Betsi Cadwaladr University Health Board - Annual Report 2018/19 1 The Annual Report and Accounts are part of the Health Board’s public annual reporting and set out our service delivery, environmental and financial performance for the year and describe our management and governance arrangements. The Annual Governance Statement, which is provided as an Appendix to this document, forms part of the Accountability Report section of this Annual Report, and provides a detailed report on our governance, arrangements for managing risk and systems of internal control. The Annual Quality Statement, published separately, provides information on the quality of care across our services and illustrates the improvements and developments we have taken forward over the last year to continuously improve the quality of the care we provide. Copies of all these documents can be downloaded from the Health Board’s website at www.wales.nhs.uk/sitesplus/861/page/40903 or are available on application to the Health Board’s Communications Team at BCUHB, Block 5, Carlton Court, St Asaph Business Park, St Asaph, LL17 0JG, by telephone on 01248 384776 or by e-mail to [email protected]. 2 “To improve health and provide excellent care” Contents Chairman's Foreword .................................................................................................................. 6 PART ONE - PERFORMANCE REPORT Overview ................................................................................................................................. 8 Chief Executive’s Statement ............................................................................................... 8 Our purpose and activities ................................................................................................ 10 Planning framework .......................................................................................................... 12 Key issues & risks affecting delivery of objectives ............................................................ 13 Performance Analysis .......................................................................................................... 14 Summary........................................................................................................................... 14 Staying healthy ................................................................................................................. 15 Immunisation .............................................................................................................................................. 15 Smoking cessation ..................................................................................................................................... 16 Safe care........................................................................................................................... 17 Infection prevention .................................................................................................................................... 18 Antimicrobial prescribing ............................................................................................................................ 18 Welsh Government reportable serious incidents ....................................................................................... 19 Never events .............................................................................................................................................. 19 Dignified care .................................................................................................................... 20 Procedures postponed at short notice ....................................................................................................... 20 Caring for people with dementia ................................................................................................................ 21 Effective care .................................................................................................................... 22 Delayed transfers of care ........................................................................................................................... 23 Mortality ..................................................................................................................................................... 23 Timely care ....................................................................................................................... 24 Referral to Treatment ................................................................................................................................. 25 Emergency Department ............................................................................................................................. 26 Diagnostics ................................................................................................................................................ 27 Cancer diagnosis and treatment ................................................................................................................ 28 Stroke care ................................................................................................................................................. 28 Mental health assessments and interventions ........................................................................................... 30 Individual care ................................................................................................................... 32 Care Treatment Plans ................................................................................................................................ 32 Staff and resources ........................................................................................................... 33 Our productivity .......................................................................................................................................... 33 DNAs (“Did Not Attend”) ............................................................................................................................ 34 Our staff ..................................................................................................................................................... 34 Our activity ........................................................................................................................ 36 Well-being of Future Generations (Wales) Act .................................................................. 37 Sustainability Report ........................................................................................................... 41 Partnership Working .................................................................................................................................. 42 ISO14001:2015 Environmental Management System .............................................................................. 42 Environmental and Waste Training ............................................................................................................ 43 Corporate Environmental Objectives Programme ..................................................................................... 43 Waste Management ................................................................................................................................... 45 Energy & carbon management .................................................................................................................. 46 Transport .................................................................................................................................................... 48 Sustainable procurement ........................................................................................................................... 48 Sustainable construction ............................................................................................................................ 49 Biodiversity & natural environment ............................................................................................................ 50 Summary of performance – utility resource use and waste ....................................................................... 51 Long Term Expenditure Trends .......................................................................................... 56 Annual Quality Statement .................................................................................................... 56 Betsi Cadwaladr University Health Board - Annual Report 2018/19 3 PART TWO - ACCOUNTABILITY REPORT Corporate Governance Report ............................................................................................ 57 Directors’ Report ............................................................................................................... 57 The Board .................................................................................................................................................. 57 Audit Committee ........................................................................................................................................ 57 Register of directors’ interests ................................................................................................................... 58 Data security .............................................................................................................................................. 60 Compliance with cost allocation requirements .........................................................................................