other valuation factors affecting the pension scheme as a whole.

2015-16 Name Salary (£) Benefits in Pension Total (Bands of kind benefits (Bands of £5K) 5K) (to nearest (to nearest £100) £000) Mr S Moore, Chief 170 – 175 86 260 – 265 Executive Mr J Teape (from 80 – 85 63 36 120 – 125 07/09/2015) Mrs C A Oakley 120 – 125 78 200 – 205 Mrs K Miles 120 – 125 5 130 – 135 Mrs L Gostling 110 – 115 138 250 – 255 Ms K Davies 105 – 110 0 105 – 110 Mrs SL Jennings 95 – 100 35 130 – 135 Dr P Kloer 150 – 155 82 235 – 240 Miss T Owen 105 – 110 18 125 – 130 Mr P Hawkins(to 15 – 20 0 15 – 20 25/05/2015) Mr Peter Skitt (from 40 – 45 22 65 – 70 02/05/2015 to 06/09/2015)

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2014-2015 Salary Benefits in Pension Name (£) kind benefits Total

(bands (to nearest (to nearest of £5k) £100) £000) (to nearest £000)

Mr S Moore (from 05/01/2015) 40 - 45 41 14 60 – 65 Mrs K Howell (to 04/01/2015) 120 - 125 61 0 125 – 130 Mr T Purt (to 15/06/2014) 45 - 50 7 17 60 – 65 Dr S Fish 150 - 155 40 52 210 – 215 Mrs C A Oakley 110 - 115 45 155 – 160 Mrs K Miles 120 - 125 43 165 – 170 Mrs L Gostling (from 01/08/2014) 70 - 75 153 225 – 230 Ms J Wilkinson (to 31/07/2014) 35 - 40 7 16 55 – 60 Ms K Davies 110 - 115 37 211 325 – 330 Mr C M Wright (to 30/11/2014) 65 - 70 31 95 – 100 Ms SL Jennings 95 - 100 25 301 400 – 425 Dr P Kloer 120 - 125 47 165 – 170 Miss T Owen 105 - 110 35 140 – 145 Mr P Hawkins 120 - 125 134 250 – 255

Staff Composition: Board Level Post Holders Female Male Total FTE Headcount FTE Headcount FTE Headcount

Hywel Dda UHB Chairman and Independent 4.00 4 6.00 6 10.00 10 Members Executive Team 6.00 6 3.00 3 9.00 9 Total 10.00 10 9.00 9 19.00 19

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Whole Workforce Female Male Total FTE Headcoun FTE Headcoun FTE Headcoun t t t Staff Group Add Prof Scientific and 173.51 204 93.53 114 267.04 318 Technical Additional Clinical Services 1,220.5 1,899 279.81 365 1,500.3 2,264 7 8 Administrative and Clerical 1,110.3 1,347 217.72 232 1,328.0 1,579 1 3 Allied Health Professionals 397.78 481 83.53 94 481.31 575 Estates and Ancillary 380.09 690 404.46 591 784.55 1,281 Healthcare Scientists 88.69 100 64.70 69 153.39 169 Medical and Dental 226.27 306 402.47 530 628.73 836 Nursing and Midwifery 2,355.4 3,000 214.35 244 2,569.8 3,244 Registered 7 2 Students 7.00 7 Total 5,959.6 8,034 1,760.5 2,239 7,720.2 10,273 8 7 6

Managers excluding clinical managers Female Male Total FTE Headcount FTE Headcount FTE Headcount

Senior Managers Band 8a 28.52 29 24.00 24 52.52 53 Band 8b 14.55 15 14.00 14 28.55 29 Band 8c 7.59 8 6.60 7 14.19 15 Band 8d 6.00 6 9.00 9 15.00 15 Band 9 2.00 2 2.00 2 4.00 4 Total 58.66 60 55.60 56 114.26 116

Sickness absence data 2015-16 2014-15 Days lost (long term) 128,637 122,266 Days lost (short term) 55,723 56,762 Total days lost 184,360 179,028 Total FTE as at 31 March 7,720.26 7,500.07 Average Working Days Lost 12.77 12.59 Total Staff employed as at 31 March (headcount) 10,273 9,928 Total Staff employed in period with no absence (headcount) 2,506 2,831 Percentage of staff with no sick leave 31.98% 32.22%

The Average Working Days Lost figure is the cumulative sickness rate for April to March (5.60% for 2015-16) multiplied by 228, the Chartered Institute of Personnel and Development (CIPD) standard for working days available in a year.

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The percentage and total number of staff without absence in the year has been sourced from the standard ESR Business Intelligence (BI) report. With regard to the reporting in relation to the percentage of staff with ‘no sickness’, the standard BI report excludes new entrants and also bank and locum assignments. Therefore, the number of staff who have had a whole year with no sickness absence is being divided into a smaller number than the total headcount at the end of the year.

Staff Policies All key employment policies are developed on an All Wales basis and then ratified locally by the Workforce & Organisational Development sub-committee. These policies are developed in partnership with Trade Unions and are approved though the Welsh Government Partnership Forum Business Committee. Equality Impact Assessments are produced, recorded, and made available for All Wales policies by a sub group of the Partnership Forum.

Local employment policies are developed and reviewed through the Employment Policy Review group that is chaired by a senior member of the Workforce and OD directorate. The group membership consists of managers, trade union representatives and specialist advisors such as those with specialist knowledge of equality and diversity and data protection. Local policies are produced in partnership with trade union colleagues and go out for general consultation. Equality Impact assessments are developed by a sub group of the Policy Review group that includes a specialist advisor for equality and diversity.

Local policies go for formal sign off through both the Health Board’s Partnership Forum and the Workforce & OD sub-committee.

The Health Board’s Equality and Diversity policy sets out the Health Board’s commitment with the key points detailed below:

• Ensure that individuals are recruited, promoted and trained on objective criteria based upon the aptitude and abilities of the individual concerned. • Treat staff, potential staff and the public we serve fairly, with dignity and respect and will support staff if they feel they are being unfairly treated. • Ensure that all our procedures and policies are non-discriminatory and are adhered to by all our employees. • Where appropriate, take positive action to promote equality of opportunity in relation to recruitment, retention, promotion, training, benefits and all terms and conditions of employment. • Value the diversity of the people and communities we serve and commit to ensuring that health care services, facilities and resources are accessible and responsive to the needs of all individuals and groups within all our local communities. • Strive to achieve a climate of equality for all current and future employees and will ensure that we value and fully utilise the skills of our entire workforce whilst providing the highest standards of services. • Work towards the elimination of discriminatory attitudes and practices in the working environment and in the way services are commissioned and delivered. • Hywel Dda University Health Board is committed to implementing the policy in a way which meets the equality and diversity needs of staff in line with the Equality

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Act 2010. It is the responsibility of managers and staff to ensure that they implement this policy/procedure in a manner that meets the needs of people from diverse groups. It is always best to check with individual staff what their needs are, but needs may include providing information in an accessible format, considering mobility issues, being aware of sensitive/cultural issues. Managers will remain sensitive to the specific requirements of staff members with disabilities when handling issues of capability, ensuring compliance with the provisions of the Act. • It is expected that all staff will be mindful of the provisions of the Equality and Diversity Policy when enacting any other employment policy.

Within the objectives of the policy, the following key points are outlined. The objectives for committing Hywel Dda University Health Board to equality issues are as follows:

• To promote respect and dignity as everyone’s right, whether staff or patient. • To recruit, develop and retain a workforce that is able to deliver high quality services that are fair, accessible, appropriate and responsive to the diverse needs of different individuals and groups. • To demonstrate that Hywel Dda University Health Board values and respects the diversity of the people who work within its services. • To achieve a representative leadership reflecting the diversity of our wider society. • To ensure that the learning and development environments are non-discriminatory and promote understanding and skills to meet the needs of all staff members. • To work towards a workforce profile that reflects that of the population we serve. • To provide a quality of service to the community that recognises, understands and respects the diversity of its make up. • To support all members of our local communities in applying for employment within the organisation. • To ensure that procedures and the working environment encourage staff to report incidents of discrimination or harassment and that staff are confident that complaints will be dealt with efficiently and effectively. To avoid the cost of discrimination in terms of staff well being, morale and reputation.

Expenditure on Consultancy Consultancy services are the provision to management of objective advice and assistance relating to strategy, structure, management or operations of an organisation in pursuant of its purposes and objectives. During the year, the Health Board spent £317,000 on consultancy services.

Tax Assurance For Off-Payroll Appointees In response to the Government’s review of the tax arrangements of public sector appointees, which highlighted the possibility for artificial arrangements to enable tax avoidance, Welsh Government has taken a zero tolerance approach and produced a policy that has been communicated and implemented across the Welsh Government. Tax assurance evidence has been sought and scrutinised to ensure it is sufficient from all off-payroll appointees. Sponsored bodies should also provide assurance of compliance with this tax policy within their annual governance statements.

Details of these off-payroll arrangements are published on Health Board’s website www.hywelddahb.wales.nhs.uk.

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Exit Packages Redundancy and other departure costs have been paid in accordance with the provisions of the NHS Voluntary Early Release Scheme (VERS). The exit costs detailed below are accounted for in full in the year of departure on a cash basis as specified in EPN 380 Annex 13C. Where the Health Board has agreed early retirements, the additional costs are met by the Health Board and not by the NHS pension scheme. Ill-health retirement costs are met by the NHS pension scheme and are not included in the table below.

This disclosure reports the number and value of exit packages taken by staff leaving in the year. Note: the expense associated with these departures may have been recognised in part or in full in a previous period.

The Health Board receives a full business case in respect of each application supported by the line manager. The Directors of Finance and Workforce & OD approve all applications prior to them being processed. Any payments over an agreed threshold are also submitted to Welsh Government for approval prior to Health Board approval. Details of exit packages and severance payments are as follows:

Exit Number of Number of Total Number of Total packages compulsory other number departures number of cost band redundancies departures of exit where exit (including packages special packages any special payments payment have been element) made Number Number Number Number Number less than 0 0 0 0 2 £10,000 £10,000 to 0 4 4 0 10 £25,000 £25,000 to 0 1 1 0 3 £50,000 £50,000 to 0 0 0 0 2 £100,000 £100,000 to 0 0 0 0 0 £150,000 £150,000 to 0 0 0 0 0 £200,000 more than 0 0 0 0 1 £200,000 Total 0 5 5 0 18

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2015-2016 2015-2016 2015-2016 2015-2016 2014-2015 Exit Cost of Cost of Total cost Cost of Total cost packages compulsory other of exit special of exit cost band redundancies departures packages element packages (including included in any special exit payment packages element) £'s £'s £'s £'s £'s less than 0 0 0 0 8,528 £10,000 £10,000 to 0 61,109 61,109 0 211,004 £25,000 £25,000 to 0 47,791 47,791 0 120,977 £50,000 £50,000 to 0 0 0 0 142,487 £100,000 £100,000 to 0 0 0 0 0 £150,000 £150,000 to 0 0 0 0 0 £200,000 more than 0 0 0 0 284,000 £200,000 Total 0 108,900 108,900 0 766,996

Our Parliamentary Accountability and Audit Report Where the Health Board undertakes activities that are not funded directly by the Welsh Government the Health Board receives income to cover its costs. Further detail of income receive is published in the Health Board’s annual accounts, within note 4 miscellaneous income.

The Health Board confirms it has complied with cost allocation and the charging requirements set out in HM Treasury guidance during the year.

Remote Contingent Liabilities Remote contingent liabilities are those liabilities which, due to the unlikelihood of a resultant charge against the Health Board, are not recognised as an expense nor as a contingent liability.

Where the Health Board undertakes activities that are not funded directly by the Welsh Government, the Health Board receives income to cover its costs. Further detail of income received is published in the Health Board’s annual accounts, within note 4 ‘Miscellaneous Income’.

Long-term Expenditure Trend The Health Board has a requirement to report on long term expenditure trends and detailed below is the expenditure incurred over the last five years from 2011/12 to 2015/16 within the main programme areas of:

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• Hospital and community health services; • Primary health care services; and • Healthcare from other providers

The expenditure trends of the Health Board over its main programme areas from 2011/12 to 2015/16 are as follows:

Programme 2011/12 2012/13 2013/14 2014/15 2015/16 Area £000’s £000’s £000’s £000’s £000’s Primary 170,154 167,692 171,809 172,710 172,740 Health Care Services Healthcare 159,094 161,480 166,287 173,091 179,320 from Other Providers Hospital and 430,064 427,978 421,029 435,040 457,847 Community Health Services

500 450 Primary Health Care 400 Services 350 £m 300 Healthcare from Other 250 Providers 200 150 100 Hospital and 50 Community Health 0 Services 2011/12 2012/13 2013/14 2014/15 2015/16

Where the Health Board undertakes activities that are not funded directly by the Welsh Government, the Health Board receives income to cover its costs which will offset the expenditure reported under the programme areas above. When charging for this activity, the Health Board has complied with the cost allocation and charging requirements as set out in HM Treasury guidance. The miscellaneous income received for the last five years is as follows:

2011/12 2012/13 2013/14 2014/15 2015/16 £000’s £000’s £000’s £000’s £000’ Miscellaneous 58,020 58,127 56,107 53,436 51,698 Income

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Remote Contingent Liabilities Remote contingent liabilities are those liabilities which, due to the unlikelihood of a resultant charge against us, are therefore not recognised as an expense or as a contingent liability. Detailed below are the remote contingent liabilities as at 31st March 2016: 2015-16 2014-15 £000's £000' Guarantees 0 0 Indemnities 7,795 8,131 Letters of Comfort 0 0 Total 7,795 8,131

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11. Our Financial Statements

Annual Accounts 2015/16

The National Health Service Finance (Wales) Act 2014 came into effect from 1 April 2014. The Act amended the financial duties of Local Health Boards under section 175 of the National Health Service (Wales) Act 2006. From 1 April 2014, section 175 of the National Health Service (Wales) Act places two financial duties on Local Health Boards:

• A duty under section 175 (1) to secure that its expenditure does not exceed the aggregate of the funding allotted to it over a period of three financial years • A duty under section 175 (2A) to prepare a plan in accordance with planning directions issued by the Welsh Ministers, to secure compliance with the duty under section 175 (1) while improving the health of the people for whom it is responsible, and the provision of health care to such people, and for that plan to be submitted to and approved by the Welsh Ministers.

We have submitted an Integrated Medium Term Plan for the period 2015/16 to 2017-19 in accordance with the planning directions issued by the Welsh Ministers. The plan submitted has not been approved by the Minister for Health and Social Services.

In 2015/16, we recorded an overspend against our Revenue Resource Allocation of £31.199m.

An abridged set of accounts is set out below. Full copies of the audited annual accounts can be obtained from our website at http://www.wales.nhs.uk/sitesplus/862/page/75118.

Summary Financial Statements

Operating Cost Statement and Achievement of Operational Financial Balance for the year ended 31 March 2016 2016 2015 £’000 £’000 Expenditure on Primary Healthcare Services 172,740 172,710 Expenditure on Healthcare from other Providers 179,320 173,091 Expenditure on Hospital and Community Health 457,847 435,040 Services Total Expenditure 809,907 780,841 Less : Miscellaneous Income 51,698 53,436 LHB Net Operating Costs Before Interest and 758,209 727,405 Other Gains and Losses Investment Income 0 0 Other (Gains) / Losses 6 0 Finance Costs 46 43 Net Operating Costs for the Financial Year 758,261 727,448

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Our accounts are prepared using Government Resource Accounting principles as stipulated by the Welsh Government in the ‘Local Health Board Manual for Accounts 2015/16’.

We receive 93% of our income from Welsh Government in the form of a resource limit amounting to £726.907m.

Statement of Financial Position as at 31 March 2016

31 March 31 March 2016 2015 £'000 £'000 Non-current assets Property, plant and equipment 237,647 235,470 Intangible assets 991 992 Trade and other receivables 16,664 16,755 Total non-current assets 255,302 253,217 Current assets Inventories 8,090 8,627 Trade and other receivables 17,952 20,201 Other financial assets 324 319 Cash and cash equivalents 2,052 355 Non-current assets Held for Sale 258 80 Total current assets 28,676 29,582 Total assets 283,978 282,799 Current liabilities Trade and other payables 79,275 70,527 Provisions 9,965 15,827 Total current liabilities 89,240 86,354 Net current assets/ (liabilities) (60,564) (56,772) Non-current liabilities Trade and other payables 0 0 Other financial liabilities 0 0 Provisions 16,947 17,187 Total non-current liabilities 16,947 17,187 Total assets employed 177,791 179,258

Financed by : Taxpayers' equity General Fund 160,953 159,166 Revaluation reserve 16,838 20,092 Total taxpayers' equity 177,791 179,258

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Statement of Cash flows for year ended 31 March 2016 2015-16 2014-15 £'000 £'000 Cash Flows from operating activities Net operating cost for the financial year (758,261) (727,448) Movements in working capital 13,291 10,761 Other cash flow adjustments 18,162 27,979 Provisions utilised (10,254) (14,425) Net cash outflow from operating activities (737,062) (703,133) Cash Flows from investing activities Purchase of property, plant and equipment (15,387) (25,411) Proceeds from disposal of property, plant and equipment 57 868 Purchase of intangible assets (238) (516) Payment for other financial assets (319) (319) Disposal of other financial assets 314 0 Net cash inflow/(outflow) from investing activities (15,573) (25,378) Net cash inflow/(outflow) before financing (752,635) (728,511)

Cash flows from financing activities Welsh Government funding (including capital) 753,646 727,938 Capital grants received 686 567 Net financing 754,332 728,505 Net increase/(decrease) in cash and cash equivalents 1,697 (6) Cash and cash equivalents at 1 April 355 361 Cash and cash equivalents at 31 March 2,052 355

Pensions Details of our pension costs can be found in Note 5 of the Annual Accounts.

External audit Our external auditor is the Wales Audit Office. The auditor was remunerated £408k for the statutory audit work, including Value for Money audits, carried out during the year.

Public Sector Payment Policy – Measure of Compliance Welsh Government requires us to pay non–NHS trade creditors in accordance with the CBI prompt payment code and NHS bodies in accordance with Government Accounting rules.

The target is to pay 95% of creditors within 30 days of receipt of goods or a valid invoice (whichever is later) unless other payment terms have been agreed with the supplier.

No amounts have been included in the accounts arising from claims made by small businesses under the Late Payments of Debts Commercial (Interest) Act 1998.

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Public Sector Payment Policy Number of Invoices Value of Invoices £’000 NHS Total bills paid 2015-16 3,406 203,466 Total bills paid within target 3,088 201,529 Percentage of bills paid 90.7% 99.0% within target

Non-NHS Total bills paid 2015-16 173,417 373,574 Total bills paid within target 149,044 351,675 Percentage of bills paid 85.9% 94.1% within target

Total Total bills paid 2015-16 176,823 577,040 Total bills paid within target 152,132 553,204 Percentage of bills paid 86.0% 95.9% within target

Financial Position for 2015/16 During the year, we spent £809.907m on services. Of this, £172.740m was spent on primary healthcare services, £179.320m spent on healthcare from other providers and £457.847m spent on hospital and community health services. The following diagrams provide further explanation of the expenditure:

Primary Healthcare Services

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Hospital and Community Health Services

Healthcare from Other Providers

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Tax Assurance For Off-Payroll Appointees In line with the Welsh Government policy on the tax arrangements of public sector appointees implemented to prevent artificial arrangements to enable tax avoidance, tax assurance evidence has been sought from all off-payroll appointees and scrutinised to ensure it is sufficient. Sponsored Bodies should also provide assurance of compliance with this tax policy within their annual governance statements. Details of these off-payroll arrangements are as follows:

Table 1: For all off-payroll engagements as of 31 March 2016, for more than £220 per day and that last for longer than six months

No. of existing engagements as of 31 March 2016 13 Of which... No. that have existed for less than one year at time of reporting 6 No. that have existed for between one and two years at time of 7 reporting No. that have existed for between two and three years at time of 0 reporting No. that have existed for between three and four years at time of 0 reporting No. that have existed for four or more years at time of reporting 0

Table 2: For all new off-payroll engagements, or those that reached six months in duration, between 1 April 2015 and 31 March 2016, for more than £220 per day and that last for longer than six months

No. of new engagements, or those that reached six months in duration, 19 between 1 April 2015 and 31 March 2016 No. of the above which include contractual clauses giving the department the right to request assurance in relation to income tax and 19 National Insurance obligations No. for whom assurance has been requested 19 Of which... No. for whom assurance has been received 3 No. for whom assurance has not been received 16 No. that have been terminated as a result of assurance not being 0 received.

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Table 3: For any off-payroll engagements of board members, and/or, senior officials with significant financial responsibility, between 1 April 2015 and 31 March 2016

No. of off-payroll engagements of board members, and/or, senior 0 officials with significant financial responsibility, during the financial year. No. of individuals that have been deemed “board members, and/or, senior officials with significant financial responsibility”, during the financial year. This figure should include both off-payroll and on-payroll 0 engagements.

We confirm that all existing off-payroll engagements, outlined above, have at some point been subject to a risk based assessment as to whether assurance is required that the individual is paying the right amount of tax, and where necessary, that assurance has been sought.

Mr Steve Moore Chief Executive Hywel Dda University Health Board (on behalf of the Board)

Date: 22 September 2016

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