Bundle Health Board 14 May 2020
10.30am via WebEx
1 10:30 - 20/45 Sylwadau Agoriadol y Cadeirydd / Chair's Introductory Remarks - Mr Mark Polin 1. To note in public that the Minster has approved a 12 month extension of tenure for Mr Ffrancon Williams as SRG Chair, ahead of amendments to the Regulations being made, to allow for continuity. In addition the SRG has supported a 12 month extension to Mr Gwilym Ellis-Evans' tenure as SRG Vice Chair. 2. To note in public that Health Board Chair's Action has been taken to approve business cases for the procurement and construction of the three temporary hospitals at Bangor, Llandudno and Deeside and to approve an SBAR on the provision of piped oxygen infrastructure. 3. To note in public that F&P Chair's Action had been undertaken to approve contract awards for managed service contracts for Electrophoresis and Glycated Haemoglobin services. Note that John Cunliffe (whilst supportive) wished to note his concern at the length of the contract at 8 years. 4. To note in publlic that Health Board Chair's Action has been taken regarding settlement of a high value claim with permission given for the Acting Associate Director of Quality Assurance and Assistant Director of Patient Safety and Experience to instruct counsel via the Claims Manager to commence negotiation at a joint settlement meeting. 2 10:32 - 20/46 Ymddiheuriadau am Absenoldeb / Apologies for Absence 3 10:33 - 20/47 Datganiadau o Fuddiant / Declarations of Interest 4 10:34 - 20/48 Cofnodion Drafft Cyfarfod y Bwrdd Iechyd a gynhaliwyd yn gyhoeddus ar 15.4.20 er cywirdeb ac adolygu'r Cofnod Cryno o Weithredoedd / Draft Minutes of the Health Board Meeting held in public on 15.4.20 for accuracy and review of Summary Action Log 20.48a Minutes Board 15.4.20 Public V0.02.docx 20.48b Summary Action Log Public v194.doc 5 10:39 - 20/49 Diweddariad Covid-19 Update - Dr Chris Stockport Verbal report 6 10:54 - 20/50 Cynnal Llywodraethu Covid19 / Maintaining Governance Covid19 - Ms Dawn Sharp Recommendations: The Board is asked to: 1. Note the updated report 2. Approve the additional variations to the Standing Orders 3. Note the continued revised approach to Board decision making 4. Note the continued revised approach to meetings in public 5. Approve the Covid-19 Cabinet Terms of Reference 20.50 Maintaining Good Governance Covid-19 V2.02 for Board 14.5.20.docx 7 11:04 - 20/51 Adroddiad Cyllid Mis 12 / Finance Report Month 12 - Ms Sue Hill Recommendations: 1. It is asked that the report is noted. 2. The Board is requested to delegate authority to approve the audited annual accounts and returns to the Audit Committee at their meeting of 29th June 2020. 20.51 Finance Report M12.docx 8 11:19 - 20/52 Adroddiad Integredig Ansawdd a Pherfformiad / Integrated Quality Performance Report - Mr Mark Wilkinson Recommendation: The Health Board is asked to scrutinise the report and to consider whether any area needs further escalation to be considered. 20.52a IQPR narrative report.docx 20.52b IQPR March 2020 FINALV3.pdf 9 11:34 - 20/53 Cofrestr Risg Corfforaethol / Corporate Risk Register - Mrs Gill Harris Recommendations: The Board is requested to: 1. Note, approve and ratify the Corporate Risk Register (CRR) and to gain assurance that risks articulated on it are appropriately and robustly managed in line with the Health Board`s risk management strategy and best practice. 2. To approve any changes to risks that have been requested by the various committees. 20.53 CRAF Report v5.docx 10 11:54 - 20/54 Deddf Iechyd Meddwl 1983 fel y diwygiwyd gan Ddeddf Iechyd Meddwl 2007. Deddf Iechyd Meddwl 1983 Cyfarwyddiadau Clinigwyr Cymeradwy (Cymru) 2008. Diweddaru Cofrestr Meddygon Cymeradwy Adran 12(2) Meddygon i Gymru a Diweddaru Cofrestr Clinigwyr Cymeradwy (Cymru Gyfan) /Mental Health Act 1983 as amended by the Mental Health Act 2007. Mental Health Act 1983 Approved Clinician (Wales) Directions 2008. Update of Register of Section 12(2) Approved Doctors for Wales and Update of Register of Approved Clinicians (All Wales) - Mr Simon Dean Recommendation: The Board is asked to ratify the additions and removals to the All Wales Register of Section 12(2) Doctors for Wales and the All Wales Register of Approved Clinicians. 20.54 Section 12(2) doctors.docx 11 11:59 - 20/55 Gwasanaethau Fasgwlaidd / Vascular Services ITEM DEFERRED TO EXTRAORDINARY MEETING 21.5.20 12 FOR INFORMATION 12.1 20/56 Documents Previously Circulated for Information To note that members have received the following via email: Chair's Assurance Report F&P 23.1.20 and 27.2.20 Chair's Assurance Report SPPH 5.3.20 Chair's Assurance Report DIG 13.2.20 Chair's Assurance Report QSE 28.1.20 Chair's Report SRG 03.03.20 Chair's Assurance Report CFC 10.03.20 EASC minutes 12.11.19 WHSCC Joint Committee Briefing (Private) 6.1.20 Shared Services Partnership Committee assurance report 16.1.20 WHSCC Joint Committee Briefing (Private) 28.1.20 and 10.3.20 WHSCC Joint Committee Briefing (Public) 28.1.20 and 10.3.20 EASC summary 28.1.20 12.2 20/57 Dyddiad y Cyfarfod Nesaf / Date of Next Meeting The next Health Board meeting will be held Thursday 21st May 2020 @ 2.30pm 13 20/58 Heb y Wasg a'r Cyhoedd / Exclusion of Press and Public Ystyried cynnigi Eithrio’r Wasg a’r Cyhoedd - “Bod cynrychiolwyr o’r wasg ac aelodau eraill o’r cyhoedd i gael eu heithrio o weddill y cyfarfod hwn yng ngoleuni natur gyfrinachol y materion sydd i’w trafod, y byddai cyhoeddusrwydd arnynt yn niweidiol i ddiddordeb y cyhoedd. (Adran 1 (2) Y Ddeddf Cyrff Cyhoeddus (Derbyn i Gyfarfodydd) 1960)." Resolution to Exclude the Press and Public - ''That representatives of the press and other members of the public be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest in accordance with Section 1(2) Public Bodies (Admission to Meetings) Act 1960.''
4 20/48 Cofnodion Drafft Cyfarfod y Bwrdd Iechyd a gynhaliwyd yn gyhoeddus ar 15.4.20 er cywirdeb ac adolygu'r Cofnod Cryno o Weithredoedd / Draft Minutes of the Health Board Meeting held in public on 15.4.20 for accuracy and review of Summary Action Log 1 20.48a Minutes Board 15.4.20 Public V0.02.docx
Minutes Health Board 15.4.20 V0.02 1
Betsi Cadwaladr University Health Board (BCUHB) Draft minutes of the Health Board meeting held in public session on 15.4.20 Via WebEx Conferencing Present: Mr M Polin Chair (part meeting) Prof N Callow Independent Member ~ University Cllr C Carlisle Independent Member Mr J Cunliffe Independent Member Mr S Dean Interim Chief Executive Mr G Evans Chair of Healthcare Professionals Forum Mrs S Green Executive Director of Workforce & Organisational Development (OD) Mrs G Harris Executive Director of Nursing & Midwifery / Deputy Chief Executive Mrs S Hill Acting Executive Director of Finance Mrs J Hughes Independent Member Cllr M Hughes Independent Member Mr E Jones Independent Member Mrs L Meadows Independent Member Mrs J Parry Acting Board Secretary Mrs L Reid Vice Chair Mrs L Singleton Acting Director of Mental Health & Learning Disabilities Dr C Stockport Executive Director of Primary & Community Services Mr A Thomas Executive Director of Therapies & Health Sciences Mrs H Wilkinson Independent Member Mr M Wilkinson Executive Director of Planning & Performance Mr Ff Williams Chair of Stakeholder Reference Group
In Attendance: Mrs K Dunn Head of Corporate Affairs (for minutes) Mrs M W Jones Board Adviser Mrs L M Roberts Executive Business Manager (Chair’s Office)
Apologies: Mrs M Edwards Associate Board Member, Director of Social Services Dr D Fearnley Executive Medical Director
Agenda Item Discussed Action By 20/34 Chair's Introductory Remarks
20/34.1 The Chair welcomed everyone to the meeting.
20/34.2 It was resolved that the Board endorse the Chair's Actions which had been undertaken on the following matters: An inflationary uplift of Continuing Health Care (CHC), joint funded and domiciliary care fee rates for 2020/2021; and support for an additional premium payment to the Minutes Health Board 15.4.20 V0.02 2
CHC rate as an interim payment as the Health Board develops its new CHC Pricing Methodology in conjunction with the NCCU. To allow the Health Board’s solicitors to negotiate a settlement relating to a high value Claim
20/35 Declarations of Interest
None declared
20/36 Minutes of Meeting Held in Public on 23.1.20
20/36.1 The minutes were approved as an accurate record.
20/36.2 The summary action log was reviewed and the proposals to close or defer actions were agreed.
20/37 Covid-19 Update
20/37.1 The Executive Director of Primary & Community Services provided an update CS from a set of presentation slides which would be circulated. He highlighted: There had been 398 confirmed cases in North Wales, 126 of which were current in- patients and the largest numbers were in the 70+ age group which was consistent with the rest of the UK. Surge capacity planning was continuing based on the key principles of caring for patients at home where possible and only providing essential acute care on acute sites. Challenges around the provision of oxygen were being worked through and it was noted this would predominantly affect step down facilities. The establishment of the temporary hospitals remained on target. The provision of Personal Protective Equipment (PPE) continued to be matter of concern but supply was continuing through the national procurement framework and there had been a positive and pleasing level of support from communities and local industry. Training on the use of PPE was in place across sites. Testing was progressing as well as national procurement allowed. There was now a redeployment database established of around 1000 staff. Consistent progress was being made with recruitment and a model was in place for the staffing of the temporary hospitals and to respond to expected surge capacity requirements on existing sites. A range of measures had been developed to promote and maintain staff wellbeing. In terms of health, safety and security there was a large amount of work being undertaken across multiple sites and to ensure that the Board would be able to meet new requirements in terms of Health and Safety Executive (HSE) reporting. Currently around 9% of the workforce was absent from work with the majority being reasons pertaining to self-isolation meaning there was a planned return date. In terms of non-Covid activity across the Health Board, Emergency Department (ED) attendances were down by about 50% and there was a notable reduction in other medical emergencies. Minutes Health Board 15.4.20 V0.02 3
With regard to communications the significant effort and commitment from the corporate team and others was acknowledged and that there had been excellent TV and media coverage of a positive nature.
20/37.2 Comments and questions were invited from members. A summary of the discussion is as follows:- There were differing models in terms of forecasting the peak surge but this was broadly expected in mid May although members were assured that currently BCUHB was maintaining capacity within critical care. A higher degree of certainty and confidence would be likely within the next couple of weeks. The Chair would expect to see further clarity around temporary hospitals in terms of the workforce, pathways and patient cohorts within the next few days. He also reflected that consideration needed to be given to the potential amount of time they could be needed and the implications of loss of income for the sites. The Interim Chief Executive assured the Board that the temporary hospitals’ capacity had been designed to cope with a worst case scenario. He added that the question around loss of earnings was one for the Welsh Government (WG). The Chair reiterated the general concern around PPE and that he would be raising the matter again with the Director of Finance at WG in a later call. The Chair also suggested that urgent consideration needed to be given to the situation of testing for staff and what information could be provided on this within the public SG LS domain to reassure partners and the public. The Executive Director of Workforce & OD accepted that whilst large numbers were being tested, more could be done. She indicated that an update would be emailed out to members. The Executive Director of Workforce & OD confirmed that a risk framework was to be discussed at the Cabinet meeting on the 16.4.20 including a process for Cabinet to review the risk logs from each workstream, the Health Emergency Control Centre (HECC), acute site control centres and Gold Command. Cabinet would then take a view as to whether anything required escalation to the corporate organisational risk register. The Executive Director of Workforce & OD confirmed that ideally any internal Covid-19 related correspondence should go through the ‘SRO’ workstream inboxes and she SG undertook to share these email addresses with board members.
20/37.3 The Executive Director of Nursing and Midwifery referred members to the paper relating to nurse staffing levels which set out a request to postpone routine monitoring and updates to the Board which was in line with the approach being taken by other Welsh Boards. She assured members that the previously agreed staffing levels would be maintained for as long as it was possible to do so given the current situation. She also assured the Chair of the Stakeholder Reference Group (SRG) that the priority remained of ensuring patient safety and that any breaches would continue to be recorded and reported as part of the continued work around safety dashboards, incident reporting and infection control – with the Quality Safety & Experience (QSE) Committee maintaining its oversight of these matters.
20/37.4 It was resolved that the Board: 1. Note the Welsh Government position associated with the Nurse Staffing Levels (Wales) Act 2016 under these exceptional circumstances and APPROVE the Health Boards proposed stance to: Cease the re-calculation of the Nurse Staffing Levels on Inpatient Adult Medical & Surgical Wards until such time that the Pandemic actions are no longer in force; Minutes Health Board 15.4.20 V0.02 4
Indefinitely postpone the Nurse Staffing Levels Annual Report to the Board; To redefine Nurse Staffing Levels for COVID Wards based on a revised multidisciplinary workforce approach, ahead of national guidance; To maintain the calculation, as far as reasonably possible, for designated Non COVID wards/areas (to include commissioned services).
20/38 Maintaining Good Governance
20/38.1 The Chair reported that some typographical errors had already been noted and the need to amend Appendix 2 to show that the Finance & Performance (F&P) Committee would also be suspended. The Vice Chair indicated she had also made some comments LR on the report which she would forward, in particular around the current focus for the Quality, Safety & Experience Committee. In response to a question from the Vice Chair, the Acting Board Secretary confirmed that high level risks would still come to the full Board. The Independent Member (Trade Union) suggested that reference to the regular liaison with Trade Union partners be included. In response to points raised by the Chair of the SRG, the Acting Board Secretary confirmed that reference to Advisory Groups would be incorporated into a future version, and confirmed that in terms of the section on quorum the Chair did have a casting vote.
20/38.2 Pending the agreed amendments it was resolved that the Board: JP 1. Note the report 2. Approve the variation to the Standing Orders as outlined 3. Approve the revised approach to Board decision making 4. Approve the approach to meetings in public 5. Note the suspension of Committees as set out
20/39 Financial Plan 2020-21
20/39.1 The Acting Director of Finance presented the paper which set out the proposed 2020/21 Financial Plan showing the impact of the forecast outturn, an assessment of cost pressures, financial pre-commitments; WG allocations and required cash releasing savings. She noted that the plan was a static document and not a dynamic one, and confirmed that the advice from WG had been to set the plan as it would have been prior to the impact of Covid-19 and use it as the baseline for reporting, and to identifythe reduction in non Covid-19 activity and identifying Covid-19 related costs. She drew members’ attention to the implication of Covid-19 on the organisation’s cost base and its ability to deliver targets. This had been escalated as a risk to the corporate risk register, and a separate briefing paper on financial governance and the ability to meet Standing Financial Instructions had also been drafted.
20/39.2 The Chair stated that the Board needed to firstly recognise it was being presented with a financial budget without an operational plan but that this position would need to be recovered as soon as matters returned to normal. In terms of the Board’s financial recovery this had been suspended in line with other Welsh Health Boards but he would wish to see monthly financial reporting maintained even though the F&P Committee was not currently meeting.
20/39.3 The Vice Chair of the F&P Committee raised a number of questions: Where the stated “risks of collaboration” would be documented and how they would be managed? The Acting Director of Finance responded that they had not yet been Minutes Health Board 15.4.20 V0.02 5
identified fully within the risk register and this would need to be thought through further. What appetite for transformational change the plan was assuming? The Acting Director of Finance responded that Covid-19 had actually accelerated elements of transformational change and that the positive examples of clinical leadership currently would give the organisation an advantage in terms of sustainability. Whether there were pipeline savings to meet the total cash releasing savings target of £45m? The Acting Director of Finance responded that there remained a gap which was still being worked on. Whether there was an analysis of what the budget would need to be to include referral to treatment etc. The Acting Director of Finance responded that the expectation was that this would have been matched by WG funding.
20/39.4 The Chair referred to the recovery arrangements and that this critical piece of work must be properly resourced. He also felt it would provide a good opportunity to initiate transformation and not return automatically to previous clinical pathways. He suggested that contact be made with Hywel Dda Health Board as they were ahead of North Wales in terms of their recovery programme. He also asked that a formal update JP on the recovery work and what it aimed to achieve be scheduled for a future Board meeting.
20/39.5 It was resolved that the Board: 1. Note and comment upon the 2020/21 outline budget set out in Section 5.1. 2. Note that approving a budget which does not plan for a breakeven position increases the Health Board’s cumulative deficit. This will be the sixth year where the Health Board will not have achieved breakeven, and the cumulative deficit may need to be repaid in the longer term. 3. Recognise that approving a budget which does not plan to break-even is by definition a ‘novel or contentious’ matter which has necessitated the Chief Executive as Accountable Officer to write to the Chief Executive of NHS Wales to explain the situation. 4. Note that failure to achieve breakeven for the three-year period may mean that the Health Board’s accounts are qualified by the Wales Audit Officer on the basis of regularity, following the audit of the 2019/20 financial statements. 5. Note and endorse the assessment of the Health Board’s budget deficit of £57.72m as outlined in Section 5.2. 6. Consider and approve if in agreement the unavoidable cost pressures outlined in Section 5.5. 7. The Board is advised that the Health Board’s financial risk profile will increase should it decide not to recognise these cost pressures. 8. Note that the budget does not secure assured delivery of performance targets including Referral to Treatment (RTT). 9. Consider and note the level of the savings challenge for 2020/21 and the basis on which this will be managed in order to achieve the budgeted resource allocation. 10.Approve the Executive Director of Finance’s advice of a total savings target of £45m. 11.Subject to recommendations 5 to 10, approve the recommended budget outlined in Section 5.1. Minutes Health Board 15.4.20 V0.02 6
12.Approve the use of the Accountability Agreements, based on the document included in Appendix 2. 13.Note and approve the Capital allocation as set out in Section 5.6, recognising that the Health Board will, through the Finance and Performance Committee, develop plans to spend this allocation over the year within the outlined limits. 14.Note the Cash implication as set out in Section 5.7, and the requirement to repay the cumulative cash deficit over the longer term. 15.Note the ring-fenced allocations as set out in Section 6.1. 16.Note the Risks as set out in Section 8.2 and Governance considerations set out in Section 9.
[Mr M Polin left the meeting and the Mrs L Reid Chaired from this point on]
20/40 Corporate Risk Register Update & Risk Management Strategy Update
20/40.1 The Board considered a newly described risk (3117) relating to public health and safety arising from an outbreak of COVID-19 and demand outstripping organisational capacity. It was felt that many of the controls were task oriented and were responses to an incident rather than controls that would mitigate an articulated risk. It was also GH suggested the risk description could be better articulated. Members acknowledged the risk in general and that officers would continue to fine tune the narrative and controls. The Executive Director of Workforce & OD felt there were several links to the command and control framework and suggested that the risk also be discussed at the next Cabinet SG meeting.
20/40.2 The Board considered a newly described risk (3138) relating to infection control as a result of inadequate supply, quality or usage of PPE. It was again acknowledged in principle that there needed to be a risk of this nature within the corporate risk register, however, the risk description needed amending. In addition the Executive Director of GH Nursing & Midwifery noted that it would need to be updated following a relevant meeting on the 14th and the Executive Director of Workforce & OD added that the HSE reporting requirements regarding exposure needed to be included.
20/40.3 The SRG Chair noted that both new risks were of an unacceptable score according to the risk appetite defined within the organisational Risk Management Strategy. The Board acknowledged formally that this was not a position it was happy to be in, however, it was understandable given the unprecedented situation.
20/40.4 The Board had been provided with a copy of a revised organisational Risk Management Strategy which underlined the intention and commitment to embark on the implementation and embedding of an Enterprise Risk Management (ERM) Model across the organisation. The Audit Committee Chair proposed to the Board that this was not approved as the Audit Committee had outstanding concerns over the capacity of the risk management team to fully implement this approach. The Acting Board Secretary stated that the existing Risk Management Strategy would therefore need to be extended to ensure an operational strategy was still in place until such time as the Audit Committee was assured around capacity. She also reported that a paper addressing capacity issues was to be written but had been delayed. Minutes Health Board 15.4.20 V0.02 7
20/40.5 Given the discussion it was resolved that the Board: 1. Approve in principle the new corporate risks regarding COVID-19 and PPE 2. Approve the extension of the existing Risk Management Strategy to remain as the operational strategy until further notice.
20/41 Mental Health Act 1983 as amended by the Mental Health Act 2007. Mental Health Act 1983 Approved Clinician (Wales) Directions 2018. Update of register of Section 12(2) Approved Doctors for Wales and Update of Register of Approved Clinicians (All Wales)
20/41.1 It was resolved that the Board ratify the list of additions and removals to the All Wales Register of Section 12(2) Doctors for Wales and the All Wales Register of Approved Clinicians.
20/42 Date of Next Meeting and Any Other Business
20/42.1 It was noted that the Health Board would next meet in public session on the 14th May 2020
20/42.2 The Acting Board Secretary asked the Board to agree two matters under any other business: It was noted that members had received a copy of a letter from the Wales Audit Office dated the 8th April 2020 setting out the impact of Covid-19 on the annual audit plan. The Board agreed that the approval of the organisational financial annual accounts for 2019-20 be delegated to the Audit Committee.
20/43 Public Bodies (Admission to Meetings) Act 1960
20/43.1 It was resolved that: The Board note that whilst observers are excluded from attending meetings during the Covid-19 pandemic, minutes of the discussion held in public session will be published to the website within three working days if possible. The remainder of the meeting be held in private session having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest in accordance with Section 1(2) Public Bodies (Admission to Meetings) Act 1960.
The Health Board then met in private session. The only business discussed was:
20/44 To approve the minutes of the meeting held in private on the 23.1.20 as an accurate record and to note the summary action log with proposals to close or defer actions. 1 20.48b Summary Action Log Public v194.doc
HEALTH BOARD SUMMARY ACTION LOG – ARISING FROM MEETINGS HELD IN PUBLIC
Lead Minute Reference and Action Original Update Action to be Executive Agreed Timescale closed / Member Set Actions from Health Board 25.7.19 S Hill 19/106.3 Sept 2019 29.8.19 The Executive Director of Finance will Agree a timeline for sharing piece of provide an update at the meeting on 5.9.19 work on understanding financial 28.10.19 The Executive Director of Finance is drivers undertaken by PWC with meeting with the Director of the Finance Delivery another organisation Unit in November to review the draft paper and will then confirm when the Drivers of the Deficit report December will be presented to F & P and Board, but the expectation is that it will be December. 15.1.20 The drivers of deficit paper will now be January submitted to the F&P Committee in January 2020. 23.1.20 It was confirmed that the paper had been presented to the F&P Committee in private session and had been felt to be a useful report that would help shape the work of the improvement groups February and savings plans. The Acting Executive Director of Finance would consider the best forum and approach for sharing the paper. 18.4.20 Copy of presentation and minute extract CLOSED emailed to all Board members. Actions from Health Board 23.1.20 D Carter 20/17.3 February Circulated to all board members on 18.4.20 CLOSED Share a recent QSE Patient Story on Welsh language issues with the rest of the Board. Actions from Health Board 15.4.20 1 Summary Action Plan – Health Board – arising from meetings held in public C 20/37.1 22.4.20 Presentation circulated to board members on Closed Stockport Circulate copy of presentation 21.4.20 slides used for Covid update S Green 20/37.2 14.5.20 Completed Closed L Singleton Determine what information on staff testing could be provided to reassure partners and the public. S Green 20/37.2 22.4.20A Completed and follow up meeting arranged for 6th Closed Circulate via email an update for May members on staff testing. S Green 20/37.2 22.4.20 Completed on day of meeting Closed Circulate details of all the workstream email addresses to members L Reid 20/38.1 22.4.20 Comments received and incorporated into final Closed Provide written comments on version published to website maintaining governance paper J Parry 20/38.1 22.4.20 Achieved Closed Incorporate amendments from the discussion into maintaining governance paper J Parry 20/39.4 14.5.20 Scheduling yet to be agreed at most appropriate Arrange for the Board to receive a forum briefing on Recovery arrangements in due course G Harris 20/40.1 22.4.20 Risk has been updated as requested Closed Incorporate suggested amendments to CRR3117 including the risk description and controls. S Green 20/40.1 16.4.20 Included within Risk paper submitted to Cabinet on Closed Arrange for CRR3117 to be 30.4.20 discussed at Cabinet G Harris 20/40.2 22.4.20 Risk has been updated as requested Closed Incorporate suggested amendments 2 Summary Action Plan – Health Board – arising from meetings held in public to CRR3138 including the risk description and controls.
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3 Summary Action Plan – Health Board – arising from meetings held in public 6 20/50 Cynnal Llywodraethu Covid19 / Maintaining Governance Covid19 - Ms Dawn Sharp 1 20.50 Maintaining Good Governance Covid-19 V2.02 for Board 14.5.20.docx
1
Cyfarfod a dyddiad: Health Board Meeting and date: 14th May 2020 Cyhoeddus neu Breifat: Public Public or Private: Teitl yr Adroddiad Maintaining Good Governance (Covid-19) Report Title: Cyfarwyddwr Cyfrifol: Ms Dawn Sharp Responsible Director: Interim Board Secretary Awdur yr Adroddiad Mrs Kate Dunn Report Author: Head of Corporate Affairs Craffu blaenorol: Previous version approved by Health Board 15.4.20. Updates Prior Scrutiny: scrutinized by Interim Board Secretary.. Atodiadau Appendix 1 revised Chair’s Action proforma Appendices: Appendix 2 scheduled of additional proposed variations from Standing Orders Appendix 3 Covid-19 Cabinet Terms of Reference Argymhelliad / Recommendation: The Board is asked to:
1. Note the updated report 2. Approve the additional variations to the Standing Orders 3. Note the continued revised approach to Board decision making 4. Note the continued revised approach to meetings in public 5. Approve the Covid-19 Cabinet Terms of Reference
Please tick one as appropriate (note the Chair of the meeting will review and may determine the document should be viewed under a different category) Ar gyfer Ar gyfer Ar gyfer Er penderfyniad X Trafodaeth sicrwydd gwybodaeth /cymeradwyaeth For For For For Decision/ Discussion Assurance Information Approval Sefyllfa / Situation:
Given the current and developing situation with Covid-19 it is necessary to sustain a range of variations to Board governance arrangements as agreed by the Board on 15.4.20. This updated paper sets out the proposed approach to ensuring the appropriate level of Board oversight and scrutiny to enable it to discharge its responsibilities effectively, whilst recognising the reality of executive focus and time constraints.
A summary of changes since the Health Board considered this paper at its meeting on 15th April 2020 are:
Further proposals to vary Standing Orders – as set out in Appendix 2 The inclusion of Cabinet terms of reference – see Appendix 3 2
Amendment to para 4.3 to reflect the Health Board is currently meeting monthly Amendment to para 4.4 to reflect proposals for Committee and Advisory Group meetings from June onwards Consolidation of Chair’s Action proforma and updating of standard operating procedure – see Appendix 1
Cefndir / Background:
The following narrative sets out the Health Board’s approach to ensuring the appropriate level of Board oversight and scrutiny to discharge its responsibilities effectively, whilst understanding and recognizing that the executive focus and commitment with be to respond to the COVID-19 emergency. Part of this response includes changes to ways of working and the need to continually adapt to the crisis. This requires temporary variation from the legal framework to which the Board operates. To ensure a consistent approach across Wales, the national Board Secretaries Group, having a shared knowledge and expertise for good governance, have considered and developed a set principles for good governance during the Covid-19 pandemic and these are reflected in this paper.
1. INTRODUCTION
Whilst the Health Board undergoes significant changes to react to the coronavirus emergency the Board should strip back the agenda and focus on the essential business only.
The Board’s fundamental role and purpose will remain during this period and does not change. Crucially during the current COVID-19 crisis, the Board must require and receive positive assurance, not just on service preparedness and response but also on clinical leadership, engagement and ownership of developing plans; on the health and wellbeing of staff; on proactive, meaningful and effective communication with staff at all levels and on health and care system preparedness.
At the same time, we must remember that if mistakes are made and harm done in this period then the enquiry that would surely follow would look very closely at how the Board assured itself, what questions it asked and what evidence it received.
This paper sets out BCUHBs approach to ensuring the appropriate level of Board oversight and scrutiny to discharge its responsibilities effectively, whilst recognising the reality of executive focus and time constraints. Part of the response is about ways of working, which of course can and must adapt continually during such a crisis; but part of the response requires temporary variation from the legal framework to which the Board operates – the Standing Orders (SOs) and Scheme of Reservation and Delegation of Powers (SoRD).
As there is a need for us to continually adapt, the approach set out in this paper will remain under constant review by the Chair, Interim Chief Executive and Acting Board Secretary. Any further variations to SOs, will be brought to the Board for approval or ratification.
2. WAYS OF WORKING PRINCIPLES
The differing ways of working set out in this paper will:
Allow maximum flexibility to adapt to a rapidly evolving situation 3
Minimise executive requirements for preparation of papers or attendance at meetings unrelated to the immediate requirements of COVID 19 Be sensitive to the need to ensure executive wellbeing, particularly when there is a need for 24/7 involvement Ensure all Independent Members are briefed and engaged both through the crisis and beyond Ensure Independent Members expertise and contacts are appropriately available to execs during the crisis Provide an appropriate balance between short term operational imperatives and longer term requirements for a sustainable organisation Ensure that appropriate arrangements are in place to support the organisation to exit crisis in a planned way Ensure appropriate partnership arrangements are in place to deal with both short term necessities and longer term requirements to embed improvements All meeting arrangements should reflect current guidelines on social distancing Independent Member triangulation activities during this period should be minimised and will need to rely far more than usual on what is being told by the executive for assurance. The Chair and Interim Chief Executive will be in contact daily and the Chair will brief the Independent Members on a weekly basis. A range of communication arrangements are in place and include: Daily bulletin to all staff (including all Board Members and primary care contractors) Daily Primary Care Update from Primary Care Team to contractors and managed practises Daily update to Board including Media Evening Update, Primary Care communications (as above) and HECC briefing Daily update to partners inc AMs, MPs, CHC, LAs and third sector Weekly message from CEO and Chair to all staff via email, Staff App and on intranet Weekly teleconference with WG Communications and NHS Wales communications colleagues inc PHW Workstream SITREP reporting once a week and shared with Gold Command Weekly briefing to all Independent Members (via telephone conference) Weekly Skype between Chair and local AMs Weekly Skype/Telephone conference with the Trade Unions Weekly Skype between Chair/CEO and Local Authority Leaders and CEOs and communications team representative dials in to daily LRF Media Cell call at 2pm Weekly Skype between Chair/CHC leads Vice Chair keeping in touch with Primary Care Chair/Vice Chair speak weekly and as needed
3. GOVERNANCE PRINCIPLES
The All Wales Board Secretaries Group has framed a number of governance principles that are designed to help focus consideration of governance matters over coming weeks and months.
These are:
Public interest and patient safety - We will always act in the best interests of the population of Wales and will ensure every decision we take sits in this context taking into account the national public health emergency that (COVID-19) presents. 4
Staff wellbeing and deployment – we will protect and support our staff in the best ways we can. We will deploy our knowledge and assets where there are identified greatest needs. Good governance and risk management – we will maintain the principles of good governance and risk management ensuring decisions and actions are taken in the best interest of the public, our staff and stakeholders ensuring risk and impact is appropriately considered. Delegation and escalation – any changes to our delegation and escalation frameworks will be made using these principles, will be documented for future record and will be continually reviewed as the situation unfolds. Boards and other governing fora will retain appropriate oversight, acknowledging different arrangements may need to be in place for designated officers, deputies and decisions. Departures - where it is necessary to depart from existing standards, policies or practices to make rapid but effective decisions - these decisions will be documented appropriately. Departures are likely, but not exclusively, to occur in areas such as standing orders (for example in how the Board operates), Board and executive scheme of delegation, consultations, recruitment, training and procurement, audit and revalidation. One Wales – we will act in the best interest of all of Wales ensuring where possible resources and partnerships are maximised and consistency is achieved where it is appropriate to do so. We will support our own organisation and the wider NHS to recover as quickly as possible from the national public health emergency that COVID-19 presents returning to business as usual as early as is safe to do so. Communication and transparency - we will communicate openly and transparently always with the public interest in mind accepting our normal arrangements may need to be adapted, for example Board and Board Committee meetings being held in public.
4. GOVERNANCE AND RISK
4.1 Decision Making and variation from Standing Orders The SOs and SoRD set out, together with a range of other framework documents, the arrangements for the Board and the wider organisation to make decisions. In principle, the current Board scheme of delegation and specifically the matters the Board reserves for its own decision (schedule 1 of the SOs) will remain. The aim would be to retain whole Board decision making for as long as possible, however, if the full Board was not available or could not be convened at speed it will operate with a quorum as set out in standing orders.
In the event of a critical or urgent decision(s) needing to be made, Chair’s action (Health Board Chair and Committee Chairs) will be utilised. The process for considering Urgent Action is set out in Appendix 1.
Where possible the full Board will retain decision making; If the full Board is not available or practical, it will operate with a quorum of 3 executives and 3 independent members that can be convened at speed; Chair’s Action will be used sparingly and only as a last resort. Any Chair’s Action will of course be recorded and ratified by reporting to the next available meeting in public session.
To ensure that the Health Board can facilitate agile decision making and reduce unnecessary bureaucracy, without compromising strong governance, a temporary variation to parts of the Standing Orders (November 2019 edition) were agreed by the Health Board on 15th April 2020 and some additional proposed variations are set out in the table within Appendix 2. 5
The Board and Committee structure will need to be streamlined. Executive Directors will have little time for the preparation of reports, so the Board is asked to accept oral reports where appropriate, and to accept that reports may not be received in accordance with the agreed 7 day timescale. It is important to ensure that there is a clear audit trail with minutes recording how decisions have been made.
The Interim Chief Executive, as Accountable Officer, is delegated authority by the Board to make decisions with regard to the management of the Health Board. Executive Directors have been delegated certain responsibilities and decision making powers through the Board’s SoRD. These arrangements will remain in place with regard to the ongoing functioning of the organisation. In respect of COVID-19, the Chief Executive will deploy decision making through the established command and control structure.
Decision making guidance during COVID-19 has been agreed with Gold Command. This details at which level decision can be made, who can make them and where it must be recorded. This has been developed in accordance with the Health Board’s SOs, Standing Financial Instructions (SFIs) and the SoRD. All decision logs will be reviewed by Gold Command on a weekly basis. A Covid-19 Cabinet has been established with the purpose of being responsible for oversight of key high-level strategic matters relating to the Health Board’s response to the health emergency presented by the Covid-19 pandemic. As such, the Cabinet will be the vehicle to consider whether any decisions require escalation to Board. A copy of the Cabinet Terms of Reference are attached at Appendix 3 for approval.
4.2 Financial Guidance Welsh Government has issued financial guidance to NHS Wales Organisation given the immediate challenges presented by the COVID-19 pandemic, recognising that routine financial arrangements and disciplines are disrupted and need to adapt on an interim basis. The guidance has been developed to support organisations and provide clarity on expectations for this disrupted period and until organisations return to business as usual arrangements.
4.3 Board Meetings The Board is unlikely to meet in person for the foreseeable future and so will meet through electronic/telephony means. As a result of this, members of the public will be unable to attend or observe. Board meetings will continue to be held bimonthly or more frequently as business requires.
To facilitate as much transparency and openness as possible the Health Board will undertake to:
Publish agendas and papers as far in advance as possible – ideally 7 days in advance of the meeting. Increase the use of verbal reporting which will be captured in the meeting minutes Provision for written questions to be taken from Independent Members 24 hours beforehand to assist with the flow and reduced time of meetings As well as a live action log, a pending log will be kept of actions that will not be progressed during the crisis Publish a set of minutes from the meeting (a draft approved by the Chair) to the public website as soon as possible – ideally within 3 working days.
Health Board agendas will be stripped back to essential business only and should focus on matters requiring a decision from the Board. It is accepted that Executives will attend meetings only to present specific items. The agenda for the Board Meeting during this period will cover the following as a minimum: 6
COVID-19 (update and urgent issues) Advice, requirements and guidance from Welsh Government Risk Register Recovery Programme Financial Report Minutes of the previous meeting
The website (which constitutes our official notice of Board meetings) has been updated to explain why the Board is not meeting in public.
The Chair, Interim Chief Executive and Acting Board Secretary will agree the substantive items to be brought to the Board. Any decisions that are taken at this time should be those that could not be held over until it is possible to resume the requirement to meet in public.
Board papers will be kept brief and deal with issues that require the Board to make a decision. Information not requiring a decision can be sent electronically outside of the meeting.
Executive Directors will need to broaden powers of delegation, so the Board will need to accept that there may be situations where they will be informed after the event, rather than consulted as current practice.
4.4 Standing down of Committee and Officer Groups The Board’s Committees and Advisory Group meetings have been suspended for the months of April and May 2020 other than Audit Committee and the Quality, Safety & Experience Committee which will continue to meet remotely with a stripped back attendance and agenda. From June 2020 onwards it is proposed that Committee and Advisory Group Chairs and Lead Executives review the cycles of business and forward plans to determine whether there is a need for a meeting to take place.
A range of officer-led groups have also been suspended including the Drug and Therapeutics Group and Quality & Safety Group and a Chair’s Action process will be utilized for approval of pan BCU written control documentation relating to non Covid-19 matters. This approach has been endorsed by the Executive Director of Nursing & Midwifery / Deputy Chief Executive. 7
Asesiad / Assessment & Analysis Strategy Implications There will be some interruption to aspects of the Board’s statutory functions including the suspension by Welsh Government of the normal IMTP and reporting arrangements.
Financial Implications There are no financial implications directly attributed to the implementation of the proposals set out in this paper. Welsh Government has issued financial guidance to NHS Wales Organisations given the immediate challenges presented by the COVID-19 pandemic, recognising that routine financial arrangements and disciplines are disrupted and need to adapt on an interim basis. It is anticipated that there will be changes required to the Standing Financial Instructions especially in relation to the changes to procurement processes and financial delegations. It is anticipated that guidance will be issued to NHS Wales organisations to confirm the changes that would be required. Once this has been received a further report will be considered by the Health Board.
Risk Analysis Without the proposed changes there would be a significant risk to the safety and welfare of individuals, therefore the aim of the changes is to ensure the Health Board complies with the need to protect individuals and not meet in person, whilst also trying to reduce the burden on staff from normal reporting arrangements, and thus allowing them to focus on responding to the COVID-19 emergency.
Legal and Compliance To ensure that agile decision making can continue and to reduce unnecessary bureaucracy without compromising strong governance, parts of the Standing Orders are to be varied on a temporary basis. These variations have been agreed on an All Wales basis and with Welsh Government and are in accordance with the provision within the NHS (Wales) Act 2006 – Schedule 3, Part 2 which states that “An NHS trust may do anything which appears to it to be necessary or expedient for the purposes of or in connection with its functions.”
In addition the ability within the Public Bodies (Admission to meetings) Act 1960 S.1(2) to exclude the public from a meeting for “other special reasons stated in the resolution” will be applied to protect members of the public and Health Board employees during the period of the pandemic situation.
Impact Assessment The approach set out in this paper will remain under constant review by the Chair, Interim Chief Executive and the Acting Board Secretary. Any further variations to SOs, whether as a result of further reflection or in response to direction from Welsh Government, will be brought to the Board for approval or ratification.
Y:\Board & Committees\Governance\Business Standards\Governance during Covid-19\Maintaining Good Governance Covid-19 V2.02 for Board 14.5.20.docx 8
Appendix 1
OFFICE OF BOARD SECRETARY (OBS) STANDARD OPERATING PROCEDURE (SOP)
Title Chair’s Action During Covid-19
Author Mrs Kate Dunn Head of Corporate Affairs
1. Purpose
To describe the procedure for agreeing, recording and reporting Chair’s Action on behalf of the Board and its Committees and/or Advisory Groups during the Covid-19 pandemic.
2. Responsibility / Scope
In line with Standing Order Para 2.1, Chair’s Action can be taken to allow decisions to be taken between scheduled meetings, when it is not practicable to call an extraordinary meeting.
The procedure applies to Chairs and officers who support the Board or its Committees and/or Advisory Groups. The Head of Corporate Affairs will manage the procedure on behalf of the Board Secretary.
3. Process
3.1 The need for an action to be brought to the attention of the Chair for Chair’s Action should be raised via the lead responsible officer. 3.2 The template (attached) should be completed and presented with any explanatory of background paperwork 3.3 Approval via email will be sought from individuals as required by the template 3.4 Two Independent Members will also be consulted via email. 3.5 Interim Board Secretary to confirm that correct process has been followed 3.6 Actual signed documentation will be prepared when the organisation comes out of the pandemic situation and retained corporately within the Office of the Board Secretary.
4. Reporting
The Chair should report to the next available meeting on the action taken, to ensure an appropriate minute is generated. 9
Chair’s Action on Urgent Matters
Health Board / Committee: (Please state)
Title:
Introduction, Context and Justification for not submitting this matter to the full Board/Committee: (why is Chair’s action necessary?)
Issue for Consideration: (what are the key points, associated risks, background? Also note where this matter has received prior scrutiny)
Recommendation: (what is the Chair being asked to approve/agree?)
Name of individual being asked to agree the recommendation: (with explanation where this is not the Chair or Chief Executive e.g due to conflict of interest relating to the urgent matter)
Date when this Chair’s Action will be reported to full Board/Committee:
Independent Members Consulted (print names):
1. Comments:
2. Comments:
Recommendation Approved by:
Health Board / Committee Chair or Vice-Chair ……………………………………
Chief Executive / Nominated Deputy ………….………………………..
Board Secretary (sign to confirm compliance with agreed process) ………………....………..
Dated:……………………………………….. 10
Appendix 2
SO Heading / Sub Proposed Change Number Heading 7.5.11 Executive The standing orders allow for a nominated nominated deputy to represent an Executive Director, but deputies not to have voting rights.
The organisation currently has 9 Executives with voting rights; in the event that none are available and the quorum was compromised the Board would need to determine if the nominated deputies should have voting rights. We propose to make recommendations on this if the need occurs. 10.2.2 Annual Reporting The only Annual Reports required for 2019-20 of Committees and will be from Audit Committee and the Quality, Advisory Groups Safety & Experience Committee. All other Committees and Advisory Groups will provide a summary of activity for inclusion within the Annual Governance Statement. 11
Appendix 3
Betsi Cadwaladr University Health Board Terms of Reference and Operating Arrangements
Covid-19 Cabinet Meetings
1) INTRODUCTION
1.1 The Board shall establish a group and associated governance arrangements, to be known as the Covid-19 Cabinet. The detailed terms of reference and operating arrangements in respect of these meetings are set out below.
2) PURPOSE
2.1 The purpose of the Cabinet is to be responsible for oversight of key high-level strategic matters relating to the Health Board’s response to the health emergency presented by the Covid-19 pandemic. This will involve consideration of the outputs of Gold Command and other levels within the Command Structure as necessary - providing scrutiny, challenge and seeking assurance - and also decision-making on those matters requiring escalation to the full Board.
3) DELEGATED POWERS
3.1 The Cabinet is authorised by the Board to:-
3.1.1 ensure that the Health Board has agreed a clear strategic direction, with associated objectives, in respect of its COVID-19 Response response.
3.1.2 ensure the adequacy of key arrangements fundamental to assurance, including the command structure, situation reports, decision logs, preparedness, resilience, risk registers, and intelligence gathering capability.
3.1.3 seek assurance on the progress made, through the Gold Commander in critical strategic and tactical areas such as clinical pathways (including but not limited to both COVID-19 and Non COVID-19 related care and treatment), capacity and surge planning and mobilisation (including but not limited to temporary hospitals), testing, workforce, equipment and recovery..
3.1.4 seek assurance that lessons are being learnt and that learning is being applied throughout the COVID-19 Response as appropriate.
3.1.5 seek assurance that recovery plans are in hand for a return to business as usual, incorporating lessons learned and changes in practice achieved as part of the COVID-19 Response, including a transition plan to be activated at an appropriate point in the Plan prior to the conclusion of the activation.
3.1.6 oversee the effectiveness of joint working with partners and of communications, ensuring the avoidance of reputational harm as appropriate. 12
4) AUTHORITY
4.1 The Cabinet may investigate or have investigated any activity (clinical and non- clinical) to enable it to discharge its responsibilities. It may request from officers or groups within the Command Structure and through the Gold Commander, any information it deems necessary to maintain visibility of critical issues and transparency of the full Board.
4.2 The Cabinet may also obtain external legal or other independent professional advice if it considers this necessary, in accordance with the Board’s procurement, budgetary and other requirements.
4.3 The Cabinet has the authority to consider and where appropriate, recommend full Board approval of any COVID-19 related policy or strategy within the remit of its terms of reference.
4.4 The Cabinet has the authority to review the Covid-19 Risk Register and advise the full Board on the appropriateness of the scoring and mitigating actions in place.
5) MEMBERSHIP
5.1 Members
Health Board Chairman (who will be Cabinet Chair) Health Board Vice-Chair Audit Committee Chair Independent Member (Special Advisor) Chief Executive (Cabinet Lead Executive)
5.2 In attendance
Covid-19 Gold Commander Health Emergency Control Centre Commanders Deputy Chief Executive / Executive Director of Nursing and Midwifery Senior Responsible Officer, Governance and Risk
Other Executives, officers and special advisers will join as required by the Chair, as well as any others from within or outside the organisation who the Cabinet considers should be invited, taking into account the matters under consideration at each meeting.
5.3 Member Appointments
5.3.1 The membership of the Cabinet shall be determined by the Chair, taking account of the balance of skills and expertise necessary to deliver the Cabinet’s remit and subject to any specific requirements or directions made by the Welsh Government. The Chair may if required appoint a Vice-Chair of the Cabinet, who shall be an Independent Member. 13
5.3.2 Appointed Independent Members shall normally hold office as part of the Cabinet for the duration of the Covid-19 pandemic response. A member may resign or be removed by the Chair.
5.4 Secretariat
The Secretariat will be determined by the Board Secretary.
5.5 Support to Committee Members
The Board Secretary, on behalf of the Cabinet Chair, shall arrange the provision of advice and support to Cabinet members on any aspect related to the conduct of their role.
6) CABINET MEETINGS
6.1 Quorum
At least two Independent Members must join a meeting to ensure the quorum of the Cabinet, one of whom should be the Cabinet Chair or Vice-Chair. In the interests of effective governance, it is expected that the Chief Executive and a minimum of two COVID-19 Commanders (including the Gold Commander or nominated deputy and at least one HECC Commander) must join the meeting. In the event that the Commanders are unable to attend, then deputies will be agreed.
6.2 Frequency of Meetings
Meetings shall be held at least once per fortnight.
6.3 Withdrawal of individuals in attendance
The Cabinet may ask any or all of those who normally attend but who are not members to withdraw to facilitate open and frank discussion of particular matters.
6.4 Conduct of Meetings
Meetings will be held using video-conferencing and similar technology, to comply with social distancing requirements.
7) RELATIONSHIP & ACCOUNTABILITIES WITH THE BOARD AND ITS COMMITTEES/GROUPS
7.1 Although the Board has delegated authority to the Cabinet for the exercise of certain functions as set out within these terms of reference, it retains overall responsibility and accountability for ensuring the quality and safety of healthcare for its citizens through the effective governance of the organisation.
14
7.2 The Cabinet is directly accountable to the Board for its performance in exercising the functions set out in these Terms of Reference.
8) REPORTING AND ASSURANCE ARRANGEMENTS
8.1 The Cabinet Chair shall:
8.1.1 report formally, regularly and on a timely basis to the full Board on the Cabinet’s activities.
8.1.2 ensure appropriate escalation arrangements are in place to alert the full Board of any urgent/critical matters that may affect the operation and/or reputation of the Health Board.
8.1.3 please see attached annex (i) - COVID-19 Board and Exec meeting reporting structure.
9) REVIEW
9.1 These terms of reference and operating arrangements shall be reviewed by the Cabinet as required by the Chair, and at least annually, with any changes recommended to the Board for approval.
Date of approval: 23/04/2020 (by Cabinet) 15
Annex (i) – COVID-19 Board and Exec Meeting Reporting Structure 7 20/51 Adroddiad Cyllid Mis 12 / Finance Report Month 12 - Ms Sue Hill 1 20.51 Finance Report M12.docx
Cyfarfod a dyddiad: Health Board Meeting and date: 14th May 2020 Cyhoeddus neu Breifat: Public Public or Private: Teitl yr Adroddiad Finance Report Month 12 2019/20 Report Title: Cyfarwyddwr Cyfrifol: Sue Hill, Acting Executive Director of Responsible Director: Finance
Awdur yr Adroddiad Eric Gardiner, Finance Director, Provider Report Author: Services
Craffu blaenorol: Acting Executive Director of Finance Prior Scrutiny: Atodiadau Appendix 1: Summary of Financial Appendices: Performance Appendix 2: Expenditure Appendix 3: Financial Risks and Opportunities Argymhelliad / Recommendation: It is asked that the report is noted.
The Board is requested to delegate authority to approve the audited annual accounts and returns to the Audit Committee at their meeting of 29th June 2020.
Please tick one as appropriate (note the Chair of the meeting will review and may determine the document should be viewed under a different category) Ar gyfer Ar gyfer Ar gyfer Er penderfyniad Trafodaeth sicrwydd gwybodaeth /cymeradwyaeth For For For For Decision/ Discussion Assurance Information Approval Sefyllfa / Situation: The purpose of this report is to provide a briefing on the draft unaudited financial performance of the Health Board as at March 2020.
The month 12 draft result is still subject to closure and submission to Welsh Government of the final accounts for 2019/20 and the subsequent audit by Wales Audit Office.
The Health Board’s unaudited annual accounts and returns were originally due to be submitted to Welsh Government on 28th April, although this date was subsequently deferred due to the Covid-19 pandemic, with a revised latest date for submission of 22nd May. The Health Board now plans to submit its unaudited accounts and returns on 7th May, with Wales Audit Office commencing their audit review the following week.
1 As in previous years, the Board is requested to delegate authority to approve the audited annual accounts and returns to the Audit Committee at their meeting of 29th June 2020. Following approval at this meeting, Wales Audit Office will submit the audited accounts to Welsh Government and the Auditor General for Wales.
This report does not include the effect of the 6.3% employer’s superannuation costs, which have been paid by Welsh Government on behalf of the Health Board. This cost is included in the accounts and the Monitoring Return as a year-end adjustment, increasing expenditure by £31.6m, with a corresponding increase to the Revenue Resource Limit. This does not impact on the financial position reported by the Health Board.
Cefndir / Background:
The Health Board developed a draft 2019/20 annual deficit plan of £35m, which is the basis of reports to Welsh Government. The Health Board’s control total was of a £25m deficit, requiring delivery of a further £10m of savings. The forecast deficit for the Health Board was increased to a £41m deficit in month 10.
Asesiad / Assessment: 1.0 Strategy Implications This paper aligns to the strategic goal of attaining financial balance and is linked to the well-being objective of targeting our resources to those with the greatest need.
2.0 Financial Implications
2.1 Summary
Current Month Year to Date
Original £2.9m Deficit Original £35.0m Plan Plan Deficit
Control £1.6m Deficit Control £25.0m Total Total Deficit
Actual £1.5m Deficit Actual £39.2m Deficit
Plan £1.4m Plan £4.2m Variance Favourable Variance Adverse
Control £0.1m Control £14.2m Variance Favourable Variance Adverse
2 Financial Performance 2019/20 4.5
4.0
3.5
3.0
2.5 m £ 2.0
1.5
1.0
0.5
0.0 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20
Plan - £35m Stretch Plan - £25m Actual
Achievement Against Key Targets
Revenue Resource Limit Public Sector Payment Policy (PSPP) Savings & Recovery Revenue Cash Balance Plans Capital Resource Limit Medium Term Plan
2.2 Overview
In month: The draft unaudited in-month position of a £1.5m deficit is £0.1m below the control total plan and £1.4m under the initial plan. The impact of Covid-19 has impacted expenditure across the Health Board by reducing spend in areas such as RTT, whilst increasing expenditure in other areas as plans are put in place to deal with the pandemic. Costs directly linked to Covid-19 totalled £1.2m in March.
Year to date: The draft unaudited position of the Health Board is an over spend of £39.2m, £14.2m higher than control total plan and £4.2m over the original plan. This is £1.8m less than the forecast for the year, due to the impact that Covid-19 has had on the position in March, as summarised below.
£m Forecast position for 2019/20 at Month 11 41.0 Under spend on RTT (3.6) Reduction in English NHS contracts (0.6) Spend relating to Covid-19 1.2 Increase in Prescribing spend 0.9 Increase in Medical & Surgical equipment costs 0.3 Actual position for 2019/20 39.2
Further details are provided in Appendix 1, which includes an analysis of significant unplanned cost pressures that have increased the expenditure run rate. 3 Savings: The total value of savings schemes delivered in year is £35.6m. Cash releasing savings achieved for the year, including run rate reduction schemes, amount to £33.2m against a plan of £35.0m giving a shortfall of £1.8m. Additional cost avoidance and efficiency savings of £2.4m have been delivered, which offset some cost pressures arising in-year.
£m Cash Releasing - Budget 22.4 Cash Releasing - Run Rate 10.8 Cost Avoidance 1.8 Efficiency Gains 0.6 Total savings 35.6
For 2020/21, schemes totalling £27.8m have been identified, which are either in development or in the pipeline, against a target of £45m. The Recovery programme was stepped down during March, as the organisation fully focused on Covid-19 planning.
2.3 Income and Expenditure
Income: Most of the Health Board’s funding is Welsh Government allocation through the Revenue Resource Limit (RRL). The allocation for 2019/20 totalled £1,589m.
Pay expenditure: Pay costs in March are £64.3m, an increase of £1.1m compared to February. Included in March pay are costs of £0.4m directly related to Covid- 19, £0.6m for year-end accounting adjustments (including annual leave accruals and March overtime paid in April) and £0.1m for the consultant non-consolidated pay award. In addition, total variable pay increased by £0.5m due to an increase in costs for bank, locums and overtime. Despite the increase in pay expenditure this month, Health Board pay costs are £4.4m under spent for the year, reflecting the ongoing significant number of vacancies across the organisation, particularly in nursing.
Non-pay expenditure: Excluding capital, non-pay costs increased by £16.7m in March. This includes £8.7m relating to Intermediate Care Funds (ICF) expenditure that was processed late in the year. These ICF costs were matched by income and so had no impact on the overall deficit position. In addition, £1.8m of Primary Care funding relating to Access for Hours and £0.9m of Winter Pressures funding were utilised, increasing expenditure. Prescribing increased by £1.6m and Covid-19 non-pay costs totalled £0.7m in the month.
Total non-pay over spend for the year was £23.4m, which includes £10m relating to the stretch target. The main cost pressure was Prescribing, with an adverse variance of £11.2m on spend of £108m (an increase of £5.9m compared to last year). Of this over spend, £3.5m relates to the impact of increases in national prices and £1.5m relates to growth/increased activity.
Further details on expenditure are included in Appendix 2.
4 2.4 Balance Sheet
Cash: During the financial year, the Health Board received £35m Strategic Cash Assistance from Welsh Government alongside £13m revenue working balances cash support, to allow payments to continue as normal up until the end of March 2020.
Capital: The Capital Resource Limit (CRL) for 2019/20 is £24.1m. Expenditure for the year was £24.1m meaning that the Health Board achieved its Capital Resource Limit in 2019/20.
3.0 Risk Analysis
There are two risks that are being taken forward into 2020/21. These are detailed in Appendix 3.
4.0 Legal And Compliance Not applicable.
5.0 Impact Assessment Not applicable.
5 Appendix 1 – Summary of Financial Performance
Financial Performance 2019/20
M01 M02 M03 M04 M05 M06 M07 M08 M09 M10 M11 M12 CUMULATIVE BUDGET ACTUAL VARIANCE £m £m £m £m £m £m £m £m £m £m £m £m £m £m Revenue Resource Limit (124.9) (123.2) (124.1) (129.3) (124.7) (125.5) (130.5) (126.7) (129.0) (130.1) (130.8) (190.3) (1,589.0) (1,589.0) 0.0 Miscellaneous Income (10.6) (11.9) (11.1) (11.1) (12.1) (11.3) (11.5) (11.0) (10.7) (11.1) (10.7) (19.7) (138.0) (142.8) (4.8) Health Board Pay Expenditure 64.6 61.9 62.0 62.3 62.2 62.1 64.7 62.1 62.3 62.9 63.2 64.3 759.0 754.6 (4.4) Non-Pay Expenditure 74.8 76.9 76.6 81.8 78.2 77.6 80.0 78.8 81.3 81.5 81.7 147.2 993.0 1,016.4 23.4 Total Against Stretch Plan 3.9 3.7 3.4 3.7 3.6 2.9 2.7 3.2 3.9 3.2 3.4 1.5 25.0 39.2 14.2 Stretch Target Offset 10.0 0.0 (10.0) Total Against Original Plan 35.0 39.2 4.2
M01 M02 M03 M04 M05 M06 M07 M08 M09 M10 M11 M12 2019/20 £m £m £m £m £m £m £m £m £m £m £m £m £m Planned position - stretch 2.9 2.9 2.9 2.9 1.7 1.7 1.7 1.7 1.7 1.7 1.7 1.7 25.0 Planned position - original 2.9 2.9 2.9 2.9 2.9 2.9 2.9 2.9 2.9 2.9 2.9 2.9 35.0 Actual position 3.9 3.7 3.4 3.7 3.6 2.9 2.7 3.2 3.9 3.2 3.4 1.5 39.2 Difference to original plan 1.0 0.8 0.5 0.8 0.7 (0.0) (0.2) 0.3 1.0 0.3 0.5 (1.4) 4.2
Cost pressures Prescribing - price and growth impact 0.4 0.7 0.7 0.4 1.7 1.0 0.1 0.0 5.0 Microsoft 365 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 0.1 1.1 Unfunded interims 0.1 0.1 0.1 0.1 0.1 0.1 0.4 0.4 0.2 1.5 Costs of recovery 0.2 0.2 0.2 0.2 0.2 0.2 0.2 0.3 0.1 1.8 Covid-19 costs 1.2 1.2 Total significant cost pressures 0.0 0.0 0.0 0.4 0.8 1.1 1.1 0.8 2.1 1.8 0.8 1.6 10.6
Revised deficit (actual position less pressures) 3.9 3.7 3.4 3.3 2.8 1.8 1.6 2.4 1.8 1.5 2.6 (0.1) 28.6
Compensating one-off gains Commissioning contracts (0.3) (0.9) (0.8) (0.6) (2.0) Drugs Treatment Fund (0.4) (0.4) RTT under spend (3.6) (3.6) Total significant gains 0.0 0.0 0.0 0.0 0.0 (0.7) (0.9) 0.0 0.0 (0.8) 0.0 (4.2) (6.0)
Underlying run rate (actual position less pressures, plus gains) 3.9 3.7 3.4 3.3 2.8 2.5 2.5 2.4 1.8 2.3 2.6 4.1 35.2
6 Appendix 1 – Summary of Financial Performance
Covid-19 Expenditure
Type £000 Division £000 Additional Clinical Services 36 East Area 58 Administrative & Clerical 138 Central Area 50 Allied Health Professionals 6 West Area 34 Estates and Ancillary 15 Ysbyty Glan Clwyd 176 Healthcare Scientists 3 Ysbyty Gwynedd 85 Medical and Dental 57 Wrexham Maelor Hospital 205 Nursing and Midwifery Registered 176 NW Hospital Services 31 Total Pay 430 Cancer Services 20 Clinical Service & Supplies 231 MHLD 11 Establishment Expenses 11 Corporate - Estates 124 General Supplies & Services 285 Corporate - Facilities 171 Miscellaneous Services 1 Corporate - Other 188 Premises & Fixed Plant 181 Total 1,152 Primary & Secondary Care 13 Total Non-Pay 722 Total 1,152
Pay costs are for additional work done by staff that is directly related to Covid-19.
Included in Clinical Service and Supplies costs are Medical and Surgical equipment costs of £0.12m and drugs costs of £0.05m. General Supplies and Services contains costs for bedding and laundry (£0.08m), protective clothing (£0.07m) and provisions for Catering (£0.07m). Premises and Fixed Plant mainly relates to minor works (£0.11m) and cleaning materials (£0.03m).
7 Appendix 1 – Summary of Financial Performance
M01 M02 M03 M04 M05 M06 M07 M08 M09 M10 M11 M12 CUMULATIVE BUDGET ACTUAL VARIANCE £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 £000 WG RESOURCE ALLOCATION (124,954) (123,186) (124,111) (129,295) (124,695) (125,453) (130,519) (126,714) (128,936) (130,125) (130,784) (190,285) (1,589,055) (1,589,055) 0 AREA TEAMS West Area 13,278 12,998 13,066 14,339 13,470 13,505 14,215 13,777 14,295 14,211 14,342 15,824 166,678 167,409 730 Central Area 17,294 17,075 17,051 18,030 17,448 17,475 18,178 18,092 18,428 18,260 17,811 20,359 213,528 215,596 2,068 East Area 19,050 18,928 18,905 20,129 19,420 19,251 20,216 20,062 20,584 20,639 20,198 25,189 238,926 242,832 3,907 Other North Wales 834 1,072 1,206 864 1,224 997 693 758 846 465 1,180 1,808 10,854 10,545 (309) Commissioner Contracts 16,206 16,191 16,647 18,154 19,319 16,881 16,530 17,217 16,808 17,330 18,251 15,656 209,583 205,188 (4,395) Provider Income (1,601) (1,768) (1,859) (2,268) (2,154) (2,170) (1,528) (1,626) (1,517) (1,329) (1,404) (1,531) (19,180) (20,755) (1,575) Total Area Teams 65,062 64,496 65,017 69,248 68,727 65,938 68,304 68,280 69,444 69,576 70,379 77,304 820,389 820,815 426 SECONDARY CARE Ysbyty Gwynedd 8,712 8,444 8,392 8,371 8,158 8,031 8,643 8,185 8,056 8,375 8,500 8,591 99,219 100,457 1,238 Ysbyty Glan Clwyd 10,392 10,281 10,259 10,469 10,285 10,258 10,971 10,284 10,287 10,374 10,596 10,577 119,343 125,033 5,690 Ysbyty Maelor Wrexham 8,908 8,700 8,530 8,773 8,650 8,702 9,080 8,676 8,928 9,238 9,260 9,210 104,893 106,655 1,762 North Wales Hospital Services 8,994 8,647 8,584 9,429 6,647 8,517 8,510 8,573 8,438 8,682 8,477 9,041 101,954 102,539 585 Womens 3,370 3,282 3,066 3,258 3,294 3,365 3,342 3,278 3,215 3,178 3,220 3,258 38,906 39,126 220 Total Secondary Care 40,375 39,354 38,831 40,301 37,034 38,873 40,546 38,997 38,923 39,846 40,054 40,677 464,315 473,810 9,496 Total Mental Health & LDS 10,682 10,156 10,145 10,088 10,268 10,969 10,892 10,283 10,660 10,204 9,809 11,519 126,118 126,630 513 CORPORATE Chief Executive 162 211 175 172 179 165 183 193 177 177 246 325 2,219 2,371 152 Estates & Facilities 4,445 4,216 4,119 4,161 3,967 4,029 4,203 4,140 4,087 4,090 4,128 4,340 49,544 49,924 381 Utilities & Rates 1,337 1,376 1,337 1,347 1,338 1,388 1,344 1,450 1,355 1,442 1,579 1,768 15,570 17,062 1,491 Executive Director of Finance 845 825 806 853 633 571 1,427 (956) 595 635 610 637 7,370 7,482 111 Executive Director of Nursing & Midwifery 835 1,021 935 1,029 944 946 891 922 1,097 1,080 1,016 982 10,787 11,696 909 Executive Medical Director 1,463 1,433 1,461 1,582 1,599 1,619 1,654 1,622 1,615 1,685 1,778 1,930 19,510 19,443 (67) Executive Director of Workforce & OD 963 962 951 947 955 896 1,091 891 968 917 1,346 1,135 11,014 12,022 1,009 Director of Planning & Performance 178 157 169 170 160 128 201 251 174 163 174 111 2,339 2,038 (301) Executive Director of Public Health 80 110 82 129 98 98 110 102 86 125 108 136 989 1,263 275 Director of Corporate Services 0 0 0 0 0 0 0 0 0 0 0 0 (605) 0 605 Office to the Board 202 195 127 179 185 152 190 188 172 203 184 197 2,079 2,173 94 Director of Therapies 34 31 31 31 29 28 26 25 267 46 45 45 763 638 (126) Executive Director of Primary Care & Comm Services 75 75 92 68 55 64 64 77 114 63 54 123 1,220 924 (295) Director of Turnaround 90 135 112 148 224 87 255 990 799 593 568 482 2,759 4,483 1,724 Total Corporate 10,709 10,747 10,397 10,816 10,366 10,171 11,639 9,895 11,506 11,219 11,836 12,212 125,557 131,517 5,961 Total Other Budgets incl. Reserves 1,951 2,149 3,135 2,523 1,866 2,459 1,878 2,483 2,350 2,481 2,143 50,096 77,677 75,515 (2,162) TOTAL - STRETCH PLAN (£25.0m) 3,825 3,716 3,414 3,681 3,566 2,957 2,740 3,224 3,947 3,202 3,437 1,524 25,000 39,233 14,233 Stretch Target Offset 10,000 0 (10,000) TOTAL - ORIGINAL PLAN (£35.0m) 3,825 3,716 3,414 3,681 3,566 2,957 2,740 3,224 3,947 3,202 3,437 1,524 35,000 39,233 4,233
8 Appendix 2 – Expenditure
Pay Expenditure
Total Pay
£68M
£66M
£64M
£62M
£60M
£M
£58M
£56M
£54M
£52M
£50M Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Substantive Agency Bank Locum Other Non Core Overtime Additional Hours WLI's Average Total Pay Actuals Cumulative YTD YTD YTD M01 M02 M03 M04 M05 M06 M07 M08 M09 M10 M11 M12 YTD RTT Budget Actual Variance £m £m £m £m £m £m £m £m £m £m £m £m £m £m £m £m Administrative & Clerical 8.4 8.1 8.1 8.0 8.1 8.1 8.2 8.2 8.4 8.4 8.6 8.4 104.7 99.0 (5.7) 0.5 Medical & Dental 14.3 14.0 14.3 14.7 14.7 14.4 16.9 14.5 14.6 14.8 14.6 15.7 170.7 177.5 6.8 3.0 Nursing & Midwifery Registered 21.3 20.1 20.1 20.2 19.7 20.0 19.9 19.9 20.0 20.2 20.3 20.5 253.8 242.2 (11.6) 0.6 Additional Clinical Services 10.0 9.2 9.3 9.3 9.0 9.2 9.0 8.9 7.4 8.9 8.1 8.7 99.0 107.0 8.0 0.1 Add Prof Scientific & Technical 2.5 2.6 2.3 2.4 2.8 2.6 2.7 2.8 3.9 2.8 3.3 2.9 35.4 33.6 (1.8) 0.0 Allied Health Professionals 3.7 3.7 3.7 3.7 3.7 3.7 3.8 3.7 4.0 3.7 3.6 3.6 45.3 44.6 (0.7) 0.6 Healthcare Scientists 1.2 1.2 1.1 1.1 1.1 1.1 1.2 1.1 1.1 1.1 1.6 1.2 14.2 14.1 (0.1) 0.0 Estates & Ancillary 3.2 3.0 3.1 2.9 3.1 3.0 3.0 3.0 2.9 3.0 3.1 3.2 38.2 36.5 (1.7) 0.1 Students 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.1 0.1 0.0 Savings to be allocated (2.3) 2.3 Health Board Total 64.6 61.9 62.0 62.3 62.2 62.1 64.7 62.1 62.3 62.9 63.2 64.3 759.0 754.6 (4.4) 4.9 Primary care 1.9 1.8 2.0 1.9 2.0 1.8 1.9 1.9 1.8 1.8 2.0 2.8 20.2 23.6 3.4 0.0 Total Pay 66.5 63.7 64.0 64.2 64.2 63.9 66.6 64.0 64.1 64.7 65.2 67.1 779.2 778.2 (1.0) 4.9
9 Appendix 2 – Expenditure
Further Pay Analysis Total variable pay in March was £8.4m (12.6% of total pay); £68M 17600 £91.9m year to date (11.8% of total pay). This is £0.5m more £66M 17400 than in February and is the highest level for the whole year.
£64M 17200 Increases have been seen particularly in costs for bank (by £0.2m), locums (£0.2m) and overtime (£0.1m). £62M 17000
£60M 16800 £M WTE
£58M 16600
£56M 16400
£54M 16200
£52M 16000
£50M 15800
Core Pay Agency Bank Locum Other Medical Pay Overtime Additional Basic Pay WLIs Pay Budget Budgeted WTE Actual WTE Expenditure on agency staff for Month 12 is £3.2m, representing Agency Spend 4.8% of total pay, a decrease of £0.1m on last month. Total
£4.0 M spend on agency for the year was £38.1m, an increase of £6.5m on the 2018/19 agency spend of £31.6m. £3.5 M
£3.0 M Medical agency costs have increased by £0.1m to an in-month
£2.5 M spend of £1.4m. Total Medical agency spend for 2019/20 was £16.3m, an increase of £2.3m on 2018/19 expenditure of £14m. £2.0 M
£1.5 M Nurse agency costs totalled £1.1m for the month, the same as last month, giving a total of £13.5m for the year. This is £0.6m £1.0 M more than the cost in 2018/19, where £12.9m was spent. £.5 M
£.0 M Other agency costs reduced by £0.2m to £0.7m for March and mainly arise from Admin and Clerical (£0.3m) as a result of posts Ysbyty Glan Clwyd Ysbyty Maelor Wrexham Other Mental Health & LDS involved in the recovery programme. In total, £8.3m was spent Ysbyty Gwynedd East Area Central Area West Area Medical Agency Agency Nursing Other Agency on other agency in 2019/20, £3.6m more than in 2018/19. 10 Appendix 2 – Expenditure
Non-Pay Expenditure
Non-Pay Expenditure (Excluding Capital Costs)
101
96
91
86 m £ 81
76
71
66 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20
Actual £m Average Non-Pay
Actuals Cumulative YTD Y T D Y T D M01 M02 M03 M04 M05 M06 M07 M08 M09 M10 M11 M12 Budget Actual Variance £m £m £m £m £m £m £m £m £m £m £m £m £m £m £m Primary Care 16.7 17.0 17.3 16.9 17.4 17.3 18.6 18.1 17.0 17.6 18.0 20.9 214.5 212.8 (1.7) Primary Care Drugs 8.2 8.2 8.2 8.2 8.6 8.7 8.8 8.3 9.9 10.5 9.4 11.0 96.8 108.0 11.2 Secondary Care Drugs 5.9 6.0 5.6 6.3 5.8 5.9 6.0 6.1 6.0 6.6 5.6 6.4 69.1 72.2 3.1 Clinical Supplies 5.3 5.6 5.5 5.9 5.6 5.6 5.7 5.6 6.2 5.5 6.6 7.9 68.3 71.0 2.7 General Supplies 1.8 2.3 1.3 5.3 2.6 3.3 2.8 2.5 2.7 2.6 3.3 13.9 43.9 44.4 0.5 Healthcare Services Provided by Other NHS Bodies 21.1 21.0 21.5 23.1 22.2 21.5 20.6 21.8 21.6 22.3 23.0 20.4 265.1 260.1 (5.0) Continuing Care and Funded Nursing Care 8.3 8.3 8.1 8.0 8.2 8.0 7.9 8.0 9.3 7.5 7.3 8.2 97.7 97.1 (0.6) Other 5.1 5.9 5.6 5.2 5.0 4.5 7.1 5.6 5.8 6.2 5.8 7.1 55.6 68.9 13.3 Non-pay costs 72.4 74.3 73.1 78.9 75.4 74.8 77.5 76.0 78.5 78.8 79.0 95.8 911.0 934.5 23.5 Cost of Capital 2.4 2.6 3.5 2.9 2.8 2.8 2.5 2.8 2.8 2.7 2.7 51.5 82.0 82.0 0.0 Total non-pay including cost of capital 74.8 76.9 76.6 81.8 78.2 77.6 80.0 78.8 81.3 81.5 81.7 147.3 993.0 1,016.5 23.5
11 Appendix 2 – Expenditure
Primary Care: £1.8m of the increase in costs relates to Access for Hours. This is fully funded and so does not impact on the Health Board position. In addition, GP Out of Hours costs have increased by £0.7m. The Health Board continues to see cost pressures within Managed Practices and Out of Hours, particularly in relation to locum GP costs, and more recently an increase in dispensing cost of drugs.
Primary Care drugs: This remains one of the Health Board’s key risks going into 2020/21, particularly with the impact of Covid-19 which is not quantifiable at the year- end due to the two month delay in the release of Prescribing data. There has been an increase in costs of £1.6m in March, reflecting a move to an average rather than lowest forecast model. The average forecast model is considered to be the most appropriate given the continued increase in Prescribing costs throughout 2019/20, along with the uncertainty brought by the pandemic. Total cost of Prescribing in 2019/20 was £108m, which is £5.9m higher than in 2018/19.
Secondary Care drugs: Costs have increased by £0.7m in March. Increases were particularly see in Cancer and Haematology drugs (£0.4m).
Clinical Supplies: Costs have increased by £1.3m, of which £0.2m relates to Covid-10 expenditure. Additional costs across a range of medical and surgical equipment, implant and patient appliance categories totalled £0.8m. These are costs that are not directly related to the pandemic, but have arisen due to forward planning for potential increases in demand or future disruption.
General Supplies: Expenditure in March is significantly higher than throughout the rest of the year due to £8.7m of funded ICF costs that have been processed in the month, along with expenditure of £0.9m on the Winter Plan, which is also fully funded. In addition, £0.3m of Covid-19 expenditure has been incurred.
Healthcare Services Provided by Other NHS Bodies: March expenditure is lower than had been forecast as outsourced RTT work was not able to go ahead as other NHS providers ceased routine elective activity in response to the pandemic.
Other non-pay expenditure: Increase in costs in March primarily relates to year end Losses adjustments (£0.4m) and year end accounting adjustments to recognise Charitable Funds expenditure, matched with income (£0.7m). The £10m additional savings which were required to meet the control total are included here as an adverse variance. In addition the ‘Other’ category includes year to date over spends on IT costs (£2.0m), external consultancy (£1.5m) and energy costs (£1.5m).
12 Appendix 2 – Expenditure
Cost of Capital: Year-end Capital adjustments for depreciation and impairments are always processed in March, significantly increasing costs in the month. These are fully funded so do not impact on the Health Board position.
RTT
The Health Board received RTT funding of £20.5m for the full year, £16.9m of which was spent, giving a £3.6m under spend. The response to Covid-19 during March meant that additional work by the Health Board to reduce waiting lists and outsourced activity to be undertaken by other providers could not be completed as planned.
Support Expenditure Category YG YGC YWM Other Services Outsource Total £000 £000 £000 £000 £000 £000 £000 Total Pay 1,769 1,484 443 405 816 - 4,917 Theatre Non Pay 279 231 148 658 Other Non Pay 792 1,089 268 133 89 2,371 Outsourced Activity 359 4,077 4,436 Insourcing 1,345 615 1,122 1,438 4,520 Sub Total - Non Pay 2,416 1,935 1,538 133 1,886 4,077 11,985 Total Expenditure 4,185 3,419 1,980 538 2,702 4,077 16,901 Cardiology 16 16 s c
i Gastro / Endoscopy 2,101 1,256 1,395 34 4,785 t
s Neurophysiology - 10 10 o
n Ophthalmology 71 71 g a
i Radiology 2,658 2,658 D Urology 50 50 Sub Total 2,171 1,256 1,461 - 2,702 - 7,590 Anaesthetics 7 1 18 26
s Dermatology 56 56 t
n ENT 49 231 10 289 e i t
a Dermatology 56 56 p t General Surgery 211 294 15 4 525 u O
Gen Med 2 2 s
e Gynaecology 16 16 s a
c Max Fax 171 2 173 y
a Oral 53 393 446 D
s Ophthalmology 531 26 122 327 1,005 t n
e Orthopaedics 1,027 742 218 114 3,206 5,308 i t
a Other 225 225 p n
I Urology 127 244 81 538 990 Validation 7 62 125 194 Sub Total 2,014 2,163 519 538 - 4,077 9,311 Total Expenditure 4,185 3,419 1,980 538 2,702 4,077 16,901
13 Appendix 3 – Financial Risks and Opportunities
Key Decision Point & Issue Description Risk Owner £m Summary Mitigation Sue Green, It has not yet been determined how this case will Risk: Junior Executive Director There was a significant test legal case focusing on how NHS impact on the Health Board and what the financial 1 Doctor of Workforce & organisations should address monitoring for junior doctors. implications may be. Further investigations are monitoring Organisational being undertaken to quantify any potential impact. Development Sue Green, NWSSP Employment law team have confirmed that the holiday Executive Director Risk: 2 pay issues arising from the Flowers judgement are ongoing and The Health Board is monitoring the situation. of Workforce & Holiday pay the outcome of the Supreme Court appeal is awaited. Organisational Development
Total
14 8 20/52 Adroddiad Integredig Ansawdd a Pherfformiad / Integrated Quality Performance Report - Mr Mark Wilkinson 1 20.52a IQPR narrative report.docx
1
Cyfarfod a dyddiad: Health Board Meeting and date: 14th May 2020 Cyhoeddus neu Breifat: Public Public or Private: Teitl yr Adroddiad Integrated Quality & Performance Report (IQPR) Report Title: Cyfarwyddwr Cyfrifol: Mr Mark Wilkinson Executive Director of Planning & Responsible Director: Performance Awdur yr Adroddiad Dr Jill Newman, Director of Performance Report Author: Craffu blaenorol: This paper has been scrutinised and approved by the Prior Scrutiny: Director of Performance. Atodiadau 1) IQPR for March 2020 Appendices: Argymhelliad / Recommendation: The Health Board is asked to scrutinise the report and to consider whether any area needs further escalation to be considered. Ar gyfer Ar gyfer Ar gyfer Er penderfyniad Trafodaeth sicrwydd gwybodaeth /cymeradwyaeth For Decision/ For For For Approval * Discussion* Assurance* Information* Sefyllfa / Situation: This is a shortened Integrated Quality and Performance Report set in the context of the Covid-19 Pandemic. This report provides the end of year key performance indicator data without exception reports. Committee reports for QSE and F&P are being produced in the same manner to ensure that the Health Board is aware of the performance. A number of indicators were and continue to be affected by the impact of the pandemic for a variety of reasons including: compliance with national and professional guidance in relation to routine activity at this time, the need to minimise risk of harm to shielding and vulnerable groups, staff availability and safety. A number of national performance indicators have been stood down from formal reporting to release staff time to manage the pandemic. Cefndir / Background:
Our report outlines the key performance and quality issues that have been determined to align to our Annual Plan for 2019/20. The performance is scrutinised using the national delivery framework indicators via the Finance and Performance Committee and Quality, Safety and Experience Committees of the Board.
The Financial Balance is discussed in detail in the Finance Report. 2
Asesiad / Assessment The Executive Summary provides an overview of the key performance issues relating to both unscheduled and planned care. Strategy Implications The performance measures within the IQPR are aligned with the Annual Plan and identified as the key performance indicators in monitoring and managing the Health Board’s strategy. Financial Implications The delivery of the performance indicators contained within our annual plan will have direct and indirect impact on the financial recovery plan of the Board. Our operational plan is aligned to our resource allocation for delivery Risk Analysis The RAG-rating reflects the performance against the Plan. Where there aren’t Plan Profiles, the performance is measured against the national target. Impact Assessment The operational plan has been Equality Impact Assessed. The Health Board is asked to scrutinise the report and to consider whether any area needs further escalation. 1 20.52b IQPR March 2020 FINALV3.pdf Integrated Quality and Performance Report – Health Board 1
March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Table of Contents.. Page 1 2
Cover Page 1 Agency & Locum Spending 20 Table of Contents 2 Agency & Locum Spending 21 Table of Contents page 2 3 Financial Balance: 22 About This Report 4 Sickness & Absence Rates 23 Annual Plan 2019/20: Remit of QSE Committee 5 Mandatory Training Rates 24 Annual Plan 2019/20: Remit of F&P Committee 6 PADR Rates 25 Overall Summary Dashboard 7 Chapter 3a : Planned Care Summary Dashboard 26 Executive Summary – Unscheduled Care 8 Referral to Treatment 27 Executive Summary – Planned Care 9 Diagnostic Waits 28 Chapter 1: Quality – Summary Dashboard 10 Cancer 29 Infection Prevention Graphs 1 11 Follow up Waiting List 30 Infection Prevention Graphs 2 12 Eye Care Measure 31 Infection Prevention Measures 13 Chapter 3b: Unscheduled Care Summary Dashboard 32 Serious Incidents 14 Emergency Department and Minor Injuries Units 4 Hour Waits 33 Serious Incidents: Falls 15 Emergency Departments 12 Hour Waits 34 Serious Incidents: Healthcare Acquired Pressure Ulcers 16 Ambulance Handover Delays over 1 Hour 35 Mortality 17 Delayed Transfers of Care (DToC) 36 Chapter 2: Our Finance & Resources – Summary Dashboard 18 Stroke Care 37 Ward Nurse Staffing Rates 19
Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Table of Contents.. Page 2 3
Chapter 4: Mental Health summary Dashboard 38 Mental Health Measures – Adult 39 Mental Health Measures – Children and Young Adults (CAMHS) 40 Chapter 5: Primary Care Summary Dashboard 41 Access to Dentists 42 Continuing Health Care Packages and Lengths of Stays 43 Appendix 1: Further Information 44
Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly About this Report.. 4
This Integrated Quality & Performance Report is intended to provide a clear view of current performance against a selected number of Key Performance Indicators (KPI) that have been grouped together to triangulate information.
The measure code relates to the code applied within the NHS Wales Annual Delivery Framework, which the Welsh Government hold the Board accountable for delivering. A key difference in the structure of the IQPR for 2019/20 compared to 2018/19 is that the report reflects the organisational priorities as set out in the Board’s Annual Plan. Each of the reported measures are mapped to the corresponding work programme via a reference number at the right hand side of the Measure Component Bar ( shown below). The next page contains a list of the Programmes in the Annual Plan aligned to the committees of the Board. The actual performance reported is compared to the Plan in the first instance, with the colour of the font used to depict whether the performance is better or worse than Plan. For completeness the report also includes comparison against national targets.
It is noted that this report is produced mid the Covid-19 pandemic and therefore resources have been redirected to the management of the pandemic. As such this report provides data only with exception reporting suspended to release time for staff to work on the pandemic. The national reporting of a number of indicators have been suspended for performance management purposes due to the pandemic. The data in this report is impacted by the pandemic and should therefore be used for information and not for performance management purposes.
Status Key:
Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Annual Plan 2019/20.. Remit of QSE Committee 5
Annual Annual Plan Programme Plan No AP001 Smoking Cessation Opportunities increased through 'Help Me Quit' programmes AP004 Delivery of ICAN Campaign promoting mental well-being across North Wales communities AP005 Implement the 'Together for Children and Young People Change Programme' AP006 Improve outcomes in first 1000 days programmes AP007 Further develop strong internal and external partnerships with focus on tackling inequalities AP009 Put in place agreed model for integrated leadership of clusters in at least three clusters, evaluate and develop plan for scaling up AP013 Develop and implement plans to support Primary Care sustainability AP015 Implementation of RPB Learning Disability Strategy AP025 Fully realise the benefits of the newly established SuRNICC Service AP027 Develop Rehabilitation Model for people with Mental Health or Learning Disability AP039 Implement Year Three of the'Quality Improvement Strategy' AP045 Develop a 'Strategic Equality Plan for 2020-2024 AP047 Develop an integrated workforce development model for key staff groups with health and social care partners NIP Not in Plan i.e. Measures are required by NHS Wales Delivery Framework, but are not linked to actions in the Operational Plan
Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Annual Plan 2019/20 .. Remit of F&P Committee 6
Annual Annual Plan Programme Plan No AP022 Transform Eye Care Pathway to deliver more care closer to home, delivered in partnership with local optometrists Systematic reviews and plans developed to address service sustainability for all planned care specialties. Implement Year One plans, AP024 for example Endoscopy, Rheumatology and Gynaecology AP026 Implement new Single Cancer Pathway across North Wales AP028 Demand: Improved Urgent Care Out of Hours / 111 Service AP029 Demand: Enhanced Care Closer to Home Pathways AP031 Demand: Improved Mental Health crisis response AP033 Flow: Emergency Medical Model AP037 Discharge: Integrated Health and Social care AP038 Stroke Services AP041 Build on Quality Improvement work to develop the BCU improvement system and delivery plan for efficient, value based health care Deliver Year One of the 'Health & Safety Improvement Programme' focussing on high risk/ high impact priorities whilst creating the AP043 environment for a safety culture AP046 Deliver Year One 'Leadership Development Programme' to priority triumvirates AP056 Delivery of information content to support flow / efficiency NIP Not in Plan i.e. Measures are required by NHS Wales Delivery Framework, but are not linked to actions in the Operational Plan
Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Summary Dashboard. Headlines 7
Most Improved Plan National Code Measure Status 0 Profile Target DFM023 Serious Incidents due for Assurance 63.00% >= 50% >= 90% 12 Emergency Department 4 Hour Waits DFM072 75.9% >= 75% >= 95% (inc MIU) Emergency Department 12 Hour Waits DFM073 902 <= 1,240 0 (ex MIU) DFM071 Ambulance Handovers within 1 Hour 320 <= 438 0 3 All 3 DFM063 Cancer 31 Days (non-USC Route) 98.3% >= 98% >= 98% Chapters Primary Quality Of Most Concern Care0 Plan National Code Measure Status 10 Profile Target 0 DFM056 Follow-up Waiting List Backlog 95,075 <= 74,307<= 74,555 0 Finance & 35 5 0 Mental Referral to Treatment (RTT): > 36 Resources DFM053 11,798 AP 0 Health Weeks 0 7 1 DFM064 Cancer: 62 Days (USC Route) 79.40% >= 83.5% >= 95% 0 3 4 Unscheduled Planned 0 DFM054 Diagnostic Waits: > 8 Weeks 2,061 AP 0 Care Care Compared to the previous report, of the 47 Measures rated, Performance has 7 improved for 15, is worse for 30 and static for 2. 4 00 00 Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Performance Executive Summary.. Page 1 8
The Executive Team believes the key areas of concern in relation to performance are within the Unscheduled Care and Planned Care Chapters of this report. The end of year performance on many of the planned care indicators was adversely affected by the Covid-19 pandemic due to the suspension of non- essential services from the middle of March 2020. Since the declaration of the pandemic attendances at ED and MIU and elective referrals have declined significantly, leading to concerns that patients may not be self- referring due to the concerns around Covid-19 infection or lack of awareness of service continuity in other areas. Communications are re-enforcing the need to contact GPs should patients have any worrying symptoms at this time and nationally and locally the work of the Essential Services cell is focussing on guidelines to ensure these services continue throughout the peaks and troughs of Covid-19 with the aim of minimising the risk of harm relating to life-saving or life-impacting aspects of service delivery. Partly as a consequence of the reduction in attendance at ED and MIU and the redesign of system entry points to address Covid-19, the unscheduled care indicators show positive movement at the end of March. This has continued and strengthened throughout April, with slight increase in attendance being seem towards the end of the month. Conversely, while referrals are reduced for planned care the length of waits has increased due to the postponement in non-essential surgery, clinics, diagnostics. Alternative ways of reviewing patients has been introduced, however the speed of introduction does mean that not all records have been updated to reflect this in the performance data for this report. Unscheduled Care Performance against Plan - 12 months summary view to 31st March 2020 BCU HB Target Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Plan 85.0% >= 74% >= 75% >= 76% 74.0% 75.0% 76.0% 77.0% 72.0% 72.0% 72.0% 73.0% 74.0% 4 Hour 95% Actual 71.11% 69.48% 71.21% 71.49% 73.72% 73.04% 71.68% 71.15% 72.12% 66.32% 68.60% 66.38% 75.94% Plan 900 1,500 1,395 1,290 1,209 1,085 990 961 1,320 1,364 1,364 1,218 1,240 12 Hour 0 Actual 1,635 1,743 1,660 1,444 2,044 1,786 1,977 1,757 1,786 2,272 2,096 1,832 932 1 Hour Ambulance Plan 900 540 341 270 248 186 120 404 600 620 620 551 438 0 Handover Actual 438 700 616 447 811 694 896 809 792 1,114 1,042 660 320 Plan 75.0% 65.0% 65.0% 65.0% 65.0% 65.0% 65.0% 65.0% 65.0% 65.0% 65.0% 65.0% 65.0% Cat A 8 Minutes 65% Actual 70.4% 70.0% 70.2% 69.0% 68.0% 69.6% 69.0% 68.9% 62.9% 59.9% 68.0% 68.6% N/A Note: Amber has been applied where performance is within 3% of Plan. * Figures for March 2020 will be affected by Covid-19 and should be read with caution Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Performance Executive Summary.. Page 3 9
Planned Care: The end of year RTT position, while affected by cancellation of non-essential surgery and clinics from 16th March and loss of the additional activity planned during the final weeks of the year, did result in a year end position in line with expected performance, demonstrating that the actions taken in the last quarter were starting to turn the increasing number of over 36 week waits . Nevertheless the year end position is 5,456 higher than at the end of March 2019. Diagnostic performance at the end of March had recovered considerably in relation to endoscopy, however increases in radiological , cardiac and neurological diagnostics resulted in the year end position being overall an improvement of 216 better than the preceding year. Endoscopy improvement has not been sustained in April 2020 due to the guidelines introduced to maintain patient and staff safety during the pandemic and so only essential procedures are taking place at the present time. The volume of patients overdue their follow up appointment was also adversely affected by the loss of activity in the second half of March and ended the year well above the plan. Changes to the future delivery of outpatients with introduction of more virtual clinics and technologically enabled consultations are likely to continue in the post covid-19 era and these will be helpful in both risk assessing and managing the needs of patients post initial treatment. Cancer 31 day target was delivered. A reduction in demand and an increase in wait for diagnosis and treatment in line with guidelines is being experienced for urgent suspected cancer . Additional communications have been provided to encourage patients with symptoms to continue to present and the planning cell is considering options for protective surgical capacity for patients with a cancer diagnosis. Planned Care Performance against Plan - 12 months summary view to 31st March 2020 BCU HB Target Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Plan 5,714 6,838 7,465 7,961 8,846 8,021 7,227 7,683 AP AP AP AP AP RTT over 36 wks 0 Actual 6,004 6,870 7,499 7,998 8,900 10,167 10,052 10,768 11,525 12,378 12,792 11,654 11,798 Diagnostics 8wks Actual 0 2,277 2,548 2,857 2,827 2,793 2,957 2,816 2,443 2,233 2,502 2,583 1,832 2,061 Plan 70,000 87,712 86,835 85,967 83,903 81,890 79,924 78,006 76,134 74,307 Followup Overdue 0 Actual 87,712 88,210 88,079 88,511 88,648 91,288 90,569 89,909 89,235 92,810 93,324 92,497 95,075 Plan 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% 98.00% Cancer 31 Day 98% Actual 97.20% 100% 98.30% 98.30% 99.50% 98.10% 96.40% 99.50% 97.08% 98.00% 98.80% 98.80% 98.30% Plan 82.00% 83.00% 84.00% 84.00% 84.00% 84.00% 85.00% 86.00% 87.00% 83.50% 83.50% 84.00% Cancer 62 Day 95% Actual 88.00% 82.20% 81.50% 80.40% 84.90% 86.00% 82.60% 82.90% 85.40% 83.30% 80.70% 85.30% 79.40% Single Cancer Pathway 78.00% 80.00% 76.00% 77.00% 75.10% 76.60% 77.50% 76.00% 74.00% Amber is used where performance is within 3% of Plan Cancer is reported 1 month in arrears * Figures for March 2020 will be affected by Covid-19 and should be read with caution Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Chapter 1: Summary. Quality 10
Plan National Code Measure Status Profile Target 3 0 DFM021a Infection Prevention: E.Coli 81.40 <= 67 <= 67 DFM021b Infection Prevention: S.Aureus 28.56 <= 20 <= 20 DFM021c Infection Prevention: C.Difficile 25.42 <= 22 <= 22.13 0 DFM021d Infection Prevention: Klebsiela 140 <= 106 <= 106 Quality DFM021e Infection Prevention: Aeruginosa 42 <= 27 <= 27 DFM023 Serious Incidents due for Assurance 63.00% >= 50% >= 90% 0 LM023a Serious Incidents: Patient Falls 9 NIP <= 11 0 Serious Incidents: Healthcre Acquired LM023b 4 0 0 10 Pressure Ulcers (HAPU) Infection 0 Prevention Smoking DFM040 Concerns: Timely Replies 63.20% >= 50% >= 75% Mortality: Universal Mortality Reviews 1 DFM027 93.50% >= 95% >= 95% 5 0 (UMR) 0 2 Mortality: Crude Mortality Rate (74 Incidents & DFM028 0.83% < 0.70% Reduce years of age or less) Concerns Mortality DFM006 Smoking Cessation: Quit Attempt 3.08% >= 4.3% >= 5% 3 2 DFM007 Smoking Cessation: Quit Validated 35.71% >= 39.3% >= 40% 0 Integrated Quality and Performance Report Compared to the previous report, of the 13 Measures in this Health Board Version March 2020 chapter, Performance has improved for 6 and worse for 7. Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Chapter 1 – Quality. Infection Prevention Graphs 11
Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Chapter 1 – Quality. Infection Prevention Rates
Please Note: Although all graphs show Feb-20, the data does show up to 31st March 2020
Integrated Quality and Performance Report Health Board Version March 2020 12 Chapter 1 – Quality. Infection Prevention 13
Responsible Same Oversight National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Executive Actual Status Period Last Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Committee Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Officer Year
Cumulative rate of laboratory DFM021a confirmed E.coli bacteraemia cases Deborah Carter QSE <= 67 AP039 <= 67 Mar-20 81.40 82.44 97.85 83.59 88.38 - 83.77 85.63 83.39 - 83.04 83.11 85.52 - 83.86 81.91 81.40 - per 100,000 population
Cumulative rate of laboratory confirmed S.aureus bacteraemias DFM021b Deborah Carter QSE <= 20 AP039 <= 20 Mar-20 28.56 3rd 24.99 26.21 27.57 29.29 - 28.35 27.75 29.13 - 29.31 29.13 29.46 - 29.89 28.86 28.56 - (MRSA and MSSA) cases per 100,000 population Cumulative rate of laboratory DFM021c confirmed C.difficile cases per Deborah Carter QSE <= 22.13 AP039 <= 22 Mar-20 25.42 N/A 24.56 19.22 21.54 25.42 - 24.06 25.69 27.99 - 29.31 28.49 28.51 - 26.82 26.05 25.42 - 100,000 population
Cumulative Number of laboratory New for DFM021d confirmed Klebsiela cases per Deborah Carter QSE <= 106 AP039 <= 106 Mar-20 140 N/A 13 18 29 - 43 59 74 - 89 99 113 - 123 135 140 - 19/20 100,000 population
Cumulative Number of laboratory New for DFM021e confirmed Aeruginosa cases per Deborah Carter QSE <= 27 AP039 <= 27 Mar-20 42 3rd 1 3 6 - 11 13 19 - 24 27 31 - 35 40 42 - 19/20 100,000 population
Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Chapter 1 – Quality Incidents Graphs 14
Responsible Same Oversight National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Executive Actual Status Period Last Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Committee Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Officer Year
Of the serious incidents due for DFM023 assurance, the percentage which were Deborah Carter QSE >= 90% AP039 >= 50% Mar-20 63.00% 1st 18.57% 25.00% 38.24% 48.28% - 51.52% 46.51% 51.60% - 39.50% 62.16% 69.44% - 55.00% 65.00% 63.00% - assured within the agreed timescales
Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Chapter 1 – Quality.. Falls Reported as Serious Incidents 15
Responsible Same Oversight National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Executive Actual Status Period Last Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Committee Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Officer Year Number of Patient Falls reported as LM023a Deborah Carter QSE <= 11 NIP <= 11 Mar-20 9 N/A 9 6 12 19 0 19 12 10 - 6 9 12 - 12 7 9 - Serious Incidents
Number of Patient Falls reported as Serious Incidents 20
15
10
5
0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2018/19 2019/20 Target
Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Chapter 1 – Quality.. Pressure Ulcers (HAPU) 16
Responsible Same Oversight National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Executive Actual Status Period Last Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Committee Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Officer Year Number of Healthcare Acquired LM023b Pressure Ulcers reported as Serious Deborah Carter QSE 0 NIP 0 Mar-20 4 N/A 2 3 4 2 - 2 6 2 - 10 10 4 - 2 3 4 - Incidents
Number of Healthcare Aquired Pressure Ulcers reported as Serious Incidents Total Number of Hospital Aquired Pressure Ulcers (All Grades) 90 700 80 600 70 500 60 50 400 40 300 30 200 20 100 10 0 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2018/19 2019/20 Target 2019/20
Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Chapter 1 – Quality. Mortality Graphs 17
Responsible Same Oversight National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Executive Actual Status Period Last Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Committee Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Officer Year
Percentage of universal mortality DFM027 reviews (UMRs) undertaken within 28 David Fearnley QSE >= 95% AP039 >= 95% Mar-20 93.50% 2nd 0.00% 92.10% 95.80% 96.70% - 90.50% 91.70% 90.50% - 89.60% 91.20% 92.80% - 96.80% 93.80% 93.50% - days of a death
Crude hospital mortality rate (74 years DFM028 David Fearnley QSE Reduce AP039 < 0.70% Mar-20 0.83% 4th 0.74% 0.73% 0.83% 0.76% - 0.74% 0.71% 0.75% - 0.80% 0.79% 0.80% - 0.82% 0.82% 0.83% - of age or less)
Universal Mortality Reviews carried out within 28 Days of Crude Mortality Rates: 74 years of age and under Death 0.90% 100.00% 0.80% 0.70% 80.00% 0.60% 60.00% 0.50% 0.40% 40.00% 0.30% 0.20% 20.00% 0.10% 0.00% 0.00% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
2018/19 2019/20 Target 2018/19 2019/20 Target
Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Chapter 2: Summary. Finance & Resources 18
Plan National Code Measure Status Profile Target WGM001 Ward nurse staffing fill rate (%) 85.00% AP >= 95% Ward nurse staffing skill mix ratio (% WGM002 55.00% AP >= 60% Reg) 0 00 LM001F Finance: Agency & Locum Spend £5.02m AP TBA Sickness absence rates (% Rolling 12 DFM091 5.68% <= 4.20% <= 4.31% months) DFM087 PADR Rate (%) 73.28% >= 85% >= 85% Finance & DFM090 Mandatory Training (Level 1) rate (%) 84.72% >= 85% >= 85% Resources LM002F Finance: Financial Balance £39.23m <= £35m <= £25m
7
Compared to the previous report, of the 7 Measures in this Integrated Quality and Performance Report chapter, Performance has improved for 2 and worse for 5. Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Chapter 2 – Finance & Resources. Ward Staffing Levels: Graphs 19
Responsible Same Oversight National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Executive Actual Status Period Last Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Committee Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Officer Year WGM001 Ward Staff Fill Rate Percentage Deborah Carter QSE >= 95% NIP AP Mar-20 85.00% N/A 87% 85% 86% 86% - 85% 84% 86% - 87% 86% 86% - 82% 87% 85% -
Ward Staff Skill Mix Ratio of WGM002 Registered v Non-Registered Deborah Carter QSE >= 60% NIP AP Mar-20 55.00% N/A 55% 55% 55% 55% - 55% 55% 55% - 56% 56% 56% - 56% 56% 55% - Percentage
Ward Staffing Levels Fill Rate (Medical & Surgical Acute) Ward Staffing Skill Mix Ratio Registered : Unregistered (Medical & Surgical Acute) 100% 65% 80% 60% 60% 55% 40%
20% 50%
0% 45%
Jul-19 Jul-18
Apr-19 Oct-19 Apr-18 Oct-18
Jan-19 Jun-19 Jan-20 Jun-18
Mar-19 Mar-20 Mar-18
Feb-19 Feb-20
Jul-18 Jul-19
Nov-18 Dec-18 Aug-19 Sep-19 Nov-19 Dec-19 Aug-18 Sep-18
May-19 May-18
Apr-18 Oct-18 Apr-19 Oct-19
Jun-18 Jan-19 Jan-20 Jun-19
Mar-18 Feb-19 Mar-19 Feb-20 Mar-20
Nov-18 Dec-18 Nov-19 Dec-19
Aug-19 Sep-19 Aug-18 Sep-18
May-18 May-19 Actual Target Actual Target
Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Chapter 2 – Finance & Resources. Agency & Locum Graphs 20
Responsible Same Oversight National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Executive Actual Status Period Last Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Committee Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Officer Year
Cost of Agency & Locum spend within New for LM001F Sue Green F&P TBA NIP AP Mar-20 £5.02m N/A £2.6m £3m £3.7m - £4.1m £4.2m £3.96m - £4.34m £3.66m £3.86m - £4.78m £4.93m £5.02m - Month 19/20
Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Chapter 2 – Finance & Resources. Agency & Locum Graphs 21
Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Chapter 2 – Finance & Resources. Financial Balance Graph 22
Responsible Same Oversight National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Executive Actual Status Period Last Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Committee Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Officer Year
Cumulative Deficit Position against the LM002F Sue Hill F&P <= £25m NIP <= £35m Mar-20 £39.23m N/A 0.00 £3.83m £7.54m £10.96m - £14.64m £18.20m £21.16m - £23.9m £27.1m £31.1m - £34.3m £37.7m £39.23m - planned Financial Balance (£'s)
Please note the financial position for March 2020 is a draft figure is awaiting audit sign off, expected end of May 2020.
Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Chapter 2 – Finance & Resources. Sickness Absence: Graphs 23
Responsible Same Oversight National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Executive Actual Status Period Last Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Committee Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Officer Year
Percentage of sickness absence rate of DFM091 Sue Green F&P <= 4.31% AP043 <= 4.20% Mar-20 5.68% 3rd 4.98% 4.92% 5.05% 5.10% - 5.13% 5.16% 5.22% - 5.29% 5.22% 5.26% - 5.24% 5.22% 5.68% - staff
Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Chapter 2 – Finance & Resources. Mandatory Training: Graphs 24
Responsible Same Oversight National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Executive Actual Status Period Last Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Committee Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Officer Year Percentage compliance for all completed Level 1 competencies within the Core DFM090 Sue Green F&P >= 85% AP046 >= 85% Mar-20 84.72% 1st 84.00% 84.10% 85.00% 84.00% - 85.00% 85.00% 85.00% - 84.00% 84.58% 85.13% - 85.61% 85.37% 84.72% - Skills and Training Framework by organisation
Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Chapter 2 – Finance & Resources. PADR: Graphs 25
Responsible Same Oversight National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Executive Actual Status Period Last Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Committee Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Officer Year
Percentage of headcount by organisation who have had a Personal Appraisal and DFM087 Development Review (PADR)/medical Sue Green F&P >= 85% AP046 >= 85% Mar-20 73.28% 3rd 67.10% 66.90% 68.80% 70.00% - 72.00% 73.00% 74.10% - 73.50% 75.20% 75.40% - 75.49% 75.81% 73.28% - appraisal in the previous 12 months (excluding doctors and dentists in training)
Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Chapter 3a: Summary.. Operational Performance: Planned Care 26
Plan National Code Measure Status 0 Profile Target 1 DFM052 Referral to Treatment (RTT): < 26 Weeks 76.41% AP >= 95% DFM053 Referral to Treatment (RTT): > 36 Weeks 11,798 AP 0 LM053a Referral to Treatment (RTT): > 52 Weeks 3,113 AP 0 Planned DFM054 Diagnostic Waits: > 8 Weeks 2,061 AP 0 Care DFM063 Cancer: 31 Days (non USC Route) 98.30% >= 98% >= 98% DFM064 Cancer: 62 Days (USC Route) 79.40% >= 83.5% >= 95% 00 7 0 DFM065 Cancer: 62 Days (Single Pathway) 74.00% AP Improve DFM056 Follow-up Waiting List Backlog 95,075 <= 74,307<= 74,555 Other DFM057 Eye Care Measure 65.40% AP >= 95% RTT 1 3 Cancer 3 0 1
Compared to the previous report of the 9 Measures in this Integrated Quality and Performance Report chapter, Performance has improved for 3 and worse for 6. Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Chapter 3a – Planned Care. Referral to Treatment 27
Responsible Same Oversight National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Executive Actual Status Period Last Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Committee Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Officer Year
The percentage of patients waiting DFM052 Gill Harris F&P >= 95% AP024 AP Mar-20 76.41% 7th 84.80% 83.21% 82.22% 83.00% - 82.00% 80.24% 79.94% - 78.65% 78.08% 76.74% - 76.54% 78.13% 76.41% - less than 26 weeks for treatment
The number of patients waiting more DFM053 Gill Harris F&P 0 AP024 AP Mar-20 11,798 7th 6,004 6,768 7,396 7,886 - 8,900 10,167 10,052 - 10,768 11,525 12,378 - 12,792 11,654 11,798 - than 36 weeks for treatment
The number of patients waiting more LM053a Gill Harris F&P 0 AP024 AP Mar-20 3,113 N/A 2,301 2,369 2,540 2,506 - 2,496 2,621 2,730 - 2,880 3,177 3,391 - 3,203 3,093 3,113 - than 52 weeks for treatment
BCU Level - RTT Waits % <= 26 Weeks: March 2020 BCU Level - RTT Waits Number > 36 Weeks: March 2020 100% 14,000 95% 12,000 90% 10,000
85% 8,000 6,000 80% 4,000 75% 2,000
70% 0
Jul-18 Jul-19
Jul-18 Jul-19
Oct-18 Oct-19 Apr-18 Apr-19
Apr-18 Oct-18 Apr-19 Oct-19
Jun-18 Jun-19 Jan-19 Jan-20
Jun-18 Jan-19 Jun-19 Jan-20
Mar-18 Mar-19 Mar-20
Feb-19 Feb-20
Feb-19 Feb-20 Mar-18 Mar-19 Mar-20
Nov-18 Nov-19 Aug-18 Sep-18 Dec-18 Aug-19 Sep-19 Dec-19
Aug-18 Dec-18 Aug-19 Dec-19 Sep-18 Nov-18 Sep-19 Nov-19
May-18 May-19
May-18 May-19 RTT 26W % Target Control Line Upper Control Limit Lower Control Limit RTT Over 36W Target Control Line Upper Control Limit Lower Control Limit
Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Chapter 3a – Planned Care. Diagnostic Waits: Graphs 28
Responsible Same Oversight National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Executive Actual Status Period Last Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Committee Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Officer Year
The number of patients waiting more DFM054 than 8 weeks for a specified Adrian Thomas F&P 0 AP024 AP Mar-20 2,061 7th 2,278 2,548 2,857 2,827 - 2,793 2,957 2,816 - 2,443 2,233 2,502 - 2,583 1,832 2,061 - diagnostic test
BCU Level - Diagnostic Waits Number of Breaches: March 2020 4,000 3,500 3,000 2,500 2,000 1,500 1,000 500
0
Jul-18 Jul-19
Apr-19 Oct-19 Apr-18 Oct-18
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May-19 May-18 Actual Target Control Line Upper Control Limit Lower Control Limit
Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Chapter 3a – Planned Care. Cancer 29
Responsible Same Oversight National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Executive Actual Status Period Last Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Committee Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Officer Year
The percentage of patients newly diagnosed with cancer, not via the urgent route, that started definitive DFM063 Adrian Thomas F&P >= 98% AP026 >= 98% Mar-20 98.30% 4th 97.22% 100% 98.44% 98.33% - 99.49% 98.15% 96.40% - 99.48% 97.08% 98.00% - 98.80% 98.80% 98.30% - treatment within (up to & including) 31 days of diagnosis (regardless of referral route)
The percentage of patients newly diagnosed with cancer, via the urgent DFM064 suspected cancer route, that started Adrian Thomas F&P >= 95% AP026 >= 83.5% Mar-20 79.40% 3rd 87.60% 83.23% 81.55% 81.05% - 84.88% 86.62% 82.60% - 82.90% 85.40% 83.30% - 80.70% 85.30% 79.40% - definitive treatment within (up to & including) 62 days of receipt of referral
Percentage of patients starting first New for DFM065 definitive cancer treatment within 62 Adrian Thomas F&P Improve AP026 AP Feb-20 74.00% 2nd 77.10% 79.00% 78.00% - 77.00% 76.00% 77.00% - 75.10% 76.60% 77.50% - 76.00% 74.00% 0.00% - 19/20 days from point of suspicion
BCU Level - Cancer Waiting Times - 31 Day - March 2020 BCU Level - Cancer Waiting Times - 62 Day from Receipt of Referral - March 2020 100.00% 100.00% 98.00% 96.00% 95.00% 94.00% 92.00% 90.00% 90.00% 88.00% 85.00% 86.00% 84.00% 80.00% 82.00%
80.00% 75.00%
Jul-18 Jul-19
Jul-18 Jul-19
Apr-18 Oct-18 Apr-19 Oct-19
Apr-18 Oct-18 Apr-19 Oct-19
Jun-18 Jan-19 Jun-19 Jan-20
Jun-18 Jan-19 Jun-19 Jan-20
Feb-19 Feb-20 Mar-20 Mar-18 Mar-19
Feb-19 Feb-20 Mar-20 Mar-18 Mar-19
Dec-18 Nov-18 Nov-19 Dec-19
Aug-18 Aug-19 Sep-19 Sep-18
Dec-18 Nov-18 Nov-19 Dec-19
Aug-18 Aug-19 Sep-19 Sep-18
May-18 May-19
May-18 May-19 Actual Target Control Line Upper Control Limit Lower Control Limit Actual Target Control Line Upper Control Limit Lower Control Limit
Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Chapter 3a – Planned Care. Follow Up Waiting List - Graph 30
Responsible Same Oversight National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Executive Actual Status Period Last Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Committee Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Officer Year
The number of patients waiting for an outpatient follow-up (booked and not <= <= DFM056 booked) who are delayed past their Gill Harris F&P AP024 Mar-20 95,075 7th 87,712 88,210 88,079 88,511 - 88,648 92,067 90,569 - 89,909 89,235 92,810 - 93,324 92,497 95,075 - 74,555 74,307 agreed target date for planned care specialities
BCU Level - Number of Follow Up Backlog: March 2020 120,000 110,000 100,000 90,000 80,000 70,000 60,000 50,000 40,000 30,000 20,000 10,000
0
Jul-18 Jul-19
Apr-19 Oct-19 Apr-18 Oct-18
Jun-18 Jan-19 Jun-19 Jan-20
Mar-18 Mar-20 Mar-19
Feb-20 Feb-19
Aug-18 Nov-18 Dec-18 Sep-19 Sep-18 Aug-19 Nov-19 Dec-19
May-19 May-18 Actual Target Control Line Upper Control Limit Lower Control Limit
Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Chapter 3a – Planned Care. Eye Care Measure 31
Responsible Same Oversight National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Executive Actual Status Period Last Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Committee Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Officer Year
95% of opthalmology R1 patients who are waiting within their clinical target New for DFM057 date or within 25% in excess of their Gill Harris F&P >= 95% AP022 AP Mar-20 65.40% 5th - - - - 63.40% 65.00% 63.07% - 64.30% 64.01% 63.45% - 64.44% 67.35% 65.40% - 19/20 clinical target date for care or treatments
Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Chapter 3b: Summary. Operational Performance: Unscheduled Care 32
Plan National Code Measure Status 0 Profile Target 3 Emergency Department 4 Hour Waits DFM072 75.94% >= 75% >= 95% 0 (inc MIU) Emergency Department 12 Hour Waits DFM073 902 <= 1,240 0 (ex MIU) DFM071 Ambulance Handovers within 1 Hour 320 <= 438 0 Delayed Transfers of Care (DToC) DFM026 68 <= 24 Reduce Unscheduled Non Mental Health Care DFM066 Stroke Care: Admission within 4 Hours 45.81% >= 50% >= 55.5% Stroke Care: Review by consultant 24 DFM067 80.80% >= 85% >= 84% Hours Stroke Care: Speech & Language 0 DFM068 44.90% AP Improve 0 Therapy Stroke Care: 6 Month Follow Up 5 DFM069 41.80% AP Improve 1 Assessment ED, Ambulance Stroke & DToC Care 4 3 00
Compared to the previous report, of the 8 Measures in this Integrated Quality and Performance Report chapter, performance has improved for 6, worse for 2. Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Chapter 3b – Unscheduled Care. ED & MIU 4Hr Graphs 33
Responsible Same Oversight National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Executive Actual Status Period Last Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Committee Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Officer Year
The percentage of patients who spend less than 4 hours in all major and DFM072 minor emergency care (i.e. A&E) Deborah Carter F&P >= 95% AP033 >= 75% Mar-20 75.94% 7th 71.09% 69.44% 71.21% 71.38% - 73.72% 73.04% 71.63% - 71.15% 72.13% 66.32% - 68.60% 66.38% 75.94% - facilities from arrival until admission, transfer or discharge BCU
BCU Level - Emergency Department (inc MIU) 4 Hour Waits: West - Emergency Department (inc MIU) 4 Hour Waits: March 2020 March 2020 100% 100% 90% 90% 80% 80% 70% 70% 60% 60% 50% 50% 40% 40% 30% 30% 20% 20% 10% 10%
0% 0%
Jul-18 Jul-19 Jul-18 Jul-19
Apr-18 Oct-18 Apr-18 Oct-19 Apr-19 Oct-19 Oct-18 Apr-19
Jun-18 Jan-19 Jan-20 Jun-19 Jan-20 Jun-18 Jan-19 Jun-19
Mar-18 Feb-19 Mar-18 Feb-20 Mar-20 Mar-19 Feb-20 Mar-20 Feb-19 Mar-19
Nov-18 Dec-18 Nov-19 Dec-19 Nov-19 Dec-19 Nov-18 Dec-18
Aug-18 Sep-18 Sep-19 Aug-19 Sep-19 Aug-18 Sep-18 Aug-19
May-18 May-18 May-19 May-19 Actual Target Control Line Upper Control Limit Lower Control Limit Actual Target Control Line Upper Control Limit Lower Control Limit
Central - Emergency Department (inc MIU) 4 Hour Waits: East - Emergency Department (inc MIU) 4 Hour Waits: March 2020 100% 100% March 2020 90% 90% 80% 80% 70% 70% 60% 60% 50% 50% 40% 40% 30% 30% 20% 20% 10% 10%
0% 0%
Jul-18 Jul-18 Jul-19 Jul-19
Apr-18 Oct-19 Apr-18 Oct-18 Oct-18 Apr-19 Apr-19 Oct-19
Jan-20 Jun-18 Jan-19 Jun-18 Jan-19 Jun-19 Jun-19 Jan-20
Mar-18 Feb-20 Mar-20 Mar-18 Feb-19 Feb-19 Mar-19 Mar-19 Feb-20 Mar-20
Nov-19 Dec-19 Nov-18 Dec-18 Nov-18 Dec-18 Nov-19 Dec-19
Sep-19 Aug-18 Sep-18 Aug-18 Sep-18 Aug-19 Aug-19 Sep-19
May-18 May-18 May-19 May-19 Actual Target Control Line Upper Control Limit Lower Control Limit Actual Target Control Line Upper Control Limit Lower Control Limit
Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Chapter 3b – Unscheduled Care. ED 12 Hr Wait Graphs 34
Responsible Same Oversight National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Executive Actual Status Period Last Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Committee Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Officer Year
The number of patients who spend 12 hours or more in all hospital major and DFM073 Deborah Carter F&P 0 AP037 <= 1,240 Mar-20 902 7th 1,608 1,743 1,594 1,445 - 2,044 1,708 1,977 - 1,757 1,786 2,272 - 2,096 1,832 902 - minor care facilities from arrival until admission, transfer or discharge BCU
BCU Level - Emergency Department 12 Hour Waits: West - Emergency Department 12 Hour Waits: March 2020 March 2020 3,000 700 2,750 2,500 600 2,250 2,000 500 1,750 400 1,500 1,250 300 1,000 750 200 500 100 250
0 0
Jul-18 Jul-19
Jul-18 Jul-19
Oct-18 Oct-19 Apr-18 Apr-19
Oct-18 Oct-19 Apr-18 Apr-19
Jun-18 Jan-19 Jun-19 Jan-20
Jan-19 Jan-20 Jun-18 Jun-19
Mar-18 Mar-19 Mar-20
Feb-19 Feb-20
Mar-18 Mar-19 Mar-20 Feb-19 Feb-20
Aug-18 Dec-18 Aug-19 Dec-19 Sep-18 Nov-18 Sep-19 Nov-19
Dec-18 Dec-19 Nov-18 Nov-19
Aug-18 Aug-19 Sep-18 Sep-19
May-18 May-19
May-18 May-19 Actual Target Control Line Upper Control Limit Lower Control Limit Actual Target Control Line Upper Control Limit Lower Control Limit
Central - Emergency Department 12 Hour Waits: East - Emergency Department 12 Hour Waits: March 2020 March 2020 1,100 1,100 1,000 1,000 900 900 800 800 700 700 600 600 500 500 400 400 300 300 200 200 100 100
0 0
Jul-18 Jul-19
Apr-18 Apr-19 Oct-19 Oct-18
Jan-19 Jan-20 Jun-18 Jun-19
Mar-18 Feb-20 Mar-20 Feb-19 Mar-19
Jul-18 Jul-19
Nov-18 Dec-18 Nov-19 Dec-19
Aug-18 Aug-19 Sep-19 Sep-18
May-19 May-18
Apr-18 Apr-19 Oct-19 Oct-18
Jan-19 Jan-20 Jun-18 Jun-19
Mar-18 Mar-20 Mar-19
Feb-20 Feb-19
Nov-18 Dec-18 Nov-19 Dec-19
Aug-18 Aug-19 Sep-19 Sep-18
May-19 May-18 Actual Target Control Line Upper Control Limit Lower Control Limit Actual Target Control Line Upper Control Limit Lower Control Limit Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Chapter 3b – Unscheduled Care. Ambulance Handover Graphs 35
Responsible Same Oversight National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Executive Actual Status Period Last Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Committee Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Officer Year Number of ambulance handovers over DFM071 Deborah Carter F&P 0 AP029 <= 438 Mar-20 320 5th 438 696 614 447 - 811 694 896 - 809 792 1,114 - 1,042 660 320 - one hour BCU
BCU Level - Ambulance Handovers over 1 Hour: West - Ambulance Handovers over 1 Hour: March 2020 March 2020 1,750 700 1,500 600 1,250 500 1,000 400 750 300 500 200 250 100
0 0
Jul-19 Jul-18
Jul-19 Jul-18
Oct-18 Apr-19 Apr-18 Oct-19
Oct-18 Apr-19 Apr-18 Oct-19
Jun-18 Jan-19 Jun-19 Jan-20
Jun-18 Jan-19 Jun-19 Jan-20
Mar-18 Feb-20 Mar-20 Feb-19 Mar-19
Mar-18 Feb-20 Mar-20 Feb-19 Mar-19
Dec-18 Nov-19 Nov-18 Dec-19
Sep-18 Aug-19 Aug-18 Sep-19
Dec-18 Nov-19 Nov-18 Dec-19
Sep-18 Aug-19 Aug-18 Sep-19
May-19 May-18
May-19 May-18 Actual Target Control Line Upper Control Limit Lower Control Limit Actual Target Control Line Upper Control Limit Lower Control Limit
Central - Ambulance Handovers over 1 Hour: East - Ambulance Handovers over 1 Hour: March 2020 700 March 2020 1,000 900 600 800 500 700 400 600 500 300 400 200 300 200 100 100
0 0
Jul-19 Jul-19 Jul-18 Jul-18
Oct-18 Apr-19 Oct-19 Oct-18 Apr-19 Apr-18 Apr-18 Oct-19
Jan-19 Jun-18 Jan-19 Jun-18 Jun-19 Jan-20 Jun-19 Jan-20
Mar-18 Mar-20 Mar-18 Feb-20 Mar-20 Feb-19 Mar-19 Feb-20 Feb-19 Mar-19
Nov-18 Dec-19 Dec-18 Nov-19 Dec-18 Nov-19 Nov-18 Dec-19
Aug-18 Sep-19 Sep-18 Aug-19 Sep-18 Aug-19 Aug-18 Sep-19
May-18 May-19 May-19 May-18 Actual Target Control Line Upper Control Limit Lower Control Limit Actual Target Control Line Upper Control Limit Lower Control Limit
Integrated Quality and Performance Report Health Board Version March 2020 Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Chapter 3b – Unscheduled Care. DToC Graphs 36
Responsible Same Oversight National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Executive Actual Status Period Last Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Committee Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Officer Year
Number of health board non mental DFM026 Deborah Carter F&P Reduce AP037 <= 24 Mar-20 68 6th 60 77 68 68 - 67 74 87 - 72 105 75 - 80 64 68 - health delayed transfer of care
BCU Level - Delayed Transfers Of Care (Non-MH): BCU Level - Delayed Transfers Of Care (MH): Number of Patients - March 2020 Number of Patients - March 2020 150 40 140 130 35 120 110 30 100 25 90 80 20 70 60 15 50 40 10 30 20 5 10
0 0
Jul-18 Jul-19
Jul-18 Jul-19
Oct-18 Oct-19
Apr-18 Apr-19
Apr-18 Oct-18 Apr-19 Oct-19
Jun-18 Jan-19 Jun-19 Jan-20
Jun-18 Jan-19 Jun-19 Jan-20
Mar-18 Mar-19 Mar-20
Feb-20 Feb-19
Feb-19 Feb-20 Mar-20 Mar-18 Mar-19
Nov-18 Dec-18 Aug-19 Nov-19 Dec-19 Aug-18 Sep-18 Sep-19
Dec-18 Nov-18 Nov-19 Dec-19
Aug-18 Aug-19 Sep-19 Sep-18
May-18 May-19
May-18 May-19 Actual Target Control Line Upper Control Limit Lower Control Limit Actual Target Control Line Upper Control Limit Lower Control Limit
BCU Level - Delayed Transfers Of Care (Non-MH): BCU Level - Delayed Transfers Of Care (MH): Number of Beddays - March 2020 Number of Beddays - March 2020 4,000 3,000 2,700 3,500 2,400 3,000 2,100 2,500 1,800 2,000 1,500 1,500 1,200 900 1,000 600 500 300
0 0
Jul-18 Jul-19
Jul-18 Jul-19
Oct-18 Oct-19
Apr-18 Apr-19
Apr-18 Oct-18 Apr-19 Oct-19
Jun-18 Jan-19 Jun-19 Jan-20
Jun-18 Jan-19 Jun-19 Jan-20
Mar-18 Mar-19 Mar-20
Feb-19 Feb-20
Feb-19 Feb-20 Mar-20 Mar-18 Mar-19
Aug-18 Sep-18 Aug-19 Sep-19 Nov-19 Nov-18 Dec-18 Dec-19
Dec-18 Nov-18 Nov-19 Dec-19
Aug-18 Aug-19 Sep-19 Sep-18
May-18 May-19
May-18 May-19 Actual Target Control Line Upper Control Limit Lower Control Limit Actual Target Control Line Upper Control Limit Lower Control Limit
Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Chapter 3b – Unscheduled Care. Stroke Care - Graphs 37
Responsible Same Oversight National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Executive Actual Status Period Last Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Committee Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Officer Year
Percentage of patients who are diagnosed with a stroke who have a DFM066 direct admission to an acute stroke Deborah Carter F&P >= 55.5% AP038 >= 50% Mar-20 45.81% 2nd 50.00% 53.20% 55.00% 69.00% - 56.00% 59.30% 61.40% - 51.20% 50.00% 45.30% - 49.50% 46.10% 45.81% - unit within 4 hours of the patient's clock start time
Percentage of patients who are assessed by a stroke specialist DFM067 Deborah Carter F&P >= 84% AP038 >= 85% Mar-20 80.80% 4th 81.32% 79.80% 80.40% 81.00% - 88.00% 75.90% 85.70% - 82.10% 82.60% 77.30% - 75.30% 69.90% 80.80% - consultant physician within 24 hours of the patient's clock start time
Percentage of stroke patients DFM068 receiving the required minutes for Deborah Carter F&P Improve AP038 AP Mar-20 44.90% 2nd - 65.00% 70.00% 69.00% - 70.00% 62.30% 59.00% - 56.70% 53.90% 56.90% - 50.90% 44.10% 44.90% - speech and language therapy Percentage of stroke patients who Qtr 3 DFM069 receive a 6 month follow up Deborah Carter F&P Improve AP038 AP 41.80% N/A 29.10% - - - 22.30% - - - 31.90% - - - 41.80% - - - 41.80% 19/20 assessment
BCU Level - Stroke Care - Admissions within 4 Hours: BCU Level - Stroke Care - Consultant Assessd within 24 Hours: March 2020 March 2020 100% 100% 90% 90% 80% 80% 70% 70% 60% 60% 50% 50% 40% 40% 30% 30% 20% 20% 10% 10%
0% 0%
Jul-19 Jul-18
Jul-18 Jul-19
Oct-19 Oct-18
Apr-19 Apr-18
Oct-18 Oct-19 Apr-18 Apr-19
Jun-18 Jan-19 Jun-19 Jan-20
Jun-18 Jun-19 Jan-19 Jan-20
Mar-18 Mar-19 Mar-20
Feb-19 Feb-20
Mar-18 Feb-19 Mar-19 Feb-20 Mar-20
Sep-18 Dec-18 Sep-19 Dec-19 Aug-18 Nov-18 Aug-19 Nov-19
Nov-18 Nov-19 Dec-18 Dec-19
Aug-18 Sep-18 Aug-19 Sep-19
May-18 May-19
May-18 May-19 Series1 Series2 Series3 Series4 Series5 Actual Target Control Line Upper Control Limit Lower Control Limit
Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Chapter 5: Summary. Mental Health 38
Plan National Code Measure Status Profile Target Delayed Transfers of Care (DToC) DFM025 21 <= 11 Reduce Mental Health 0 MHM1a - Assessments within 28 Days DFM060 82.70% N/A >= 80% (Combined) 5 MHM1b - Therapy within 28 Days DFM061 75.30% N/A >= 80% (Combined) MHM1a - Assessments within 28 Days LM060a 83.10% >= 74% >= 80% (Adult) LM061a MHM1b - Therapy within 28 Days (Adult) 76.30% >= 70% >= 80% MHM1a - Assessments within 28 Days Mental LM060b 77.80% >= 80% >= 80% (CAMHS) MHM1b - Therapy within 28 Days LM061b 65.80% >= 80% >= 80% Health (CAMHS) 0 DFM082 MHM2 - Care Treatment Plans (CTP) 90.30% >= 90% >= 90% 4 DFM083 MHM3 - Copy of Agreed plan within 10 Days 100% 100% 100%
Of the 9 Measures in this chapter, performance has improved Integrated Quality and Performance Report for 5, worse for 3, and remained static for 1 Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Chapter 5 – Mental Health. MH Measure – Adult Graphs 39
Responsible Same Oversight National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Executive Actual Status Period Last Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Committee Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Officer Year
The percentage of mental health assessments undertaken within (up to Lesley LM060a QSE >= 80% AP027 >= 74% Mar-20 83.10% N/A 75.70% 73.26% 62.55% 61.61% - 64.40% 64.80% 57.61% - 67.13% 67.33% 69.70% - 65.70% 80.50% 83.10% - and including) 28 days from the date of Singleton receipt of referral (Adult)
The percentage of therapeutic interventions started within (up to and Lesley LM061a QSE >= 80% AP027 >= 70% Mar-20 76.30% N/A 66.30% 71.22% 64.18% 72.21% - 69.41% 64.00% 64.51% - 76.45% 72.21% 74.30% - 59.70% 76.20% 76.30% - including) 28 days following an Singleton assessment by LPMHSS (Adult)
% of assessment by the LPMHSS undertaken within 28 days % of therapeutic interventions started within 28 days of referral - Adult Services following an assessment - Adult Mental Health Services 100% 90% 100% 80% 90% 80% 70% 70% 60% 60% 50% 50%
40% 40%
Jul-18 Jul-19
Jul-18 Jul-19
Apr-18 Oct-18 Apr-19 Oct-19
Apr-19 Apr-18 Oct-18 Oct-19
Jan-19 Jun-19 Jun-18 Jan-20
Jun-18 Jan-19 Jun-19 Jan-20
Mar-19 Mar-20
Feb-19 Feb-20 Mar-19 Mar-20
Feb-19 Feb-20
Aug-18 Sep-18 Nov-18 Dec-18 Aug-19 Sep-19 Nov-19 Dec-19
Aug-18 Sep-18 Nov-18 Dec-18 Aug-19 Sep-19 Nov-19 Dec-19
May-18 May-19
May-18 May-19
Actual Plan Target Actual Plan Target
Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Chapter 5 – Mental Health. MH Measure – CAMHS Graphs 40
Responsible Same Oversight National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Executive Actual Status Period Last Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Committee Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Officer Year
The percentage of mental health assessments undertaken within (up to LM060b Chris Stockport QSE >= 80% AP027 >= 80% Mar-20 77.80% N/A 75.20% 80.15% 74.74% 78.00% - 81.20% 75.80% 85.56% - 81.70% 82.73% 70.70% - 77.40% 78.20% 77.80% - and including) 28 days from the date of receipt of referral (CAMHS)
The percentage of therapeutic interventions started within (up to and LM061b Chris Stockport QSE >= 80% AP027 >= 80% Mar-20 65.80% N/A 80.90% 63.24% 58.14% 71.64% - 76.00% 79.00% 72.92% - 76.92% 86.80% 75.70% - 69.40% 64.00% 65.80% - including) 28 days following an assessment by LPMHSS (CAMHS)
% of assessment by the LPMHSS undertaken within 28 days of % of therapeutic interventions started within 28 days referral - Child Adolescent Mental Health Services following an assessment - Child and Adolescent Mental Health Services 100% 100% 80% 80% 60% 60% 40% 40% 20% 20%
0% 0%
Jul-18 Jul-19
Jul-18 Jul-19
Oct-19 Apr-18 Oct-18 Apr-19
Jun-18 Jan-19 Jun-19 Jan-20
Mar-19 Mar-20
Feb-19 Feb-20 Apr-18 Oct-18 Apr-19 Oct-19
Nov-18 Dec-18 Nov-19 Dec-19
Aug-18 Sep-18 Aug-19 Sep-19 Jun-18 Jan-19 Jun-19 Jan-20
May-18 May-19 Mar-19 Mar-20
Feb-20 Feb-19
Dec-18 Nov-18 Nov-19 Dec-19
Aug-18 Sep-18 Aug-19 Sep-19
May-18 May-19
Actual Plan Target Actual Plan Target
Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Chapter 6: Summary: Primary Care 41
Plan National Code Measure Status Profile Target % GP practices open between 17:00 DFM048 84.60% AP Improve and 18:30 Primary Dental Care: Access to NHS DFM051 49.39% AP Improve Dentists DFM086 Primary Dental Care: Reattendance 31.30% N/A M Reduce Number of CHC & Joint funded LM101 1,665 Packages of Care Cumulative cost of CHC & Joint funded Primary LM102 £88.97m Packages of Care Care Average Length of Stay (Days) for LM105 6.7 Emergency Admissions: Acute Sites Average Length of Stay (Days): LM106 28.0 3 Community 00
Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Chapter 6 – Primary Care. Access to Dentists 42
Responsible Same Oversight National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Executive Actual Status Period Last Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Committee Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Officer Year
Percentage of the health board DFM051 population regularly accessing NHS Chris Stockport F&P Improve AP007 AP Mar-20 49.39% 6th 49.30% 49.30% 49.30% 49.30% - 49.30% 49.30% 49.30% - 49.23% 49.48% 49.39% - 49.47% 49.41% 49.39% - primary dental care
Percentage of adult dental patients in the health board population re- Qtr 4 New for DFM086 Chris Stockport F&P Reduce AP007 N/A M 31.30% 7th - - - N/D - - - 36.30% - - - 34.40% - - - 31.30% attending NHS primary dental care 19/20 19/20 between 6 and 9 months
Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Chapter 6 – Primary Care. 43
Responsible Same Oversight National Plan Plan Current Wales Qtr 1 Qtr 2 Qtr 3 Qtr 4 Code Measure Description Executive Actual Status Period Last Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Committee Target Ref Target Period Benchmark 19/20 19/20 19/20 19/20 Officer Year
Number of CHC & Joint funded LM101 Chris Stockport F&P Mar-20 1,665 N/A 1,902 1,830 1,841 1,849 1,839 1,844 1,825 1,811 1,785 1,738 1,701 1,673 1,665 Packages of Care
Cumulative cost of CHC & Joint LM102 Chris Stockport F&P Mar-20 £88.97m N/A £69.42m £7.54m £15.08m £22.62m £30.29m £34.72m £45.00m £52.50m £59.46m £68.01m £75.23m £81.87m £88.97m funded Packages of Care
Average Length of Stay (Days) for LM105 Chris Stockport F&P Mar-20 6.7 N/A 5.2 5.6 5.4 5.3 5.4 5.4 5.5 5.6 5.3 5.2 6.2 5.5 6.7 Emergency Admissions: Acute Sites
Average Length of Stay (Days): LM106 Chris Stockport F&P Mar-20 28.0 N/A 26.5 27.0 28.5 29.1 30.0 26.9 30.3 27.8 29.0 25.3 29.5 28.3 28.0 Community
The Health Board is a provider of integrated care across primary, community, mental health and secondary care parts of patients pathways. Much of the data within the organisation relates to hospital care. However, our strategic direction it to provide care closer to home for our population. National indicators for access to primary care are in development and will be included in IQPR reports from April 2020. However the above local indicators are included to reflect some of the work being undertaken through the care closer to home and unscheduled care improvement groups. The Continuing Health Care indicator is included to monitor the level and cost of provision for our population.
The level of emergency admissions reflects the whole system approach to unscheduled care, ability of primary and community services to manage patients close to home and effectiveness of admission avoidance schemes. The zero day length of stay acts as an indicator on the effectiveness of ambulatory care services and the ability of primary and community care to support patients return to their normal place of residence. The average length of stay data is useful in assessing the ability to support patient flow through the whole system and facilitate patients to return to their residence at the earliest opportunity. As this is an introductory report the data presented is for information in this report , with the expectation that future reports will include information on actions, expected outcome and timescales from the improvement groups in future reports.
Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly Appendix A: Further Information. 44
Further information is available from the office of the Director of Performance which includes:
• performance reference tables • tolerances for red, amber and green • the Welsh benchmark information which we have presented
Further information on our performance can be found online at: • Our website www.pbc.cymru.nhs.uk www.bcu.wales.nhs.uk • Stats Wales www.statswales.wales.gov.uk
We also post regular updates on what we are doing to improve healthcare services for patients on social media:
follow @bcuhb http://www.facebook.com/bcuhealthboard
Integrated Quality and Performance Report Health Board Version March 2020
Put patients first Work together Value and respect each other Learn and innovate Communicate openly and honestly 9 20/53 Cofrestr Risg Corfforaethol / Corporate Risk Register - Mrs Gill Harris 1 20.53 CRAF Report v5.docx
1
Cyfarfod a dyddiad: Health Board Meeting and date: 14th May 2020 Cyhoeddus neu Breifat: Public or Private: Public Teitl yr Adroddiad Corporate Risk Register and Assurance Framework Report Report Title: Cyfarwyddwr Cyfrifol: Mrs Gill Harris – Deputy Chief Executive/Executive Director of Nursing Responsible Director: and Midwifery
Awdur yr Adroddiad Mr Matthew Joyes, Associate Director of Patient Experience & Interim Report Author: Associate Director of Quality Assurance. Justine Parry, Associate Director of Information Governance & Risk. Mr David Tita, Head of Risk Management Craffu blaenorol: The full Corporate Risk and Assurance Framework (CRAF) is Prior Scrutiny: scrutinised by the Health Board twice per year and is published on the Board’s external facing website. Individual risks are allocated to one of the Board’s Committees for regular consideration and review. This report has been approved for submission to the Committee by the Deputy Chief Executive / Executive Director of Nursing and Midwifery.
Atodiadau Appendix 1 – Details of Corporate Risk Register Report Appendices: Argymhelliad / Recommendation: The Board is hereby requested to:
1. Note, approve and ratify the Corporate Risk Register (CRR) and to gain assurance that risks articulated on it are appropriately and robustly managed in line with the Health Board`s risk management strategy and best practice. 2. To approve any changes to risks that have been requested by the various committees.
Please tick one as appropriate (note the Chair of the meeting will review and may determine the document should be viewed under a different category) Ar gyfer Ar gyfer Ar gyfer Er gwybodaeth penderfyniad Trafodaeth sicrwydd For Information /cymeradwyaeth For Discussion For Assurance For Decision/ √ & Scrutiny √ √ Approval Sefyllfa / Situation: The emergence of Covid-19 as a `wicked issue` and the debilitating impact it is having on the Health Board`s resources, strategy, tactics and operations emphasises the strategic importance of embedding a risk-based, dynamic, proactive, structured and comprehensive approach to the identification, assessment, mitigation and management of risks across the organisation.
This paper presents risks on the Health Board`s CRR with the aim of highlighting the controls and further actions being implemented in mitigating and managing them including progress and any changes that have been made since the CRR was last presented to the Board. While this coversheet articulates the key highlights/progress and changes captured in each risks, appendix 1 presents details of each of the risks on the CRR. 2
The main thrust of this paper is to provide assurance to the Board that risks to the achievement of the Health Board`s objectives and priority areas as defined in its 3 Year Plan are being robustly, efficiently and effectively mitigated and managed in line with best practice and to expected standards.
Cefndir / Background: Although the Health Board had undertaken a complete re-write of its risk management strategy which was due to be launched in April, 2020, the emerging, fluid, complicated and challenging situation now prevailing due to the Covid-19 outbreak has made it difficult for the launch to go ahead. The launch of our new Risk Management Strategy and Policy has thus been differed for the next six months until 1st October 2020 as this decision has been ratified by the Board. In order to ensure that risk management activities across the Health Board continue to be carried out in line with best practice, the current risk management strategy and its procedural documents has been extended until 30th September 2020.
This postpone has provided the opportunity for scarce resources to be channelled towards supporting the effective delivery of the Health Board`s Covid-19 strategic plan while ensuring that a dynamic risk- based approach is at its heart. On the other hand, the challenging context posed by Covid-19 does not only emphasise the need for a paradigm shift towards a more risk-based culture in which effective risk management is prioritised and put at the heart of all what we do but underlines the importance of innovation, agility and anticipation in continuously scanning the horizon for emerging risks while appropriately identifying, assessing, mitigating and managing them.
Asesiad / Assessment & Analysis The QSE held on the 5th May 2020 and after reviewing and scrutinising their risks advised on the following two key aspects: - That CRAF be fully refreshed and updated especially in light of Covid-19. Risks which have been opened on it for many years be re-considered within the wider context of understanding why commensurate progress hasn`t been made in mitigating and reducing them to their target score despite the many controls in place.
In a similar light, the QSE meeting which held on 28th January 2020, reviewed, scrutinised, approved and recommended six new risks for inclusion onto the CRR. But following extensive discussions with Clinical Executive Directors during the Risk Management Group (RMG) on the 30th January 2020, members agreed to recommend four risks for consideration for the CRR. The RMG then de-escalated two of the risks and advised further updates were required, as these should be reviewed and managed as tier 2 risks linked to the existing Health and Safety corporate risk - CRR21. The QSE also agreed to the rewording of CRR03 which removed the Care Home element as this was risk assessed, de-escalated and will be mitigated and managed at tier 2 while the core components around CHC were upheld to constitute the updated CRR03.
The Digital and Information Governance Committee (DIGC) held on 13th February 2020 received, reviewed and scrutinised their risks on the CRR and noted and acknowledged the further updates being undertaken on their risks following discussions at the RMG. The committee also considered the accuracy of the scores as well as the effectiveness of the controls and actions as captured in each of their risks and approved the increase in the current score for CRR10b from 16 to 20 as advised by the RMG.
The Finance and Performance Committee (F&P) at its meeting held on the 23rd January 2020 recommended an increase in current score for CRR06 from 12 to 20 considering the current financial 3
position of the Health Board. The Committee further noted that a financial sustainability risk assessment will be undertaken and presented at their next meeting on 30th April 2020.
The Strategy, Partnership and Population Health Committee (SPPH) which was held on 5th March 2020, reviewed and scrutinised their risks on the CRR and declined a request for CRR14 to be recommended for de-escalation. Members also noted the ongoing work by the Public Health team around COVID-19 which aligns with the wider national PHW COVID response agenda.
In summary, following review, scrutiny and monitoring from the relevant committees, the following changes have been made to CRR since the last report was received by the Board: - CRR01 Population Health. Key progress: Members at the last SPPH noted that risk controls have been updated to include working with the Regional Partnership Board to ensure population prevention focus for Building a Healthier Wales (BAHW) funding across the North Wales Region. No change to current risk score however the Committee advised for control 11 “BCUHB Operational Plan aligned with key actions for improving health identified in Public Health Wales IMTP” to be deleted. CRR02 Infection Prevention and Control. Key progress: This risk was reviewed at the QSE and members noted that it remains largely the same with no change in score as was in the previous CRR report. Infection Prevention quality visits have commenced to replace the previous “audit programme”. These visits encompass observation of clinical practices, support and advice, micro teaching, safe clean care updates, hand hygiene observations, screening and any other relevant support needed by the ward staff. Scrutiny of every avoidable infection and lessons learnt are regularly shared. CRR03 Continuing Health Care. Key progress: As per updates in the previous report, this risk has now been split into two distinct risks i.e. CHC and the Care Home strand. Both risks were reviewed at the last QSE and after much discussions, the committee was agreed that the updated version of CRR03 which focuses on CHC should replace the current CRR03 while the new risk around Care Homes should be de- escalated and managed as a tier 2. CRR05 Learning from Patient Experience. Key progress: This risk was reviewed at the QSE and members noted that it remains the same as in previous CRR report. Performance and accountability reviews include concerns monitoring as Patient Advice and Support Service has been initially established in Ysbyty Glan Clwyd. There has been no change to the current risk scoring and no change to this risk since the previous updates. CRR06 Financial Stability. Key progress: After some discussions regarding the inappropriate initial score rating, it was agreed that the initial score of this risk should be raised from 12 to 20. Further actions to mitigate this risk so as to achieve its target risk score were also discussed, agreed and have been incorporated which includes, continuously scrutinising recovery and savings delivery as the financial year elapses, potential additional escalatory grip as well as control measures. However, despite these additional actions and given the current financial position, it was recommended that current risk score be increased from 16 to 20. CRR09 Primary Care Sustainability. Key progress: Risk has been updated and controls strengthened. It was noted at the last SPPH that the controls in place for mitigating this risk have also been refreshed to take account of the current position and completion of sustainability Primary Care assessments for each of the 4
management practices. Development of a Primary Care Academic is proceeding as funding has been secured for the next three years. CRR10a National Infrastructure and Products. Key progress: This risk was reviewed at the DIGC on 13th February 2020 as members noted that it has been reviewed including its controls and further actions following feedback from the last AC and RMG. It was noted that future discussions regarding this risk will take place within the Executive Team for scrutiny alongside Area Directors. CRR10b Informatics - Health Records Key progress: Members of the DIGC noted that the updated change to the risk title had been actioned and it was proposed to increase the current score to 20. The Committee further debated and suggested the name change to being solely “health records”. The Assistant Director of Information Governance and Risk clarified that the scoring would be updated to reflect the likelihood scoring. The Committee agreed with the updated score. CRR10c Informatics infrastructure capacity, resource and demand. Key progress: Members of the DIGC noted that controls had been updated to remove an action which was not a control, the target risk date had also been amended to reflect a realistic date to implement the further actions required to achieve the target risk score. Following an in-depth review of this risk at the RMG, it was noted that the further updates would be reflected. CRR11a Unscheduled Care Access. Key progress: Members of the F&P noted that the current score of this risk has been increased from 12 to 16 to reflect the current position of the Health Board. Risk controls have also been strengthened to include reporting arrangements and further actions identified and added to support the achievement of the target risk score. CRR11b Planned Care Access. Key progress: Members of the F&P noted that this risk has been updated alongside its controls and further actions. The target risk date was amended to take into account the implementation of further actions to support the achievement of the target risk score. CRR12 Estates and Environment. Key progress: members of the F&P recognised and noted that the current score of this risk has increased from 12 to 16 to reflect the current position of the Health Board. Risk controls had been strengthened to include reporting arrangements and further actions had been identified to support the achievement of the target risk score. Increase in score of risk was agreed. CRR13 Mental Health Services. Key progress: Risk was discussed at the QSE and it was noted it has been updated, controls and further actions had been refreshed and strengthened. Recommendation to reduce the score of this risk was declined at the last QSE. CRR14 Staff Engagement Key progress: The controls in place for reducing this risk have been strengthened and updated to include implementation of all the 2016 Engagement Strategy as initiatives within the strategy have been mainstreamed into ongoing organisational development. Mechanisms currently in place to measure staff engagement on regular basis via the BeProud organisational survey and NHS Wales Staff Survey were highlighted amongst others. A request to recommend this risk for de- escalation as it has met and sustained its target score was declined as the Committee was not convinced with the robustness of the evidence that was presented to them. CRR15 Recruitment and Retention. Key progress: Key controls have been strengthened and updated with further actions identified to support achieving the target risk score. There has been no change to the current risk scoring. CRR16 Safeguarding. 5
Key progress: This risk was reviewed at the QSE and it was noted that its controls have been strengthened to include business planning, a refreshed reporting framework and the introduction of a senior management tier in the safeguarding structure. It was also noted that further actions have also been updated to support achieving the target risk score. There has been no change to the current risk scoring. CRR17 Development of Integrated Medium Term Plan. Key progress: Whilst there were no further updates to this risk, members of the SPPH noted that an updated paper will be presented to the Board to which will include the next steps of the 3 Year Outlook for 2020/21. This risk would therefore be updated following further discussions at the Board and the SPPH appropriately notified. It was agreed that the score of this risk requires further review which will be done to align with the 2020/21 operational plan that is being finalised CRR18 EU Exit - Transition Arrangements. Key progress: This risk remains unchanged from the previous report as controls have been strengthened. Following exit from the EU on 31 Jan 2020 and progress of the Withdrawal Agreement Bill (WAB) through parliament, planning and preparations have now been stood down by WG until further notice. The national leadership Group will continue to meet on a monthly basis but SRO meetings have been stood down. Position will be reviewed by WG in July 2020 and response arrangements may be stood up if required, dependent on an evaluation of political situation. CRR20 Security Risk Key progress: Risk was reviewed at last QSE and scored agreed at 20 with the target score set at 10. A comprehensive action plan is being developed to further support and ensure the achievement of target score. It was noted that significant investment will be required in order to fully and timely mitigate this risk. CRR21 Health & Safety Leadership and Management Key progress: After some extensive discussion, review and scrutiny at the QSE, members agreed that the current score should of this risk stay at 20 as this is underpinned by evidence from the gap analysis. The target risk score was also agreed at 10. Progress on the implemenation of the H&S Gap Analysis will be aligned in informing and shaping future reviews and updates of this risk. CRR22 Potential to compromise patient safety due to large backlog and lack of follow-up capacity Key progress: Approved and recommended for inclusion onto the CRR. Updates have been included which comprise some information from Informatics following a paper that was done around resourcing a permanent validation team for the Health Board as the cost of independent or external validation is very high. This will be important in informing and shaping how this risk is mitigated and managed going forward. CRR23 Asbestos Management and Control Key progress: Discussed, approved and recommended for inclusion onto the CRR. Target score needs re-considering as it sits outside the Health Board’s risk appetite. CRR24 Contractor Management and Control Key progress: Although the QSE recommended this risk for inclusion onto the CRR, members at the RMG requested for some further work to be done in strengthening the controls and further actions in place and for the title to be refreshed to focus on the potential risk and not the issue. CRR25 Legionella Management and Control. Key progress: Members at the RMG reviewed this risk and recommended that the current score should be changed to 16 to reflect the controls in place. Target score needs re-considering as it sits outside the Health Board’s risk appetite. CRR26 Non-Compliance of Fire Safety Systems 6
Key progress: Members at the RMG reviewed these risks and requested for some further work to be done in strengthening its controls and further actions. Target score needs re-considering as it sits outside the Health Board’s risk appetite.
The following two Covid-19 related risks were approved for inclusion onto the CRR following review and scrutiny at the last Board meeting. CRR27– Risk to public health and safety arising from an outbreak of COVID-19 and demand outstripping organisational capacity. Key Progress: The newly added risk focuses on highlighting the potential impact to public health and the safety of staff and patients which may result from the outbreak of Covid-19 as this could negatively affect the Health Board`s resources and operational capabilities in effectivley mitigating and managing this pandemic. CRR28 - Risk of infection from COVID-19 to staff and patients as a result of inadequate supply, quality or usage of PPE. Key Progress: This risk was discussed and approved at the last Board meeting as the shortage of PPE items, the challenge with sourcing the right PPE kits and ensuring that these are readily and sufficiently available to frontline staff has become a huge national conundrum. The need to effectively mitigate and manage this risk so as to protect the health, well-being and safety of both staff and patients was emphasised. This risk is regularly reviewed and monitored by the PPE Work-stream.
NB: Details of the full CRR are captured in appendix 1. The Audit Committee are requested to note the following risks which had been de-escalated in the past. CRR04 - Maternity Services may become unsustainable due to difficulties recruiting into specific medical posts: - was de-escalated in July 2019 following review by the Maternity SMT. CRR08 - Strategy Development: - was de-escalated in July 2018 by the Board. CRR19 - Countess of Chester Hospital - Discontinued RTT for Patients in Wales: - was de- escalated in June 2019 by the F&P Committee. CRR14 - Staff Engagement: - de-escalated in January 2020 by the Audit Committee.
Closed Risk: The following risk has been closed since the last CRR report was presented to the Board: • CRR07 - Capital Systems on the 25the June 2019 by the F&P Committee.
New risks There are no new risks for approval for inclusion onto the CRR.
After further discussion, extensive scrutiny and review, members at the RMG agreed that the following two risks should be de-escalated and managed at tier 2 as linked risks to CRR21 (Health & Safety Leadership and Management) that is already on the CRR.
Risk ID 3021 - Vibration Control Risk ID 3022 – Electrocution at Work 7
Impact Current Risk Level Very Low - 1 Low - 2 Moderate - 3 High - 4 Very high - 5
CRR03 CRR10a Very Likely CRR11a - 5 CRR11b CRR17 CRR22 CRR26 CRR05 CRR01 CRR20 Likely - 4 CRR06 CRR21 CRR09 CRR23 CRR10b CRR24 CRR10c CRR25 CRR15 CRR27 CRR16 CRR13
Likelihood CRR12 CRR18 CRR02 Possible - 3 CRR28
CRR14 Unlikely - 2
Rare - 1
Strategy Implications This CRR report is strategically important as it evidences, confirms and provides assurance to the Audit Committee that the Health Board is effectively and efficiently identifying, assessing, mitigating and managing high/extreme risk risks to the achievement of its Priority Areas and Objectives as defined in its 3 Year Plan in line with best practice and its risk management strategy.
Financial Implications The effective and efficient mitigation and management of risks has the potential to leverage a positive financial dividend for the Health Board through better integration of risk management into business planning, decision-making and in shaping how care is delivered to our patients thus leading to enhanced quality, less waste and no claims.
Risk Analysis No risks have been identified from crafting this report as the risk of inaction is far greater than that of positive engagement with its content. 8
Legal and Compliance This CRR report which will be periodically shared with the Board is intended to provide assurance.
Impact Assessment Due regard of any potential equality/quality and data governance issues has been factored into crafting this report. 9
Appendix 1: Details of the Corporate Risk Register Director Lead: Executive Director of Public Health Date Opened: 1 October 2015 Assuring Committee: Strategy, Partnerships and Population Health Date Last Reviewed: 24 April 2020 CRR01 Committee Risk: Population Health Target Risk Date: 31 March 2021 There is a risk that the Health Board fails to deliver improvements in population Health in North Wales. This is due to a failure to focus on prevention and early intervention. This will lead to higher levels of non communicable diseases such as obesity, hypertension, coronary heart disease, stroke, diabetes, and some cancers. This will lead to an increase in demand on primary and secondary care, and increase levels of health inequalities between our most and least deprived communities. Impact Likelihood Score Initial Risk Rating 4 5 20 Current Risk Rating 4 4 16 Target Risk Score 4 2 8 Movement in Current Risk Rating since last No Change presented to Board in November 2019
Controls in place Further action to achieve target risk score 1. Population health intelligence updated on a continuing basis ensuring 1. Further exploration and identification of new opportunities that information is available to support planning for and monitoring of for Health Board to secure population health improvement health status. through leadership role in strategic partnerships utilising new 2. Approved Population assessment to inform Social Services and structures - Regional Partnership Board and Public Service Wellbeing Act developed in partnership, and now informing Boards. implementation of North Wales Regional Plan for 2018-2023. 2. Health Improvement and Inequalities Transformation 3. Review of Board cycle of business completed to enable focus on (HIIT) Group lead the development of relevant section of population health issues. 10
4. Wellbeing Assessments completed and approved. 2019/22 IMTP submission, and ensure co-ordination with 5. Wellbeing Objectives and Plans approved / to be approved in the 4 other aspects of the Plan which are interdependent. PSBs. 3. Identify substantive PMO support for this programme. 6. Strategic Partnerships in place providing opportunities for advocacy 4. Participate in Live Lab work with Office of Future for improving population health with partners. Generations Commissioner and Public Health Wales to 7. Approved HB Strategy Living Healthier, Staying Well confirms provide a new focus for prevention within the delivery of emphasis on improving population health through more focus on community services, and generate learning which can be prevention. shared across Wales. 8. Baseline Assessment informing LHSW completed, underpinned by 5. Review of all other public health risks underway which will WG Public Health Outcomes Framework. inform the existing risk mitigation measures for this 9. Improved data on Primary care available to Area Teams and overarching risk. Contractors via PH Directorate website. 6. Grant funding available for Prevention and Early 10. Organisational objectives have now been revised and redefined as Intervention from Welsh Government (Building a Healthier our Wellbeing Objectives. Wales) has been made available via Health Board and 11. DPH / Public Health Consultants attend all PSBs and Part 9 Board spend allocation over three years. to advise and influence on prevention / early intervention agenda. 12. Delivery of Public Health Team workplan is aligned with operational Area Teams. 13. Public Service Boards Wellbeing Plans developed. 14. Health Improvement and Reducing Inequalities Group (HIRIG) established and working to ensure that population health and prevention initiatives are developed in Health Board Planning. 15. Continued engagement with the Live Lab work with Office of Future Generations Commissioner and Public Health Wales. Focusing on Healthy Weight in Pregnancy and Children. 16. BCUHB working with Regional Partnership Board to ensure population prevention focus for Building a Healthier Wales (BAHW) funding across the North Wales Region. Assurances Links to 11
1. Oversight by Public Service Boards and Local Authority Scrutiny Committees. Strategic Principa Special Measures 2. WG Review Meetings (JET). Goals l Risks Theme 3. Public Health Observatory reports and reviews. 4. WG Review and feedback on needs assessment. 1 2 5 6 7 PR8 Strategic and Service Planning 12
Director Lead: Executive Director of Nursing and Midwifery Date Opened: 1 March 2012 CRR02 Assuring Committee: Quality, Safety and Experience Committee Date Last Reviewed: 6 March 2020 Risk: Infection Prevention & Control Target Risk Date: 30 September 2020 There is a risk that patients will suffer harm due to healthcare associated infection. This may be caused by a failure to put in place systems, processes and practices that would prevent avoidable infection. The impact of this may increase morbidity and mortality, increase admissions and longer length of stay, increase treatment costs, reputational damage and loss of public confidence. Impact Likelihood Score Initial Risk Rating 5 4 20 Current Risk 5 3 15 Rating Target Risk Score 5 2 10 Movement in Current Risk Rating since last No Change presented to Board in November 2019 Controls in place Further action to achieve target risk score 1. Infection Prevention Sub-Group scrutinise trajactories and 1. Continue the implementation of SCC and IP via annual work performance through the regular cycle of business, quarterly programmes. and annual reports to Quality and Safety Group. 2. Consider aligning SCC with IP Annual Work Prgramme. 2. Surveillance systems and policies/SOPs in place for key 3. Implement the other actions identified in the 2019-20 annual infections, with data presented through the governance route to infection prevention programme. Board. 4. Implement actions in response to Welsh Government 3. Areas and Secondary Care sites governance arrangements Antimicrobial Delivery Plan, relevant Welsh Health Circulars and in are in place. response to multi-drug resistant organisms. Part of the ARK study and rollout. 13
4. 6 weekly Executive-led scrutiny meetings to review 5. Continue to progress key actions from Duerden and Jan Stevens infections and learning from each site in place. reports 2016, 2017, 2019 in relation to Variation, Consultant 5. Continued progress on ANTT staff training, with key trainers Microbiologist staffing and capacity, Antimicrobial Stewardship, in place, increased focus on medical staff supported by MDs, Estates and Facilities, policies and procedures and Safe Clean competencies held by individuals managers. Care. 6. External review performed August 2017; report on further 6. Scrutinise every avoidable infection and lessons learnt from these actions presented to Board. Second review report received in are shared formally from Post Infection Reviews and Deep Dives. August 2019 shows improvement, as does the internal audit on 7. Continue work on influenza preparedness and response for Safe Clean Care (SCC) assurance in June 2019. Winter 19-20 and review Pandemic policy and procedures. 7. SCC Programme launched 29-01-18. 8. 12 Key action points carried out HB wide in November 2019 8. CAUTI snapshot carried out in September 2019. which showed a decrease in 5 of the 6 trajactories. 9. Deep dive considers every 6 organisms under WG scrutiny. 9. Educational event and Link practitioners in place December 2019. 10. Canula devices and documents approved for distribution. 11. Collaberative work with Continence, Tissue Viability and pharmacy to address unwarrented variation. 12. Improved visability across the HB from IP service. 13. Review of all IP policies and SOPs. 14. Development of IP team 2020. 15. Working alongside Tissue Viability, Pharmacy and Continence service in relation to HCAIs. Assurances Links to 1. Professor Duerden report 2016. Strategic Principal Special 2. WG review of decontamination. Goals Risks Measures 3. Demonstrable improvement in line with National Benchmarks. Theme 4. CHC Bug watch visits. 5. HSE reviews. 1 2 3 4 5 6 7 PR1 Leadership 6. Internal Audits of Governance Arrangements. 14
Director Lead: Director of Primary and Community Care Date Opened: 1 November 2013 CRR03 Assuring Committee: Quality, Safety and Experience Committee Date Last Reviewed: 16 April 2020 Risk: Continuing Health Care Target Risk Date: 31 March 2021 There is a risk that the CHC National Framework is not complied with. This is due to limited understanding of the framework and inconsistent application. This could lead to poor patient experience, outcomes and value for money. Impact Likelihood Score Initial Risk Rating 4 5 20 Current Risk Rating 3 5 15 Target Risk Score 3 3 9 Movement in Current Risk Rating No Change since last presented to Board in November 2019 Controls in place Further action to achieve target risk score 1. National CHC Framework. (2014). 1. Progress programme of CHC support with NCCU, to include 2. Area and divisional CHC team with local accountability. focus on training and development, data and performance 3. Revised BCUHB CHC Improvement Group and CHC management, standard operating proceedures, stakeholder operational Group Reporting and Governance Framework agreed. engagement and realignment of CHC within the Health Board. 4. Annual WG self assessment. 2. Development of dashboard KPI's for CHC with Broadcare. 5. Contracts and contract monitoring team in place. 3. Monthly exception reporting. 6. CHC Contracts in place for all placements. 4. Develop CHC commissioning strategy. 7. Partnership established with the National Commisioning 5. Develop and finalise the joint contracting process for Collaborative Unit to oversee overarching strategy development providers in formal escalation. improving quality, experience and value. Assurances Links to 15
1. Regular meetings with Regulators (CSSIW). Strategic Goals Principal Special Measures 2.Inter-agency processes in place to review escalated concerns. Risks Theme 3. FNC Judicial Reviews of NHS Wales fee setting methodology implemented. 2 3 4 5 6 7 PR1 Strategic and Service 4. National reporting on CHC placements. Planning 16
Director Lead: Executive Director of Nursing and Midwifery Date Opened: 1 March 2012 CRR05 Assuring Committee: Quality, Safety and Experience Committee Date Last Reviewed: 22nd April 2020 Risk: Potential inability to learn from patient safety and experience concerns Target Risk Date: 31 December 2020 There is a risk that the Health Board does not listen and learn from patient safety and experience due to the untimely management, investigation and subsequent improvement actions from concerns (incidents, complaints, claims, inquests). This could lead to repeated failures in quality and safety of care, poor patient experience, loss of organisational memory and reputational damage to the Health Board. Impact Likelihood Score Initial Risk Rating 4 4 16 Current Risk Rating 3 4 12 Target Risk Score 3 2 6 Movement in Current Risk Rating No Change since last presented to Board in November 2019 Controls in place Further action to achieve target risk score 1. Processes in place to manage concerns (incidents, complaints, claims, 1. Concerns processes (incidents, complaints, claims, inquests) in accordance with PTR Regulations. inquests) being fully reviewed following appointment of 2. Corporate and divisional meetings to manage processes and cascade the new Assistant Director of Patient Safety and learning including daily reviews within divisions, weekly reviews within Experience – full process re-design will take place divisions and a weekly pan Health Board Incident and Complaint Review throughout 2020 in co-production with stakeholders, Meeting. building on national best practice. 3. Reporting to share learning and monitor performance at divisional and 2. Patent Safety Alert process to be moved to the pan Health Board levels; including divisional quality and safety reports, Patient Safety and Experience Department allowing for divisional patient experience reports and a Health Board monthly and greater integration of data/insight and activity. quarterly Patient Safety Report and quarterly Patient Experience Report. 17
4. Harm Dashboards available for local clinical leaders to identify 3. Development of a Patient Safety and Experience opportunities for learning and improvement. Learning Library on the intranet to further promote 5. Pan Health Board quality improvement collaborative programmes learning. commenced based on identified risks including a Falls Collaborative, 4. Development of a Patient Safety and Experience Sepsis Collaborative and a Healthcare Acquired Pressure Ulcer (HAPU) Bulletin to further promote learning. Collaborative. 5. Review and update of training and development with 5. Patient Safety and Experience Department in place to develop and a particular emphasis on developing and embedding manage processes and systems and offer advice and assurance – human factors and systems thinking. supported by divisional governance teams and linked to the BCU Quality 6. Implementation of new "Once for Wales" RLDatix Improvement Hub. concerns management system to aid learning across the 6. New Patient Advice and Liaison Service (PALS) fully resourced and Health Board and Wales. launched in 2019. 7. Review of the weekly incident and complaint review 7. Learning from Event (LfE) Reports prepared for all claims and redress meeting and development into a weekly Patient Safety cases. Summit. 8. The Head of Patient Safety is part of, and chairs, the All-Wales 8. Structure review within the Patient Safety and Redress Case Review Group enabling learning from across the country to Experience Department to improve the focus and profile be identified. The Patient Safety and Experience Department is of patient safety and to integrate complaints with patient represented at, and fully engaged in, each All-Wales concerns related experience/PALS. network. 9. Enhancement of the mortality review process to 9. Training programme in place to support continued learning, delivered implement the new national Medical Examiner by the Patient Safety and Experience Department. programme. 10. Patient Safety Alerts process in place to cascade learning across the 10. Workshop to be held with the Community Health Health Board. Council to develop partnership working. 11. Quality and Safety Group in place to oversee patient safety and to cascade learning from patient safety issues, and a Patient Experience Group in place to undertake the same for patient experience (divisions provide reports to both groups). 12 Joint protocol in place between Health Boards and Welsh Ambulance Service Trust to undertake joint investigations when appropriate. 13. Mortality review process in place to support learning from deaths. 18
14. Site audits by the Community Health Council (CHC) received through a single point of contact within the Health Board. 15. Inspections by Health Inspectorate Wales (HIW) received and coordinated through a single point of contact within the Health Board along with regular meetings with the HIW relationship manager. Assurances Links to 1. Welsh Risk Pool Reports. Strategic Goals Principal Special Measures 2. Monthly review by Delivery Unit. Risks Theme 3. Public Service Ombudsman Annual Report, Section 16 and feedback from cases. 3 4 5 6 PR9 PR7 PR1 Leadership 4. Regulation 28 Reports from the Coroner. 19
Director Lead: Executive Director of Finance Date Opened: 1 March 2012 Assuring Committee: Finance and Performance Committee Date Last Reviewed: 16 April 2020 CRR06 Risk: Financial Stability - Health Board Financial achievement of the control Target Risk Date: 31 December 2020 total agreed with Welsh Government There is a risk that the Health Board will fail to achieve the deficit that meets the control total set by Welsh Government.
This is due to: 1. Savings plans that are not fully identified and may not be fully delivered. 2. Expenditure exceeding plan in both pay and non-pay areas. 3. The use of non-recurrent measures to support the in-year position risking the Health Board's longer term sustainability and continued failure to achive its financial duty. 4. Failure to identify and progress transformational schemes that will position the Health Board for the longer-term.
The impact of this could increase the in-year deficit to 31 March 2020 and fail to progress towards the Control Total of £25m, and impact on the ability of the Health Board to improve its financial position in out-years.
The Health Board will remain in Special Measures until the financial position improves and will fail to attract necessary investment. Impact Likelihood Score Initial Risk Rating 4 5 20 Current Risk Rating 4 4 16 Target Risk Score 4 2 8 Movement in Current Risk Rating since last No Change presented to Board in November 2019
Controls in place Further action to achieve target risk score 1. Appointment of Recovery Director and establishment of a multi-faceted 1. Further work to identify and convert recovery Recovery Programme, including recovery challenge meetings across all opportunities, including ongoing review by 20
business areas and improvement themes, deployment of detailed grip and Improvement Groups of the All Wales Efficiency control, and active management if savings opportunity pipeline. Framework for further opportunities. 2. Scheme of Financial Delegation and Accountability Agreements in place 2. Ongoing communications to continuously embed covering all devolved budgets. financial goals across the organisation and all 3. Additional stretch targets issued across all business areas. devolved budget areas including Better Care, 4. Dedicated Chief Finance Officer embedded in the management team of Spending Well initiative. each Division (and hospital/area team). 3. Potential F&P Committee requesting attendance of 5. Focused additional recovery support provided by PwC and Finance in key divisions with recovery shortfalls to seek assurances areas of budgetary pressure. regarding further progress. 6. Programme Management software used to track and monitor the delivery of 4. Improved Financial Recovery Reporting to support savings. oversight and decision-making. 7. Reporting through Financial Recovery Group and Finance and Performance 5. Recovery and savings delivery are under Committee. continuous and progressive scrutiny as the financial year elapses. 6. Executives are discussing and agreeing potential additional escalatory grip and control measures. Assurances Links to 1. Monthly financial position reported to the F&P Committee and Board. Strategic Goals Principal Risks Special Measures 2. Finance Delivery Unit (FDU) view at the WG Special Measures Theme meeting. 7 PR2 SM4 SM1 21
Director Lead: Director of Primary and Community Care Date Opened: 1 October 2015 Assuring Committee: Strategy, Partnerships and Population Health Committee Date Last Reviewed: 09 March CRR09 2020 Risk: Primary Care Sustainability Target Risk Date: 31 March 2021 There is a risk that the Health Board may be unable to meet its statutory responsibilities to provide a primary care service to the population of North Wales. This may be due to the significant number of GPs who are able to retire within the next 5 years and the supply of GPs in training may not meet the demand created by the turnover. This could lead to delayed access for some patients to the appropriate primary care service. Impact Likelihood Score Initial Risk Rating 4 4 16 Current Risk Rating 4 4 16 Target Risk Score 4 2 8 Movement in Current Risk Rating since last No Change presented to Board in November 2019
Controls in place Further action to achieve target risk score 1. 5 Domain Sustainability risk assessment metric developed by PCUS used pan-BCUHB and by 1. Evaluation and integration of Areas to RAG rate and identify highest risk requiring support. Last assessment undertaken January new service models into primary 2020. care to ascertain their success. 2. Each Area has developed a regular practice review process to prioritise support. 2. New governance models of 3. Area Teams have developed support infrastructure to those practices experiencing significant primary care need to be challenges/pressures in terms of sustainability. assessed to identify their 4. National Sustainability assessment process allows practices to request support from the Health reliability and assurance. Board. 3. Care closer to home strategy to be evaluated. 22
5. Clinical advice available from Area Medical Directors and Cluster leads to provide support and 4. Establish primary care development advice to practices. academy and further develop 6. Salaried GPs employed by Areas, working in managed practices and also GMS practices in primary care training, including difficulty. Further GPs employed since August 2019. mentorship. 7. Agreement to employ clinical leads in managed practices to provide leadership and oversight. 5. Recruit to GP schemes being Clinical lead appointed for Blaenau Ffestiniog, Criccieth/Porthmadog, Cambria/Longford other adopted by Clusters and practices progressing recruitment at present. supported by new project 8. Recruitment and retention plan to recruit new GPs into North Wales under development. Project manager for recruitment and Management for recruitment and retention appointed. Attendance at recruitment fairs and other retention. conferences being co-ordinated to promote careers and share current vacancies in North Wales. 6. Primary care workforce plan 9. Schemes for retaining and recruiting staff e.g. Outstanding GP scheme and the GP with to be developed and fully experience scheme in place. implemented. 10. Developed Multi-Disciplinary Teams within GP practices eg physiotherapists, ANPs, 7. Further engagement with audiologist, pharmacists and this team takes on patients that were previously seen by the PG. primary care and partner 11. Developing new models of delivery of care within GP practices. organisations. 12. Primary care funding is supporting the way that services are delivered within community and 8. Demand management primary care setting to take pressure off GPs. scheme – establishing ways to 13. Emerging schemes that will further support the way that services are delivered from Primary release GP capacity and shift care eg Occupational therapy, advanced practice paramedics and GP sustainability and innovation services out of hospital settings unit have been allocated funding from Primary Care Investment funds in 2019/20 continuing into – new roles, new models, and 20/21. new services. 14. Cluster plans and funded schemes are focusing on areas such as pathways and supporting the 9. Work with Deanery to way that care is delivered at local level. increase the number of GP 15. ANPs focusing activity within Care/Nursing homes to improve patient care and reduce demand training places in N Wales. on GP visits. 10. Lobby WG for review of 16. Running 24/7 DN service to reduce out of hours call out and unnecessary ED admissions. national DDRB pay scales and 17. Navigators working within GP practices signposting patients to the right healthcare. recommendations to increase 18. Workflow optimisation training available to practices. the rates to better reflect the 19. Intermediate care funded schemes supporting primary care. different roles of salaried GPs. 23
20. 16 BCUHB managed practices in place that are providing opportunities to trial new models of 11. Accelerated role out of working and develop new areas of clinical care. advanced practice training. 21. BCUHB has approved a 'Care Closer to Home' strategy that provides a vision of the way that 12. Promote practice mergers care will be provided within community and primary care setting in the future. A CCtH and federating. transformation board has been established to oversee progress, with the first meeting held on 20 13. Project to establish a July 2018. Primary & Community Care 22. Care closer to home themes set out in annual operational plan. Priority for cluster development, Academy in place to deliver a service model, workforce development, digital healthcare and technology and estates. sustainable, fit for purpose 23. Governance and accountability of managed practices group in place; performance indicators workforce within primary and established, project management work books published, governance framework for nurses and community services through the pharmacists agreed. allocation resources and 24. Premises issues being addressed with a number of practices, including approval to assign development of new models. some premises head leases from partners to BCUHB. 14. Further development of 25. Programme for recruiting and training practice nurses funded by PC funds in place with 6 clusters/localities with partners nurses being recruited per annum. to strengthen 26. Director of Primary and Community Health Services appointed and in post. primary/community/social care. 27. Plans to progress CCtH built into IMTP 2019-20, identified leads for progressing 4 themes 15. Accelerate estates (CRTS, Clusters, Health and Worksforce/service model) Centres. improvements to ensure fit for 28. Project to establish a Primary & Community Care Academy in place to deliver a sustainable, fit purpose buildings for care in for purpose workforce within primary and community services through the allocation resources and community settings. drvelopment of new models. Project Manager appointed August 2019 and additional pacesetter proposal funding secured. 29. Changes to GP contract include partnership premium to support and encourage GPs becoming partners going forward. Assurances Links to 1. Oversight by Board and WG as part of Special Measures. 2. CHC Strategic Goals Principal Risks Special Measures visits to Primary Care. 3. GP council Wales Reviews. 4. Progress Theme reporting to Community Health Council Joint Services Planning 1 2 3 4 5 6 7 PR6 Primary Care Committee. 24
Director Lead: Executive Medical Director Date Opened: 28 March 2019 CRR10a Assuring Committee: Digital and Information Governance Committee Date Last Reviewed: 12 March 2020 Risk: National Infrastructure and Products Target Risk Date: 28 December 2020 There is a risk that the national infrastructure, technical architecture and products are not fit for purpose and do not allow the organisation to deliver benefits when planned. This may be caused by a) a one size fits all approach. b) products which are not delivered as specified (e.g. time, functionality and quality). c) the approach of the National Programme to mandate/design systems rather than standards. d) poor resilience and a "lack of focus on routine maintenance". e) Supplier capacity leading to commitment or delivery delays. f) Historic pricing models that are difficult to influence / may not be equitable. This could result in negative impacts in several key areas including:- Patient outcomes. An inability to support the strategic direction of the Health Board. Delays to delivery of transformational change. Inefficient work flows, poor system usage. Increased costs as we maintain multiple systems / pay inequitable prices. Delays with the delivery of cost saving schemes. Impact Likelihood Score Initial Risk Rating 4 5 20 Current Risk Rating 4 5 20 Target Risk Score 4 3 12 Movement in Current Risk Rating since last presented No Change to Board in November 2019 Controls in place Further action to achieve target risk score 1. Scrutiny of NWIS by DIGC. 1. Viable SLA. 2. Project Governance. 2. Development and approval of local Digital Record. 3. Implementation of recommendation's (by NWIS) from Architecture and Governance Reviews. 25
Assurances Links to 1. Public Accounts Committee Review of NWIS. Strategic Goals Principal Special Measures 2. Assurance Reports from Informatics to DIGC / EMG. Risks Theme 3. WAO - review. 4. National Architecture and Informatics Governance Reviews. 7 PR6 Not Applicable 26
Director Lead: Executive Medical Director Date Opened: 28 March 2019 CRR10b Assuring Committee: Digital and Information Governance Committee Date Last Reviewed: 22 April 2020 Risk: Informatics - Patient Records pan BCU Target Risk Date: 1 April 2022 There is a risk that patient information is not available when and where required. This may be caused by a lack of suitable storage space, uncertain retention periods, and the logistical challenges with sharing and maintaining standards associated with the paper record. This could result in substandard care, patient harm and an inability to meet our legislative duties. Impact Likelihood Score Initial Risk Rating 4 4 16 Current Risk Rating 4 4 16 Target Risk Score 4 3 12 Movement in Current Risk Rating since last presented No Change to Board in November 2019 Controls in place Further action to achieve target risk score 1. Corporate and Health Records 1. Enable actions to meet the regulatory recommendations from the ICO, Management policies and procedures HASCAS/Ockenden and Internal Audit reports. UPDATE MARCH 2020 - Last ICO review are in place pan-BCUHB. was positive with good feedback on the progress to date. A full review of all outstanding regulatory recommendations across all regulators is planned for Q1 of 2020/21. 2. iFIT RFID casenote tracking 2. (Project) Development of a local Digital Health Records system to digitise the 'acute software and asset register in place to general' patient record. UPDATE MARCH 2020 - The OJEU tender is closed and the govern the management and evaluation findings will be ready to present to the DHR Steering Group for ratification of the movement of patient records. preferred supplier on 6th March. The work on the FBC will commence next week and the project remains on track to present to the F&P Committee end of April and then the Health 3. Escalation via appropriate Board in May. committee reporting. 27
4. Key performance indicators 3. (Project) Improve the assurance of Results Management (stop printing results). monitored at BCUHB Patient Records UPDATE MARCH 2020 - The project is making good progress under the SRO of the Group (reported into the Information Secondary Care Medical Director. Requirements in the WCP to action record (enable Governance Group). stopping printing) are planned for release v3.12 expected end July/August. Work is underway in partnership with NWIS to increase ETR (test requesting in WCP) by Sept 2020, with a new e-test requesting form being developed for Cytology/Histology. The NDR national project remains sighted as a priority to enabling access to our results data locally to feed an assurance report of results not viewed/actioned. 4. (Project) Digitise the clinic letters for outpatients through implementation of Digital Dictation, and as appropriate Speech Recognition software. UPDATE MARCH 2020 - The options appraisal was undertaken to appraise the subsequent ITT responses against the incumbent supplier, to evaluate the best approach for BCUHB and its patients, demonstrating value for money and minimising recurring revenue costs. The findings from the options appraisal concluded that the incumbent supplier is the preferred choice in both technical and commercial elements, with the best chance of mitigating the migration off the PIMS to WPAS at greater pace. Progress is with Procurement to advise on the extended contract. In the meantime the preparation for the upgrades to the product in use by the pilot users is underway. 5. (Project) Digitise nursing documentation through engaging in the WNCR - Adults National Nursing systems. UPDATE MARCH 2020 - The WNCR product has been through UAT and with all showstoppers addressed, enters pilot on one live ward 02/03/20 for 4 weeks. There are a number of enhancements to be addressed which will be reviewed again by NWIS alongside any pilot findings. A local business case will need to be written to consider the evaluation and any future roll out. 6. (Project) Baseline the; storage, processes, management arrangements and standards compliance, and present the recommendations and funding requirements to work towards PAN-BCUHB Patient Records Compliance with legislation and standards in patient records management across all casenote types. UPDATE MARCH 2020 - The Project Manager post funding has been secured and interviews planned for March. Records standards will be assessed pan-BCU against the new IG Toolkit to inform the ensuing recommendations. 28
7. Engage with the Estates Rationalisation Programme to secure the future of 'fit for purpose' file libraries for legacy paper records. UPDATE MARCH 2020 - In order to ensure the YGC File Library development is fit for purpose and value for money in the wider context of evolving estates and Service plans, a full review of need is being undertaken across all schemes and Service growth demands, with an update due at the next meeting of the YGC File Library Programme Board in April. Assurances Links to 1.Chairs reports from Patient Record Group. Strategic Goals Principal Risks Special Measures Theme 2.ICO Audit. 3.HASCAS Audit. 7 PR1 Not Applicable 29
Director Lead: Executive Medical Director Date Opened: 28 March 2019 CRR10c Assuring Committee: Digital and Information Governance Committee Date Last Reviewed: 22 April 2020 Risk: Informatics infrastructure capacity, resource and demand. Target Risk Date: 15 December 2021 There is a risk that digital services within the Health Board are not fit for purpose. This may be due to: (a) A lack of capacity and resource to deliver services / guide the organisation. (b) Increasing demand (internally from users e.g. for devices/ training and externally from the public, government and regulators e.g. growing need for digital services). (c) the moving pace of technology. This could lead to failures in clinical and management systems, and a failure to support the delivery of the Health boards strategy / plans impacting negatively on patient safety/outcomes. It may also pose a greater risk to the Health board of infrastructure failures and cyber attack. Impact Likelihood Score Initial Risk Rating 4 5 20 Current Risk Rating 4 4 16 Target Risk Score 4 3 12 Movement in Current Risk Rating since last No Change presented to Board in November 2019
Controls in place Further action to achieve target risk score 1. Governance structures in place to approve and monitor plans. 1. Develop associated business cases and secure funding for Monitoring of approved plans for 2019 2020 (Capital, IMTP and resource required based upon risks and opportunities e.g. Digital Operational. Approved and established process for reviewing Health Record. requests for services. 2. Review workforce plans and establish future proof 2. Integrated planning process and agreed timescales with BCU informatics/digital capab and third party suppliers. ility and capacity. 3. Key performance metrics to monitor service delivery and increasing demand. 30
4. Risk based approach to decision making e.g. Local hosting v's 3. Review governance arrangements e.g. DTG whose remit National hosting for WPAS etc. includes review of resource conflicts has not been replaced (April 2020). Assurances Links to 1. Annual Internal Audit Plan. 2. WAO reviews and reports e.g. structured Strategic Goals Principal Special assessments and data quality. 3. Scrutiny of Clinical Data Quality by Risks Measures CHKS. 4. Auditor General Report - Informatics Systems in NHS Wales. Theme 5. Regular reporting to DIGC (for Governance). 2 3 4 5 6 7 PR6 PR5 PR2 Not Applicable 31
Director Lead: Executive Director of Nursing and Midwifery Date Opened: 14 June 2018 CRR11a Assuring Committee: Finance and Performance Committee Date Last Reviewed: 22 April 2020 Risk: Unscheduled Care Access Target Risk Date: 31 December 2020 There is a risk that systematic harm may be caused to patients needing access to unscheduled care services due to failures to be able to respond to demand in accordance with expected national targets. This may be caused by mismatches between resources available across the unscheduled care system to demands placed on the system for prolonged periods of time or inappropriate allocation of resources available to meet the demand. This could lead to an impact/effect on patient experience and outcomes, organisational reputation, delivery of national targets and recognised standards of care. Impact Likelihood Score Initial Risk Rating 4 5 20 Current Risk Rating 4 5 20 Target Risk Score 4 2 8 Movement in Current Risk Rating since last No Change presented to Board in November 2019
Controls in place Further action to achieve target risk score 1. Multi-agency Unscheduled Care (USC) Transformation Board 1. 3 EC managers substantively recruited and engaged with refreshed to USC improvement group, chaired by the Executive building better care plans (was previously 90 day improvement Director of Nursing. plan). 2. Continued cycles of improvement with 3 specific work streams: 2. Building better care plan consisting of 3 streams of work: Demand, Flow and Discharge. a. Demand - SICAT established and demonstrating reduction 3. Program manager appointed to oversee production and in transfers to ED (~30% of calls - assumption that ALL calls implementation of action plans. previously would have resulted in transfer). 4. Daily National Conference Calls with WG to address daily b. Flow - Multiple substreams including: position. 32
5. Daily Safety Huddles in place on 3 acute sites. -ambulance handover - WMH lost improved with consistent 6. Daily BCU system calls to support flow between divisions. reduction in time taken for handover. 7. Daily Board rounds on acute sites to support continuity of care -proactive triage - promoting use of alternative resources and and early discharge planning. early decision-making to reduce time in ED (Overall average time 8. Weekly MDT stranded patient review meetings to identify in ED is reducing). reasons for lack of progress to facilitate more complex -early senior decision-making - recognition of senior medical discharges across the Health Economies. staffing issues especially at WMH - requiring workforce and 9. Development of USC dashboard with live and daily roster review. performance information to support decision making. -escalation and capacity management review - test of 'grip and 10. Weekly teleconference with DU to report performance and control' at YGC site de-escalated from sitrep 4 to 2 without concerns and track improvement plans. associated reduction in overall time in ED - further work on-going 11. Sitrep reporting 3 times a day including SAPhTE for ED risk to review process and pilot at other sites. assessment. -implementation of SAFER - ongoing - small increase in numbers 12. Mental Health support located within site Police Control. of earlier discharges. 13. Frequent attenders WEDFANs group regularly review -stranded & super-stranded patient review - to launch across vulnerable patients who frequently access services to support sites. implementation of care plans. -review of acute assessment/ambulatory models with pilots to be 14. Escalation process and structure in place to provide 24/7 launched later this month at YGC & WMH. escalation from site management through bronze, silver and -review of specialty reviews for inpatients - to enable earlier gold. discharge. 15. Development of internal clinical standards to highlight best -review of imaging pathways to support early outpatient scans practice and support teams to consider ways of working to and avoid longer inpatient stay. achieve standards. c. discharge planning - work continues to reduce delays in 16. Discharge information provided to patients on admission via transfers of care and decision-making. Letter shared re. patient new discharge leaflet. choice and working with staff to encourage proactive discussions 17. Use of SHINE tool to ensure that patient safety is monitored with families and patients. and intentional rounding complete for all patients including those 3. Review of site escalation and management to support site waiting for offload from ambulances. responsibility during normal working hours. 18. EDQDF early adopter site with focus on improving KPI's, patient feedback and experience and staff feedback and 33
experience as key pieces of work within this programme and 4. Associate Director for unscheduled care replaced with specific work to improve ambulance handover. programme manager with additional interim support at area level 19. Active engagement in Every Day Counts programme to to oversee progress against building better care plan. support key pathways of discharge. 5. Engagement with National ED Quality & delivery framework. 20. Remodelling of urgent care processes in place across all 3 6. Workforce review - supported by Kendall Bluck. sites. Assurances Links to 1. Seasonal Plan. 2. RTT Plan. 3. Twice Yearly JET meetings with WG. Strategic Goals Principal Risks Special 4. Monthly meetings with Delivery Unit. 5. National Patient Flow Measures Collaborative. 6. OOHs review (both National and Internal Audit). 7. Theme Subject specific internal audit reviews. 8. Orthopaedic Plan development. 1 2 3 6 7 PR3 Leadership 9.Transformation groups reporting. 10. WPAS implementation group reporting and daily tracking. 34
Director Lead: Executive Director of Nursing and Midwifery Date Opened: 14 June 2018 CRR11b Assuring Committee: Finance and Performance Committee Date Last Reviewed: 16 April 2020 Risk: Planned Care Access Target Risk Date: 31 July 2021 There is a risk that the BCUHB is not able to provide access to planned care in accordance with the national standards. This may result in not being able to meet the timely clinical needs and expectations of patients. BCUHB will need to provide assurance to partner organisations on the management of clinical safety and treatment of the backlog. This is caused by capacity shortfalls or mismatch between allocation of available capacity and demand including booking of patients in chronological order following clinical urgency, a lack of effective utilisation of resources, conflicting pressures (management of Unscheduled Care pressures and elective delivery), equipment failure and availability of suitable facilities, workforce issues. This could lead to adverse outcomes for patients, prolonged waiting periods, an inability to meet national targets (RTT, diagnostics, cancer, clinically due review time, and impact on the financial stability and the reputation of the Health Board. Impact Likelihood Score Initial Risk Rating 4 5 20 Current Risk Rating 4 5 20 Target Risk Score 4 2 8 Movement in Current Risk Rating since last No Change presented to Board in November 2019
Controls in place Further action to achieve target risk score 1. Weekly PTL and Daily waiting times information in place for RTT, diagnostics and 1. Developing Capacity plan for Cancer. 2020/21 ongoing, which includes 2. Performance team and trackers in Cancer utilising escalation processes with operational outpatients follow up, non-planned teams. care, diagnostics and Endoscopy. 35
3. Demand and Capacity plan agreed per specialty and site confirming extent of sustainable 2. Sustainable service plans for 5 service gap. specialties are being further 4. Weekly Access meeting extended to include RTT, Diagnostics and Cancer. developed for 2020/21 including 5. Interim Planned Care leadership in place responsible for leadership across the HB feedback from the national planned providing oversight of RTT. care programme (Orthopedics, 6. Leadership in place responsible Cancer, Endoscopy and Diagnostics remedial action Ophthalmology, Urology, Maxio facial plans. and General Surgery). 7. Weekly Performance management meetings at Hospital and Area Level. 3. Review Endoscopy management 8. Weekly outsourcing meeting in place. and governance structure. 9. Elective patient pathway and outpatient improvement cells in place with clear targets for 4. Matrix working and responsibilities efficiency improvement. of clinical and operational leaders to 10. Engaged with National Planned Care, National Outpatient and Cancer Implementation be confirmed to strengthen Groups. governance. 11. Single Cancer Pathway demand and capacity submission completed and shadow 5. Enhanced governance structure reporting to monthly to WG. and responsibilities are being put in 12. Elective and Seasonal plan assumes only daycase and urgent/cancer surgery is place for 2020/21. scheduled for winter 2019/20 to support unscheduled care capacity (except at Abergele). 6. Outpatient Programme Group 13. Implemented additional eye care resource to undertake measure reporting and activity. established and commencing in 14. Insourcing and outsourcing of Endoscopy being undertaken till March 2021. February 2020. 15. Additional contracts in place to maintain non-obstetric Ultrasound 8 week waits till March 2021. 16. Programme of work in place to reduce follow up backlog monitored via QSE. Assurances Links to 1. Seasonal Plan. 2. RTT Plan. 3. Twice Yearly JET meetings with WG. 4. Monthly Strategic Principal Special meetings with Delivery Unit. 5. National Patient Flow Collaborative. 6. OOHs review (both Goals Risks Measures National and Internal Audit). 7. Subject specific internal audit reviews. 8. Orthopaedic Plan Theme development. 9.Transformation groups reporting. 10. WPAS implementation group 1 2 3 6 7 PR3 Leadership reporting and daily tracking. 36
Director Lead: Executive Director of Planning and Performance Date Opened: 1 October 2015 CRR12 Assuring Committee: Finance and Performance Committee Date Last Reviewed: 22 April 2020 Risk: Estates and Environment Target Risk Date: 30 April 2023 There is a risk that the Health Board fails to provide a safe and compliant built environment. This may be due to insufficient financial investment and estates rationalisation. This could result in avoidable harm to patient, staff, public, reputational damage and litigation. Impact Likelihood Score Initial Risk Rating 4 5 20 Current Risk Rating 4 4 16 Target Risk Score 3 3 9 Movement in Current Risk Rating since last Increased presented to Board in November 2019
Controls in place Further action to achieve target risk score 1. Three Year Outlook 2020-2023 and 2020-21 Annual Plan - Living 1. Annually agreed programme of estates Healthier Staying Well in place and reporting to the Board and Committees. rationalisation and selective demolition (2019-20). 2. Three Year Outlook 2020-2023 and 2020-21 Annual Plan - Living 2. Annually agreed programme of Disc and All-Wales Healthier Staying Well - Sec 5.4 High Quality Estates and work programme capital investment across the Estate. priorities 2020-2023 in place and reporting to the Finance and Performance 3. Development of Estates Compliance PBC and SOC (F&P) Committee, Board and other appropriate Committees. for Ysbyty Wrexham Maelor, Ystyty Gwynedd and 3. Estates Strategy - 3 yr (2019 - 2022)in place and reporting to F&P Ysbyty Glam Clwyd Hospitals. Committee. 4. Undertake six facets condition survey of the 4. Annual Estates Performance Reporting (EFPMS) to QSG and QSE. Estates for Acute and Community premises to inform 5. Annual Capital Investment Programme 2019-20 Disc and All-Wales capital investment plans (2020/23). Projects ongoing with reporting to F&P Committee and the Board. 37
6. 2020-2023 - Annual Plan Work Programmes Deliverables for High Quality 5. Implement MICAD Property Management IT Estates (Investment schemes listed within plan)in place and reporting to System to manage estate data and drawings. (2020- appropriate Committees and the Board. 2023). 7. Estates Health and Safety Compliance Audit and Action Plans 2019-20 in 6. Implement actions required following Estates place and reporting to SOH&SG, QSE and the Board. Health and Safety Compliance Audit (2019/20) 8. Estates Improvement Group (EIG) established based on Health Economy including assessing additional revenue investment Groups processing Estate rationalisation and disposals, capital investment, required for 2020-21 budget setting process. corporate accommodation and review of Leased premises. Reporting to the 7. Update Estates and Facilities Tier 5-4-3 risk Finance Recovery Group (which reports to Executive Team), F&P and the registers to reflect current status of Estates and Board. Facilities risks and mitigation required. Assurances Links to 1. Independent authorising engineer appointments. 2. Internal Audit Strategic Principal Special Measures Programme. 3. HSE Statutory Reviews and Reports. 4. EFPMS Portal Goals Risks Theme Data used by WG for Annual All Wales Report. 5. Local Authority Trading 1 2 3 4 5 7 PR5 Strategic and Standing. 6. Food Safety Assessment. 7. Annual Reports (HSE, Fire, V&A Service Planning and sustainability). 38
Director Lead: Director of Mental Health and Learning Disabilities Date Opened: 1 October 2013 CRR13 Assuring Committee: Quality, Safety and Experience Committee Date Last Reviewed: 16 April 2020 Risk: Mental Health Services Target Risk Date: 31 March 2020 There is a risk that patients receive inappropriate care within Mental Health Services due to failings in leadership and governance within the Division which could result in poor quality outcomes for patients. Impact Likelihood Score Initial Risk Rating 4 5 20 Current Risk Rating 4 4 16 Target Risk Score 4 2 8 Movement in Current Risk Rating since last No Change presented to Between August 2018 and October 2019 a reduction in score was Board in unauthorised, this has been reverted to correct score. November 2019 Controls in place Further action to achieve target risk score 1. Board assurance provided at all levels of MHLD governance framework – local, 1. Review of Tier 7 & 8 in leadership divisional and directors, MHLD presents weekly at Corporate complaints and concerns structure underway. meeting, monthly at QSG, bi monthly to QSE, Board as required/requested and F&P. 2. Improve the use of patient 2. More focussed monitoring on progress at Board level agreed and implemented. experience and real time feedback 3. Achieved and implemented renewed focus and escalation arrangements for dealing with intelligence to inform service operational issues: weekly operations meeting in each area, daily safety huddles, weekly improvements. leadership review, MHLD QSG and MHLD F&P. 3. Further embed learning culture 4. Governance Framework developed and fully embedded – review of committee names across the division. being undertaken to ensure consistency with BCUHB framework. 39
5. Recommendations from Internal Audit Review (2019) implemented. 4. Systematic implementation of 6. Mental Health Strategy approved by the Board and now in implementation phase with Quality Improvement Methodology areas sustaining strategy change and new developments evidenced with new initiatives across the division at all levels. that are being modelled across MH services as good practice. 5. Implementation of actions following 7. Senior Management and Clinical Leadership is no longer a holding structure but skill mix review on inpatients wards to implemented with a permanent structure of leadership established, including to Tier 5 & 6. inform our future staffing levels linked 8. External reviews and visits including positive HIW inspections detailed to QSE and to the All Wales Staffing Principles. Board. 6. Delivery Unit have undertaken 9. MHLD provides Quality and Performance assurance to Executive accountability demand and capacity review with the meetings in two forms of scrutiny Community Mental Health Teams, i) Divisional presentation and which will inform BCUHB and Local ii) with each area health economy and is not in escalation as a result of current progress. Authority future plans for staffing. 10. Monitoring continues via SMIF. 7. Additional actions to address 11. Implementation of HASCAS investigation and wider governance review including Sickness across MHLD includes the completion of HASCAS recommendation specific to MHLD has been successfully development of Wellness strategy achieved. This is monitored through corporate governance processes and QSE developed for MHLD – wellness, work Committee. and you! 12. Ward accreditation embedded. 13. Improved scrutiny at local and divisional level in relation to PTR has resulted in improved KPIs across all of PTR. MHLD is the only division to have 0 complaints overdue. This is monitored via QSEEL. 14. Implementation of Listening Leads and BE PROUD OD Programme across the division with full engagement at Director level. Assurances Links to 1. Board and WG oversight as part of Special Measures. Strategic Principal Special Measures 2. External reviews and investigations commissioned (Ockenden and Goals Risks Theme HASCAS). 3. HIW Reviews. 1 2 3 4 5 6 7 PR1 Mental Health 4. Internal objective accreditation. 5. External Accreditation. 40
6. Delivery Unit oversight of CTP. 7. Caniad coproduction and objective day to day review of services. 8. Enhanced WG support has now concluded following intense scrutiny and input due to assurances provided by MHLD, including PAC report as submitted evidence. 41
Director Lead: Executive Director of Workforce and Organisational Development Date Opened: 1 October 2015 CRR14 Assuring Committee: Strategy, Partnerships and Population Health Committee Date Last Reviewed: 16 April 2020 Risk: Staff Engagement Target Risk Date: 31 December 2020 There is a risk that the Health Board does not maintain a culture which promotes excellence and engagement of staff in order to transform services. This may be caused by a disconnect between stated values and actual behaviours. This could lead to poor quality services, damage to the organisations reputation, long term sustainability and low levels of workforce satisfaction and well being. Impact Likelihood Score Initial Risk Rating 4 5 20 Current Risk Rating 4 2 8 Target Risk Score 4 2 8 Movement in Current Risk Rating since last No Change presented to Board in November 2019
Controls in place Further action to achieve target risk score 1. All the requirements of the Engagement Strategy 2016 have been met. All the 1. Implement HEIW talent management initiatives within the strategy have been mainstreamed into ongoing organisational framework to retain and develop staff at development work. Tiers 1-3. 2. Workforce & Organisational Development Strategy 2019-22 in place. 2. Develop Workforce Objectives 2020-21 3. Workforce Objectives 2019-20 to meet the Workforce Strategy in place and to continue to meet the Workforce Strategy. monitored through the Annual Plan Progress Monitoring mechanism. 3. Implement Pay Progression Policy to 4. Mechanism in place to measure staff engagement on a regular basis via the drive improvements in PADR. BeProud organisational survey. 5. Mechanism in place to measure team level staff engagement through the BeProud Pioneer programme. 42
6. NHS Wales Staff Survey Organisational Improvement Plan and Divisional Improvement Plans monitored through the Workforce Improvement Group. 7. Retention Improvement plan in place. 8. PADR Improvement plan in place. Assurances Links to 1. Board and WG monitoring as part special measures. 2. Staff survey Strategic Goals Principal Risks Special benchmarked across Wales. 3.Corporate Health Award. 4. Implmentation Measures Theme of I Want Great Care. 1 2 3 4 5 6 7 PR9 Engagement 43
Director Lead: Executive Director of Workforce and Organisational Development Date Opened: 1 October 2015 CRR15 Assuring Committee: Strategy, Partnerships and Population Health Committee Date Last Reviewed: 16 April 2020 Risk: Recruitment and Retention Target Risk Date: 31 December 2020 There is a risk that the Health Board will have difficulty recruiting and retaining high quality staff in certain areas. This may be due to UK shortages for certain staff groups and the rurality of certain areas of the health board. This could lead to poor patient experience and outcomes, low morale and well being and attendance of staff. Impact Likelihood Score Initial Risk Rating 4 5 20 Current Risk Rating 4 4 16 Target Risk Score 4 2 8 Movement in Current Risk Rating since last No Change presented to Board in November 2019
Controls in place Further action to achieve target risk score 1. Embedded Medical & Dental (M&D) recruitment panel that oversees the fast 1. Improve digital media marketing via social media tracking of medical vacancies from authorisation to offer accepted. This is the train work live north wales brand now has its having a positive effect on M&D vacancy rates and time to hire (TTH) . own facebook. 2. This also includes fast tracking the EC posts for hard to fill vacancies, reports 2. Identification of recruitment co-ordinators in each submitted to the Board. secondary care high vacancy areas. Continue with 3. WOD currently reviewing options to increase admin support for M&D student recruitment and promotion of nurse recruitment by placing adverts on Trac on behalf of the lead recruiters. This is vacancies to Manchester, Chester and anticipated to further reduce TTH KPIs by ensuring adverts are ready to go live Staffordshire Universities. as soon as EC has been approved. 3. Contribution to Medical Training Initiatives (MTI) 4. Promotion of the employment brand "Train Work Live North Wales" through Bapio Scheme. digital media and marketing through key publications such as RCN careers 4. Source recruitment marketing funding to support brochures, BMJ on line and hard copy. further digital marketing. Further work on 44
The Tender for international nursing recruitment is nearing completion; bidder recruitment pipelines such as trainees, graduates presentations took place in February with anticipated contract award in March. return to practice, cadet scheme and overseas First cohort of Nurses could be arriving in July 2020 with planned numbers of candidates. circa 25 per month. 5. Finalise and implement the all Wales approach 5.New calendar of recruitment events being organised for 2020. This will include to Student Streamlining Process which will ensure planning and attendance at local and national job fairs for nurses in particular. that the HB complies with the national agreed 6.Deeper analysis of the time to hire showing more specifically where the hot- process and manage the Bursary Schemes in spots and delays are in the process, leading to improvements. conjunction with NWSSP. Implemented a new process to review all posts to ensure that the BCUHB is 6. Finalise tendering process for an international compliant with the Welsh Language Standards - work led by the Workforce recruitment campaign to bring 200+ RN into BCU Information Systems Manager, compliance of existing process reported to the form overseas, this is due to complete in March Welsh Language Forum on a quarterly basis, and will be included in Annual 2021. Report for Welsh Language. 7. Implement a new process to embed Welsh 7. Identification of top 10 priority areas for nurse recruitment is in place, the Language Standards as part of the Establishment team are focusing on adverts out versus vacancies and then using enabling Control process. This will be achieved by techniques to improve the time to hire. reviewing the Portal, the aim is to enable the HB to Streamlined process for internal vacancies in place, which also allows a focus to report on all posts and triangulate data back to be placed on these. appointees in the HB. 8. Recruitment lead for BCUHB working with Corporate Nursing on a number of 8. Work is currently underway to review the Exit recruitment pipelines such as fast track of HCA band 4 to adult nurse course at Questionnaire process to encourage further Bangor University (2 year course will provide 12 nurses in 2020). feedback on our leavers. Positive changes to bursary system on degree nursing courses at Welsh 9. Further work to develop our retention strategy Universities will commit graduates to 2 years working in the Welsh NHS. being led by the Head of OD. 9. A focus on retention with appraisal compliance and mandatory training 10. Implement a return to practice campaign later in monitored. 2019 - although challenges raised in November 10. National KPI's Time to Hire focus on recruitment timescales monitoring both 2018 to Bangor University on lack of places for within BCUHB and NWSSP. BCU RTP nurses. Corporate Nursing taking 11.TRAC system in place which ensures standardised processes, this is forward. monitored through the Workforce Monthly Reports including time to hire which enables Managers, HR and the Board to understand on a monthly basis where 45
the recruitment difficulties are. Summary of monthly dashboard reported to F&P Committee Quarterly. 12.Implementation and promotion of flexible working: part time working, job share, compressed hours, annualised hours, flexi, career breaks, personalised annual leave etc. 13. Staff benefits such as cycle to work schemes and other non-pay benefits in place. 14. HR and Recruitment Team continue to promote best practice through times of organisational change, redeployment and secondments and through flexible working arrangements. 15. An agency cap for medical and dental staff in place, with tight controls in place to reduce agency expenditure. National reporting is conducted monthly, which will be reviewed regularly. 16. BCU HB contributes to the All-Wales Recruitment campaigns - 'train, work, live' brand. BCU Recruitment Team now has the SPOC which is promoted nationally and locally. Student nurse recruitment is the most successful pipeline and BCU have worked with WG/SSP to introduce a more robust method of recruiting our nurse graduates resulting in 130 nurses joining in September 2019 and a further 75 planned to join in March 2020.Resource implications Assurances Links to 1. Staff surveys. 2. WG reporting (e.g. sickness absence and long term Strategic Principal Risks Special Measures disciplinary cases). 3. NMC Royal College and Deanery Reviews and Goals Theme Reports. 4. Review of NWSSP recruitment timescales 1 2 3 4 5 6 7 PR4 Leadership 46
Director Lead: Executive Director of Nursing and Midwifery Date Opened: 19 May 2016 Assuring Committee: Quality, Safety and Experience Committee Date Last Reviewed: 16 April 2020 CRR16 Risk: A Failure To Discharge Statutory and Legislative Safeguarding Target Risk Date: 31 March 2020 Responsibilties There is a risk that the Health Board does not discharge its statutory and moral duties in respect of Safeguarding. This may be caused by a failure to develop and implement suitable and sufficient safeguarding arrangements, develop an engaged and educated workforce and provide sufficient resources to manage the undertaking. This could impact on those persons at risk of harm to whom BCUHB has a duty of care. Impact Likelihood Score Initial Risk Rating 4 5 20 Current Risk Rating 4 4 16 Target Risk Score 4 2 8 Movement in Current Risk Rating since last presented No Change to Board in November 2019 Controls in place Further action to achieve target risk score 1. A cycle of Business Planning meetings have been 1. The third and final phase of the review of all Safeguarding JDs will implemented within the Nursing and Midwifery Directorate which be submitted to A4C January 2020. scrutinises and reviews Level 1 and 2 Risks and is attended by 2. Vacant posts continue to be progressed through the establishment the Associate Director of Safeguarding. control approval process to maintain a fully funded Safeguarding 2. A refreshed Safeguarding Reporting Framework has been Team. implemented which sets out clear lines of accountability and is 3. Further structural activity is planned to ensure business continuity underpinned by a Cycle of Business. and stability within the Corporate Safeguarding Team. This includes the provision of a 7 day on call, flexible working service. This was incorporated into the Structure Report at QSG 10th January 2020. 47
3. A standardised data report on key areas including Adult at 4. In line with the HASCAS Recommendation / DO Recommendation Risk, Child at Risk and DoLS is submitted to Safeguarding 8, 6, 11 and 9. A Business Case is to be presented to the Finance Forums in order that data is scrutinised and risks identified. and performance Group. 4.Risk Management has been embedded into the processes of 5. The legal framework and organisational accountability for the Reporting Framework by being included as a standing item Deprivation of Liberty Safeguards [DoLS] continues to place on the Safeguarding Governance and Performance and increased demands upon the organisation. In addition DoLS will be Safeguarding Forum[s] Agendas. Issues of Significance reports replaced by the Liberty Protection Safeguards [LPS] in 2020/2021 require risks to be identified and reported on in terms of and will have a greater impact upon activity. The recent Supreme mitigating action. Court Judgement relating to 16/17 yr olds, came into force on the 5. The new Senior Management tier has been appointed to 26.9.19. A National Task and Finish Group and a BCU within the Safeguarding Structure. This will strengthen strategic implementation group is to be convened to support the review and oversight in key areas. identify the impact the new legislation will have on organisations. 6. A paper has been presented to QSG on the 10.1.20, in line 6. The programme of work to support the implementation of the with HASCAS / DO recommendation Numbers 8 and 6 and 11 Supreme Court Judgement and the increased activity is to be driven and 9. This is relating to the review and effectiveness of the by a Task & Finish Group as agreed by QSG and completed by Safeguarding structure and progress report relating to the DoLS 31.3.20 (see Risk 2548. 2017-2018 action plan. Key controls have been implemented by 7. A review of the DoLS structure and service provision is a priority increasing the number of DoLS Signatories, development of a activity for 2019-20 and a key requirement from HASCAS. An options Signatories Governance Framework and Specialist training. paper which sets out options for the DoLS Team will be presented to Bespoke DoLS Training and reporting of compliance and activity QSG in January 2020. See Risk 2548. at Safeguarding Forums in accordance with the Safeguarding 8. The appointment of a Named Doctor, Adult at Risk remains Reporting Framework has been put in place. See Risk 2548. outstanding however positive discussions have taken place with the 7. Bespoke training continues to be delivered to key high priority Office of the Executive Medical Director. The business case to be areas with responsibilities for 16/17 yr olds who may be / or presented at Finance and Performance Group is to include the experience a deprivation of their liberty as a result of a Supreme financial requirements to support the appointment of a Named Doctor Court Judgement 26.9.19. Adult at Risk and additional clinical support. 9. Fully engage with the Corporate Safeguarding Governance Audit and Deprivation of Liberty Safeguarding [DoLS] Audit, conducted by the NHS Wales Shared Services Partnership Audit and Assurance Service. Engage with any actions identified. 48
Assurances Links to 1. Strengthened Governance and Reporting arrangements. 2. Enhanced Strategic Goals Principal Risks Special Measures engagement with partner agencies. 3. Safe and effective data collection Theme and triangulation of organisational data to identify risk. 4. Improved 3 7 PR9 Governance compliance against recognised omissions relating to the review and development of Safeguarding policies and Training materials. 5. Regional Safeguarding Boards. 49
Director Lead: Executive Director of Planning and Performance Date Opened: 10 October 2016 CRR17 Assuring Committee: Strategy, Partnerships and Population Health Committee Date Last Reviewed: 16 April 2020 Risk: Development of IMTP (Integrated Medium Term Plan) Target Risk Date: 31 December 2020 There is a risk that the Health Board cannot deliver safe and sustainable services to the population of North Wales which may be because there is not an agreed plan for the next 3 years. This could lead to an inability to address and improve health and healthcare services. Impact Likelihood Score Initial Risk Rating 4 5 20 Current Risk Rating 4 5 20 Target Risk Score 4 2 8 Movement in Current Risk Rating since last No Change presented to Board in November 2019
Controls in place Further action to achieve target risk score 1. The timetable to develop the 2019/22 IMTP was discussed and agreed by SPPH 1. Revised Plan to SPPH Committee on 5th Committee on 9th August 2018. March 2020. 2. The Health Board approved approach for developing the 2019/22 IMTP on 6th 2. On 12th March, there will be a full board September 2018. workshop. The intention is to make the focus 3. Unscheduled Care - 90 day plan launched and measures and trajectories agreed of the day the plan, and associated aspects. for inclusion in the AOP for 2018/19. 3. Final version of the plan to the executive 4. Transformation fund proposals developed with RPB partners Proposals for team on 18th March 2020. Community Services, children, mental health and learning disabilities submitted to 4. Plan presented to Board on 26th March Welsh Government. 2020. 5. Workplan established to develop 2019/22 IMTP with 3 CEO sponsored workshops held on 4th October, 8th November and 13th December 2018. 50
6. Care closer to home service transformation plan and approach reviewed and re- profiled under the leadership of the Director of Primary and Community Services. 7. Board resolved to develop a 3 year plan for 2019/22 and WG notified. 8. Board received draft 2019/22 3 year plan in January 2019. 9. Planned care delivery group established in January 2019. Work programme under development including; RTT, diagnostics, cancer and outpatient plans, infrastructure/support, Strategic/tactical change - Acute hospital care programme schemes, Policy/national programmes - National delivery plans, Enablers - PMO turnaround schemes with a focus short term productivity and efficiency improvements and processes i.e. transactional rather than transformational. 10. Feedback from WG received around ensuring a clear work programme for 2019/20 to deliver improvements in RTT and Unscheduled care. 11. Three Year outlook and 2019/20 Annual plan presented to Board in March 2019. Plan approved with further work identified and agreed around elective care in the specialties set out on page 40 of the paper. 12. The Board received an updated plan in July 2019 and recommended that further work be undertaken led by F&P Committee to scrutinise underpinning planning profiles, specifically RTT, (including diagnostics), unscheduled care alongside the financial plan for 2019/20. 13. Completed profiles at BCU level and submitted to F&P Committee on 22nd August 2019. 14. Site and speciality core activity profiles developed. 15. Draft 2020/23 Cluster plans developed to feed into health economy plans. 16. Key deliverables for 2020/23 developed in September 2019. 17. Health economy planning arrangements established to support development of 2020/23 plan with linked support from corporate planning team. 18. 2020/23 Planning principles and timetable prepared and presented to EMG, F&P and SPPH Committees. Identified plan development actions to be implemented September - December. 51
19. Plan updates provided to SPPH Committee meetings and workshops from October. Following our financial review, our aim is to develop a refreshed Three Year Outlook for 2020/23 alongside a Work Programme for 2020/21 in the context of our statutory duty to produce a three-year IMTP. 20. Draft health economy plans for 2020/23 developed in November 2019 for initial review by Improvement Groups. 21. F&P Committee received on 19th December 2019 the draft Three Year Outlook and Annual Plan for 2020/21 (v.0.02)together with draft 2020/21 Work Programme incorporating North Wales wide actions and specific health Economy Actions. 22. Draft 2020/23 plan presented to Board in committee in January 2020. Principles to further inform strategy and plan development identified. The annual plan guidance for 2020/21 provided by WG was presented together with our local assessment of progress and where further work is required and the route map and timetable to complete the outstanding work, specifically around Planned Care and our Financial Plan.
Assurances Links to 1. Board and WG oversight as part of Special Measures. 2. Oversight of Strategic Principal Special Measures plan development through the SPPH Committee. 3. All Wales peer Goals Risks Theme review system in place. 4. Joint Services Planning Committee of 1 2 3 4 5 6 7 8 PR5 Strategic and Service Community Health Council.5. Regular links to advisory for a - LPF, SRG, Planning HPF. 52
Director Lead: Executive Director of Planning and Performance Date Opened: 19 December 2018 CRR18 Assuring Committee: Strategy, Partnerships and Population Health Committee Date Last Reviewed: 22 April 2020 Risk: EU Exit - Transition Arrangements Target Risk Date: 31 December 2020 There is a risk that the Health Board (HB) will fail to maintain a safe and effective healthcare service. This may be caused by a lack of clarity and understanding at UK level in respect of the impact of withdrawal from the European Union (EU), and a subsequent failure by the HB to develop robust withdrawal contingency plans. This could lead to a disruption of service delivery and thereby adversely impact on outcomes for patients in terms of safety and access to services. Impact Likelihood Score Initial Risk Rating 4 4 16 Current Risk Rating 4 3 12 Target Risk Score 4 1 4 Movement in Current Risk Rating since last No Change presented to Board in November 2019
Controls in place Further action to achieve target risk score 1. BCUHB Task & Finish Group established, currently paused. Following extension to date of exit to 31 Jan 2020 and progress 2. Potential risks and issues identified for no deal Brexit, will be of the Withdrawal Agreement Bill through parliament, planning further updated as implementation period progresses. and preparations have been stood down by WG until further 3. Participation with regional and national co-ordinating groups notice. The national leadership Group will continue to meet on a will re-commence as required. monthly basis but SRO meetings have been stood down. 4. Engagement with Executive Team will continue as required to ensure cascade of any necessary actions. Position will be reviewed by WG in July 2020 and response 5. Update briefings will continue to staff via Bulletin, and arrangements may be stood up if required, dependent on webpages will be updated, as the situation develops. evaluation of political situation; however, currently the risk of 6. Lower level risks entered onto Datix and linked to CRR18 will leaving on 31 January 2020 without the passing of the WAB is be updated as required. significantly reduced. 53
Assurances Links to 1. Reporting to Executive Team and SPPH Committee Strategic Goals Principal Special Measures 2. WAO audit of preparedness Risks Theme 3. WG oversight through national work streams 1 2 3 4 5 6 7 PR1 Not Applicable 54
Director Lead: Executive Director of Workforce and Organisational Date Opened: 2 July 2019 Development CRR20 Assuring Committee: Quality, Safety and Experience Committee Date Last Reviewed: 16 April 2020 Risk: Security Risk Target Risk Date: 1 November 2020 There is a risk the Health Board fails to ensure that a suitable systems are in place to protect staff, patients and stakeholders from security, violence and aggression incidents arising out of our work activity. This is due to lack of formal arrangements in place to protect premises and people in relation to CCTV, Security Contract issues (personnel), lone working, lock down systems, access control and training that provides assurance that Security is effectively managed. Impact Likelihood Score Initial Risk Rating 5 4 20 Current Risk Rating 5 4 20 Target Risk Score 5 2 10 Movement in Current Risk Rating since last presented No Change to Board in November 2019
Controls in place Further action to achieve target risk score 1) There is a system in place for a contractor (Samsun) to A systematic approach is required to both physical and people aspects manage the physical/people aspects of Security for the of the risks identified. This includes: organisation. 1. A complete review of CCTV and recording systems. 2) A V&A Case manager is in place to support individuals 2. Finalise and implement the CCTV Policy. who have been exposed to violence and aggression 3. Clear lines of communication with the contractor, review of the incidents. contract in relation to key holding responsibilities and reporting on 3) An external contractor is supporting the Head of H&S to activities to be implemented. review all aspects of Security across the Board. 4. Responsibilities of Security roles within BCUHB to be clearly defined. 55
4) An external Police Support Officer is in place part time to 5. Lone worker procedures and risk assessments further established. support the organisation and staff. 6. Reducing numbers of violence incidents to staff through clear markers and systems for monitoring violent patients. 7. Comprehensive review of Security on gaps in system which was provided to the Strategic OHS group. Assurances Links to 1. Health and Safety Leads Group Strategic Goals Principal Risks Special Measures Theme 2. Strategic Occupational Health and Safety Group 3. QSE 3 SM4 SM1 56
Director Lead: Executive Director of Workforce and Organisational Date Opened: 31 March 2016 Development CRR21 Assuring Committee: Quality, Safety and Experience Committee Date Last Reviewed: 16 April 2020 Risk: Health & Safety Leadership and Management Target Risk Date: 1 November 2020 There is a risk that the Health Board fails to achieve compliance with Health and Safety Legislation due to insufficient leadership and general management. This could have a negative impact on patient and staff safety, including organisational reputation and prosecution. Impact Likelihood Score Initial Risk Rating 5 4 20 Current Risk Rating 5 4 20 Target Risk Score 5 2 10 Movement in Current Risk Rating since last No Change presented to Board in November 2019 Controls in place Further action to achieve target risk score 1. Health and Safety risk assessment systems are in place in 1. Undertaken gap analysis of 31 pieces of legislation. Completed some service areas to protect staff, patients and others from within specified time frame (117 inspections in 7 weeks). hazards. 2. Action plan developed based on non compliance with legislation. 2. Health and Safety Management arrangements further 3. Develop a programme of intervention and training through TNA developed. Review. 3. Strategic Health and Safety Group in place meeting regularly 4. Identified RIDDOR reports and scrutiny of process, looking at (3 times in 3 months). improved RCA system. 4. Risk Assessments and safe systems of work in place. 5. 12 Month action plan developed and 3 year strategy, that is 5. Mandatory Training in place. owned by Divisions and Senior Leaders. 6. Clinical and Corporate Health and Safety Teams established. 57
7. Corporate Health and Safety Team established. 6. Further develop individual risk register for items of none. 8. Programme of Annual Self-Assessment Audits. compliance identified through gap analysis 8-10 specific items. 9. Gap analysis in place. 7. Review Divisional governance arrangements so that they marry 10. Health and Safety Walkabouts. with H&S governance system and reporting to Strategic OHS 11. Health and Safety Report to QSE and Board. Group. 12. Health and Safety Improvement Project Plan. 8. Implement findings of internal audit review of process of inspection and governance. Assurances Links to 1. Health and Safety Leads Group Strategic Goals Principal Risks Special Measures Theme 2. The Strategic Occupational Health and Safety Group 3. QSE 1 2 3 SM4 SM1 58
Director Lead: Executive Director of Nursing and Midwifery Date Opened: 11 November 2019 Assuring Committee: Quality, Safety and Experience Committee Date Last Reviewed: 09 March 2020 CRR22 Risk: Potential to compromise patient safety due to large backlog and Target Risk Date: 31 December 2020 lack of follow-up capacity. The is a risk that patient safety and experience may be comprised due to the Health Board's lack of follow-up capacity especially in outpatients specialities within Secondary across all three sites. This could lead to claims, poor patient experience, harm, reputational damage and deterioration in patient conditions who might have missed their 100% follow-up target. Impact Likelihood Score Initial Risk Rating 4 5 20 Current Risk Rating 4 5 20 Target Risk Score 4 2 8 Movement in Current Risk Rating since last No Change presented to Board in November 2019
Controls in place Further action to achieve target risk score 1. Ophthalmology and Cancer services have The current reported number of backlog patients who have exceeded their follow up been validated and patients who might have time by a 100% stands at 57,187 as of the end of December, of which 6,332 are come to harm due to missing their follow-up booked and 50,855 are un-booked. have been prioritised and seen in clinics. 1. Continue the work to date outlined in the previous action plan following the best 2. Monitoring of follow-up numbers at weekly practice methodology but support with the best practice methodology outlined above. meetings. 2. Focus on the highest risk specialities for the immediate implementation of harm 3. Tendering completed for an external reviews with agreed trajectories for reduction by: company to validate all follow-ups in OPD. - Urology 4. Close links with all services to ensure - Cardiology appropriate care planning for patients are in - General surgery place. - Ophthalmology 59
5. Strong clinical engagement and project 3. Work on the trajectory of 15% reduction of the backlog by March 2020 and monitor management support established. these on a weekly basis through the local PTL meeting. 6. Prioritisation of patients at clinical risk and 4. Establish a process that will allow the Health Board to contact all patients who are harm reviews being undertaken for all over 52 weeks and currently un-booked to establish if they still require an appointment patients who have missed their 100% follow- in the larger specialties. up. 5. Review any new patient breaching 52 weeks or over 100% beyond their follow-up appointment will have a harm review to prevent growth of the backlog. 6. Agree monitoring and governance arrangements. 7. Discussion on resourcing a sustained in-house validation team ongoing as procuring indepndent validation is expensive. Assurances Links to 1. Monitoring and governance arrangements for this risk in place. Strategic Principal Risks Special 2. Review of Ophthalmology and Cancer patients now completed. Goals Measures Theme 3. Risk is now regularly reviewed at QSE with potential of adding onto the CRR. 2 3 4 5 7 NA Strategic and Service Planning 60
Director Lead: Executive Director of Workforce and Organisational Date Opened: 7 January 2020 CRR23 Development Assuring Committee: Quality, Safety and Experience Committee Date Last Reviewed: 16 April 2020 Risk: Asbestos Management and Control Target Risk Date: 2 November 2020 There is a significant risk that BCUHB is none compliant with the Asbestos at Work Regulations 2012. This is due to the evidence that not all surveys have been completed and re-surveys are a copy of previous years surveys. There are actions outstanding in some areas from surveys. This may lead to the risk of contractors, staff and others being exposed to asbestos, resulting in death from mesothelioma or long term ill health conditions, claims, HSE enforcement action including fines, prosecution and reputation damage to BCUHB. Impact Likelihood Score Initial Risk Rating 5 4 20 Current Risk Rating 5 4 20 Target Risk Score 5 2 10 Movement in Current Risk Rating since last No Change presented to Board in November 2019
Controls in place Further action to achieve target risk score 1. Asbestos Policy in place and partially 1. Undertaking a re-survey of 10-15 premises to determine if the original surveys are implemented due to lack of complete valid. This is problematic as finances are not available for this work, increasing the risk of asbestos registers on all sites. exposure to staff and contractors. 2. A number of surveys undertaken, 2. Update and review the Asbestos Policy and Management Plan. quality not determined. 3. Review schematic drawings and process to be implemented to update plans from 3. Asbestos management plan in place. Safety Files etc. This will require investment in MiCad or other planning data system. 4. Asbestos register available on some 4. Ensure priority assessments are undertaken and highest risk escalated. sites, generally held centrally. 61
5. Targeted surveys were capital work is 5. Evaluate how contractors are provided with information and instruction on asbestos planned or decommissioning work within their work environment. Ensure work is monitored. undertaken. 6. Ensure all asbestos surveys are available at all sites and there is a lead allocated for 6. Training for operatives in Estates. premises. 7. Air monitoring undertaken in some 7. Annual asbestos surveys to be tracked and monitor for actions providing positive premises where there is limited clarity assurance of actions taken to mitigate risks. on asbestos condition. 8. Update intranet pages and raise awareness with staff who may be affected by asbestos. 9. QR Code identification to be provided on all areas of work with identified asbestos signage in non public areas. 10. Lack complete asbestos registers on all sites picked up in H&S Gap Analysis Action Plan. Assurances Links to 1. Health and Safety Leads Group Strategic Goals Principal Risks Special Measures Theme 2. Strategic Occupational Health and Safety Group 3. QSE 1 2 3 SM4 SM1 62
Director Lead: Executive Director of Workforce and Organisational Date Opened: 7 January 2020 Development CRR24 Assuring Committee: Quality, Safety and Experience Committee Date Last Reviewed: 16 April 2020 Risk: Contractor Management and Control Target Risk Date: 1 December 2020 There is a risk that BCUHB fails to achieve compliance with Health and Safety Legislation due to lack of control of contractors on sites. This may lead to exposure to substances hazardous to health, non compliance with permit to work systems and result in injury, death, loss including prosecution, fines and reputation damage. Impact Likelihood Score Initial Risk Rating 5 4 20 Current Risk Rating 5 4 20 Target Risk Score 5 2 10 Movement in Current Risk Rating since last No Change presented to Board in November 2019
Controls in place Further action to achieve target risk score 1. Control of contractors procedure in 1. Identify current guidance documents and ensure they are fit for purpose. place and partially implemented due to 2. Identify service Lead on each site to take responsibility for Contractors and H&S lack of consistency and standardisation. Management within H&S Policy). 2. Evaluation of standing orders and 3. Draft and implement a Control of Contractors Policy that all adhere to including IT and assessment under Construction Design other services who work on BCUHB premises. and Management Regulations. 4. Identify current tender process & evaluation of contractors, particularly for smaller 3. Induction provided to some contractors contracts consider Contractor Health and Safety Scheme on all contractors. This will but not all. Not all come through ensure minimum H&S are implemented and externally checked prior to coming top site. operational Estates such as IT. 5. Evaluate the current assessment of contractor requirements in respect of H&S, 4. There are a number of permit to work Insurance, competencies etc. Is the current system fit for purpose and robust? paper systems in place. 63
6. Identify the current system for signing in / out and/or monitoring of contractors whilst on site. Currently there is no robust system in place. Electronic system to be implemented such as SHE data base. 7. Identify level of Local Induction and who carry it out and to what standard. 8. Identify responsible person to review RA's and signs off Method Statements (RAMS), skills, knowledge and understanding to be competent to assess documents (Pathology, Radiology, IT etc.). 9. Identify the current Permit To Work processes to determine whether is it fit for purpose and implemented on a pan BCUHB basis. 10. Lack of consistency and standisation in implementation of contractor management procedure picked up in H&S Gap Analysis Action Plan. Assurances Links to 1.Health and Safety Leads Group Strategic Goals Principal Special Measures Theme 2.Strategic Occupational Health and Safety Group Risks 3.QSE 1 2 3 SM4 SM1 64
Director Lead: Executive Director of Workforce and Organisational Date Opened: 7 January 2020 Development CRR25 Assuring Committee: Quality, Safety and Experience Committee Date Last Reviewed: 16 April 2020 Risk: Legionella Management and Control. Target Risk Date: 30 November 2020 There is a significant risk that the BCUHB is non-compliant with COSHH Legislation (L8 Legionella Management Guidelines). This is caused by a lack of formal processes and systems to minimise the risk to staff, patients, visitors and General Public, from water- borne pathogens (such as Pseudomonas). This may ultimately lead death, ill health conditions in those who are particularly susceptible to such risks, and a breach of relevant Health & Safety Legislation. Impact Likelihood Score Initial Risk Rating 4 5 20 Current Risk Rating 5 4 20 Target Risk Score 5 2 10 Movement in Current Risk Rating since last presented No Change to Board in November 2019 Controls in place Further action to achieve target risk score 1. Legionella and Water Safety Policy in place 1. Update Corporate H&S Review template and H&S Self Assessment Template and being partially impemented due to lack of to ensure that actions are completed by all wards and Departments to ensure consistency and standardisation. systems are in place. 2. Risk assessment undertaken by clear water. 2. Ensure that engineering schematics are in place for all departments and kept 3. High risk engineering work completed in line up to date under Estates control. Implement MiCAD/database system to ensure with clearwater risk assessment. all schematics are up to date and deadlegs easily identified. 4. Bi-Annual risk assessment undertaken by 3. Departments to have information on all outlets and deadlegs, identification of clear water. high risk areas within their services to ensure they can be effectively managed. 65
5. Water samples taken and evaluated for 4. Departments to have a flushing and testing regime in place, defined in a legionella and pseudomonis. Standard Operating Procedure, with designated responsibilities and recording 6. Authorising Engineer water safety in place mechanism Ward Manager or site responsible person. who provides annual report. 5. Water quality testing results and flushing to be logged on single system and shared with or accessible by departments/services - potential for dashboard/logging system (Public Health Wales). 6. Standardised result tracking, escalation and notification procedure in place, with appropriate escalation route for exception reporting. 7. Awareness and training programme in place to ensure all staff aware? Departmental Induction Checklist. 8. BCUHB Policy and Procedure in place and ratified, along with any department- level templates for SOPs and check sheets. 9. Water Safety Group provides assurance that the Policy is being effectively implemented across all sites, this requires appropriate clinical and microbiology support to be effective. 10. Lack of consistency and standardisation in the implementation of the Legionella and Water Safety Policy picked up in the H&S Gap Analysis Action Plan. Assurances Links to 1. Health and Safety Leads Group Strategic Goals Principal Risks Special Measures Theme 2. Strategic Occupational Health and Safety Group 3. QSE 1 2 3 SM4 SM1 66
Director Lead: Executive Director of Workforce and Organisational Date Opened: 7 January 2020 Development CRR26 Assuring Committee: Quality, Safety and Experience Committee Date Last Reviewed: 16 April 2020 Risk: Non-Compliance of Fire Safety Systems Target Risk Date: 1 November 2020 There is a risk that the Health Board's is non-compliant with Fire Safety Procedures (in line with Regulatory Reform (Fire Safety Order 2005). This is caused by a lack of robust Fire Safety Governance in many service areas /infrastructure (such as compartmentation), a significant back-log of incomplete maintenance risks, lack of relevant operational Risks Assessments. This may lead to major Fire, breach in Legislation and ultimately prosecution against BCUHB. Impact Likelihood Score Initial Risk Rating 4 5 20 Current Risk Rating 4 5 20 Target Risk Score 4 2 8 Movement in Current Risk Rating since last No Change presented to Board in November 2019
Controls in place Further action to achieve target risk score 1. Fire risk assessments in place in a number of service areas. 1. BCUHB required to comply with all elements of the Fire 2. A number of areas have evacuations. Safety Order 2005. 3. There is a fire safety group established. 2. Review Internal Audit Fire findings and ensure all actions 4. There is a fire Policy in place. are taken. 5. The Fire Authority regularly inspect BCUHB premises and provide 3. Identify how actions identified in the site FRA are escalated reports on their findings which have action plans in place. to senior staff and effectively implemented. 6. Appointed fire engineer in place who oversees fire safety system 4. Identify how site specific fire information and training is in place. conducted and recorded. 7. Commission independent shared services audits. 5. Consider how bariatric evacuation training - is undertaken define current plans for evacuation and how this is achieved? 67
8. Information from unwanted fire alarms and actual fires is collated 6. How is evacuation training delivered / monitored? and reviewed as part of the fire risk assessment process. 7. How is fire safety advice provided to contractors, define when this happens? 8. AlbaMat training - is required in all service areas a specific training package is required with Fire and Manual Handling Team involved. 9. Ensure actions from the fire authority findings are escalated and actions completed reporting back to the Strategic OHS Group. Assurances Links to 1. Health and Safety Leads Group Strategic Principal Risks Special 2. Strategic Occupational Health and Safety Group Goals Measures 3. QSE Theme 1 2 3 SM4 SM1 68
Director Lead: Executive Director of Nursing and Midwifery Date Opened: 13 March 2020 Assuring Committee: Quality, Safety and Experience Committee Date Last Reviewed: 16 April 2020 CRR27 Strategic, Partnership and Population Health Committee Risk: Risk to public health and safety arising from an outbreak of COVID-19 Target Risk Date: 31 December 2020 and demand outstripping organisational capacity There is a risk to public health and safety from an outbreak of coronavirus (COVID-19) and this may impact on the ability of the Health Board to respond to this, arising from increased unscheduled demand on healthcare resources (including specialist resources and equipment) and a reduction in available resource to meet that demand such as workforce shortages arising from staff who are unwell or self-isolating. Impact Likelihood Score Initial Risk Rating 5 5 25 Current Risk Rating 5 4 20 Target Risk Score 5 1 5 Movement in Current Risk Rating since last presented to No Change Board in November 2019 Controls in place Further action to achieve target risk score Preventative controls: 1 - Ongoing real time management via Health 1 - Health Emergency Control Centre (HECC) activated 7 days per week supported Emergency Control Centre (HECC), local by local control centres control centres and work streams - each work 2 – Specialist work streams in place reporting to incident control team including stream as a PRAID log to track and clinical group management actions 3 – Emergency plans and business continuity plans 2 – Establishment of a recovery group and 4 – Access to specialist public health, clinical, operational and governance advice recovery plan 69
5 – Coordinated communication links with Welsh Government and Public Health Wales 6 – Public health messages including on social media and posters in hospitals 7 – Infection control measures in line with national guidance 8 – National guidance reviewed and cascaded - daily staff bulletin 9 – Advice for staff issued by Workforce and Organisational Development
Response controls: 1 - Health Emergency Control Centre (HECC) activated 7 days per week (extending hours as necessary) supported by local control centres 2 – Specialist work streams in place reporting to incident control team including clinical group 3 – Emergency plans and business continuity plans 4 – Access to specialist public health, clinical, operational and governance advice 5 – Coordinated communication links with Welsh Government and Public Health Wales 6 – Infection control measures in line with national guidance 7 – National guidance reviewed and cascaded - daily staff bulletin 8 – Self isolation measures for staff in line with national guidance 9 – Agreement to utilise temporary staffing off framework 10 – Non-essential activities stood-down i.e. corporate meetings 11 – Cancelling clinically appropriate non-urgent and elective activity 12 - Development of additional capacity and field hospitals 13 - Staff testing in line with national guidelines 14 - Additional staffing through retired staff returning and volunteers 15 - Public donations being coordinated through Awyr Las and checked for infection control and health and safety standards 16 – Multi agency co-ordination through SCG and TCG and Military Liaison Officer 17 - Establishment of daily PPE Taskforce led by Executive Director of Nursing and Midwifery/Deputy CEO 70
18 – Staff wellbeing support through BCU Staff Wellbeing & Support Service and national Health for Health Professionals Wales (HHPW)
Recovery controls: 1 – Establishment of a recovery group and recovery plan Assurances Links to 1. Command and contol structures (see COVID-19 Command Structure Strategic Goals Principal Risks Special Measures Framework) Theme 1 2 3 4 5 6 7 PR7 PR1 PR3 Not Applicable PR8 PR4 71
Director Lead: Executive Director of Nursing and Midwifery Date Opened: 8 April 2020 Assuring Committee: Quality and Safety Group Date Last Reviewed: 15 April 2020 CRR28 Risk: Risk of infection from COVID-19 to staff and patients as a result of Target Risk Date: 31 December 2020 inadequate supply, quality or usage of PPE There is a risk to patients and staff arising from the shortage of PPE supply (as a result of increased demand globally), the quality of PPE being less than needed (as a result of utilising alternative supply chains and manufacturers) and incorrect use by staff. It is also recognised that staff have anxieties about these issues and this may impact on their wellbeing, confidence and resilience. Impact Likelihood Score Initial Risk Rating 4 4 16 Current Risk Rating 4 3 12 Target Risk Score 4 1 4 Movement in Current Risk Rating since last presented to No Change Board in November 2019 Controls in place Further action to achieve target risk score 1. Daily PPE Taskforce led by Executive Director of Nursing and 1. Modelling tool to be developed detailing PPE requirements Midwifery against future predicated demand 2. Daily PPE Stock Report to HECC Silver and Gold Command 2. Flow of communication in regards to PPE to be simplified 3. PPE guidance to staff issued in line with national guidance 3. Development of an SOP for ordering, storage, distribution and from Public Health Wales monitoring of PPE 4. PPE guidance detailed in daily staff COVID bulletin 4. Telephone line to be established for staff to raise concerns 4. Expert advice to senior leaders and clinical leaders available from infection control team 5. Dedicated PPE email account for staff queries and concerns 6. Face fit testing programme in place 72
7. Donations of PPE received via Awyr Las and checked against infection control and health and safety standards Assurances Links to 1. Command and control structures (see COVID-19 Command Structure Strategic Principal Risks Special Measures Framework) Goals Theme 2. PPE Taskforce (daily meeting led by Executive Director of Nursing and Midwifery / Deputy CEO) 3 5 6 PR9 PR1 PR4 Not Applicable 3. Daily PPE Stock Report to HECC Silver and Gold Command 4. Regular review of risk by PPE Taskforce and governance meetings 10 20/54 Deddf Iechyd Meddwl 1983 fel y diwygiwyd gan Ddeddf Iechyd Meddwl 2007. Deddf Iechyd Meddwl 1983 Cyfarwyddiadau Clinigwyr Cymeradwy (Cymru) 2008. Diweddaru Cofrestr Meddygon Cymeradwy Adran 12(2) Meddygon i Gymru a Diweddaru Cofrestr Clinigwyr Cymeradwy (Cymru Gyfan) /Mental Health Act 1983 as amended by the Mental Health Act 2007. Mental Health Act 1983 Approved Clinician (Wales) Directions 2008. Update of Register of Section 12(2) Approved Doctors for Wales and Update of Register of Approved Clinicians (All Wales) - Mr Simon Dean 1 20.54 Section 12(2) doctors.docx
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Cyfarfod a dyddiad: Health Board Meeting and date: 14th May 2020 Cyhoeddus neu Breifat: Public Public or Private: Teitl yr Adroddiad Mental Health Act 1983 as amended by the Report Title: Mental Health Act 2007. Mental Health Act 1983 Approved Clinician (Wales) Directions 2018. Update of register of Section 12(2) Approved Doctors for Wales and Update of Register of Approved Clinicians (All Wales)
Cyfarwyddwr Cyfrifol: Dr David Fearnley, Executive Medical Director Responsible Director: Awdur yr Adroddiad Mrs Heulwen Hughes, All Wales Approval Report Author: Manager for Approved Clinicians and Section 12(2) Doctors
Craffu blaenorol: Dr David Fearnley Prior Scrutiny: Atodiadau Appendix 1: Mental Health Act 1983 as Appendices: amended by the Mental Health Act 2007Mental Health Act 1983 Approved Clinician (Wales) Directions. Update of Register of Approved Clinicians for Wales Appendix 2: Mental Health Act 1983 - Update of Register of Section 12(2) Approved Doctors for Wales
Argymhelliad / Recommendation: The Board is asked to ratify the attached list of additions and removals to the All Wales Register of Section 12(2) Doctors for Wales and the All Wales Register of Approved Clinicians. Please tick one as appropriate (note the Chair of the meeting will review and may determine the document should be viewed under a different category) Ar gyfer Ar gyfer Ar gyfer Er penderfyniad Trafodaeth sicrwydd gwybodaeth /cymeradwyaeth For Decision/ For For Assurance For Approval Discussion Information Sefyllfa / Situation: Betsi Cadwaladr University Health Board is responsible for the initial approval, re- approval, suspension and termination of approval of Approved Clinicians and Section 12(2) Doctors in Wales. 2
Cefndir / Background: The change introduced to the Mental Health Act 1983 was the abolishing of Responsible Medical Officers (RMOs) and Community Responsible Medical Officers (CRMOs) and the introduction of Approved/Responsible Clinicians (ACs and RCs) in their place.
The Minister for Health and Social Services agreed that as of the 3rd November 2008, Wrexham Local Health Board (LHB) would act as the Approval Body for Approved Clinicians and section 12(2) Doctors on behalf of the LHBs in Wales. The transfer of function from Wrexham Local Health Board to Betsi Cadwaladr University Health Board took place on 1st October 2009.
Asesiad / Assessment & Analysis
Strategy Implications
It is important to ensure the highest standards of governance for approving and re-approving practitioners who are granted these additional responsibilities, which apply when people are mentally disordered
Financial Implications
The Approvals Team receive a ring-fenced budget from Welsh Government to support the monitoring and approvals of Clinicians in Wales.
Risk Analysis
To ensure that all Clinicians are approved and reapproved within the agreed timescales, the All Wales Approval Panel assesses applications according to the Procedural Arrangements agreed with Welsh Government.
Legal and Compliance
The Approval Process meets the legislative requirements of the Mental Health Act 1983 (as amended 2007) and the Mental Health Act 1983 (Approved Clinicians)(Wales) Directions 2018
Impact Assessment
An impact assessment is considered unnecessary for this update paper. The Approval Process is part of the Legislative process 3
Update of Register of Approved Clinicians and Section 12 (2) Approved Doctors for Wales 5th March 2020 – 28 April 2020
AC S12 (2) Approvals and Re- 17 8 approvals Removed – Expired 1 1 Approvals suspended 0 0 Approvals re-instated – 1 0 returned to work in Wales Approval Ended 0 0 Retired 1 0 Removed – AC approved NA 2 No longer registered 0 1 Transferred from AC NA 0 register Approval Ended as no 0 0 longer working in Wales Registered without a 0 0 licence to practice APPENDIX 1 Mental Health Act 1983 as amended by the Mental Health Act 2007. Mental Health Act 1983 Approved Clinician (Wales) Directions Update of Register of Approved Clinicians for Wales 5th March 2020 – 28 April 2020 Approvals and re-approvals – 17 Surname First Name Workplace Expiry Date Lawrence Mary Hamadryad CMHT, Hamadryad Road, Butetown, Cardiff CF10 5UY 05 March 2025 Owen Elin Ty Penfro, 67A Pembroke Road, Canton, Cardiff CF5 1QQ 08 March 2025 Ubawuchi Christopher Nant y Glyn Resource Centre, 10 Nant y Glyn Road, Colwyn Bay LL29 7PU: 29 January 2021 Ablett Unit, Ysbyty Glan Clwyd, Rhuddlan Road, Bodelwyddan, Rhyl LL18 5UJ Baker Sylvia Tonteg Hospital, Church Road, Church Village, Pontypridd CF38 1HE 12 March 2025 Hassan Ahmed Mugab Delfryn House, Argoed Hall Lane, Mold, Flintshire CH7 6FQ 16 March 2025 Abdelrahman Manjunatha Harsha Hergest Unit, Ysbyty Gwynedd, Penrhosgarnedd, Bangor LL57 2PW 24 March 2025 Gutting Petra Hergest Unit, Ysbyty Gwynedd, Penrhosgarnedd, Bangor LL57 2PW 30 March 2025 Jones Martin Peter CMHT, Pwll Glas Resource Centre, Pwll Glas Road, Mold, Flintshire CH7 1RA 31 March 2025 Devakumar Azeeza Glan Traeth Day Hospital, 2 Alexandra Road, Rhyl, Denbighshire LL18 3AS 02 April 2025 Van Diepen Erik Hergest Unit, Ysbyty Gwynedd, Penrhosgarnedd, Bangor, Gwynedd LL57 18 November 2021 2PW Mulligan Caroline Ty Llywelyn, Bryn y Neuadd, Aber Road, Llanfairfechan LL33 0HH 02 March 2022 Foster Sarah Frances Fan Gorau, Montgomery County Infirmary, Llanfair Road, Newton SY16 2DW 13 April 2025 Obeid Tarig Glan Traeth Day Hospital, Alexandra Road, Rhyl, Denbighshire LL18 9EA 13 April 2025 Surname First Name Workplace Expiry Date Khan Akhtar Brocerwyn Centre, St Caradog Ward, Fishguard Road, Haverfordwest, 13 April 2025 Mamoud Pembrokeshire SA61 2PZ Muthuvelu Premraj Hafod, Beechwood Road, Rhyl, Denbighshire LL18 3EU 15 April 2025 Kotwal Chandan Cefni Hospital, 59 Bridge Street, Llangefni, Anglesey LL77 7PP 24 September 2023 Saeed Rugiyya Llanfair Unit, University Hospital Llandough, Penlan Road, Penarth CF64 2XX 17 July 2020
Approvals re-instated – 1 Surname First Name Workplace Expiry Date
Islam Rezaul Barry Hospital, Colcot Road, Barry CF62 8YH 31 May 2023
Approvals expired – 0 Surname First Name Workplace Expiry Date
Approvals Suspended – 0 Surname First Name Workplace Expiry Date
Retired – 1 Surname First Name Workplace Expiry Date
Halford Peter David Neath Port Talbot Child & Family Clinic, Children's Centre, Neath Port Talbot 24 March 2020 Hospital, Baglan Way, Port Talbot SA12 7BX
No longer Registered - 0 Surname First Name Expr1004 Expiry Date
No longer working in Wales – 0 Surname First Name Expr1004 Expiry Date
Approvals Ended – 0 Surname First Name Workplace Expiry Date
APPENDIX 2 Mental Health Act 1983 Update of Register of Section 12(2) Approved Doctors for Wales 5th March 2020 – 28 April 2020 Approvals and Re-approvals – 8 Date Approval Surname First Name Workplace Expires Pooley Owen John Meddyfga Penbryn, Dwyran, Llanfairpwll 10 March 2025 Kavisekara Manjula Zone R, Old Person Mental Health Department, Princess of Wales Hospital, 11 March 2025 Bridgend Ap Ieuan Endaf Y Ganolfan Iechyd, Ffordd Penmynydd, Llanfairpwll, Ynys Mon LL61 5YZ 18 March 2025 Curran Catherine Private Address 19 March 2025 Davies-Kabir Megan Ty Bryn, St Cadocs Hospital, Caerleon NP18 3XQ 19 March 2025 Eyre Olga Tonteg Child and Family Clinic, Church Road, Tonteg, Pontypridd CF38 1HE 23 March 2025 Annear Delia Park Road Wellbeing Centre, Park Road, Pontypool, Torfaen NP4 6NZ 03 April 2025 Udo Daniel Ogechi Felindre Ward, Bronllys Hospital, Brecon, Powys LD3 0LU 13 April 2025
Removed – Expired – 1 Date Approval Surname First Name Workplace Expires
Cooper Miriam Kier Hardie Health Park, Aberdare Road, Merthyr Tydfil CF48 1BZ 06 April 2020
Removed – AC approved – 2 Date Approval Surname First Name Workplace Expires Khan Akhtar Mamoud Trehafod/Cefrn Coed Hospital, Waunarlwydd Road, Swansea SA2 0GB 15 July 2020 Saeed Ruggiyya University Hospital Llandough, Penlan Road, Llandough, Penarth CF64 2XX 07 August 2022
No longer registered – 0 Date Approval Surname First Name Workplace Expires
Transferred from AC Register – 0
Surname First Name Date Approval Expires Workplace
No longer working in Wales – 0 Date Approval Surname First Name Workplace Expires
No longer registered – 1 Date Approval Surname First Name Workplace Expires
Linden David Edward Dept of Psychological Medicine, Cardiff University, Sir Henry Wellcome 17 December 2020 Building Heath Park, Cardiff CF14 4XN
Removed – Retired – 0 Date Approval Surname First Name Workplace Expires