Cwm Taf Cares · 1 | Page Cwm Taf University Health Board Three Year Integrated Plan 201 Cwm Taf...

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Cwm Taf University Health Board

Three Year Integrated Plan

201

Cwm Taf Cares

(For submission to WG on 31 March



2015/16 – 2017/18

Cwm Taf Cares

Final Draft submission to WG on 31 March 2015)

31 March 2015



Cwm Taf Cares

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CONTENTS

1. EXECUTIVE SUMMARY 10

2. PROGRESS IN DELIVERING OUR PLAN

2.1 Our Quality and Performance Trajectories 2.2 Progress in Implementing our Cross Cutting Themes 2.3 Overview of Other Progress made

14 14 17 18

3. HEALTH BOARD PROFILE 22

3.1 Introduction 3.2 Overview 3.3 Service Provided 3.4 Quality & Patient Experience 3.5 University Health Status, Teaching, Research &

Innovation 3.6 Workforce 3.7 Performance 3.8 Financial Overview 3.9 Partnership Working and Co-Production

22 22 24 32 34 38 39 42 43

4. LOCAL POPULATION NEEDS AND CHALLENGES 46

4.1 Population Demography 4.2 Cwm Taf Population Projections 4.3 Deprivation 4.4 Health Inequalities 4.5 Cause of Premature Mortality 4.6 Lifestyle & Health 4.7 Ageing Population & Dementia 4.8 Focus on Outcomes

4.8.1 Smoking 4.8.2 Immunisation 4.8.3 Obesity 4.8.4 Alcohol 4.8.5 Conceptions

47 48 49 50 54 55 58 59 60 61 62 65 66

5. STRATEGIC CONTEXT 69

5.1 Our Journey 5.2 Priorities 5.3 Key Messages

69 69 70

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5.4 Clinical Strategy 5.5 Prudent Healthcare 5.6 Performance and Information

5.6.1 Integrated Quality and Performance Dashboard

5.6.2 Importance of Data Quality 5.6.3 Health Records and Clinical Coding 5.6.4 Profiled Performance 5.6.5 Demand and Capacity Profiles

71 78 79 79 80 81 82 86

5.7 Integration and Partnership 5.7.1 Why Partnership working and what will it

achieve? 5.7.2 Service Integration 5.7.3 Partnership Priorities for 2015/16 5.7.4 Staff Partnership 5.7.5 Citizen Engagement 5.7.6 Single Integrated Plan 5.7.7 Third Sector 5.7.8 Cwm Taf Health & Social Care Economy 5.7.9 Communities First 5.7.10 Housing 5.7.11 Carers 5.7.12 Volunteers 5.7.13 Corporate Social Responsibility 5.7.14 Work Experience

90 90 91 94 95 97 100 102 102 103 103 104 104 105 106

5.8 Integrated Assessment Process 5.9 Equality & Diversity 5.10 Bilingual Skills Strategy 5.11 Ensuring Integration with our Partners’ Plans

5.11.1 Velindre NHS Trust 5.11.2 NHS Wales Shared Services Partnership 5.11.3 Public Health Wales 5.11.4 Welsh Health Specialised Services

Committee 5.11.5 Emergency Ambulance Services

Commissioner and Welsh Ambulance Services Trust

107 107 108 109 109 110 110 111 111

6. QUALITY ASSURANCE AND IMPROVEMENT 113

6.1 Our Aim 6.2 Quality Assurance

6.2.1 Actions Identified 6.2.2 New Priorities

6.3 Patient Experience

113 114 115 115 118

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6.3.1 Listening to Feedback from Patients 6.3.2 Executive Walk Rounds

119 120

6.4 Quality Improvement 6.5 Quality Indicators

6.5.1 Delivery of Safe Care 6.5.2 Delivery of Effective Care 6.5.3 Achieving Excellent Patient Experience 6.5.4 Achieving Excellent Staff Experience 6.5.5 Measuring Improvement

6.6 Quality Triggers 6.6.1 Mortality Review 6.6.2 Learning from Coroner Inquests 6.6.3 Healthcare Associated Infections 6.6.4 Reported Patient Safety Incidents 6.6.5 Formal Complaints 6.6.6 Patient Experience Feedback 6.6.7 Safeguarding

6.7 Priorities 6.8 Openness and Transparency

120 121 121 121 122 122 122 123 124 125 125 126 127 128 129 129 131

7. SERVICE CHANGE PLANS AND PRUDENT

HEALTHCARE

132

7.1 Prevention

7.2 Chronic Conditions 7.2.1 Self Care 7.2.2 Pain Management 7.2.3 Diabetes 7.2.4 Heart Disease 7.2.5 Respiratory Disease

135 144 145 148 149 153 156

7.3 Adult Mental Health 7.4 Child and Adolescent Mental Health 7.5 Drug and Alcohol Services 7.6 Learning Disabilities 7.7 Oral Health 7.8 Family Services 7.9 Frail Elderly 7.10 Urgent & Emergency Care 7.11 Cancer 7.12 Stroke 7.13 End of Life Care 7.14 Liver Disease 7.15 Eye Care 7.16 Organ Donation 7.17 Rare Diseases 7.18 Neurological Conditions

158 161 164 167 169 171 173 176 180 183 185 187 187 189 189 190

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7.19 Accessible Healthcare 7.20 Medicines Management 7.21 Primary and Community Care

191 192 196

7.22 Secondary Care 7.22.1 South Wales Programme: The Outcomes 7.22.2 Planned Care 7.22.3 Critical Care 7.22.4 Clinical and Non-Clinical Support Services

214 214 225 230 233

7.23 Commissioning 7.23.1 Specialist Services

237 243

8. WORKFORCE & ORGANISATIONAL DEVELOPMENT 249

8.1 Workforce Profile 8.2 Key Workforce Assumptions 8.3 Key Workforce Challenges 8.4 Workforce Savings

8.4.1 Projected 3-Year Changes 8.5 Rebalancing the Workforce

8.5.1 Workforce Redesign to Support Service Change

8.5.2 Maximising Workforce Efficiency 8.5.3 Reducing the Workforce

8.6 Organisational Development

249 254 254 257 257 258 259 269 280 286

9. FINANCE 290

9.1 Overview of Financial Plan 9.2 Quality and Safety 9.3 Update on Financial Performance in 2014/2015 9.4 Summary of the Financial Plan for 2015/2016 to

2017/2018 9.5 Allocation Changes and Other Income Changes 9.6 Inflationary, Service Demand and Cost Pressures 9.7 Investment in Change, New Service and Delivery

Models 9.8 Medium Term Savings Plan 2015/2016 to 2017/2018 9.9 Balance Sheet and Cash Flow 9.10 Key Risks to the 3 Year Financial Plan 2015/16 9.11 Key Risks to the Financial Plan in Years 2 and 3

290 291 291 292 294 296 301 306 314 315 318

10. ENABLERS 320

10.1 Information, Communications and Technology 320

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10.2 Capital and Estates 10.2.1 Estates 10.2.2 Capital

323 323 325

11. DELIVERY, STEWARDSHIP & GOVERNANCE 329

11.1 Planning Approach 11.2 Delivery Model

11.2.1 Benchmarking 11.2.2. Opportunities for Improvement 11.2.3. Cross Cutting Themes 11.2.4. Governance for Delivery

11.3 Corporate Governance 11.4 Principal Risks to Delivery and Mitigating Actions

329 332 333 333 334 335 337 343

12. SUPPLEMENTARY ANNEXES


A.1 Integrated Performance Dashboard – ‘At a Glance’ A.2 Service Delivery Plan Summary A.3 Demand & Capacity Plans A.4 Local Primary & Community Care Projects By Cluster Area A.5 Engagement Plan A.6 Key Organisational Risks Welsh Government

C1

Outcomes Framework - Delivery of Measures

C2 Bed Capacity C3 Outpatient RTT C4 IPDC RTT C5 Direct Access Diagnostics C6 Service Change C7 Finance - Plan Summary+ C8 Finance – Resource Planning Assumptions C9 Finance – Statement of Comprehensive Net Income/Expenditure – 3 yrs

C10 Finance – Statement of Comprehensive Net Income/Expenditure – Profiles

C11 Finance – Revenue Resource Limit Assumptions C12 Income and Expenditure Assumptions (Wales NHS) C13 Finance – Year 1 Savings Plan C14 Finance – Years 2 & 3 Savings Plan C15 Finance – Risks and Mitigating actions C16 Contracted WTE & Correlation

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C17 Asset Investment Summary C18 Asset Investment Detail C19 Revenue Funded Infrastructure C20 Workforce - WTE C21 Workforce - £ C22 Workforce - Recruitment Difficulties Summary C23 Educational Commissioning information

Supplementary Sheets

C24 Delivery - Finance C25 Delivery - Workforce

C26 Workforce - Contracted WTE

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Message from the Chair and Chief Executive

Allison Williams Dr Christopher Jones CBE Chief Executive Chairman

We are very pleased to introduce the Cwm Taf University Health Board three year integrated plan for the period 2015 - 2018. The plan continues to build upon our achievements of the last year and outlines the opportunities and challenges ahead. Our maturity in the planning process, demonstrated by Welsh Government’s decision to approve our plan last year, recognises the extent of our related work to continue to strengthen our planning processes. We continue to learn from the process and apply that learning to develop and strengthen our plan going forward. We are confident that our Plan puts the University Health Board in a strong position ensuring local services are safe and effective and are organised to deliver the best possible outcomes for our patients.

Quality and safety continues to underpin our system of integrated planning. Within the context of a community that experiences significant challenges in terms of deprivation and the burden of ill-health, the focus is clearly on quality of delivery, improved patient experiences, ensuring optimal access to services, and equity of resources.

Delivering a strengthened primary care service, taking forward the outcomes of the South Wales Programme in partnership with other Health Boards, and an overarching focus on the reduction of health inequalities remains key areas of focus within the plan. We recognise the significant challenges in delivering the transformative change set out in this plan. In particular, ensuring we respond effectively to the opportunity of more integrated care, that we reduce the variation in the quality of primary and community care, and that we remain well placed to adapt to an evolving, changing healthcare environment.

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A key strength of Cwm Taf is the ability to work together with our communities and partner agencies to deliver a whole-system approach to public service delivery. This underlying philosophy values individuals, builds upon their own support systems and considers their place in the wider community. We value and recognise the importance of our partnership working with service users, carers and the wider public to involve them meaningfully both in decisions about individual treatment and care as well as engagement and consultation about service changes.

Our workforce is clearly our most significant asset and we recognise that to meet the challenges in our Plan, we need to ensure our staff and Primary Care contractors are fully engaged to embrace the principles of Working Differently Working Together. The success of any plan is in its implementation and we are committed to fully engaging our staff on the way that we implement our Plan and ensure our workforce is supported through these changes, working closely together and in partnership with our staff representatives including our Working in Partnership Forum.

The plan outlines many challenges in the coming years these include, growth in our population need, increased costs and significant resource constraints. The lifespan of this plan will be particularly challenging with further real terms reductions in resource allocations, along with significant clinical service redesign over this period. In financial terms the plan assumes £43.2m of re-design and efficiency savings over 3 years (9.3% of controllable expenditure) plus £5.1m of non-recurring savings in 2015/16.

Our focus in the plan is making most effective use of all the resources available to the University Health Board, as opposed to focusing only on agreed financial savings targets. Whilst the healthcare needs of our local population and the quality and safety of patient care remains our number one priority, the University Health Board understands and is committed to radically redesigning both systems and services in order to ensure that the best value is achieved from its resources.

We are determined that by implementing our transformation programme and by working closely with our partners that we will maximise the resources available to us to ensure that we can continue to deliver safe and effective services to the population of Merthyr Tydfil and Rhondda Cynon Taff. Working together remains important to us and is essential if we are to make our vision a reality.

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1. EXECUTIVE SUMMARY

We are pleased to present our refreshed Three Year Plan (hereafter known as ‘the Plan’) for Cwm Taf University Health Board, for the period 2015/16 to 2017/18. This Plan builds upon our last Board and Welsh Government approved Plan for the period 2014/25 to 2016/17 and updates it for the forthcoming three year period.

The integrated planning process is a central tenet of the way in which we do business in Cwm Taf, clearly linked with our ‘Cwm Taf Cares’ philosophy which sets the patient and the delivery of quality services at the heart of all we do.

The Plan has been developed as part of a ‘bottom-up’ planning process, building upon our Directorate, Locality, Corporate Department and Cross-Cutting Theme plans. It integrates our service, workforce and financial plans and makes explicit links with the performance and quality improvements we intend to achieve over the coming three year period.

The Plan is an opportunity to both reflect upon the achievements of the last year and the opportunities and challenges ahead. The past twelve months have seen scrutiny and significant service and financial challenges in the NHS in Wales, much of it on an unprecedented scale.

The challenge facing us in the future is set out in terms of balancing our population needs, with providing safe and high quality services and together with us needing to respond to a challenging financial agenda.

The challenge for us in leadership positions in the Health Board is to create a culture and a plan which we can deliver for the benefit of our population, where compassionate care can flourish and where all staff feel cared for, no matter what challenges we face with budgets and targets. As it is for all healthcare organisations across the UK, developing a Plan which meets our objectives of maintaining and improving quality and safety, while achieving cost reductions of around 3.4% each year for the next three years is very challenging. Our refreshed Plan continues to demonstrate the ambition of the Board to drive forward improvements in the standards of care for our patients, whilst remaining focused on an ever challenging financial and performance agenda. The Board acknowledges the real challenges to ensuring its delivery and they continue to recognise that engaging the ongoing support of all our staff, clinical and managerial leaders and other key stakeholders to achieve the necessary ‘transformation through innovation’ will be the key to its delivery.

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1.1 Vision & Strategy

Our vision as a University Health Board is to:

Care for our communities and patients by preventing ill-health, promoting better health, providing excellent services and reducing the

need for inpatient care wherever possible through the provision of strengthened home, primary and community care.

In three years time …. …. if we are to be successful at the end of this year period we will have achieved a range of priority objectives including:

• a reduction in ill health across our communities; • strengthened core primary care services through

extending enhanced services across federated practices to improve equity of access;

• the development of Cluster Hubs to further drive locality working, thus facilitating a demonstrable shift of service from secondary to primary care;

• implemented innovative workforce and service

models in primary, community care services which have reduced unnecessary hospital admissions and delivered a demonstrable shift of services from secondary to primary care;

• delivered truly integrated services with our partners across areas such as health and social care and reablement services, particularly for children and the frail elderly;

• implemented redesigned secondary care service models across our ‘fragile’ service areas, as part of wider alliance arrangements with our partner LHBs and Trusts and;

• embedded prudent healthcare in our service planning and delivery.

All of this, we will have achieved as far as possible with the use of innovative workforce models and working closely in partnership with our staff, partners and local communities; in line with our quality and performance trajectories and within a financial envelope which is both value for money and affordable.

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• We will prevent ill health, protect good health and promote better health.

• We will provide care as locally as possible wherever it is safe and sustainable.

• Our services will be of the best quality and delivered within efficient, affordable and effective models of care.

• More care will be delivered in primary and community based settings, reducing the need for hospital inpatient care wherever possible.

• Developing joined-up health and social care services by working with our partner Local Health Boards, Trusts, Local Authorities and the Third Sector.

• With a strong sense of corporate social responsibility, we will work with our staff, partners and communities themselves, building on strong local relationships and the solid foundations of the past.

• We will use our University Health Board status to ensure that working with our academic partners, we bring research, innovation and high quality teaching to support our staff and services.

• We will ensure a strongly governed system and pay due regard to equality which will underpin everything we do.

1.2 Strategic Objectives

The Health Board has the following five strategic objectives, principally derived from the Institute for Healthcare Improvement (IHI) Triple Aim, which provides a clear framework for our plan. These objectives are:-

• To improve quality, safety and patient experience.

• To protect and improve population health.

• To ensure that the services provided are accessible and sustainable into the future.

• To provide strong governance and assurance.

• To ensure good value based care and treatment for our patients in line with the resources made available to the Health Board.

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As a Health Board, our key priorities for 2015/16 are:-

• Continue to improve patient experience throughout the Health Board.

• Develop our clinical service strategy, including the implementation of the outcomes of the South Wales Programme and ensure innovation and prudent healthcare is at the heart of our service provision and redesign.

• Implement our refreshed primary and community care plans including evidencing the shift from secondary to primary care.

• Continue to develop truly integrated services with our partners including Local Authorities and the Third Sector, across areas such as health and social care and reablement services, particularly for children and the frail elderly.

• Continue to improve scheduled & unscheduled patient care, patient flow and urgent care processes.

• Engage with an increasing number of members of the public in Cwm Taf through our regular public fora events and social media.

• Continue work to meet our quality and performance trajectories.

• Involve patients in the design and development of new clinically led and patient focused services, both in and out of hospital.

• Improve data quality and business intelligence, including reporting and transparency.

• Address high sickness rates amongst staff.

• Ensure compliance with legislation.

• Achieve financial balance.

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2. PROGRESS IN DELIVERING OUR PLAN

This chapter offers an update on progress in implementing the Health Board’s current Plan, both in terms of achievements and challenges.

Overall, we continue to make solid and steady progress in delivering our 3 Year Integrated Plan and in fact this will be the third year that we have moved from delivering an organisational ‘turnaround’ agenda into delivering a much more mature, innovative and exciting transformational agenda for the Health Board. Two major highlights for us this year, as a result, were winning a national award for our work on improving scheduled and unscheduled care patient flow across our hospitals and also obtaining the Platinum Award in the Corporate Health Standard. Our Board maintains a strong focus on quality, performance and delivery and we are able to demonstrate that we are an organisation that has matured in our governance and assurance arrangements. The Health Board is also projecting breakeven in 2014/15 which will be a success given the challenging nature of our plan and a lower than average share of additional Welsh Government allocations. Whist challenges remain going forward, we will continue to build on our achievements and celebrate our success with notable improvements in performance and quality outcomes having been delivered for our community. 2.1 Our Quality and Performance Trajectories

In terms of the quality and performance improvement trajectories we have set ourselves in our current plan, we have made some significant improvements including:

• The %age of Health Board residents who made a quit attempt via smoking cessation services is amongst the best performance across Wales. Smoking rates continue to decrease over the last three years, from 31% to 24% in Merthyr Tydfil and in Rhondda Cynon Taf from 28% to 26%.

• The Health Board is above profile and achieving the 95% target for each of the five childhood vaccinations at age 1 and 2. Primary childhood immunisation rates across the Health Board are overall the best in Wales with uptake greater than 95% and 90.4% achievement against Tier 1 (all at age 4 vaccines).

• We have a positive, ongoing programme of staff vaccinations for seasonal flu for frontline staff with improving uptake rates.

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• Cwm Taf practices have made the most significant improvements to GP access when compared to the rest of Wales

• We are sustaining our significant reduction in clostridium difficile infection rates and MRSA infection rates.

• We continue to have the best performance across Wales for the number of over one hour emergency ambulance patient handovers with on average less than 10 breaches a month since October 2013. In June 2014 we were the only Health Board ever to achieve zero over one hour handover breaches.

• In terms of %age of our patients referred as non-urgent suspected cancer seen within 31 days, our position is often above our profiled position and achieves the 98% target, a position we plan to maintain.

• In terms of compliance against the stroke bundles, we are usually on profile for care bundles 1, 3 and 4, with care bundle 2 proving more challenging in terms of access to a stroke unit within 24 hours. The introduction of a ring-fenced bed on both or our District General Hospital sites led to improvement this year, although the recent delivery of our acute stroke centre of excellence and early supported discharge service should lead to further considerable improvement in quality and performance of service.

• We are currently off our overall profiled position for RTT targets,

although with the exclusion of ophthalmology, we are currently forecasting there will be no patients waiting over 52 weeks and fewer patients waiting over 36 weeks than last year. Ophthalmology has been a significant challenge and further detail can be seen later in the Plan in terms of the current improvement actions we are taking to remedy this situation.

• In terms of our diagnostic waiting times, we anticipate achieving no patients waiting over 8 weeks for MRI and CT by the end of 2014/15 and continue to work hard to achieve improved performance in other diagnostic areas.

• We participated and received the Professor Stephen Palmer Report reviewing the Mortality Review processes across Wales which commended the work taking place in Cwm Taf across our acute and community services.

• In addition to progress in achieving and improving our performance against a number of core targets, the Health Board has also been working closely with Welsh Government Performance colleagues to ensure that reporting into the newly developed Unscheduled Care Dashboard is accurate and timely.

• Using the A&E module of the Myrddin system Cwm Taf has implemented a fully live emergency care system which captures all elements of the patient journey from presentation at Emergency Care Centres to admission onto a ward and discharge following completion of the patient’s episode of care. The system can be integrated into Primary Care, which enables our GPs to access all

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information regarding the patient’s attendance at the A&E department. This is also integrated via a live feed into the national Unscheduled Care Dashboard and also forms part of Cwm Taf’s internal A&E Monitor for operational management.

• The Health Board is working with Welsh Government colleagues to establish reporting processes for patients referred with a suspicion of cancer. Using the Tracker 7 system, developed by the Information Team at Cwm Taf in 2011, this collaboration is seeking to expand the logic to incorporate reporting capability for a single cancer

pathway, with further work to be undertaken in 2015.

In terms of our more challenging areas of quality and performance improvement:

• Our %age of Category A emergency ambulance responses within

8 minutes remains significantly below our monthly profiled position of 62.5%, with performance being consistently below 60% since November 2013. This is a high priority area for attention for the Board and we are working closely with the Emergency Ambulance Services Commissioner and Welsh Ambulance Services Trust (WAST) on required improvements including the implementation of our ‘Explorer’ project which will see no vehicles dispatched to calls outside the Cwm Taf boundary (with some exceptions) during the April with a view to improving response times and outcomes for patients.

• In terms of our eye care services, we have specific challenges in ophthalmology. Chapter 5, sub section 5.6.5 provides a demand and capacity plan which covers new and follow up outpatients and surgical treatments. It shows the interventions being made and their impact over the year in a way that enables the service to monitor and track them. It also shows that the planned interventions both address the recurring capacity gaps currently and address the backlogs. Chapter 7, section 7.15 outlines our Eye Care Plan. Some of the important interventions are community interventions particularly by optometrists and these are also reflected in our primary care development plan outlined in section 7.21. Chapter 9. Also highlights the investment we are making in this priority area.

• In terms of the %age of our patients referred as urgent suspected cancer seen within 62 days, we have been below our profiled position for the first part of this financial year, however recent months have indicated improvement, which we are working hard to sustain.

• For A&E measures (%age of patients waiting less than 4 hours and the number of patients waiting more than or equal to 12 hours for completed treatment in A&E), we are off our profiled position, although between May 2014 and August 2014, our 4 hour

performance was consistently above 90% and the number of 12

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hour breaches was consistently below 65. However, performance deteriorated during the Winter when we put our Gold and Silver Command operations in place as part of our Unscheduled Care Plan and we are now getting our system ‘back into balance’ with recent performance improvements.

• Unfortunately we are still not consistently achieving the 90% target of all of our residents, who are in receipt of secondary mental

health services, having a valid Care Treatment Plan. We had seen a continual improvement in performance earlier this year, when the 90% target was achieved, but there has since been another decline in performance. The Directorate has developed an action plan which aims for compliance by the end of March 2015 and this remains under close scrutiny by the Health Board.

2.2 Progress in Implementing Our Cross-Cutting Themes

The Health Board continues to make progress in implementing its eight Cross Cutting Themes in 2014/15. There have been a number of significant achievements to date, as can be seen below, and progress also made in delivering significant enablers for achieving further large scale service change and redesign in 2015/16. Achievements include:

• The redesign of Older Persons Mental Health services has supported a move away from a bed based model and as a result the organisation has reduced its bed complement by 18 beds. This also facilitated a reinvestment in community services to ensure a robust community infrastructure is in place moving forward.

• Won a National Award for our work focusing on flow through scheduled and unscheduled care.

• Our medium term ambition is to create a University Health Park on the site of Dewi Sant hospital and we have moved inpatient services from there to the Royal Glamorgan Hospital.

• In parallel, we have strengthened our community based

provision to ensure that where possible we avoid inappropriate admissions to hospital or facilitate earlier appropriate discharges from hospital with suitable support.

• We have established our Stroke Early Supported Discharge

Service, one of the first in Wales, which promotes active rehabilitation in a patient’s own environment and also established our Stroke Centre of Excellence at Prince Charles Hospital

• We have made a range of improvements in Planned Care for example a reduction in the number of 36 week breaches in orthopaedics and gynaecology and significant improvements in Orthopaedic Day of Surgery Admission (DOSA) rates.

• We have agreed our nursing establishments for older people’s mental health, general wards and A&E to ensure quality and safety of care.

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• We have established a Referral Management Centre which is supporting the Health Board in ensuring best use of our local resources and specialist skills in terms of commissioned services.

• Working with our clinicians, we are improving outpatient productivity with systems under development to reduce cancellation rates and DNAs and improve follow-up ratios alongside the development of referral criteria and integrated pathways, setting a 5% efficiency target for 2015/2016. We are implementing ‘text and remind’ and self-service check-in services, which will all bring about significant service improvements in 2015/2016 for our patients visiting these services.

Of real significance is the early engagement with our Community Health Council, which has allowed us to progress a number of these key service changes with both their agreement and support. 2.3 Overview of Other Progress Made

The following offers a summary of other key achievements during 2014/2015:

Protecting and Improving our Public’s Health and Reducing Health

Inequalities

• Supporting Primary Care GPs in developing locality cluster plans. • Maintaining our focus on the prevention agenda and reducing Health

Inequalities. • Public Health network model for Communities First support commended. • Public Health Midwife recruited. • Introduction of Prescribing Advisors to embed prevention messages in their

work. • Increasing numbers of community pharmacists that offer specialist support

for people who wish to quit smoking. • Diabetic services - implementation of the Maternal Obesity Service within

Rhondda Cynon Taf; Introduction of Conversation Maps (education programme) within Primary Care; Engagement with patients and service users to improve education programmes; National recognition of the standard of delivery of the X-PERT programme within Cwm Taf; Collaborative working with DRSSW; Improvements in the care of patients whilst in hospital and access to IV antibiotic treatment for patients with osteomyelitis in the community.

• Respiratory care - Increased the number of Community Pharmacies delivering smoking cessation services; Implemented two quality improvement initiatives in collaboration with GSK in relation to Inhaler technique training and building skills within primary care; Developed a Medication Use Review service for Care Homes which includes respiratory medication.

Patient Experience, Safety and Quality

• Developed and approved our Quality Strategy (2014-17), Quality Delivery Plan(2014/15) and Patient Experience Plan (2014-17), aligned to our philosophy of care ‘Cwm Taf Cares’ and established a Quality Steering

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Group to oversee operational implementation of agreed priorities. • Introduced a Quality Blog, led by Clinical Executive leads. • Developed our measures for quality and safety, with agreed quality triggers

that are featured within the Integrated Quality & Performance Dashboard. • Introduced a Quality Report, focusing on quality assurance & improvement. • Working closely with our communities and partners (CHC) to inform quality,

safety and patient experience developments. • Routine Board Member walkrounds in place with focus on patient safety and

quality of care. • Unannounced Executive Director led walkrounds established in response to

‘Trust to Care’ report. • Focused partnership Dignity visits in place. • 2014 Fundamentals of Care audit completed and identified learning

informing the development of improvement work across the Health Board. • Continued to embed transforming safe and effective care across all hospital

inpatient areas. • Working closely in partnership with 1000 Lives improvement team to ensure

improvement work is taken forward along with our Improving Quality Together (IQT) trained staff.

• Completed a review of our priorities in response to ‘Trusted to Care’ the report into care at ABMU Health Board

• Reviewed our progress of actions in response to the Older People Commissioners Report ‘Dignified Care?’

• Participated fully in the Keith Evans Review by Welsh Government of ‘Putting Things Right’ and responded.

• Responded to the Evans (Concerns) Review. • Fully participative in established Cancer Peer Review process. • Successful Research, Development and Innovation Conference aligned to

our University Health Board status.

Access to Patient Centred Services

• Implementing an electronic GP Referral System. • Established a local Chronic Pain Service meaning that people living in

Merthyr Tydfil and the Cynon Valley no longer have to travel to Cardiff to access the Chronic Pain Service.

• Developing our @Home Services to support people to maintain their health and wellbeing in the community instead of hospital including: o successfully developing the Community Integrated Assessment

Service (CIAS) launched in 2012; o extended access to reablement services and enhanced service

embedded to facilitate an earlier discharge for people with mild to moderate cognitive impairment;

o development of ‘Community Wards’ o Development of Community IV Service.

• Following a patient engagement session, the Head and Neck cancer SLT and CNS set up Patient support group and established website.

• Sustained our significant reduction in inpatient cancellations due to lack of bed availability.

• Phone First for the Minor Injuries Service at Ysbyty Cwm Rhondda implemented as part of the sustainable model for our Minor Injuries Units in Cwm Taf.

• Ophthalmic Diagnostic & Treatment Centre established in Ysbyty Cwm Rhondda.

• Primary Care Dental Extraction Service was established in the Dental Teaching Unit.

• Working with the Welsh Ambulance Services NHS Trust (WAST) to introduce

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a range of positive improvements across the scheduled care system, including:

o Three new pathways to enable to avoid admission to hospital and remain in their own homes

o Use of Community First Responders o Team based worked and a new management structure

• Development of a clinically led Palliative and End of Life Care Strategy focused on the development of a locality wide model which addresses both the estates provision and improving the quality and co-ordination of palliative care services in Cwm Taf.

• Mental Health developments include: o Development of a mental health service in GP practices across Cwm

Taf. o Enhanced Transport System for access to Mental Health Services.

• Cancer Services – we have continued to develop our local Cancer Delivery Plan and our achievements include:

o A number of successful bids with Macmillan. o Establishment of a Community Cancer Awareness Network. o Establishment of Nurse Led Prostate Specific Antigen (PSA) clinics

across Cwm Taf. o Embedding the concept of the key worker within Cwm Taf.

• Colorectal Multi Disciplinary Team at Prince Charles Hospital awarded speciality status by the Association of Coloproctology of Great Britain and Ireland.

• Caring for the frail elderly: during 2014 the Health Board, its Local Authority and Third Sector partners received funding from the Intermediate Care Fund which has allowed partners to strengthen its community infrastructure and address a number of priorities including the scoping of a single point of access to intermediate care services and the integration of @Home services across health and social care.

• In addition the partners are in the process of developing a joint commissioning statement for older people, to replace separate strategies and approaches of each of the public sector agencies.

Working Differently, Working Together, Working in Partnership

• Opening of Merthyr’s new Academic Centre on the Keir Hardie University Health Park site, supporting between 60 and 90 medical students each week from Cardiff University’s School of Medicine with a strong emphasis on community medicine and direct patient contact.

• Achieving Platinum in the Corporate Health Standard. • Sustained improved levels of Personal Development Reviews (PDRs) and

good performance with consultant job plan review. • Strong engagement with Staff Side in supporting service change agenda. • Successful National Nurse of the Year Awards ceremony with all five

shortlisted staff receiving awards in their nominated categories. • Working in partnership through the Regional Collaborative Board and the

Local Service Boards, participated in reviews of the Single Integrated Plans in Rhondda Cynon Taf and Merthyr Tydfil and contributed to the production of Annual Reports.

• Consolidated the much valued Expert Patient Programme (EPP). • Developments agreed by the Health Board; delivered either primarily by the

Health Board or where required by new ‘alliances’ of networked hospitals:

o Acute medicine & Emergency Medicine o Local paediatric assessment/ piloting of the PAU. o Working within Alliance on obstetrics and neonates & paeds. o Diagnostic hub development.

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• Strong integrated planning processes established across the Health Board. • Continued strengthening of Health Board Governance arrangements. • Forecasting break even year end position.

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3. HEALTH BOARD PROFILE 3.1 Introduction This chapter offers an overview of the Health Board in terms of services

provided and the context in which it operates. Cwm Taf Local Health Board was established on 1 October 2009 and is led by its Chairman, Chief Executive and a Board of Executive Directors, Independent Members and Associate Members. In July 2013, the Health Board was awarded University Health Board status by the Minister for Health and Social Services and we became Cwm Taf University Health Board (known hereafter as the Health Board or Cwm Taf Health Board). This was an important achievement in our development journey and is a source of pride for the Cwm Taf community. We are confident that this is helping us in our ongoing drive to provide high quality, responsive care and services for our community.

3.2 Overview The resident population of the Health Board area (Merthyr Tydfil and Rhondda Cynon Taf) was estimated to be 295,135 in 2013, accounting for 10 per cent of the Welsh population. Almost 81% of the population live in Rhondda Cynon Taf Local Authority and the remaining 19% in Merthyr Tydfil. The Health Board’s catchment population increases to 330,000 when including patient flow from the Upper Rhymney Valley, South Powys, North Cardiff and the Western Vale.

Key Facts

Cwm Taf Wales

Areas size 536 km2 20,736 km2

Total population 295,100 3,082,400

Life expectancy at birth - males - females

RCT 76.5 80.8

MT 76.9 80.9

78.3 82.3

Persons per km2 551.0 148.70

%age population from ethnic minority background 2001

4% 6.8%

Total births 3,481 33,747

Total deaths 3,226 32,138

%age lower super output area (LSOAs) in most deprived 5th of Wales

31% 20%

Source: Public Health Wales (2015)

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The Health Board provides a full range of hospital and community based services to the residents of Rhondda Cynon Taf and Merthyr Tydfil. These include the provision of local primary care services; GP Practices, Dental Practices, Optometry Practices and Community Pharmacy and the running of hospitals, health centres and community health teams. The Health Board is also responsible for making arrangements for the residents of Rhondda Cynon Taf and Merthyr Tydfil to access health services where these are not provided within Cwm Taf. Detailed information about the services we provide and our facilities can be found on our website in the section ‘Local Services’. This can be accessed from the home page, or via the following link Our Services.

Cwm Taf’s main hospital and community based sites are:

Royal Glamorgan Hospital Prince Charles Hospital Ysbyty Cwm Cynon Ysbyty Cwm Rhondda Pontypridd & District Cottage Hospital (Y Bwthyn)

Dewi Sant Hospital

Ysbyty George Thomas Keir Hardie University Health Park

In the primary care sector, Merthyr Tydfil and Rhondda Cynon Taf has:

• 46 General Medical Practices • 35 Dental Practices • 28 Optometrist Practices • 77 Community Pharmacies

The Health Board employs on average 6,900 whole time equivalent (WTE) staff, a headcount of approximately 8100 and has a total pay bill of circa £297M per annum. 6.8% staff turnover is amongst the lowest in Wales (3.8% excluding retirements and VERS). The following graph highlights how our workforce is made up by staff groups. As the second largest employer in the area, a significant number of our workforce live and work within the communities that we serve.

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Health Board’s estate covers a total land area of 74 hectares with buildings having a total gross internal floor area of 178,002m2. The estimated value of our property is in the region of £300m, with equipment valued at a further £20m. As a result of the significant investment that has taken place over recent years, the Health Board’s estate is now the most modern in Wales.

New Emergency Care Centre – Prince Charles Hospital Ysbyty Cwm Cynon

3.3 Services Provided

In terms of clinical activity, the Health Board directly provides, or

contracts for the following services each year:

Primary & Community Care

Contacts

Secondary Care Contacts

Over 1.3m GP and Practice Nurse ‘contacts’ within general practices

472,456 Outpatients

Appointments - 332,140 new patient appointments

- 340,316 follow up

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appointments

335,014 District Nursing face-to-face contacts 13,598 District Nursing non face-to-face contacts

58,716 Inpatients - 8,227 planned/elective - 50,489 emergency/non elective

13,024 Day Cases

117,509 A&E Attendances - 111,198 new attendances - 6,278 follow up attendances

Primary Care Within core primary care provision there are four practitioner services; medical, dental, pharmaceutical and optical. These practitioners are independent of the Health Board and the services are contracted by the Health Boards to provide their particular service. The key role of primary care services in Cwm Taf is to: • provide a first point of contact with healthcare services; • offer continuity of care (diagnosis, prescribing and care management); • provide a universal service, co-ordination of care 24 hours a day, 7

days per week across primary, secondary and social care systems; • improve the health of the population through health promotion and

primary prevention.

In Cwm Taf we have 46 GP practices, supported by a total of 170 general practitioners. Each year, there are over 1.3m GP and Practice Nurse ‘contacts’ within general practices in Cwm Taf. The Primary Care and Community Services healthcare team consists of General Medical Practitioners (GP’s), Practice Nurses & Healthcare Care Support Workers (HCA’s), Phlebotomists, Managers and Reception staff that are employed by the GP practice. They then work very closely with other health staff they do not employ such as Health Visitors, District Nurses, Community Midwives, and other community staff such as Community Psychiatric Nurses and Therapists. Our GP ‘in hours’ service provides acute as well as routine provision and our community services are supported by an ‘Out of Hours’ GP service (OOH’s) patients. The OOH’s service is for those patients who are ill and feel that they cannot wait for an appointment with their GP the next day.

The GP OOH’s service is currently provided through the process of telephone triage, telephone advice, home visit or appointment at one of the designated centres (YCC/YCR/PCH/RGH). During 2013/14 there were 58,000 contacts with the out of hours service.

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In terms of general NHS dental services, we have 35 dental practices (GDS) supported by 107 Dentists. In addition to dental services being provided by Independent Dental Practitioners there are 2 Community Dental Services (CDS) practices, a Dental Teaching Unit based in Porth, and 10 Community Dental Services Clinics providing treatment to children and adults with special needs. Over the last 24 months 171,136 patients have been treated by a Cwm Taf Dentists. Our general ophthalmic services contracts ensure a comprehensive eye examination, appropriate to individual need, symptoms and general health. There are 28 optician premises in Cwm Taf supported by 69 optometrists. In the year ending 2013 there were 84,230 primary NHS eye examinations undertaken across the Cwm Taf population. We also have 77 NHS Community Pharmacies within Cwm Taf Health Board. Last year (2013-14) community pharmacists within Cwm Taf dispensed 8,039,839 prescription items, on average each pharmacy in Cwm Taf will dispense over 400 prescription items every day. Alongside the four provider professionals are a range of other services provided by the Primary and Localities Directorate that work as part of the primary care team. These include District Nurses, Health Visitors & School Health Nurses. These professional groups provide core/generic services, as well as specialist services delivered within a variety of community settings, as well as patients own homes. Health visiting is a universal, preventive, public health service and contributes greatly to the Welsh Government commitment for children to have a good start in life. Health Visitors within the Health Board support this vision by working to reduce health inequalities and social exclusion, focusing on public health, supporting parents and families of pre-school children, promoting infant, maternal and family health, reducing ill health by safeguarding children from abuse and developing community capacity. Health Visitors work as part of a skill mix team, with a team leader and community nursery nurses and carry a caseload of up to 250 families. Health Visitors are GP attached and also work very closely with the wider multi-disciplinary and all partner agencies in the community. Flying Start is the Welsh Government’s targeted Early Years Programme for families with Children under 4 years of age, living in some of the most disadvantaged areas of Wales. Within Cwm Taf Flying Start Health Visitors provide an enhanced service to families and Children promoting their Health and wellbeing. Flying Start Health Visitors have a reduced caseload 1-110, and are supported by the Flying Start Midwife, Community Nursery Nurse, Speech and Language Therapist along with our partner agencies

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which include Barnado's, Parenting, Language and Play and Child care settings. School Nurses within the Health Board are responsible for the health and wellbeing of school aged children 5-19 years of age. Each school nurse has responsibility for a Secondary school and its feeder primary schools providing a key link with secondary and primary care services. School Nurses work as part of a multi disciplinary team and provide a public health role which includes: Immunisations, Safeguarding, Health promotion and health education, School Entry Health reviews, Child measurement programme, audiology screening, drop in sessions weekly in secondary schools, home visits, care plans, training for school staff, reviewing and monitoring A&E attendance.

District nurses play a key role in providing care and support in the community in partnership with the Primary Healthcare Team and Local Authority. They support population and case management, support and care for patients who are unwell, recovering at home and at end of life and also facilitate independence. Additionally, District Nurses provide a vital role in keeping hospital admissions and readmissions to a minimum and ensuring that patients can return to their own homes as soon as possible. Primary Care Support Unit

The Primary Care Support Unit (PCSU) assists in delivering a sustainable model of care by supporting GP Practices with salaried GPs and Nurses when they experience recruitment and retention problems or need support/management in the event of crisis. It also supports areas of work including chronic pain clinics, mortality reviews, QOF visits, nursing home assessments, PCH dermatology service, YCR minor surgery clinics, educational ‘sessional’ cover and ‘sessional’ cover for GPs/CDs undertaking LHB projects/development. We are also developing our Clinical Nursing Services to provide advanced clinical nurse skills and facilitation roles to support general practise and chronic disease management. These include Practice Nurse ‘Nurse Practitioner’ sessions; specialist support and advice for discreet areas of practice such as anti-coagulation and training and education tailored to the needs of GP Practice-based staff. The Primary Care Support model has proven to be a very effective and flexible resource over recent years. It has been praised in our recent HIW review and it is an area prioritised for further strengthening and development – certainly locally, and potentially on a wider Health Board basis as is described later on in Chapter 7, section 7.21.

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Community Care

The community services within Cwm Taf are varied, with many being different and innovative. These services are currently described as part of the Community Resource Team, the @Home service, and Continuing Health Care. The Community Integrated Assessment service (CIAS) provides a multi-disciplinary assessment facility for those patients who are likely to require hospital admission in the next 24-48hrs unless there is prompt intervention. The aim of the team is to pull together community interventions that could support the patients remaining within their own home therefore preventing a hospital admission. We also have a Home IV Service which provides Intravenous Treatment at home provided by Specialist Nurses. This prevents patients needing a long stay in hospital for this intervention. Our multi professional reablement service helps to prevent people having unnecessary hospital admissions by helping them accommodate their illness or condition by learning or relearning the skills necessary for daily living. The Continuing Health Care and Funded Nursing Care Team are responsible for the assessment, delivery/commissioning and monitoring of services provided to individuals that meet the sole eligibility criterion for Continuing NHS Health Care and NHS Funded Nursing Care. They continually monitor and evaluate service provision, to ensure effective use of resources. We class our dedicated Palliative Care facilities/clinicians as a specialist provision with the in-patient facilities currently provided from Ysbyty Cwm Cynon and Y Bwthyn Hospitals, alongside services provided within the community in patients’ homes. In 2015 we will see the move of the beds from Y Bwthyn site to a newly developed facility in the Royal Glamorgan Hospital. This will improve access to acute facilities for this client group and this is being supported by Macmillan Cancer Support. Other community services include:

• Lymphoedema Service: Nurse led service providing prevention schemes and specialist assessment and treatment facility for those diagnosed with Cancer and Non cancer related Lymphoedema.

• Tissue Viability Service: Specialist advice regarding clinical management of complex wounds, pressure ulcers and leg ulcers.

• Aural Care Service: Advanced Nurse Practitioner led service to provide a specialist assessment and treatment facility for the removal of ear wax.

• Diabetes Nurse Facilitator Service: Provide a range of services including Specialist support/advice/training/education to Practice

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based staff, District Nursing staff, Care Home staff and Community Hospital staff in relation to all aspects of Diabetes care.

• Respiratory Nurse Facilitator Service: specialist support/advice/training/education to Practice based staff and other community based staff in relation to all aspects of respiratory care including diagnosis, treatment and management of COPD, Bronchiectasis, Asthma, Interstitial Lung Disease and Home Oxygen Therapy.

• Parkinson’s Disease Clinical Nurse Specialist Service: provides clinical support, education and specialist advice for all aspects of Parkinson’s Disease care. It provides an assessment/review service within community hospital and within the patient’s own home. Nurse led clinics are held in community hospital and health park facilities.

• Home Oxygen Therapy Service: the Home Oxygen Therapy service provides a specialist assessment, treatment and review service for all new patients to determine their need for a Home Oxygen Service before either Long Term Oxygen Therapy or Ambulatory Oxygen is initiated.

• Immunisation Coordinator service: development of high quality Immunisation and Vaccination services across Cwm Taf Health Board.

• Clinical Practice Educator Service: Supports the provision of professional leadership for nurses working in General Practices across Cwm Taf Health Board.

This year we have facilitated the move of the rehabilitation beds from Dewi Sant hospital into Royal Glamorgan Hospital for the Taf Ely population. Our Rehabilitation facilities within our hospitals are now focussed on 3 sites; Ysbyty Cwm Cynon, Ysbyty Cwm Rhondda, Royal Glamorgan. These beds are used for rehabilitation of patients to ensure that they are able to function appropriately to manage within their ‘home setting’. Significant work has been done to maximise ‘flow’ and to reduce the average length of stay (ALOS) within these hospitals to ensure that patients are transferred home as quickly as possible, to reduce dependency.

The following table provides a summary of our full year secondary care

activity for 2013/2014 and 2014/15 year to October 2014.

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Source: HEALTH BOARD Performance Data

Outpatient Activity: 2013/14 - 2014/15

Directorate Specialty 2013/14 2014/15 (April - October)New F-up Total New F-up Total

General Surgery 9364 13823 23187 5702 7935 13637Urology 3118 8088 11206 2229 4894 7123Trauma & Orthopaedics 14982 32377 47359 9350 19290 28640

Sub Total 27464 54288 81752 17281 32119 49400ENT 7913 14302 22215 4903 8772 13675Ophthalmology 8288 26892 35180 3722 12334 16056Oral Surgery 4602 8081 12683 3273 3820 7093Restorative Dentistry 236 644 880 42 289 331Orthodontics 535 6982 7517 459 3713 4172

Sub Total 21574 56901 78475 12399 28928 41327Anaesthetics 759 974 1733 415 755 1170

Sub Total 759 974 1733 415 755 1170General Medicine 18115 16890 35005 11038 10530 21568Gastroenterology 1616 4593 6209 1015 2953 3968Cardiology 2881 5430 8311 1479 2768 4247Dermatology 4760 9827 14587 2697 5933 8630Respiratory Medicine 2379 5781 8160 1259 3395 4654Nephrology 247 1959 2206 252 1280 1532Neurology 564 869 1433 279 464 743Rheumatology 3778 9924 13702 2217 6034 8251Care of the Elderly 0 0 0 0 0 0

Sub Total 34340 55273 89613 20236 33357 53593Haematology 2428 35265 37693 1579 20951 22530General Pathology 254 1041 1295 129 629 758Chemical Pathology 566 0 566 81 1 82

Sub Total 3248 36306 39554 1789 21581 23370Rehabilitation 244 1637 1881 411 1314 1725Palliative Medicine 107 557 664 80 246 326

Sub Total 351 2194 2545 491 1560 2051Paediatrics 3022 6549 9571 1507 3394 4901SCBU 0 0 0 0 0 0

Sub Total 3022 6549 9571 1507 3394 4901Obstetrics 5821 17959 23780 3058 12210 15268Gynaecology 8678 11065 19743 5190 6259 11449Midwife Episode 0 0 0 0 0 0Genito-Urinary Medicine 8095 5217 13312 5718 3450 9168

Sub Total 22594 34241 56835 13966 21919 35885Mental Handicap 73 328 401 39 211 250Mental Illness 1852 16072 17924 1043 9169 10212Children & Adolescent Psychiatry 3518 28873 32391 1743 13577 15320Psychotherapy 19 63 82 0 0 0Old Age Psychiatry 356 1089 1445 222 540 762CDAT 1199 9849 11048 709 6117 6826

Sub Total 7017 56274 63291 3756 29614 33370Radiotherapy 136 616 752 66 341 407

Sub Total 136 616 752 66 341 407Nurse Led 11635 36700 48335 6705 19708 26413

Sub Total 11635 36700 48335 6705 19708 26413Total 132140 340316 472456 78611 193276 271887

Localities & Community

Surgical

Head and Neck

ACT

Acute Medicine

Pathology

Children and Young Children

Obstetrics & Gynaecology

Mental Health

Radiology

Nurse Led

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Source: Health Board Performance Data

As well as delivering services to its local population, the Health Board provides patient care services to the populations of other Health Boards. Aneurin Bevan University Health Board is the largest external commissioner of services from Cwm Taf and this reflects the patient flow from the Upper Rhymney Valley. Where we are unable to provide services locally, usually for more specialist or tertiary services, the Health Board makes arrangements with other Health Boards or Trusts to provide these services on its behalf. In addition, the Welsh Health Specialised Services Committee (WHSCC) commissions highly specialised services on behalf of all the Welsh Health

Inpatient Activity: 2013/14 - 2014/15

Directorate Specialty 2013/14 2014/15 (April - October)Elective Non-elective Total Elective Non-elective Total

General Surgery 2243 6248 8491 1474 3867 5341Urology 868 399 1267 470 280 750Trauma & Orthopaedics 1667 2888 4555 1087 1565 2652Sub Total 4778 9535 14313 3031 5712 8743ENT 1302 787 2089 822 488 1310Ophthalmology 95 94 189 50 54 104Oral Surgery 455 400 855 310 232 542Restorative Dentistry 3 0 3 0 0 0Orthodontics 8 0 8 0 0 0Sub Total 1863 1281 3144 1182 774 1956Anaesthetics 10 26 36 18 1 19Sub Total 10 26 36 18 1 19General Medicine 148 20484 20632 73 12148 12221Gastroenterology 0 135 135 1 90 91Cardiology 20 371 391 17 330 347Dermatology 0 4 4 0 1 1Respiratory Medicine 0 110 110 0 121 121Nephrology 0 0 0 0 0 0Neurology 0 0 0 0 0 0Rheumatology 0 18 18 0 19 19Care of the Elderly 40 1062 1102 7 581 588Sub Total 208 22184 22392 98 13290 13388Haematology 3 113 116 0 94 94General Pathology 0 0 0 0 0 0Chemical Pathology 0 0 0 0 0 0Sub Total 3 113 116 0 94 94Rehabilitation 0 825 825 0 444 444Palliative Medicine 6 261 267 9 118 127Sub Total 6 1086 1092 9 562 571Paediatrics 161 7884 8045 75 4037 4112SCBU 0 510 510 0 253 253Sub Total 161 8394 8555 75 4290 4365Obstetrics 2 3383 3385 0 2679 2679Gynaecology 1025 1442 2467 627 955 1582Midwife Episode 0 2145 2145 0 427 427Genito-Urinary Medicine 0 0 0 0 0 0Sub Total 1027 6970 7997 627 4061 4688Mental Handicap 0 0 0 0 0 0Mental Illness 6 604 610 6 344 350Children & Adolescent Psychiatry 13 47 60 0 34 34Psychotherapy 0 0 0 0 0 0Old Age Psychiatry 152 249 401 38 187 225CDAT 0 0 0 0 0 0Sub Total 171 900 1071 44 565 609

Total 8227 50489 58716 5084 29349 34433

Surgical

Head and Neck

ACT

Mental Health

Acute Medicine

Pathology

Localities & Community

Children and Young Children

Obstetrics & Gynaecology

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Boards. In summary for 2014/2014, the forecast outturn of these ‘flows’ is as follows:

Inflow Outflow

£m £m

Aneurin Bevan 19.369 0.819 ABMU 4,230 4.522 Cardiff and Vale 5.908 20.167 WHSSC 4.706 55,304 Velindre - 6,630 Powys 1,034 - Hywel Dda 0.180 0.290

Total 35.427 87,732

Source: Cwm Taf University Heath Board Commissioning Plan 2015 -2018

3.4 Quality & Patient Experience

Safe Care, Compassionate Care (2013), the National Governance Framework to enable high quality care in NHS Wales, has informed the development of the Health Board’s Quality Strategy and Quality Delivery Plan. The Triple Aim is the foundation of our plans, ensuring that our services are:

We are committed to ensuring that we put patients and carers at the centre of all our work, engaging and listening to those who use our services to inform our quality improvement priorities and to address any concerns. ‘Cwm Taf Cares’ is our philosophy and the Quality Strategy and Quality Delivery Plan embrace this to ensure that we deliver services that are safe and effective, by staff that deliver care with compassion. Putting the patient at the heart of all that we do is fundamental to our vision of ‘Cwm Taf Cares’ and our Three Year Plan. It is about the creation of a leadership culture which nurtures compassionate care. The linkages between the delivery of safe, high quality, patient centred services and staff health and well being is well evidenced. Therefore, part of the ‘Cwm Taf Cares’ philosophy has a strong focus on our staff caring for themselves and each other. The essence of ‘Cwm Taf Cares’ threads through our Plan and Quality Strategy and is central to our workforce and organisational development approaches.

In his report, Sir Robert Francis QC, captured the learning against five key themes, underpinned by a fundamental quality improvement culture and the adoption of common values which are built into our Quality Strategy:

• Providing the highest possible quality and excellent patient experience;

• Improving health outcomes and helping reduce inequalities; • Getting high value from all our services.

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Our Plan reflects our drive to further improve quality, safety and efficiency and our approach over the next three years will build on current good practice to optimise these, focusing on the quality improvement priorities across NHS Wales including working closely with the 1000 Lives Improvement Service. This includes:

• Further and sustained improvements in patient flow; • Inverse Care Law Programme; • Improving Quality Together – Model for Improvement. • Accurate, useful and relevant information.

Our Quality Delivery Plan identifies a number of key measures that are regularly reviewed by our Quality Steering Group to determine and support priorities and actions for quality improvement. Triangulation of information and measures, which include patient/carer feedback and review of our Integrated Performance Dashboard, has informed the following four local quality improvement priorities:

We also measure and publish the quality of our service delivery in our Integrated Performance Dashboard with key indicators published for:

• Patient experience/feedback • Pressure damage • Infection rates • Hand hygiene • Mortality Rates • Immunisation Rates

Further indicators are also constantly being developed to reflect patient outcomes. Chapter 6 is dedicated to providing further detail about our aims and ambitions in terms of driving further quality improvement across the Health Board, as well as setting out our priorities and outcomes expected over the next three years.

• Fundamental standards; • Openness, transparency and candour; • Compassionate, caring and committed staff; • Strong, patient centred healthcare leadership; • Accurate, useful and relevant information.

• Improving the care of elderly, frail patients. • Prudent health care – medicines management • Prudent health care – population health • Coproduction – communication, engagement and learning.

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3.5 University Health Board Status, Teaching, Research & Innovation

University Health Board

Securing University Health Board status in 2013 has been a major achievement for Cwm Taf, recognising and helping us build upon the strong relationships that have flourished over the years between ourselves, the University of South Wales and Cardiff University. Strong academic and service partnerships support the promotion of health and wellbeing and high quality, safe and effective patient care, by ensuring the workforce is well educated and trained, the community is well informed and empowered and research opportunities are maximised. Our Academic Partnership Board is responsible for strategic collaboration between the Health Board, the University of South Wales and Cardiff University to deliver our shared strategic goals, to provide and strengthen quality, safety and health improvement, whilst gaining an international reputation for excellence, research and innovation. The Board and its Steering Group provide a formal mechanism whereby the strategic and operational benefits of partnership will be established and integrated across the Health Board and local universities. The Health Board and our partner universities have a long standing history of collaborative working, with existing and expanding good practice in areas such as degree programme design, delivery and sponsorship. University Health Board status brings further opportunities for collaborative academic ventures and joint academic appointments, the development of new roles and outcome based practice, all of which will help enhance recruitment and retention in the partner organisations. Research and Teaching

The Health Board already has an extensive research and development portfolio, undertaking and supporting high quality collaborative research studies registered on the National Institute for Social Care and Health Research (NISCHR) Clinical Research Portfolio, or are “Pathway to Portfolio” projects. We also support non-commercial research projects in primary and secondary care and public health medicine. Through the appropriate distribution of the NHS R&D funding allocation CT Health Board can provide financial resources where required in support of high quality research. The current portfolio of research includes Sepsis, Paediatrics, Vascular Disease, Mental Health, ENT, Midwifery, Primary Care, Diabetes, Cancer, plus other areas that fall within the research and development priorities identified by the NISCHR, Welsh Government and Cwm Taf University Health Board.

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University Health Board status is bringing a distinct advantage to the Health Board in achieving its strategic aim of increasing the commercial research undertaken across the organisation. An increase in commercial research income would complement the funding received from NISCHR and any successful grant applications. The combined income can then be re-invested into developing the Health Board’s research infra-structure, further developing the research activities of all health care professionals. Ensuring that research is integral to the roles and professional development of all health care professionals will be an important step in developing and maintaining a research culture across the organisation. It will also be important for the University Health Board to encourage and support the development of research leadership in addition to research activity, as both are critical in attracting additional research funding into the organisation. A further exciting development early this year was the opening of our undergraduate medical education facility on the Merthyr Tydfil Health Park site. This is in response to Cardiff University School of Medicine’s proposal to establish a teaching and research base for undergraduate medical trainees at the Merthyr Tydfil Health Park as part of a wider network of community-based teaching hubs. Through the continuous development of partnerships with academia and industry, we are at the forefront of research studies investigating priority areas such as Smoking Cessation and Knowledge Transfer. These are important regional level studies, supported financially by Cwm Taf, which aim to develop the evidence base that could change the processes used to reduce smoking in pregnancy and the translation of research findings into clinical practice. A Research Delivery Group (RDG) has been established by the South East Wales Academic Health Science Partnership (SEWAHSP) with a view to developing a “Citizens Cohort” study called the Cwm Taf Valleys Project. This is a developing collaboration between the Health Board, University of South Wales, Public Health and Cardiff University. The research partners may evolve to include bio-informatics and genomics using a population based cohort model. Our strategic vision of developing Keir Hardie University Health Park as a centre for such research activity will be very attractive for all partners, in addition to helping form the link with the education and training of all health care professionals. The facility has office accommodation for our researchers and academic partners, at the centre of the community. This provides a visible and accessible interface with the population served, to encourage recruitment and participation in high quality research.

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The success of obtaining University Health Board status also provides additional opportunities for collaborative research, where combining the skills and resources of the NHS, academia and industry can only serve to raise the quality of the research being undertaken. This will also help with the quality and increase the likelihood of success of future funding applications. The relationships developed with academia and industry have already proved fruitful with success at the MediWales Innovation Awards last year, providing an excellent platform on which to develop the research portfolio and partnerships further. Cwm Taf has also started to engage with its research community to develop its academic and evaluative approach to primary care. Our recent discussions with lead academics and practitioners have underlined how important it is to focus on proper evaluation during a period of austerity. We have paid attention to recent studies on non-communicable diseases, also known as chronic diseases, and have taken a number of key messages from the World Health Organisation in starting to develop our approach. As a result, we have completed some intensive work to frame our primary care research, evaluation and development proposition with our stakeholders. Next steps include the development of an academic primary care unit and the scoping of a research framework/cohort study for the Cwm Taf area. Both are in their early phase of development, but positive discussions have taken place with a number of academic institutions and academic/practitioner leads about the way forward. The following diagram offers an outline of our emergent research framework which will have a strong link into our work Inverse Care Law programme.

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The most important outcome of research activity is to provide the evidence base required to translate robust research findings into clinical practice for the health, clinical improvement and experience of our patients. However, the additional benefits that research and innovation can generate, to include a considerable contribution to the wealth and economic development and stability of the population, should not be underestimated. Innovation

In terms of the Health Board’s innovation programme, we have a wide ranging set of priorities, with a focus on service innovation as well as technology enabling solutions. Much of our Plan revolves about the need for us to be really innovative and challenging in how we model our services and workforce for the future, particularly in implementing the outcome of the South Wales Programme and in the next step ambitions we are setting out for our primary, community and increasingly integrated services. The following sets out some of our work and provides a rounded picture of what we are looking for in terms of support and investment from partners, as well as ourselves, in some of our innovation work in Cwm Taf. Examples of service innovation in our Plan include:

• Paediatric assessment service development at Royal Glamorgan Hospital, which

will allow the majority of children to be cared for locally. • Acute medical model development at RGH, which will allow for the continued care

of the vast majority of patients locally, with only small numbers requiring the tertiary/specialist services at UHW. This model includes the expansion of our acute physician model and also the introduction of rapid response ambulances to facilitate transfers where required.

• Introduction of new types of staff to address operational challenges, such as emergency care flow co-ordinators, pre-assessment co-ordinators and teams and ANPs in trauma and orthopaedics

• Endoscopy services - innovations in the way in which we organise and run our endoscopy services, improving efficiency and quality standards such as JAG.

Examples of technology innovation in our Plan include:

• Keeping patients well and independent and avoiding the need for hospital attendance or admission: all of our tele-health solutions would fall into this category, with technologies aimed at enabling patient led/remote monitoring of chronic conditions and early alerts when health is deteriorating, or technologies aimed at enabling communication between patients and professionals without the need for a face to face contact.

• Integrating care across professions and sectors: development of the electronic health record through the clinical portal, with access to up to date information on all aspects of a patients care available to all clinicians and service providers including GPs.

• Providing care as locally as possible, whilst acknowledging the push to centralise

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some highly specialist aspects of care: using technology to enable remote review and diagnosis of patients by specialists within tertiary centres, avoiding the need for the transfer of the patient

• Dealing with workforce challenges: we are facing challenges in workforce in relation to the various pathology services, which could be addressed through the centralisation of pathology services across South Wales / Wales, using technology such as automated microbiology testing. The development of the Diagnostic Hub at RGH is designed in part to address difficulties with the recruitment and retention of radiology staff, as well as improving the quality and efficiency of the diagnostic services offered to the population

• Improving efficiency / reducing cost: E-rostering systems designed to improve management of rosters and reduce costs of overtime / bank / agency; Increased access to ICT devices which enables staff to work effectively and efficiently wherever they are, reducing travel time, reducing accommodation costs and increasing value added time - this can ideally be aimed at staff who are in the community or who work in acute sites; introduction of technologies that streamline the outpatient system, for example text and remind, self service check in, which will reduce DNA rates and improve RTT performance; better use of the ESR system, for example for to introduce self service; implementation of the National ED ICT system – moving to a paperless ED department and improving information available; Technology to improve the scheduling and management of processes within the Health Board e.g. theatre and outpatient scheduling; Introduction of technology for digital dictation; Development and introduction of various technology advances in clinical equipment that reduces length of stay, improves outcomes, increases throughput, reduces invasiveness of procedures etc

• Improving information management: development and use of our business intelligence system; Implementation of the National Community Information system; Improving / developing a range of clinical information systems, potentially nationally.

During 2015/16 the Academic Partnership Board and Steering Group will continue to develop and implement its Business Plan, Teaching Strategy and joint Research and Development Strategy, formalising our shared priorities into a detailed implementation programme aimed at maximising the opportunities afforded by achieving University Health Board status.

3.6 Workforce

The Board has adopted an organisational development approach to the maturing Health Board. The intention has been to build capacity and capability from within to enable staff to change, improve quality of service delivery and continuously enhance performance, improvement and quality improvement trajectories. Given the health challenges facing the Cwm Taf population and in the context of the Triple Aim philosophy, the priority has been to build leadership capacity and capability amongst key individuals, teams and staff groups, so that they are empowered to take responsibility to make the necessary change happen and so continue to improve our services for patients and the population.

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There are a range of definitions in the literature describing ‘organisational development’; the one used which most closely reflects Cwm Taf approach is:

‘A planned, holistic approach to improving organisational effectiveness – one that aligns strategy, people and processes1

As we move forward, in the context of ‘Together for Health’ and the agenda set out in ‘Working Differently Working Together’, the Welsh Government’s strategic approach to workforce development; continuing and extending our organisational development cycle and approach is a critical enabler for us to ensure delivery of the Plan.

Optimising the opportunities flowing from being an integrated University Health Board and translating these into tangible results and improvements for our patients and the population is essential in this next three year cycle. This will only become possible when staff are fully engaged and there is credible clinical leadership distributed throughout the organisation, underpinned by robust management and visionary leadership at the top of the organisation working well with our partners and with a very definitive focus on the primary care setting and the whole patient experience pathway.

In this same cycle, the opportunities from attaining University Health Board status are there now to be reaped. This too will be underpinned by our organisational development approach and will help us achieve our Triple Aim intentions.

The Health Board’s workforce is clearly its most significant asset and it is through the commitment, professionalism and dedication of our staff that we are able to deliver high quality services to our population. The Health Board’s workforce plan is provided in detail in Chapter 7.

3.7 Performance During 2014-15, the Health Board remained committed to improving services to patients and achieving key targets set locally and by the Welsh Government. Good progress was made across the Health Board in 2013/14, which has been largely sustained during 2014/15. This includes areas such as improved patient flow which has enabled better unscheduled care services, winter planning and capacity for scheduled care service delivery. Chapter 2 provides a summary of our progress in 2014/2015.

1 The Tayside Centre for Organisational Effectiveness

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The Health Board reports regularly on its performance including the ‘Tier One’ targets set by Welsh Government. The key reporting mechanisms are through the Health Board, Executive Board, the Board’s Quality and Safety Committee, Finance and Performance Committee and through other Health Board meetings. The following provides a summary of current performance in a number of key performance and quality target areas. A fuller snapshot is available in our monthly Integrated Performance Dashboard, with the latest ‘At a Glance’ details attached at Annex A1.

Type of Target

Explanation of Target How we are performing

Delivering Local Health Care (Primary Care Delivery)

This relates to services provided outside of hospital.

Good progress has been made in establishing locality models which included some surgical services, ear, nose and throat services and outpatients.

Dignity in care This relates to areas of patient experience and how we provide treatment in a dignified way.

During the consultation run by the Older People’s Commissioner 12 key themes were identified where service users reported low levels of satisfaction. These were published in the “Dignified Care?” report. The Health Board developed a comprehensive plan which the Board continues to monitor and this remains one of our highest priorities for the older populations of Cwm Taf.

Quality in Care This relates to areas such as our infection and immunisation rates.

We are not currently achieving on all three Health Associated Infection indicators. We will continue to focus on reducing these as a priority.

Mortality Rates This relates to our death rates for specific conditions compared to similar types of services.

Producing timely mortality information is reliant upon timely clinical coding of consultant episodes. This has previously been a challenging target for the Health Board but significant progress has been made this year. Due to the poor general health of our population as well as other factors, such as no local hospice facilities, benchmarking of our performance in this area is problematic. We remain committed to improving in this area and are continually monitoring this target and have robust actions in place. We have an established mortality case note review of all hospital inpatient deaths.

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Access Elective Referral to Treatment Times

This relates to how long patients wait for planned procedures.

The Health Board has made progress in this area, however there have been particular problems in ophthalmology which have affected performance. The recent unscheduled care pressures over the winter months also impacted on our ability to deliver all of the elective care we would have wished. With the exclusion of ophthalmology, we are currently forecasting there will be no patients waiting over 52 weeks and fewer patients waiting over 36 weeks than last year. Ophthalmology has been a significant challenge and further detail can be seen later in the Plan in terms of our current improvement actions we are taking to remedy this situation.

Unscheduled Care This relates to how long people wait to be treated in our Minor Injuries and Emergency departments. It also looks at how long ambulances remain at hospital while patient care is transferred.

The Health Board has delivered and sustained improved performance in the area of unscheduled care for a large part of this year until the winter months when we have experienced significant pressures at our Accident and Emergency departments. Each acute hospital site regularly achieves above 90% in the handover of ambulances, which often puts the Health Board at the forefront in this area. The Health Board remains committed to making further sustainable improvements in all areas of unscheduled care access.

Cancer This relates to waiting times for those patients referred with either a non-urgent or an urgent suspected cancer.

The Health Board regularly meets the 31 day cancer target. Whilst the 62 day target remains challenging, there has been a recent improvement more recently with a minimum of 90% of patients being treated within 62 days, which we plan to sustain.

Efficiency and Productivity

This relates to how we deliver day surgery, when we admit patients for surgery, and how long patients stay in our hospital beds.

The improvements in hospital inpatient length of stay have been continued for a large part of this year but further work is required in other areas such as day of surgery admission and theatre utilisation. We have also set a 5% outpatient efficiency target for 2015/16.

Stroke This relates to how we treat patients with acute stroke.

Performance against the acute stroke bundles improved significantly in January to March 2014 as a result of the ring-fencing of stroke beds on our two acute stroke wards. This impacted positively on various

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performance indicators particularly in bundle 2 which has been challenging for all Health Boards across Wales. Welsh Government is proposing to introduce a new set of more challenging targets in 2015/16 against which we are now shadow monitoring our performance. Performance is also now reported on a quarterly basis against the RCP standards via the SSNAP audit which allocates an overall score of A (highest) to E (lowest). The Royal Glamorgan Hospital, along with most of the other hospitals in Wales, is currently at an overall level E, whereas Prince Charles rose to an overall level D in the latest quarter (July to Sept 2014). Our recently implemented redesign of stroke services is driven by the need to improve our compliance with these various clinical guidelines and performance targets.

Finance and HR Capacity Utilisation

This relates to whether the Health Board achieves financial balance and the achievement of annual local sickness and absence workforce targets.

Despite a significant financial challenge during the year, the Health Board is aiming to meet its statutory financial duty in 2014/2015. The Health Board is projecting breakeven in 2014/15 which will be a success given the challenging nature of the plan and a lower than average share of additional Welsh Government allocations. We have not met the sickness absence target consistently during the year. However, progress has been made with the specialist sickness team continuing to provide support and advice to directorates across the Health Board. By introducing designated HR support the Health Board has seen a noticeable decrease in the number of long term cases that are being supported.

3.8 Financial Overview The Health Board is forecasting a breakeven position for 2014/2015. The underlying projected deficit the Health Board will take into the 3 year plan period is £9.4m. The financial outlook resulting from this underlying deficit and the further real terms reduction in resource allocations over the plan period presents a significant challenge to the Health Board. The achievement of a balanced financial plan over the three years of the plan

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assumes redesign and efficiency savings of £43.2m over the next three years (9.3% of controllable expenditure), plus £5.1m of non recurring savings in 2015/16.

The Health Board has a Plan which sets out a range of inter-related, innovative service changes across the health system, which taken together will be critical enablers for achieving the priority objectives outlined at the start of the Plan, and particularly the development of primary and community care to enable a re-focussing of care towards community settings. These enablers are also critically important to successfully deliver the South Wales Programme changes, which will have the greatest impact on Cwm Taf.

The upfront costs of this package of change are significant and it is this which requires the headroom funding of £12.4m as it cannot be afforded within the allocations already announced. This package of investment, and agreeing the additional Welsh Government funding without which it would be unaffordable, is an absolutely critical element of the Plan and further detail on the underpinning funding plan can be seen in Chapter 9. This shows that the Health Board plans to deliver a break-even position over the three year period.

3.9 Partnership Working and Co-Production The Health Board has embraced the ideals of co-production, which offers a transformative, whole-system approach to public service delivery. This underlying philosophy values individuals, builds upon their own support systems and considers their place in the wider community. This approach requires us to move away from service-led or top-down approaches to one of genuine citizen empowerment, involving service users and their communities in the co-commissioning, co-design and co-evaluation of services. This radically different approach to the planning and provision of health care will need new skills and attitudes, along with health care systems that operate very differently to the way in which they currently work. This will be challenging, however above all, we recognise that managing the increasing pressures on statutory sector services associated with demographic changes and the growth in health expenditure, needs a ‘transformational’ change. This can only be achieved by developing a genuine and reciprocal partnership between professionals, service-users and their communities with patient centred, inspirational leadership. Good examples of co-production can be found in our approach to mental health planning and service development. Services users and carers are members on the Together for Health Mental Health Partnership Board and we also have a service user involvement project that enables users to

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take part in the design and development of new projects and services. Further detail plans and priorities for partnership working and co-production can be seen in Chapter 5. Single Integrated Plans

The Health Board recognises the fundamental principles of working with partners to produce and implement collaborative strategies which encompass a range of priorities relating to Health, Social Care and Wellbeing, Children and Young People and Community Safety. The Local Service Boards (for Rhondda Cynon Taf, Merthyr Tydfil and a Regional Collaboration Board covering both areas) are at the heart of our multi agency planning, agreeing strategic priorities and driving improvements in service areas to tackle the most difficult problems facing our communities. The local priories for partnership working are captured within the Single Integrated Plans (SIPs) for each county borough council area. Following the first year of implementation, partners have reviewed and refreshed the Plans for both Merthyr Tydfil and Rhondda Cynon Taf. The Health Board is a joint signatory to both SIPs and they have been aligned to the Health Board’s plans. This can be seen further in Chapter 5 in the Plan when we come to specific actions and deliverables. Social Services and Wellbeing (Wales) Act 2014 This Act simplifies the web of legislation that previously regulated social care in Wales and is designed to make access to services easier and more understandable to those who need them. It will cover services for both children and adults and will, as far as possible, integrate the arrangements for both of these groups so that social care is provided on the basis of need and not age. The Act focuses on

• People – putting an individual and their needs at the centre of their care, giving them a voice and control over reaching outcomes that help them achieve wellbeing.

• Wellbeing - supporting people to achieve their own wellbeing with better access to information and community support.

• Earlier intervention – increasing preventative services within the community to minimise the escalation of critical need.

• Collaboration – strengthening duties of collaboration between social services and the NHS as well as strong partnership working with other agencies including the Third Sector.

• Integration - more effective and better integrated models of care and support which provide a more responsive range of services

• Workforce - a better qualified workforce with skills that enable people to work across organisational boundaries.

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A Regional Partnership Board has been established and a collaboration agreement developed to develop and implement plans and to provide assurance that the Cwm Taf health and social care community will be ready to deliver the requirements of the Act when it goes live on 1st April 2016. In preparing for the implementation of the Act particular considerations for the UHB are population and individual assessments; the delivery or procurement of services which promote wellbeing; the provision of information, advice and assistance; safeguarding; and promoting social enterprises. Integrated Services Good progress has been made within Cwm Taf in developing a range of intermediate care services. Examples include the Community Equipment Store; Reablement; Community Mental Health Teams; and the Integrated Family Support Team. During 2015/16 the further development of integrated services will focus upon:

• Implementation of a Joint Commissioning Statement for Older People/ the frail elderly.

• Development of an integrated @Home service. • Further development of integrated intermediate care services,

building upon the experiences of the Intermediate Care Fund in 2014/15.

• Further roll-out of integrated assessment. Securing better outcomes for older people, preventing crises, promoting independence and well-being through joint commissioning and the development of integrated services will be the key drivers.

________________________

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4. LOCAL POPULATION HEALTH NEEDS AND CHALLENGES

This chapter sets out our local population needs and challenges that drive

the provision and development of our services across the whole system of services we provide.

All Health Boards have a two-fold role; to look after people when they are ill and also to work closely with their partners to improve the overall health of their local population. Like all Health Boards in Wales, Cwm Taf is facing significant challenges to manage changes in the population and the associated growth in health expenditure. In this context, we recognise that demographic changes alone will compel us to reform health care. Keeping pace with this increasing demand and the rising costs of health care will require a very different approach. Cutting health care is unlikely to be the solution to this challenge because health ‘need’ will move from one setting to another, potentially costing more. We will need to take an approach that delivers ‘transformation through innovation’ and it is more important than ever that we understand the way our population is changing and that we renew the focus on improving population health overall. Working in partnership with Local Authorities, Third Sector partners and our local community and in particular, embracing the philosophy of co-production, is a key tenet of our approach.

‘Together for Health’ set out the tough challenges facing our healthcare system in Wales which it identifies to be – a rising elderly population, enduring inequalities in health, increasing numbers of patients with chronic conditions, rising obesity rates and a challenging financial climate. It grouped these challenges into five main themes:-

• Health has improved but not for everyone and our population is ageing;

• Health care quality has improved but the NHS can do even better; • Expectations are continually rising; • Medical staffing is becoming a real limitation on our services; • Funding is limited.

We recognise these as very real challenges reflected in our own local population and are challenges that we must face, as we continue to deliver high quality services.

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4.1 Population Demography The resident population of the Health Board area is estimated to have been 295,135 in 20132 accounting for 10 per cent of the Welsh population. Cwm Taf is geographically the second smallest Health Board area in Wales, but also the second most densely populated area. Compared to the Wales average there are over three times as many people per square km living in the Health Board area. Within Cwm Taf, 20 per cent of the population live within the County Borough of Merthyr Tydfil with the remaining population living within Rhondda Cynon Taf. Merthyr Tydfil contains the smallest population whilst Rhondda Cynon Taf has the second largest population of all local authorities in Wales. The catchment population served by the University Health Board increases when including the Upper Rhymney Valley, South Powys, North Cardiff and the Western Vale. Table 1 below illustrates the estimated population and gender numbers by locality (co-terminous with former Borough Councils) across the Cwm Taf Health Board area, in 2010.

Table 1 – Cwm Taf Resident Population Distribution (2010

The age profile of our population is similar to Wales but with slightly higher proportions of persons aged under 5 years and in the 20-44 year age group, and slightly higher proportions of persons aged 60 and over.

In 2013 there were approximately 303,400 individuals registered with Cwm Taf Health Board general practices3. This includes patients registered with practices located at the Health Board boundary and who live in neighbouring Health Board areas.

2 https://statswales.wales.gov.uk/Catalogue/Population-and-Migration/Population/Estimates/Local-

Authority/PopulationEstimates-by-LocalAuthority-Year 3 Public Health Wales Observatory, GP Cluster Profile (Cwm Taf HB), using Welsh Demographic Service, NHS Wales Informatics

Service data, 2012.

Males Females Persons

Cynon Valley 30200 32300 62500

Merthyr Tydfil27200 28500 55700

Rhondda Valley 33800 35400 69200

Taff Ely 50400 52200 102600

Cwm Taf HB 141600 148400 290000

* rounded to the nearest 100 persons

Produced by the Public Health Wales Observatory, using MYE (ONS)

Rounded mid-year population estimates*, former borough

councils in Cwm Taf HB, 2010

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Table 2 – Number of practices and total list size, GP clusters in Cwm Taf HEALTH BOARD, 2012

The needs of the Cwm Taf population have been described at a smaller geographical level to inform health and social care planning at a local GP Cluster level. There are four separate GP Cluster Plans for the practices serving the Rhondda, Cynon, Merthyr Tydfil and Taff Ely populations based on the need of their local population. The central and northern areas of Cwm Taf share similar deprivation and health profiles whereas the population of South Taf Ely experience less deprivation and better heath. These characteristics are reflected in the Cwm Taf population level analysis that follows.

4.2 Cwm Taf Population Projection Current projections see a rise in the total resident population of Cwm Taf to 298,600 by the year 2033. This is primarily due to a rise in the older population. The number of residents age 75 years and over is projected to rise from 23,300 (7.9 per cent of total population) in 2013 to 37,100 (12.4 per cent of total population) in 2033. The number of persons aged 65 and over resident in Cwm Taf is projected to increase by 37% over the same period4. Overall, our population is living longer and the increase in elderly population is likely to result in an increase in the prevalence of chronic conditions such as circulatory and respiratory diseases and cancers.

4 Data source: Older Peoples Indicator Report http://howis.wales.nhs.uk/sitesplus/922/page/52072

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Meeting the needs of the growing elderly population will be a key challenge for the Health Board. In the current economic climate, the relative (and absolute) increase in economically dependent and, in some cases, care-dependent populations will pose particular challenges to communities.

4.3 Deprivation Overall the health of our population is improving however, within the Health Board we have areas of significant deprivation and far too many people still experience poor health. Many of the causes of poor health are difficult to tackle. Cwm Taf is an economically deprived area, with low levels of employment and educational attainment. These factors, along with other aspects of the physical environment, impact on the lifestyles of people living in the Health Board area. Within the Health Board boundaries there are well recognised areas of deprivation, particularly in the post industrial areas such as in the Rhondda and Cynon Valleys and Merthyr Tydfil as illustrated in Figure 2. Within Cwm Taf, 34% of the resident population live in the most deprived areas of Wales as determined by the Welsh Index of Multiple Deprivation (2011). The Health Board has the highest proportion of LSOAs5 in the most deprived fifth in Wales6.

5 Following the 2001 Census the ONS derived a set of statistical geographies in England and Wales called super output areas

to improve the reporting of small area statistics. Lower Super Output Areas (LSOAs) contain around 1,500 people; Middle Super Output Area (MSOA) have a mean population of 7,500. Upper Super Output Areas (USOA) have a mean population of 32,000.

6 Deprivation fifths for Wales have been produced by ranking all Lower Super Output Areas (LSOAs) and grouping them into

five groups (fifths), based on the Welsh Index of Multiple Deprivation (2011). Recently published WIMD (2014), 31% of the resident population live in the most deprived areas of Wales.

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

2013

2014

2015

2016

2017

2018

2019

2020

2021

2022

2023

2024

2025

2026

2027

2028

2029

2030

2031

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2034

2035

2036

Estim

ate

d p

opula

tion c

ount

75+

65-74

45-64

25-44

15-24

5-14

0-4

Figure 1: Projected population, counts by age group, Cwm Taf UHB,

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Figure 2 – Pattern of Deprivation, Cwm Taf University Health Board (WIMD 2011)

4.4 Health Inequalities There is a significant variation in people’s life expectancy across Wales, with those living in the most deprived communities living shorter lives than those in the least deprived areas. The comprehensive review of health inequalities in England7 demonstrated the clear causal link between deprivation and poor health. Deprivation is a wider concept than poverty (lack of money) and refers to wider problems caused by a lack of resources and opportunities. The Welsh Index of Multiple Deprivation (WIMD) is constructed from eight different types of deprivation – income, housing, employment, access to service, education, health, community safety and physical environment. The deprivation-health link is demonstrated for Cwm Taf in the maps below, which show that areas of greatest deprivation generally also experience higher mortality in the under 75 age group.

7 Fair Society: Healthy Lives (The Marmot Review), University College London, 2010

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Figure 3 - Deprivation and Premature Mortality in Cwm Taf

The association between deprivation and health is clearly apparent with the differences in the mortality rates demonstrated between our most deprived communities and least deprived areas

Figure 4 - Mortality in males under 75 in Cwm Taf, Europ100,000 population

Source: Public Health Wales Observatory

Deprivation and Premature Mortality in Cwm Taf

The association between deprivation and health is clearly apparent with the differences in the mortality rates demonstrated between our most deprived communities and least deprived areas (Figure 4).

Mortality in males under 75 in Cwm Taf, European age standardised rates (EASR) per

Source: Public Health Wales Observatory

The association between deprivation and health is clearly apparent with the differences in the mortality rates demonstrated between our most

ean age standardised rates (EASR) per

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In excess of 40% of the populations of Rhondda and Cynon Valleys and Merthyr Tydfil live in the most deprived areas of Wales. The proportion is much lower in Taff Ely (19%) yet still represents 19,800 individuals (table 4). Table 3 – Population distribution, by deprivation (Cwm Taf Localities)

Deprivation not only limits life expectancy8, it also is a determinant of the age at which we lose our good health. Barnett et al (2012)9 found that this occurs 10-15 years earlier in those living in the most deprived circumstances compared with the most affluent. Individuals no longer living in ‘good health’ are also more likely to have multiple morbidities, and for mental health issues to be one of their diagnoses. The marked difference in healthy life expectancy10 across Wales is shown in Figure 4. In Cwm Taf the healthy life expectancy for women (2005-09) is 60.6 years, the lowest in Wales and statistically significantly shorter than all other Health Board areas. For Cwm Taf males the equivalent is just 60 years, again the lowest in Wales and statistically significantly shorter than all other Health Board areas.

The Male Life expectancy at birth in England in 2011-13 was 79.4 years, and 78.3 years in Wales. This was less in RCT (76.5 years) which was ranked 340 out of the 346 local authority areas in England and Wales for male life expectancy at birth, and Merthyr Tydfil (76.9 years) was ranked 330 out of 346 local authorities. Female Life expectancy at birth in England was 83.1 years; Wales 82.3 years; RCT 80.8 years (334 out of 346 local authority areas) and Merthyr Tydfil 80.9 years (331 out of 345 local authorities).

8 Life expectancy is the average number of years an individual of a given age (usually a new born) is expected (in a statistical

sense) to live if current age-specific mortality rates continue to apply. 9 Epidemiology of multi-morbidity and implications for health care, research, and medical education: a cross-sectional study,

The Lancet, 10.05.12, DOI:10.1016/S0140-6736(12)60240-2 10 Healthy Life Expectancy represents the number of years a person can expect to live in good health, and is often used as a

measure of quality of life.

AreaLeast

Deprived

Next Least

DeprivedMedian

Next Most

Deprived

Most

Deprived

% living in

most deprived

fifth

Cynon Valley 4,200 1,600 14,200 16,600 25,900 41.5

Merthyr Tydfil 1,500 3,000 10,400 17,100 23,800 42.6

Rhondda Valley 1,400 1,600 8,800 27,700 29,700 42.9

Taff Ely 24,300 21,900 19,100 17,600 19,800 19.3

Cwm Taf HB 31,300 28,100 52,500 79,000 99,100 34.2

*Rounded to the nearest 100 persons

Produced by Public Health Wales Observatory, using MYE (ONS) and WIMD 2011 (WG)

Population* by fifth of deprivation, former Cwm Taf county districts, 2010

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Figure 5 - Life Expectancy & Healthy Life Expectancy

Females Males

Inequity in life expectancy is also evident within the Cwm Taf area, as illustrated in Figure 6. The difference in life expectancy between males in the most and least deprived areas of Cwm Taf is 8 years. In other words, a male born in the least deprived area of Cwm Taf can expect to live 8 years longer than a male born in the most deprived area. For females the equivalent difference in life expectancy is 6 years.

Figure 6 – Life expectancy within Cwm Taf

The life expectancy gap between the least and most deprived is widening. Stark differences are further highlighted for healthy life expectancy and disability free life expectancy11 within Cwm Taf.

11 Disability Free Life Expectancy represents the number of years a person can expect to live free of a chronic condition or

Limiting Long Term Illness.

81.5

82.7

81.8

82.0

81.0

81.2

80.0

67.9

67.5

66.3

65.7

64.5

63.4

60.6

45 50 55 60 65 70 75 80 85

Betsi Cadwaladr UHB

Powys THB

Cardiff and Vale UHB

Hywel Dda HB

ABM UHB

Aneurin Bevan HB

Cwm Taf HB

Healthy life expectancy Life expectancy

Life expectancy and healthy life expectancy at birth, ranked health boards,

females, 2005-09

Produced by Public Health Wales Observatory, using ADDE & MYE (ONS), WHS (WG)

x-axis truncated

95% confidenceinterval

79.1

77.3

77.3

77.4

76.9

76.5

75.4

67.7

65.7

64.2

64.0

62.0

61.7

60.0

45 50 55 60 65 70 75 80 85

Powys THB

Betsi Cadwaladr UHB

Cardiff and Vale UHB

Hywel Dda HB

Aneurin Bevan HB

ABM UHB

Cwm Taf HB

Healthy life expectancy Life expectancy

Life expectancy and healthy life expectancy at birth, ranked health boards,

males, 2005-09

Produced by Public Health Wales Observatory, using ADDE & MYE (ONS), WHS (WG)

x-axis truncated

95% confidenceinterval

45

50

55

60

65

70

75

80

85

Least deprived Next least deprived

Middle Next most deprived

Most deprived

Year

s

Males, SII = 8.0 (6.9; 9.1)

Females, SII = 6.0 (4.3; 7.8)

Produced by Public Health Wales Observatory, using ADDE, MYE (ONS), WIMD (WG)

Axis truncated

Life expectancy at birth by fifths of deprivation, Cwm Taf UHB, 2005-09

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Figure 7

12 The impact of living for longer in poor health on our health, social care and third sector services, and communities cannot be ignored. The Health Board has a role in reducing health inequalities through ensuring appropriate access to services and in working with partners to tackle the wider determinants of health.

4.5 Cause of premature mortality Cancers and circulatory disease are consistently the major causes of premature mortality in Cwm Taf. Over 60% of deaths in people under 75 years are attributable to these causes. Cardiovascular (circulatory) disease was selected as the focus of Cwm Taf’s Inverse Care Law Programme as it was one of the major causes of premature mortality in Cwm Taf for which there are clinically and cost effective interventions. The downward trend in cardiovascular deaths over the last decade has been greater than that for cancer. In 2012 38% of premature deaths were attributable to Malignant Cancer and 23.2% due to cardiovascular disease.

LE 2

005-0

9

HLE 2

005-0

9

DFLE 2

005-0

9

45

50

55

60

65

70

75

80

85

Least deprived Next least deprived Middle Next most deprived Most deprived

Year

s

LE 2005-09 HLE 2005-09 DFLE 2005-09

Life expectancy, healthy and disability-free life expectancy at birth, males, Cwm Taf HB

2005-09

Y-axis truncated

Produced by Public Health Wales Observatory, using ADDE/MYE (ONS), WHS/WIMD (WG)95% confidence interval

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Figure 7 – Percentage of all cause deaths caused by circulatory disease and malignant cancer Cwm Taf Health Board

4.6 Lifestyle and Health

There are consistently higher proportions of people reporting key illnesses in Cwm Taf than across Wales. For many of the lifestyles and key illnesses included in the Welsh Health Survey and the GMS Quality and Outcomes Framework, Cwm Taf is statistically significantly worse than Wales.

36.9 32.6 32.0 32.4 30.5 26.6 29.7 26.6 23.8 27.2 23.2

32.232.3 35.3 35.1 38.8

36.5 34.4 37.037.2

35.638.1

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Circulatory disease Malignant cancer

*Mortality for circulatory disease has not been adjusted for coding changes in 2011

Percentage of all-cause deaths caused by circulatory disease* and

malignant cancer, persons under 75, Cwm Taf UHB, 2002-2012Produced by Public Health Wales Observatory, using ADDE & MYE (ONS)

%

smoker

%

obese

Isle of Anglesey 25 20 2 3 2 10 10 10 1 1 1

Gwynedd 21 18 2 3 1 10 10 10 1 1 1

Conwy 22 17 2 3 2 10 10 10 1 1 1

Denbighshire 23 18 3 4 2 10 11 10 1 2 1

Flintshire 21 21 3 4 2 11 11 11 1 1 1

Wrexham 25 20 3 4 2 12 12 12 1 1 1

Powys 21 19 2 3 1 10 10 10 1 1 1

Ceredigion 22 19 2 3 1 10 10 11 1 1 1

Pembrokeshire 24 22 2 3 1 10 11 10 1 1 1

Carmarthenshire 21 24 3 4 2 10 10 10 1 2 1

Swansea 23 21 2 3 2 10 10 10 1 2 1

Neath Port Talbot 25 25 3 4 2 12 12 11 1 2 1

Bridgend 23 25 3 4 2 12 12 11 2 2 1

The Vale of Glamorgan 21 22 2 3 2 11 11 10 1 2 1

Cardiff 21 20 2 3 2 11 11 11 1 2 1

Rhondda Cynon Taf 26 25 3 4 2 13 13 12 1 2 1

Merthyr Tydfil 24 28 3 4 2 13 13 13 1 2 1

Caerphilly 23 26 3 4 2 13 13 12 1 2 1

Blaenau Gwent 28 26 3 4 2 13 13 13 1 1 1

Torfaen 26 26 3 4 2 12 12 12 1 2 1

Monmouthshire 18 18 2 3 1 10 10 9 1 1 1

Newport 24 22 3 4 2 12 12 11 1 2 1

Betsi Cadwaladr UHB 23 19 3 3 2 11 11 10 1 1 1

Powys tHB 21 19 2 3 1 10 10 10 1 1 1

Hywel Dda HB 23 22 2 3 2 10 10 10 1 1 1

ABM UHB 23 23 3 4 2 11 11 11 1 2 1

Cardiff & Vale UHB 21 20 2 3 2 11 11 11 1 2 1

Cwm Taf UHB 26 26 3 4 2 13 13 12 1 2 1

Aneurin Bevan UHB 24 24 3 4 2 12 12 12 1 2 1

Wales 23 22 3 4 2 11 11 11 1 2 1

Statistically significantly worse than Wales

Not statistically significantly different

Statistically significantly better than Wales

% CHD (QOF) % hypertension (QOF) % stroke (QOF)

Statistical significance is determined using the confidence intervals (CIs) of the local value. If

the national average falls outside the local CI, the difference is deemed to be statistically

significant.

M/F/P =

Males/females/personsM

P M FP P F F

Back to contents

page

P M FP M F

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Source: Public Health Wales Observatory, Cardiovascular disease indicators (WHS & QoF indicators)

The Welsh Health Survey is undertaken annually and provides information about the health of people living in Wales, the way they use health services and their health related lifestyle at a local authority level. A report produced by the Cwm Taf Public Health Team, aggregating six years of data from the Welsh Health Survey (2003/4-2009) at geographies below Local Authority level, has allowed more detailed analysis of the health of the population and highlights the differences across Cwm Taf13. Note: Due to the aggregation of data over several years, the results at sub-local authority level presented here appear different to those at local authority level due to the different time periods.

The key messages are:

• There are consistently higher proportions of people reporting key illnesses in Cwm Taf than across Wales. The highest percentages of people reporting key illnesses are generally in the Upper Super Output Areas14 of Merthyr Tydfil, Rhondda Fach, Rhondda Fawr and South Cynon.

• People living in all areas of Cwm Taf consistently report poorer health and have lower SF-36 physical and mental component summary scores than the average scores across Wales. People living in Merthyr Tydfil, the Rhondda and South Cynon report poorer health status than people living in North Cynon and Taff Ely. The self-reported health status in these areas is statistically significantly poorer than the rest of Wales.

• Health related lifestyles are generally poor in Cwm Taf. Six of the nine USOAs have statistically significantly higher proportions of people with a Body Mass Index (BMI) classed as overweight or obese. With the exception of Merthyr Tydfil North, all USOAs report lower physical activity levels than the rest of Wales; the percentage of adults reporting smoking is higher than for Wales for all USOAs with the exception of North Cynon and South West of Taff Ely. Highest levels of smoking are seen in South Cynon and North Merthyr Tydfil.

• The use of GP and Hospital services varies among USOAs. A statistically significantly higher proportion of people in Rhondda Fach and Merthyr Tydfil North reported attending hospital because of accidents in the previous 3 months.

• The patterns exhibited for many of the indicators show associations between poor outcomes and area deprivation.

13 A profile of health and lifestyle in Cwm Taf. Cwm Taf Public Health Team. November 2013 14 Upper Super Output Area (USOA) is a statistical geography with a mean population of 32,000. There are nine USOAs in

Cwm Taf.

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A summary of the health and lifestyles measures at sub Local Authority level is shown overleaf12: Table 4: Summary of Measures – key health related lifestyles

Table 4: Summary of Measures – key illnesses or health status

The prevalence of chronic conditions in the Cwm Taf localities can be estimated from the Practice disease registers established as part of the GMS Contract Quality and Outcomes Framework as presented in a recent GP Cluster Report for Cwm Taf15.

15 GP Cluster Profile available at: http://www.wales.nhs.uk/sitesplus/922/page/67885

Adults who reported key health related lifestyles (age-standardised), by USOA, 2003/04-2009Per cent

USOA Name

Approximate Corresponding GP Cluster Area

Smoker (%)

Physical activity: meets

guidelines (%)

BMI: Overweight

or obeseBMI:

Obese

Rhondda Cynon Taf 001 Cynon South 30 29 62 23Rhondda Cynon Taf 002 Cynon North 23 28 58 22Rhondda Cynon Taf 003 Rhondda Fach 30 22 62 26Rhondda Cynon Taf 004 Rhondda Fawr 28 22 62 24Rhondda Cynon Taf 005 Taff Ely South West 21 28 62 23Rhondda Cynon Taf 006 Taff Ely North 29 27 62 26Rhondda Cynon Taf 007 Taff Ely South East 26 27 57 23Merthyr Tydfil 001 Merthyr Tydfil North 30 31 58 21Merthyr Tydfil 002 Merthyr Tydfil South 27 28 60 23WALES 25 30 56 20

Source: Welsh Health Survey. See WHS reports and webpages for full details of survey, methods and questions.

http://wales.gov.uk/topics/statistics/theme/health/health-survey/?lang=en


Adults who reported key illnesses or health status (age-standardised), by USOA, 2003/04-2009

Per cent

USOA Name USOA codeHigh blood pressure

Any heart condition (excluding high blood pressure)

Any respiratory

illness

Any mental illness Arthritis Diabetes

Any chronic illness

Limiting long term

illness (%)

General health status: fair or poor

health (%)

SF-36 Physical

component summary

score (1)

SF-36 Mental

component summary

score (1)

Rhondda Cynon Taf 001 3000059 23 12 17 12 16 8 52 34 29 46.6 47.8Rhondda Cynon Taf 002 3000060 22 9 16 10 17 5 50 31 23 48.0 48.9Rhondda Cynon Taf 003 3000061 24 11 17 13 21 5 55 29 31 47.2 47.2Rhondda Cynon Taf 004 3000062 22 11 17 14 19 6 54 33 30 46.7 47.9Rhondda Cynon Taf 005 3000063 22 9 14 9 13 6 48 28 22 48.7 49.5Rhondda Cynon Taf 006 3000064 19 11 15 13 16 6 53 28 21 48.4 47.9Rhondda Cynon Taf 007 3000065 21 12 14 13 16 7 49 27 24 48.0 48.6Merthyr Tydfil 001 3000066 22 11 15 14 18 6 52 32 29 47.1 47.4Merthyr Tydfil 002 3000067 24 11 16 12 20 7 54 33 29 46.7 47.7WALES 19 9 14 10 14 6 48 28 21 48.7 49.8

Source: Welsh Health Survey. See WHS reports and webpages for full details of survey, methods and questions.

http://wales.gov.uk/topics/statistics/theme/health/health-survey/?lang=en


Not statistically significantly different (1) higher score indicates better health

Statistically significantly better than Wales

Statistical s ignificance is determined using the confidence intervals (CIs) of the local value. If the national average fal l s outside the local CI, the difference is deemed to be statistically s ignificant.

Currently being treated for

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The absolute numbers are shown below and are likely to be an underestimate of true prevalence.

4.7 Ageing Population and Dementia Latest statistics predict an increasing proportion of people aged over 65 in the population. In particular, the rising costs of dementia (human, societal and economic) will be felt as our older population increases and the number of people becoming care dependant increases. This will have a significant impact on individuals, carers and health and social care services.

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Figure 9: Cwm Taf University Health Board population estimates of dementia by age band

Source: Public Health Wales Observatory http://howis.wales.nhs.uk/sitesplus/922/page/52072

The strength of evidence around dementia prevention is currently limited16. However, the ecurrent advice to prevent dementia includes advocating healthy lifestyles17,18,19 specifically:

- Stopping smoking

- Reducing alcohol intake

- Eating a healthy diet

- Participating in physical and social activity

It has been estimated that by promoting and adopting middle age, an individual’s risk of developing dementia could be reduced by approximately 20%20

4.8 Focus on Outcomes

The NHS Wales Delivery Framework 2013clarity about the delivery priorities and the need to focus on prevention, standards and outcomes. Framework for Wales 2014the NHS Delivery Framework published in November 2014. Simmunisation and Obesity are outlined below.

16

Public Health Wales (2012) Dementia: Prevention and Early Intervention. 17

The Cochrane Collaboration (2011)

Evidence Base. 8-11-2011 18

Aarsland D, Sardahaee F S, Anderssen S, Ballard C.

A systematic review. Aging Ment Health 2010;14(4):38619

Elwood P, Galante J, Pickering J, Palmer S, Bayer A, et al.

Diseases and Dementia: Evidence from the Caerphilly Cohort Study.doi:10.1371/journal.pone.0081877 20

Russ T C, Starr J M. Clinical Evidence Editorial (2010)

Group

0

500

1000

1500

2000

2500

3000

2011

Cwm Taf University Health Board population estimates of dementia by age band

: Public Health Wales Observatory Older People’s Indicators, (2012) Cwm Taf Health Board http://howis.wales.nhs.uk/sitesplus/922/page/52072

The strength of evidence around dementia prevention is currently . However, the evidence that is available suggests that the best

current advice to prevent dementia includes advocating healthy specifically:

Stopping smoking

Reducing alcohol intake

Eating a healthy diet

Participating in physical and social activity

It has been estimated that by promoting and adopting healthy lifestyles in middle age, an individual’s risk of developing dementia could be reduced

20.

Focus on Outcomes

NHS Wales Delivery Framework 2013-14 and Future Plansclarity about the delivery priorities and the need to focus on prevention, standards and outcomes. This has been reinforced in the NHS Outcome

or Wales 2014-2015: Right Care, Right Place, Right Time and the NHS Delivery Framework published in November 2014. S

and Obesity are outlined below.

Dementia: Prevention and Early Intervention. North Wales Public Health Team

Cochrane Collaboration (2011) Dementia and Cognitive Improvement Group. Review of 'Prevention of Dementia'

Aarsland D, Sardahaee F S, Anderssen S, Ballard C. Is physical activity a potential preventive factor for vascular dementAging Ment Health 2010;14(4):386-95

Elwood P, Galante J, Pickering J, Palmer S, Bayer A, et al. (2013) Healthy Lifestyles Reduce the Incidence of Chronic

Diseases and Dementia: Evidence from the Caerphilly Cohort Study. PLoS ONE 8(12): e81877.

Russ T C, Starr J M. Clinical Evidence Editorial (2010) Could early intervention be the key in preventing dementia?

2015 2020 2025 2030

Cwm Taf University Health Board population estimates of dementia by age band

(2012) Cwm Taf Health Board

The strength of evidence around dementia prevention is currently vidence that is available suggests that the best

current advice to prevent dementia includes advocating healthy

healthy lifestyles in middle age, an individual’s risk of developing dementia could be reduced

14 and Future Plans provides clarity about the delivery priorities and the need to focus on prevention,

This has been reinforced in the NHS Outcome Right Care, Right Place, Right Time and

the NHS Delivery Framework published in November 2014. Smoking,

North Wales Public Health Team

Dementia and Cognitive Improvement Group. Review of 'Prevention of Dementia'

Is physical activity a potential preventive factor for vascular dementia?

Healthy Lifestyles Reduce the Incidence of Chronic

Could early intervention be the key in preventing dementia? BMJ

65-69

70-74

75-79

80-84

85+

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4.8.1 Smoking

Tier 1 Target Domain: Need and prevention

• Smoking

– 5% of smokers make a quit attempt via smoking cessation services, with at least a 40% Carbon Monoxide

(CO) validated quit rate at 4 weeks

The Welsh Health Survey 2012/13 indicates that 24 % adults in Cwm Taf are smokers, which equates to approximately 59,100 individuals. To achieve the Tier 1 target, 2957 individuals in Cwm Taf, should make a quit attempt via smoking cessation services annually, and of these at least 40% would need to be carbon monoxide (CO) validated quitters at four weeks. Within Cwm Taf, approximately 3.8% of the smoking population made a quit attempt in 2013/14, based on quarter 1-3 data. Support is provided through our specialist NHS services, which includes Community Pharmacy, Stop Smoking Wales and a new Maternity Smoking Cessation Support Service (MAMMS) being piloted in the Rhondda. Between 25% (MAMMS) and 40% (community Pharmacy) were validated as quitters at 4 weeks. In addition to the above target, the Welsh Government has set an ambitious target to achieve a national smoking prevalence rate of 16% by 2020. To achieve this, approximately 7,200, or 11.5% of our smoking population would need to be referred each year to smoking cessation services. A recent economic study by Swansea University estimates that smoking accounts for:

The pattern of smoking across Cwm Taf is illustrated below:

- 22% adult hospital admission costs - 6% outpatients costs - 13% GP consultations - 12% practice nurse consultation costs - 14% prescribing costs

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Figure 10

At USOA level, 21 to 30 per cent adults reported smoking in Cwm Taf. Seven USOAs reported smoking above the Welsh average of 25 per cent. Smoking in one USOA (Taff Ely South West) was statistically significantly lower than the average for Wales. Two USOAs (Cynon South and Merthyr Tydfil North) were statistically significantly higher than the average for Wales. Chapter 5 outlines the actions we are taking to further reduce smoking prevalence in the Cwm Taf area.

4.8.2 Immunisation

Immunisation is a key public health intervention, preventing significant morbidity and mortality from a number of serious illnesses. High uptake rates are required to achieve “herd immunity‟. Once herd21 immunity is

21 Herd immunity is a form of immunity that occurs when the vaccination of a significant portion of a

population (or herd) provides a measure of protection for individuals who have not developed immunity.

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achieved little disease circulates in the community, with the effect that unvaccinated individuals are also protected.

Tier 1 Target Domain: Need and prevention

• 95% vaccination of all children to age 4 with all scheduled

vaccines. (This is the best in Wales)

• Immunisation – 75% uptake of influenza vaccination among:

• 65 years and over

• Under 65s in at risk groups

• Pregnant women

– 50% uptake of influenza vaccine among Health care

workers

Immunisation uptake is increasing year on year in all our target groups.

Our level of flu immunisation for patients has increased, but much more work is needed to support all practices to achieve the 75% uptake in all target groups. This is detailed in action plans and will ensure that we continue to increase towards target levels. We have increased our staff immunisation rate from a very low base of 9% to being within reach of the 50% target for 2013/14. Further work will be undertaken for 2014/15 and onwards to achieve and exceed this target.

We achieve the 95% target rate for most of the individual childhood vaccines, but do not yet achieve the composite target. However with the collaborative multi-disciplinary working we have in place this is resulting in increasing rates each quarter. In addition, definitive areas each have their own action plans which are also contributing to increasing uptake.

4.8.3 Obesity

The burden of ill health caused by being overweight and obese has rising health and cost consequences and implications.

Most recent data from the Welsh Health Survey shows that the levels of overweight and obesity are levelling out; 63% of adults in Rhondda Cynon Taff, and 65% in Merthyr Tydfil describe themselves as overweight or obese compared to the Wales average of 59% (Welsh Health Survey 2012-13). This is the highest for all Health Boards in Wales and significantly higher than the Wales average of 59%.

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A more detailed analysis of Welsh Health Survey data, for Cwm Taf, shows that Cwm Taf Health Board has the highest percentage of the most severely obese people (BMI 40+), compared with other Health Boards in Wales. The numbers of adults who are obese is startling, with: • 62,400 adults have a BMI of 30+ • Of these, 20,500 have a BMI of 35+ • Of these, 6,300 have a BMI of 40+ • Of these, 900 have a BMI of 50+

Health BoardNumber in

pop.*(95% CI)

Number in

pop.*(95% CI)

Betsi Cadwaladr UHB 116,700 (110,900 - 122,500) 34,400 (31,000 - 37,800)

Powys tHB 22,000 (19,300 - 24,700) 7,000 (5,500 - 8,500)

Hywel Dda UHB 76,500 (71,400 - 81,600) 23,500 (20,400 - 26,700)

ABM UHB 100,900 (94,700 - 107,100) 33,200 (29,300 - 37,000)

Cardiff & Vale UHB 74,000 (68,000 - 80,000) 24,200 (20,700 - 27,800)

Cwm Taf UHB 62,400 (57,800 - 66,900) 20,500 (17,700 - 23,300)

Aneurin Bevan UHB 117,000 (111,200 - 122,800) 38,500 (34,800 - 42,100)

Wales 569,500 (555,500 - 583,500) 181,200 (172,600 - 189,700)

Produced by Public Health Wales Observatory using WHS (WG), MYE (ONS)

* Estimated number rounded to nearest 100

BMI 30+ BMI 35+

Estimated number of people in the population aged 16+ with a BMI of 30 and over

or 35 and over, Wales health boards, 2011-12 obesity prevalence applied to 2013

population estimates

48

50

52

54

56

58

60

62

64

66

2004/6 2005/7 2007/8 2008/9 2009/10 2010/11 2011/12 2012/13

Adults with a BMI classified as overweight or obese

(%, age-standardised) 2003/05 - 2012/13

Produced by Cwm Taf Public Health, using WHS (WG) data

Rhondda Cynon Taf Merthyr Tydfil Cwm Taf UHB Wales

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Health Board

Number in

pop.* (95% CI)

Number in

pop.* (95% CI)

Betsi Cadwaladr UHB 9,600 (8,500-10,600) 1,300 (900-1,700)

Powys tHB 1,600 (1,100-2,000) 200 (0-300)

Hywel Dda HB 5,500 (4,700-6,400) 800 (500-1,100)

ABM UHB 9,000 (7,800-10,200) 1,200 (800-1,600)

Cardiff & Vale UHB 7,200 (6,000-8,300) 800 (500-1,200)

Cwm Taf UHB 6,300 (5,300-7,300) 900 (500-1,300)

Aneurin Bevan UHB 11,200 (10,000-12,400) 1,600 (1,200-2,100)

Wales 50,300 (47,600-53,000) 6,800 (5,800-7,800)

Produced by Public Health Wales Observatory using WHS (WG), MYE (ONS)

* Estimated number rounded to nearest 100

Estimated number of people in the population aged 16+ with a BMI of 40 and over or

50 and over (based on WHS data for 2007 - 2012), Wales health boards, 2012

BMI 40+ BMI 50+

The map, below, illustrates the extent of obesity, by USOA in Cwm Taf (2003/4-2009). Compared with the Wales average of 20%, all areas in Cwm Taf have levels of obesity above 20%.

Data from the All Wales, Child Measurement Programme shows that Cwm Taf has highest prevalence of overweight and obesity in this age group.

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Child Measurement Programme: % children aged 4/5 who are overweight or obese (2013) Source: Public Health Wales

The Child Measurement Programme has only reported twice and so assumptions on trends in childhood obesity should be treated with caution until more information for future years becomes available.

Fruit and vegetable consumption for adults and children in Cwm Taf is below the Welsh average, as are physical activity rates. Chapter 7 outlines the actions we are taking to tackle obesity in the Cwm Taf area.

4.8.4 Alcohol

Alcohol misuse is a major preventable cause of premature mortality, and the estimated annual NHS cost of dealing with alcohol in Wales is between £70-85 million. Alcohol related mortality shows a clear connection with health inequalities, in that whilst alcohol consumption is highest in the least deprived groups, alcohol attributable mortality rates are three times higher in the most deprived groups.

Alcohol consumption above guidelines is higher in Cwm Taf Health Board (43%) than Wales (42%). Binge drinking is statistically significantly higher in Cwm Taf Health Board (29%) than Wales (26%). Rhondda

0

10

20

30

40

50

60

70

80

Rhondda

Cynon Taf

Merthyr

Tydfil

Blaenau

Gwent

Wales

Overweight or obese

Overweight not obese

Obese

0

10

20

30

40

2011/12 2012/13

%

% children aged 4/5 who are overweight or obeseSource: Public Health Wales, Child Measurement Programme

Rhondda Cynon Taf Merthyr Tydfil Cwm Taf Health Board Wales

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Cynon Taf (29%) has the joint highest proportion of people reporting binge drinking in Wales (WHS, 2012/13).

4.8.5 Conceptions Despite a downward trend within Cwm Taf, rates of teenage conceptions have been consistently higher than the Welsh average for many years as illustrated in the graph below. The under 18 conception rate in Merthyr has come down from 54.1 in 2011 to 31.9 in 2012, and in RCT from 40.3 in 2011 to 35.5 in 2012. For comparison, the rate for Wales has reduced from 34.2 in 2011 to 30.8 in 2012.

0

5

10

15

20

25

30

35

2003/5 2004/6 2005/7 2007/8 2008/9 2009/10 2010/11 2011/12 2012/13

Adults reporting binge drinking of alcohol (%, age-standardised) 2003/05 - 2012/13

Produced by Cwm Taf Public Health Team, using WHS (WG) data

Rhondda Cynon Taf Merthyr Tydfil Cwm Taf UHB Wales

0

10

20

30

40

50

60

70

80

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Ra

te p

er

1,0

00

fe

ma

les

Conceptions in females aged 15-17 rate per 1000 females, 2003 -

2013Produced by Cwm Taf Public Health Team using ONS data England

North East England

Wales

RCT

MT

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Further analysis of data over a 6 year period (2005-2010) has allowed mapping of conception rates in females aged under 18 years, by electoral division to help inform targeting of services. The darker shaded areas highlight the electoral wards with higher rates of conceptions for under 18s. Across Cwm Taf, the rates of 19 wards were statistically significantly higher compared to Wales. Action has been targeted to these areas.

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Chapter 7 outlines the actions we are taking to reduce teenage conception and alcohol consumption in the Cwm Taf area.

In summary, our key messages are:

• By 2033 the population growth in Cwm Taf is projected to result in a 59% increase in the number of residents over 75 years of age.

• The increase in elderly population is likely to result in an increase in prevalence of dementia, chronic conditions such as cardiovascular, respiratory diseases and cancers.

• Of all Health Boards, Cwm Taf Health Board has the highest proportion (34%) of its population living in the most deprived areas of Wales; 61% live below the Wales median of deprivation; Deprivation is not confined to small geographical areas; indeed three of the four localities (Merthyr, Cynon and Rhondda Valleys) have in excess of 40% of their population living in areas classed as the most deprived in Wales. As few as 11% of the Cwm Taf population live in the least deprived.

• Residents of Cwm Taf experience the lowest life expectancy in Wales. A male born in Cwm Taf can expect to live 75.4 years (Wales average 77 years), of which only 60 years are in “good” health. Males living in the most deprived areas of Cwm Taf live 23 years, almost one third of their lives with a limiting long term illness or disability.

• Cardiovascular disease and cancers are the major causes of premature mortality (under 75 years) in Cwm Taf residents.

• There are consistently higher proportions of people reporting key illnesses and unhealthy lifestyles in Cwm Taf than across Wales (Welsh Health Survey). The prevalence of chronic conditions is higher in Cwm Taf than the Wales average (GMS Quality and Outcomes Framework) and this is likely to be an underestimate of the true prevalence in the population.

• Teenage conception rates are reducing yet remain among the highest in Wales.

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5. STRATEGIC CONTEXT This chapter sets out the strategic context in which we intend to operate as a Health Board during delivery of the Plan and includes an overview of our clinical strategy, priorities, performance trajectories and importance of delivering integrated services, working in partnership with others. 5.1 Our Journey

As stated in our Executive Summary, the last few years have been very challenging for the Health Board. It acknowledged its own position in 2011/12 as the start of a journey from ‘turnaround’ to ‘transformation’. The Health Board is on this journey and is demonstrating the maturity necessary to continue its journey through a ‘transformational into a developing stage’ over the next three years, underpinned by a clear and integrated programme of strategic and organisational development with a focus on:

• reducing ill health across our communities; • strengthening core primary care services through extending

enhanced services across federated practices to improve equity of access;

• developing Cluster Hubs to further drive locality working, thus facilitating a demonstrable shift of service from secondary to primary care;

• implementing innovative workforce and service models in primary, community care services which have reduced unnecessary hospital admissions and delivered a demonstrable shift of services from secondary to primary care;

• delivering truly integrated services with our partners across areas such as health and social care and reablement services, particularly for children and the frail elderly;

• implementing redesigned secondary care service models across our ‘fragile’ service areas, as part of wider alliance arrangements with our partner LHBs and Trusts and;

• embedding prudent healthcare in our service planning and delivery.

5.2 Priorities As a University Health Board, our over-arching priorities for 2015-16 are:-

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• Continue to improve patient experience throughout the Health Board.

• Develop our clinical service strategy, including the implementation of the outcomes of the South Wales Programme and ensure innovation and prudent healthcare is at the heart of our service provision and redesign.

• Implement our refreshed primary and community care plans including evidencing the shift from secondary to primary care.

• Continue to develop truly integrated services with our partners including Local Authorities and the Third Sector, across areas such as health and social care and reablement services, particularly for children and the frail elderly.

• Continue to improve scheduled & unscheduled patient care, patient flow and urgent care processes.

• Engage with an increasing number of members of the public in Cwm Taf through our regular public fora events and social media.

• Continue work to meet the 62-day cancer target

• Involve patients in the design and development of new clinically led and patient focused services, both in and out of hospital.

• Improve data quality and business intelligence, including reporting and transparency.

• Address high sickness rates amongst staff.

• Ensure compliance with legislation.

• Achieve financial balance.

5.3 Key Messages In terms of key messages about the context we are operating in, the following sets out some of the most pressing: • Demand is increasing in primary care, community services and

diagnostic services and we need to continue to address this in order to enable secondary care admission reduction.

• There is overall an underlying demand pressure due to the ageing population.

• While non-elective activity has not been growing significantly, this is due to the demand management and community alternatives to admission from initiatives the Health Board have put in place such as CIAS.

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• In addition, as it is the less complex cases that are being avoided, the casemix and dependency of the remaining cases admitted into secondary care is greater.

• A total planned savings over the 3 year period of £43.2m which represents a reduction of around 9.3% of the Health Board’s controllable expenditure (excluding capital charges and primary care contracts), around 3.1% per annum.

• Recurring investment in new service and delivery models of £2.0m each year, across three years, plus a further recurring investment in 2015/16 of £12.4m in Primary & Community care & Innovation - subject to Welsh Government funding to provide better patient care at lower cost.

• A key enabler of the new clinical models in the South Wales Programme will be, significantly improved primary care in order to deliver increased pre-hospital differentiation of patients requiring emergency care. £12.4m has been built into the plan from 2016/17 to improve services, with a fundamental element of this to address this challenge for primary care.

• Provision of £5.7m has been made in 2015/16 for the non-recurring costs of the change programme and to meet non-recurring cost pressures and partly funded through an agreed £1.9m Invest to Save allocation from the Welsh Government.

5.4 Clinical Strategy As the basis for our clinical strategy, it is acknowledged that within the Health Board, we face significant challenges in 2015/2016 and over the following years, particularly in terms of improving health outcomes for our communities, system sustainability, performance and ensuring the financial health of the organisation. The report ‘A decade of austerity in Wales? The funding pressures facing the NHS in Wales to 2025/26’ sets out clearly the tough challenges facing our healthcare system in Wales. It highlights the situation where funding for the Welsh NHS is being reduced in real terms whilst the demand pressures on services continue to rise. These pressures come from a growing and ageing population and rising unit costs largely due to wage pressures. This sets a challenge to the Health Board and the people of Wales to recognise that whilst huge strides have been made in recent years, the status quo is no longer an option. The Future Generations (Wales) Bill looks to future-proof our communities to ensure that they are protected from pressures that threaten their viability and survival. This means that in meeting pressing short term needs, as a Health Board, we must also make every effort to safeguard the long term interests of our local communities by addressing

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intergenerational challenges such as health inequalities, raising skills, and mitigating the impact of climate change. Our local Public Health Strategic Framework 2012-13 provides further detailed commentary on the health of the communities that we serve and is in congruence with the Public Health Wales 3 Year Plan which sets out to increase healthy life expectancy by five years by 2023. Importantly for us, in 2015/16 we will commence implementing our Joint Commissioning Statement for Older People in Cwm Taf. This describes our next step service model for older people with complex needs and services for the frail elderly. It will determine how the Health Board and Local Authorities will either provide services or procure services from the Third Sector, independent sector or social enterprises, which will span universal to specialist needs. The Health Board has also undertaken local needs assessments both for its GP cluster populations and carried out specific studies in areas such as heart disease and critical care, to support the development of our service planning and redesign, and some of the key issues are described in Chapter 3 – Local Health Needs & Challenges. Our programme of work is designed to reduce health inequalities through the targeted provision of highly integrated disease prevention and health promoting primary care and community focused services. Through this and wider work, the Health Board and the Cwm Taf Public Health Team continue to work with statutory and Third Sector partners in implementing local action plans targeted at: Work is currently underway with our clinicians and partners to refresh our clinical service strategy and determine next steps in our local service planning and delivery, including a strengthened commissioning approach and improved demand management. This is informed by All Wales strategic documents such as ‘Together for Health’, ‘Our Plan for a Primary Care Service for Wales up to March 2018’ and All Wales Service Delivery Plans, as well as work delivered as part of

� Reducing smoking prevalence rates � Reducing levels of obesity. � Reducing teenage pregnancy rates. � Improving mental health and wellbeing. � Reducing the harm from alcohol and drugs. � Increasing vaccination and immunisations

rates. � Reducing accident and injury rates.

Improving health at work.

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the South Wales Programme, which is now moving into its implementation phase. The Health Board is firmly committed to the need to further improve service integration both within its own clinical services and together in partnership with other Local Health Boards, Local Authorities, the Third Sector and local communities. Further details can be found in Chapter 7, Service Change Plans and Prudent Healthcare on our services initiatives and change plans and in the Director of Public Health’s Annual Reports including the most recent Annual Report for 2013. Finally the work we have undertaken with our partner LHBs and Trusts as part of the South Wales Programme has shown the major and innovative service design we need to be undertaking and implementing over coming months and years in partnership with our staff and communities, in fragile service areas such as paediatrics, obstetrics, neonates and emergency medicine, in order to ensure they remain high quality and sustainable services for the future. This includes plans for exciting developments such as the Diagnostic Hub, acute medicine model and Paediatric Assessment Unit in the Royal Glamorgan Hospital The Health Board is implementing its whole-system, integrated healthcare strategy for the benefit of our patients and the populations we serve. This is our blueprint for creating healthier communities and ensuring that effective and high quality healthcare services lie at the heart of our service delivery and patient experience. In our clinical strategy model, primary and community care must be the foundation of integrated care, where we support patients by building services around their needs. This requires us to continue to bring processes together both within our organisation and with partners; to bring our professionals further together in the spirit of much closer working and all with the aim of improving outcomes for patients and overall population through the delivery of integrated care. The pace of integration is being accelerated where service outcomes for the patients and populations are clear to see. Traditionally, the healthcare system can be represented by the diagram outlined in figure below.

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The future model of care will need to continue to follow a similar relationship, however, the dynamic is likely to change to reflect the descriptors outlined in figure below.

Whilst there are continually evolving changes and developments within all components of the model, it is within the Locality Services and the Integrated Primary Care and Community Services areas that the most

Tertiary Services

DGH Services

Community Services

Tertiary Services

DGH Services

Locality Services

Integrated Primary Care and Community Services

Self Care and Supported Self Care

Increased focus on proactive assessment with sign-posting to a range of statutory and non-statutory services to help people stay healthy and support independent living where necessary

Joint working between all contractor professions (not just GPs) and community-based health and social care services focusing on prevention, early intervention, reablement and rehabilitation

Primary Care, Community and Secondary Care clinicians working together at locality level, in line with Prudent Healthcare principles to deliver more equitable and specialised out-of-hospital care

Hospitals and Hospital Clinicians working together across organisational and professional boundaries to deliver joined-up services but potentially in a smaller number of places. Some traditionally tertiary services devolved to DGHs in networked arrangements.

Highly specialised care delivered in a very small number of places as part of a networked approach to integrated patient care

Cwm Taf Primary and Community

Services Strategy

Self Care

Primary Care

(Predominantly GPs)

This basic model remains largely unchanged since the inception of the NHS. The levels of care and their linear relationship remain the same although the capacity and capability for treatment, particularly within DGH and tertiary care has changed beyond all recognition over the 60+ years.

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significant change needs to happen to shift the balance of care. This is the focus of the Cwm Taf Primary and Community Services Strategy, our over arching Clinical Strategy and the basis for our 3 Year Plan. An additional recurring allocation of £12.4m in 2015/16 is assumed for Primary and Community care development, continuing intermediate care investment and investment in innovation and technology to deliver the Health Board’s vision for transformation and enable the South Wales Programme changes. Further details on this are provided in Chapter 9.

Within the financial plan the total planned savings over the 3 year period of £43.2m represents a reduction of around 9.3% of the Health Board’s controllable expenditure (excluding capital charges and primary care contracts), around 3.1% per annum.

When developing our three year efficiency and re-design savings plans therefore, we have been mindful of the requirement to phase in programmes of work to ensure a whole systems approach, aligned to our clinical strategy, is being adopted and to target work on improvements where there is the biggest opportunity. To facilitate this, we have eight Cross-Cutting themes which we have used to plan and prioritise the development of the overall Plan. This work is being informed by the benchmarking and other data referred to earlier in the plan. Progress and deliverables from these themes over the last 12 months can be seen in Chapter 2.

Unscheduled Care, Planned Care, Frailty This theme is led by the Chief Operating Officer and builds on the significant programme of work undertaken in 2014/15. It includes:

• Further improvements in efficiency and patient flow; • Full year effect of bed reconfiguration in 2014/15; and

Our Cross-Cutting Themes are as follows:

1. Planned Care/Urgent & Emergency Care/Frailty 2. Prudent Healthcare 3. Service Redesign & Site Rationalisation 4. Outpatient Improvement and Patient Care Administration 5. Prescribing 6. Contracting & Commissioning 7. Workforce Productivity Improvement 8. Non Pay

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• Delivery of efficiencies in planned care by increasing theatre utilisation through improved booking processes and reduced cancellations.

Service Redesign and Site Rationalisation

Led by the Director of Planning and Performance, this theme is aligned to the improvements in patient flow and manages the service redesign and site rationalisation work programme associated with a range of changes including stroke service redesign, development of the use of Dewi Sant Hospital and closure of Tonteg and Y Bwthyn Hospitals. In addition, it will also oversee further associated service changes in 2015/2016, including non clinical accommodation efficiencies and breast service redesign. Outpatients and Patient Care Administration

The foundations for delivering improvement in our outpatient service have been laid in 2014/15, with this theme being led by the interim Director of Primary, Community and Mental Health. The identified enablers implemented, or currently being implemented, include:

• Referral Management – referral criteria and integrated pathways. • Reduced DNAs – Text & remind implementation & partial booking. • Improved service and efficiencies: Self-service check-in system.

A 5% efficiency target for improvement has been set for achievement through system improvements resulting in reduced clinic cancellations, improves clinic productivity and improved management of follow-ups. In addition, improved outpatient productivity together with the proposed centralisation of records storage will allow the organisation to achieve efficiencies within patient care administration. Workforce Productivity The organisation has identified opportunities across its corporate, medical and nursing workforce which given their nature are best delivered via a cross cutting theme. The Director of Workforce and Organisational Development leads the following programme of work in close association with the Medical and Nursing Directors:

• Introduction of new flexible benefits schemes; • Reduction in travel expenses; • Delivery of corporate directorates savings targets; • Reduction in medical agency spend via the introduction of e-

rostering and managed service; and • Review of specialist and non-ward nursing roles.

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Prescribing

Led by the Director of Facilities, this theme spans primary care, community and acute services. The work programme includes:

• The introduction of a prescribing incentive scheme for primary care; • Management of growth in the primary care prescribing budget; • A review of community based prescribing in key service areas such

as urinary catheters, diabetes and respiratory products etc; and • Changes in prescribing in acute settings.

Non Pay Having exploited a number of efficiencies in traditional non-pay management in 2014/2015, this theme, led by the Director of Finance, will focus on product selection and rationalisation in 2015/16. Contracting and Commissioning

Jointly led by the Director of Planning & Performance and Director of Finance, this Cross Cutting Theme supports Directorates in several areas of work including the repatriation of appropriate services back to the Health Board, ensuring appropriate management of contracts and flows to neighbouring Health Boards and identifing opportunities to broaden the services provided for patients in other Health Boards. Prudent Healthcare Led by the Director of Public Health, in addition to continuing the programme of work commenced in 2014/15 in relation to lifestyle management, NICE Do Not Do procedures and INNU, this theme will broaden its scope in 2015/2016 to undertake the following clinically led reviews:

• Demand for diagnostics in secondary care. • Outpatient follow-up practice; (in collaboration with the outpatients

theme). • Primary Care led reviews of variations in referral rates. • A prudent approach to the selection of clinical products in secondary

care.

In addition senior clinicians will be leading the following service reviews with the aim of ensuring appropriate pathways are in place in line with the principles of Prudent Healthcare:

• INR; • Urology Cancer;

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• Ophthalmology; • Cardiology; • Hip Replacement; and • Audiology.

The function of our Executive Programme Board (EPB) is to oversee the development of the Health Board’s Three Year Plan specifically in relation to the Cross-Cutting Themes, the implementation of the themes and to ensure that Executive leads and their teams are held to account for delivery. Further detail on the associated savings plans can be seen in Chapter 9 and arrangements for how the EPB fits with our wider governance and delivery arrangements can be seen in Chapter 11.

Chapter 7 sets out the detail of our service redesign priorities and work programmes which make up our Clinical Strategy. Many of these are ‘whole system’ and transformational in nature, underpinned by detailed, supporting service delivery plans and linked to workforce, financial, capital and performance plans. Further examples of prudent healthcare being delivered locally within our services and Directorates can also be found here. Annex A2 also provides summary details of our underpinning service delivery plans across a range of areas including identification of Executive and Clinical Leads, together with our planning and delivery groups taking this work forward.

5.5 Prudent Healthcare

As can be seen from the above and particulary the cross-cutting theme work, the Health Board is developing its approach to embedding prudent healthcare into, and across the organisation as part of a clinical, value based framework. Our intention is to increasingly use evidence of clinical and cost effectiveness to:

• Ensure we are delivering the right services to the right patients. • Ensure we not only improve services to patients but also to improve

the outcomes for patients, improve the health of the population and reduce health inequalities.

• Developing processes to examine the services we provide and then look at the available evidence base for clinical and cost effectiveness.

This is based on national prudent health care advice and guidance, and also in part on the prioritisation work undertaken by Welsh Health Specialised Services Committee (WHSCC) in developing their approach which is summarised in the diagram below:

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Importantly the evidence base for prudent healthcare should not only outline what is clinically and cost effective, but also provide evidence of those groups of patients that have the best ability to receive the optimum benefit from any intervention. The work in WHSSC identified that this approach can support the prioritisation of resources to achieve best outcomes based on clinical evidence. Not all patients with the same condition would necessarily see the same optimum outcome from treatment and, often, this requires a ‘drill down’ to identify clinical characteristics that have demonstrated an ability to achieve optimum outcomes. Directorates/Localities have highlighted areas which clearly demonstrate a “prudent” approach as part of their refreshed local 3 Year Plans, where procedures/services we either provide or commission are of no, or limited clinical effectiveness in order to ensure that all of our services are both clinically and cost effective, representing good value for money. This work will also continue to be led as a Cross-Cutting Theme, underpinned by clinical engagement and led by our Director of Public Health as outlined above. Further specific examples of our current and planned application of prudent healthcare can be seen throughout Chapter 7.

5.6 Performance and Information

5.6.1 Integrated Quality and Performance Dashboard

The Health Board has in place a comprehensive Integrated Quality and Performance Dashboard that is presented monthly at Executive Board, regularly at a number of sub-committees and bi-monthly at the Health Board public meeting, as part of our openness and transparency agenda

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with our public. Since its inception in October 2012, the Dashboard has evolved significantly to encompass key performance indicators that cover:

• Need and Prevention • Quality and Safety • Experience and Access • Use of Resources

The report is also segmented to highlight any areas which may be under formal escalation measures by the Welsh Government, sets out our performance and quality targets for the year and is supported by a covering report that seeks to expand on key areas, as well as to highlight areas of best practice within the Health Board. We are currently working to automate dashboard reporting further, as part of our new business intelligence system that we have purchased this year and are currently implementing. The system aims to provide further information to our local clinical teams and Directorates, as well as corporately and is the next transformational step in our performance and information agenda. 5.6.2 Importance of Data Quality

The key to ensuring the Board is kept abreast of any potential areas of concern with regard to performance and information is data quality. The Health Board continually strives to ensure that its data and information is of the highest quality. The Performance and Information team work closely with Clinical Directorates to ensure that the recording of data is as real-time as is possible and that it mirrors the patient pathway. To that effect, a Data Quality Group is in operation, together with an Information Governance Group chaired by an Independent Member and the Corporate Risk Committee also takes an active interest in data quality. Our policies outline the Health Board’s approach to data quality and are explicit in the responsibilities held by individual staff members. To ensure ownership of performance monitoring and data quality at an operational level, the Performance and Information Team has developed a Ward Dashboard and a number of other local Directorate Dashboards are also in operation including in Mental Health, Maternity and Stroke Services. As an interactive business intelligence tool, the Dashboard facilitates the local production of key performance indicators, with the ability to review changes in delivery over the last three years. Based on quantitative measures currently, the tool will be further developed to include qualitative measures linked to the national Nursing Dashboard.

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We have a Data Quality Steering Group (DQSG), chaired by one of our consultant surgeons and with a membership consisting of Assistant Directors and Heads of Nursing from operational areas. The DQSG has a Data Quality Audit Programme with an annual timetable covering issues access, clinical and administrative areas. Findings from these audits inform programmes of work to improve the quality and timeliness of Cwm Taf’s data, with certain data quality targets also included with the Dashboard itself. 5.6.3 Health Records and Clinical Coding The development, improvement of standards and completeness in our health records and clinical coding, including improving the storage and digitisation of our Health Records, is a priority for the Health Board as a key part of delivering high quality patient care as well as supporting the information agenda. Ensuring we are maintaining appropriate health record standards, providing high quality and timely clinical coding information and moving to the latest technology to improve access to the health record for our clinicians, is a key enabler as we look to transform our services. An integral part of this agenda is continuing to improve both the timeliness and quality of our clinical coding building on the Wales Audit Report 2014 on clinical coding. The service is currently provided across three sites, both acute hospitals and at Ysbyty Cwm Cynon. There has been considerable improvement in the timeliness and backlog removal of clinical coding since April 2012 and the department is now focused on delivering the national targets set for this year and setting more ambitious targets for 2015/2016. Latest performance against the national targets is showing progress continues to be made in meeting the 95% in month target with the latest reported month, October 2014, recording 94.9% complete. The rolling 12 months target of 98% from November 2013 to October 2014 is currently at 98.2%. A particular current priority is to focus on further improvement in the quality of our coding though ongoing clinical engagement. Clinical engagement is an essential component in ensuring our improvements are delivered consistently. The department has regular presentation slots at junior doctor induction sessions and also maintains ongoing dialogue with the Medical Leadership Forum. Senior consultant engagement has been secured within each specialty area to conduct clinical coding audits, in addition there are plans to align individual coders with lead clinicians to ensure the opportunity for engagement and dialogue is constant.

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In addition to engaging with clinical leads, the Health Board has recently supported the Clinical Coding Supervisor to successfully achieve the Coding Auditor qualification and a number of our codes are going through the accreditation programme. This gives the Health Board access to high quality, regular audits of its coding quality. The Health Board has also successfully integrated more electronic information into the Myrddin PAS, such as clinical letters and discharge advice letters, which facilitates more timely and accurate coding. This will be further enhanced with the introduction of pathology and radiology results. The Health Records service has traditionally been managed separately with each of the acute and community hospitals holding their own hospital and/or specialty records. The result is that there is no full clinical history available to the treating clinician and this means that there is an inherent clinical risk to the patient. There are also significant storage issues and associated clinical and operational risks across the Cwm Taf sites. The capacity to rationalise and address these will be created through a new medical records storage and scanning service which is being implemented in 2015/2016 following our purchase of what be will a centralised medical records storage centre. This is also a key enabler for the Health Board to take the tactical step towards achieving a fully computerised electronic health record system in the medium term. The creation of this electronic health record will resolve storage issues, remove the need for manual handling, eradicate the scenario of un-tracked/misplaced notes, release secretarial time and allow for the disposal of Health Board properties. The introduction of this technology would liberate the health record to General Practitioners, other health professionals and the patient themselves, being readily available in any primary, community and secondary care facility without the current constraints of geographical location. 5.6.4 Profiled Performance The following table outlines the profiled performance that we will be aiming for as Health Board over the next three years, as we strive for improvement in our service provision:

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Frequency Targetend

2013/142014/15 2015/16 2016/17 2017/18

5107 5005 4905 4807 4711

1005 985 965 946 927

65 years and over 68.0% 69.0% 75.0% 75.0% 75.0%

Under 65 years in at risk

groups60.0% 61.0% 75.0% 75.0% 75.0%

Pregnant Women 50.0% 51.0% 75.0% 75.0% 75.0%

Healthcare Workers 50.0% 51.0% 75.0% 75.0% 75.0%

5in1 age 1 97.9% 95.0% 95.0% 95.0% 95.0%

MenC age 1 95.0% 95.0% 95.0% 95.0%

MMR1 age 2 96.2% 95.0% 95.0% 95.0% 95.0%

PCV age 2 95.0% 95.0% 95.0% 95.0%

HibMenC Booster age 2 95.0% 95.0% 95.0% 95.0%

Quarterly

Assessment5% 3.4% 3.2% 5.0% 5.4% 5.4%

Quarterly

Assessment40% 33.3% 34.0% 40.0% 40.0% 40.0%

Annual

assessmentReduction 29.0% 30.0% 30.0% 27.5% 25.0%

Local 50% 40% 45% 50% 50% 50%

Frequency Targetend

2013/142014/15 2015/16 2016/17 2017/18

Monthly Improvement

Monthly Improvement 2.5% 2.2% 2.0% 1.9% 1.9%

Monthly 95% 95.0% 95.0% 95.0% 95.0% 95.0%

Monthly 98% 97.4% 98.0% 98.0% 98.0% 98.0%

Annual

assessmentImprovement 72 79 87 96 106

Annual

assessmentImprovement 89% 97% 100% 100% 100%

Annual

assessmentImprovement 89.0% 91.8% 92.6% 93.3% 94.1%

Frequency Targetend

2013/142014/15 2015/16 2016/17 2017/18

Improvement 98.0% 98.0% 99.0% 99.0% 99.0%

Improvement 96.0% 98.0% 98.5% 99.0% 99.0%

Monthly 95% 90.5% 95.0% 95.0% 95.0% 95.0%

Monthly 0 638 638 0 0 0

Monthly Improvement n/a 0 0 0 0

Monthly 95% 88.9% 92.0% 95.0% 95.0% 95.0%

Monthly 0 1282 650 0 0 0

Monthly 65% 54.5% 50.0% 65.0% 65.0% 65.0%

Monthly 95% 84.0% 90.0% 95.0% 95.0% 95.0%

Monthly Improvement 200 50 40 30 20

Monthly 98% 95.5% 98.0% 98.0% 98.0% 98.0%

Monthly 95% 80.7% 90.0% 95.0% 95.0% 95.0%

Annual


Monthly 91.3% 95.0% 95.0% 95.0% 95.0%

Monthly 56.6% 90.0% 95.0% 95.0% 95.0%

Monthly 74.9% 95.0% 95.0% 95.0% 95.0%

Monthly 82.2% 95.0% 95.0% 95.0% 95.0%

RAMI (2013 Casemix)

Crude Mortality

Deliverable

Eradication of patients spending longer than 12 hours in

Emergency Dept

% of Cat A Ambulance responses within 8 minutes

% of Ambulance handover < 15 minutes

Number of patients waiting > 36 weeks for treatment - all

% of new patients spend no longer than 4 hours in an

Emergency Dept

95%

Uptake of Influenza

vaccination amongst:75%

% estimated LHB smoking population treated by NHS

smoking cessation

% estimated LHB smoking population treated by NHS

smoking cessation who are CO-validated as successful

% valid principle diagnosis code 3 months after episode end

date - monthly

Number of NISCHR clinical research profile studies and

commercially sponsored studies

Number of audits the organisation is participating in

against the national clinical audit programme

% of people aged 45+ who have a GP record of blood

pressure

95%First day bundle (2)

First 3 days bundle (3)

First 7 days bundle (4)

% of patients referred as non-urgent suspected cancer

starting treatment within 31 days of a decision to treat

% valid principle diagnosis code 3 months after episode end

date - rolling 12 months

% of reception class children (aged 4/5) classified as

overweight or obese.

% of patients waiting less than 26 weeks for treatment -

Deliverable

Number of Ambulance handover > 1 hour

Patients treated by an NHS dentist in last 24 months as %

of the population

First hours bundle (1)

Delivery Framework Profile 2015-2016 3 Year IMTP

% of patients referred as urgent suspected cancer

starting treatment within 62 days of referral

% GP practices offering appointments between 17:00 and

18:30 at least 2 days per week

Quarterly

Assessment

STAYING HEALTHY - I am well informed & supported to manage my own physical & mental health

Deliverable

Number of emergency admissions for basket of 8 chronic

conditions

Number of emergency readmissions for basket of 8 chronic

conditions

Annual

assessment

Reduction

(rolling 12

months)

Monthly

Due to the change in rationale each year and the rebasing of RAMI it is

not possibel to predict a comparable performance for this measure with

any degree of logic or accuracy.

Vaccination of all children

to age 4 with all

scheduled vaccines

Uptake of Influenza vaccination amongst staff

Annual

assessment % of GP practices open during daily core hours or within 1

hour of the daily core hours

% of patients waiting less that 8 weeks for diagnostics

EFFECTIVE CARE - I receive the right care and support as locally as possible & I contribute to making that care successful

TIMELY CARE - I have timely access to services based on clinical need and am actively involved in decisions about my care

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Cwm Taf has made very significant strides on development of performance data in recent years, but primary care data is not as strongly represented in our Dashboard as secondary care. Developing this element of the Dashboard is a priority over the coming year. Currently we report on the following areas that are aligned to our work: • Childhood Immunisation Rates • Flu Vaccination up-take • GP Access (all day opening & appointments available between 5pm-

8pm) • Quality and Outcome Framework achievement • Units of Dental Activity undertaken Dental Contract.

In 2015/16 the Health Board will adopt the primary care indicators recently developed and agreed by the Welsh Government and Chief Executives and will then build further indicators which will be expressed at a system, operational, cluster and patient outcome level. The WG Primary Care Measures will focus on the following indicators:

Frequency Targetend

2013/142014/15 2015/16 2016/17 2017/18

Monthly 80% 71.0% 80.0% 80.0% 80.0% 80.0%

Monthly 90% 93.8% 90.0% 90.0% 90.0% 90.0%

Monthly 90% 82.4% 90.0% 90.0% 90.0% 90.0%

6 monthly 100% 100.0% 100.0% 100.0% 100.0% 100.0%

Annual


Frequency Targetend

2013/142014/15 2015/16 2016/17 2017/18

Monthly Improvement 43.0% 47.3% 52.0% 57.2% 63.0%

Frequency Targetend

2013/142014/15 2015/16 2016/17 2017/18

Monthly 3.0 2.7 2.4 2.2 1.9

Monthly 3.3 3.0 2.7 2.4 2.2

Monthly139 over 18

month periodn/a 118 106.20 95.58 86.02

Monthly12 over 18

month periodn/a 12 10.80 9.72 8.75

Monthly Reduction 518 414 332 265 212

Improvement 96.0% 97.0% 98.0% 100.0% 100.0%

Improvement 100.0% 100.0% 100.0% 100.0% 100.0%



Frequency Targetend

2013/142014/15 2015/16 2016/17 2017/18

Monthly Reduction 5.66% 5.0% 4.5% 4.5% 4.5%

Local 85% 59.4% 65.0% 85.0% 85.0% 85.0%

Local 85% 85% 80.0% 85.0% 85.0% 85.0%

Local 85% 51% 80.0% 85.0% 85.0% 85.0%

Annual

assessmentImprovement 99.8% 99.0% 99.0% 99.0% 99.0%% of total medical staff undertaking performance appraisals

OUR STAFF & RESOURCES - I can find information about how the NHS is open & transparent on its use of resources & I can make

careful use of them.

% staff absence due to sickness

Deliverable

Deliverable

Deliverable

% procedures postponed on >1 occassions, had

procedure <= 14 days/earliest convenience

Deliverable

Number of new Never Events

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

Number of cases of MRSA per 100, 000 of the population

DIGNIFIED CARE - I am treated with dignity & respect & treat others the same

Quarterly

Assessment

SAFE CARE - I am protected from harm and protect myself from known harm

Number of healthcare acquired pressure sores in a hospital

% compliance with patient safety solutions - alerts

% compliance with patient safety alerts - rapid response

Reduction

DToC delivery per 10,000 LHB population - mental health

(rolling 12 mths)

DToC delivery per 10,000 LHB population - non mental

health (rolling 12 mths)

% staff to have PDR in previous 12 months

% Consultant to have job plan review in previous 12 months

% SAS Doctors to have job plan review in previous 12 months

INDIVIDUAL CARE - I am treated as an individual, with my own needs and responsibilities

% assessments by the LPMHSS undertaken within 28 days

from date of referral

% therapeutic interventions started within 56 days

following an assessment by LPMHSS

% of LHB resisdents (all ages) to have a valid CTP

completed at the end of each month

% of hospitals with arrangements in place to ensure

advocacy is available for qualifying patients

% over over 65 registered as having dementia with their

GP practice

Number of new Serious Incidents (including Pressure Ulcers)

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• Staying Healthy: Screening & Immunisations • Safe Care: Antibiotic Prescribing • Effective Care: Dying Well • Dignified Care: Dying Well • Timely Care: Urgent Care & Access • Individual Care: Medication Reviews, Health Inequalities &

Dementia care • Access & Quality: Capacity & Demand, Chronic Conditions

Management • Workforce: Shift to out of hospital care.

Meanwhile, the primary care team will focus on the development of performance management and service improvement approaches to ensure:

• the continuation of the more detailed performance management that takes place with practices operationally;

• the development of stronger approaches to reducing variation across the benchmarked practice population;

• the development of ambitious and inspiring quality and service improvement activities that should take place as part of our emerging cluster and research models.

The following diagram summarises our approach:

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5.6.5 Demand and Capacity Profiles

In order to ensure that our planning assumptions relating to our service redesign plans and bed reconfigurations, as can be seen later on in the Plan in Chapter 7, are realistic and achievable, the demand and capacity modelling developed in 2014/15 has been further enhanced and extended for 2015/2016. Summary details of our high level bed capacity can be seen in Welsh

Government Technical Annex 2. This has allowed operational colleagues, in conjunction with the Information Department, to model through the efficiencies expected to be gained from the service redesign and the improvements in which we are investing in over the coming months and years. The focus of demand and capacity modelling in the 2014/15 Plan was inpatient admissions, length of stay and associated bed requirements. This has now been extended to cover theatres, outpatients, imaging modalities and endoscopy, with emerging work in other areas, and this will be further developed again during 2015/16. Examples of the outputs of the demand and capacity modelling can be seen at Annex A3. The examples show these outputs at specialty level but the Information Department has been working with individual directorates to deconstruct these models to consultant level, which will identify capacity issues at a much more granular level and also identify areas for potential release of capacity in other areas to compensate. The models use demand that has been derived from historical activity and also actual conversion rates. The demand and capacity planning has factored in national benchmarking at an UQ level via CHKS and has been moderated where necessary to ensure our ambition is realistic. The efficiency indicators considered are length of stay (LOS), day of surgery admission rates (DOSA), daycase rates and new to follow-up rates. The Theatre demand and capacity work also factors in the effective use of CEPOD lists and how improved utilisation can increase capacity for elective work. To summarise, in terms of demand changes and potential improvements in efficiency and utilisation, the modelling work factors in: Inpatients

• Volume of admissions – demand trends, potential admission avoidance schemes.

• Length of stay. • Day case rates. • Day of surgery admission rates.

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Theatres • Average sessions per annum per consultant and session cancellation

rates. • Overall percentage utilisation of session time. • Average cases per list. • Demand for individual specialties and consultants.

Outpatients

• Session lengths. • DNA rates. • Follow-up rates and follow-up backlog. • Clinic templates.

Imaging

• Scans per day. Endoscopy

• Weighted points per session. The main service improvement and redesign enablers and solutions, as can be see later on in the Plan, particularly in Chapter 7, and which are being factored into the modelling include:

Demand • Implementation of thresholds around BMI and smoking. • Adherence to INNU guidance. • Potential repatriation of Cwm Taf residents from neighbouring

Health Boards. • Changes to WAST pathways. • Increased input of acute physicians.

Length of stay

• Further flow improvements. • Liaison psychiatry service development. • Further extension of the acute physician service. • Increasing currently low DOSA rates through elective care re-

design. • Close working with Local Authorities to improve response times and

implement the Choice Policy. • Increased acute therapy provision to speed up access to therapy

assessment and treatment. • Increased utilisation of the CIAS and @Home services both from

Primary and Secondary Care to avoid admission or promote early discharge.

• Improved MDT meetings.

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• Community service improvement enablers in a variety of areas, including for example: early supported discharge of stroke patients, reablement for patients with cognitive impairment and increased support for nursing homes from district nursing.

Theatre utilisation

• Improved booking through internally designed booking tool. • Improved visibility of available sessions and under-utilised/over-

booked lists. • Reduced cancellations through better communication with patients,

improved pre-operative assessment and adherence to a minimum notice annual leave policy.

Outpatients

• Text and remind service to reduce DNAs. • Review of follow-up practices. • Review of variation in referral rates between different GP practices

and associated outcomes. • Review of clinic templates to maximise capacity. • Self-service check-in facilities to improve accuracy of patient

information, inform choice and improve data collection of outpatient activity.

Endoscopy

• Improved booking processes to minimise cancellations and DNAs. • Adequate scope numbers. • Decontamination processes improved. • All endoscopy sessions supported with endoscopy nurses.

Ophthalmology

• This is an example of a whole specialty/service demand and capacity plan, which covers new and follow up outpatients and surgical treatments. It is our most challenging service area.

• It shows the interventions being made and their impact over the year in a way that enables the service to monitor and track them.

• It shows that the planned interventions both address the recurring capacity gaps currently and address the backlogs.

• Some of the important interventions are community interventions particularly by optometrists and these are reflected in the primary care development plan.

• This demonstrates a higher level of specificity in the planning of the impact of different interventions over time and looks across the whole pathway from community/primary into secondary. It is also reflected in the service and financial Chapters 7 and 9.

The modelling shows that with properly resourced and planned programmes to capitalise on the opportunities above, together with closer

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working with our partners, there is the potential to action the following, much of it as part of our work programme on the Cross Cutting Themes: • Reduce our bed capacity appropriately, without affecting patient safety

and quality, and in line with investment in alternative models of care. The initial work identifies a plan to reduce our requirement for beds by 50-53 beds across the Health Board over the course of the year. After taking account of demand growth in some areas, and the phasing of performance improvements, we are planning to release the equivalent of one ward (circa 26 beds), the detailed plan for which is under development. This is consistent with the £1.4m planned savings from further bed reductions in the financial plan.

• Increase productivity within operating theatres and reduce non-core costs, treat more Cwm Taf patients within Cwm Taf and potentially reduce capacity slightly. Work to date has identified how changes in consultant job plans and reconfiguring theatre timetables can realign areas where additional capacity is required, with specialties that have too much capacity currently.

The modelling undertaken to date illustrates that there is inappropriate “planned” CEPOD capacity, which will become more evident once the changes to the general surgery on-call rota are implemented. Re-aligning the capacity for CEPOD will reduce the impact of emergency procedures on elective lists.

Currently, including limited productivity gains for theatre activity, the modelling shows a potential release of at least 6.5 lists per week. It is anticipated that this will increase as the detailed Directorate plans are completed. These lists can then be utilised to bring back cases currently either operated on outside Cwm Taf or operating on at premium rates. This is broadly consistent with the £800k target saving from the planned care Cross-Cutting Theme which is in the financial plan.

• Increase activity through our clinics, improving outpatient wait

performance and reduce clinic numbers slightly. This will enable the Directorate to:

o manage the backlog for follow-up patients within existing capacity and identify areas where recurring demand exceeds capacity;

o identify areas where there is opportunity to offer capacity to assist other Health Boards or remove capacity where appropriate;

o reduce the need for additional ad hoc capacity in outpatient clinics.

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This work will be overseen and enabled through the Outpatient Cross-Cutting Theme, which has been set a 5% productivity and efficiency target through the various interventions planned.

• Reassign activity from theatres to outpatients and from outpatients to primary care. This has not yet been modelled but will be included in the work plan that will progress during the first quarter of 2015/16.

• Implement the required changes to deliver a balanced plan for endoscopy and ophthalmology. There currently is a recurrent capacity gap in both areas, but the demand and capacity plans shown within the annexes set out the enablers and the plan for bringing these areas into balance, whereby capacity increases and productivity and utilisation improvements enable the Health Board to meet recurrent demand and reduce the backlog of both RTT cases and surveillance cases. Again the financial implications of these plans, in terms of both investment costs and productivity savings, are included in the financial plan.

The Health Board is now further developing the above plans at both Cross Cutting Theme level and Specialty/Directorate level.

5.7 Integration and Partnership 5.7.1 Why Partnership working and what will we achieve?

The Health Board’s vision and strategic objectives emphasise our values which involve caring for our patients and securing improved health outcomes for our communities. However, people do not suffer from poor health in a vacuum and many other social, cultural, economic and environmental factors will influence their health and wellbeing, their lives and those of their families. The Health Board is committed to working in partnership and we recognise that it is only by changing the practice of public bodies and other organisations working independently of one another and by looking for collaborative solutions, that we will make a real difference, improving people’s lives for the better, and make the greatest positive impact on our population now and in the future. To ensure this holistic and integrated approach which is citizen centred and designs services around people, not organisations, the Health Board continue to work closely in partnership with a wide range of stakeholders, including Local Authorities, Third Sector, our staff and independent contractors, the Police, the independent sector, Universities, business partners, the Community Health Council, volunteers and not least service users and carers.

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Our ambitions for working in partnership are that it should have the following impacts: • the development and implementation of shared priorities and actions

which will focus on better outcomes for people and the added value that working collaboratively brings;

• the development and strengthening of a new relationship between the Health Board and those who use our services through co-production – we must deliver services with people not to people;

• the empowerment of people and partners to enable their proactive and meaningful engagement in the design and delivery of services;

• to support, value and complement the efforts of individuals and communities to improve their own health and wellbeing and have more choice and control over their care;

• a focus on prevention and early intervention which will reduce those needs which can be avoided and enable us to respond to those needs which are unavoidable;

• the coordination and integration of services around the needs of individuals, particularly the most vulnerable;

• the reshaping of services to ensure sustainability, particularly at a challenging time of financial austerity across the public sector;

• the joint commissioning of services where provision overlaps between health and social care to ensure the most efficient use of our collective public service resources, but more importantly to improve responses to and outcomes for service users;

• a positive, proactive contribution from the Health Board to the six statutory well-being goals for Wales:

- A prosperous Wales. - A resilient Wales. - A healthier Wales. - A more equal Wales. - A Wales of cohesive communities. - A Wales of vibrant culture and thriving Welsh language.

5.7.2 Service Integration

The Health Board already has a strong history of working in partnership across a range of service areas. Where services are disconnected and confusing for service users to understand and access, we fail people and do not make the best use of our collective resources across the public sector. If we coordinate and join up our services effectively we can ensure the right care is provided in the right place at the right time. This means working together more effectively across different parts of the NHS like primary and secondary care, as well as integrating services across health and social care and with the Third Sector.

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The following sections highlight examples of the way in which we work in partnership with different population groups in our communities. Older people

The issues facing older people are complex and interrelated, requiring a joined up response across all sectors, combining and focusing the efforts of different service providers to avoid gaps or duplication and achieve maximum impact. Within Cwm Taf we have already successfully integrated our community equipment and reablement services and have introduced integrated assessment for discharges from community hospitals. In 2015/16 we will be implementing our Joint Commissioning Statement for Older People in Cwm Taf. This will describe our service model for older people with complex needs/ the frail elderly and will determine how the UHB and Local Authorities will either provide services or procure services from the Third Sector, independent sector or social enterprises, which will span universal to specialist needs. Our Shared Vision for Integrated services for Older People, agreed between the Health Board, Merthyr Tydfil CBC and Rhondda Cynon Taf CBC is: Supporting people to live independent, healthy and fulfilled lives. This will

be achieved by providing health and social care services that are:

- integrated, joined up and seamless;

- focused on prevention, self management and reablement; - responsive and locally delivered in the right place, at the right

time and by the right person; - safe, sustainable and cost effective

and which will:

- promote healthy lifestyles and prevent ill health;

- promote independence and protect the vulnerable; - improve services and joint working.

The principles outlining the way we will work to develop services for the frail elderly are outlined in Chapter 7, Section 7.9 and further detail on what the Health Board will be doing over the next three years to contribute to delivering this vision for older people is in Section 7.15.

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Mental Health

There have been considerable improvements to mental health service provision locally over the last decade. Within Cwm Taf, a 5 Year Strategy (2011-16) for Mental Health Services in Rhondda Cynon Taf and Merthyr Tydfil has been developed by the Health Board in partnership with Public Health Wales, Rhondda Cynon Taff County Borough Council, Merthyr Tydfil County Borough Council, the Third sector, mental health service users and carers. This strategy encompassed the promotion of mental health and wellbeing in the whole population, and the provision of mental health services to adults of all ages, from first contact in the community and primary care through to specialist community and inpatient care and support.

Further detail on what the Health Board will be doing over the next 3 years to contribute to delivering this vision for mental health services is in Chapter 7, Sections 7.3 and 7.4. on Adult Mental Health and Child and Adolescent Mental Health Services (CAMHS) respectively. Children, Young People and their Families

Our staff work with a range of partners to maximise every opportunity to make a positive difference to children and families, working to support the needs of the whole family as well as the problems of an individual child or young person. Our Shared Vision is to:

• Support the underlying principle of keeping our children and young

people out of hospital. We are working towards developing fully integrated, child and young person friendly services to support and

Our Shared Vision is to:

• Promote and improve the mental health and emotional wellbeing of

the local population. • Provide prompt and effective assessment and access to services

within primary care and the wider community, that help people to manage their mental health needs, with an emphasis on early

intervention, self care, peer and carer support.

• Provide timely, integrated interventions as close to home as possible for people needing to access specialist mental health

support, and to prevent and respond to crises; to ensure appropriate support in places of safety.

• Provide local services that promote rehabilitation, recovery, independence, and social inclusion, and that challenge stigma.

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care for our children, young people and their families.

• Provide safe, sustainable and accessible services to children, young people and their families across the Health Board area by integrating

current services and working differently across multi agency multi disciplinary staffing groups, outreaching where possible to provide

services across our communities as close to peoples homes as possible.

• Aim for children and young people across the Health Board area to be healthy, well educated resilient and confident individuals contributing

to and living safely within their communities. Further detail on what the Health Board will be doing over the next 3 years to contribute to delivering this vision for children, young people and families is in Chapter 7, Sections 7.4 and 7.8. on Child and Adolescent Mental Health Services (CAMHS) and families respectively. 5.7.3 Partnership Priorities for 2015/16

Building upon these successes, the following section provides a summary of some of the Partnership priorities which will be progressed in 2015/16: • Advising on and preparing the Health Board for implications of the

Social Services and Wellbeing Act, Future Generations (Wales) Bill and Local Government reform.

• A new Regional Partnerships Board has been established and a collaboration agreement developed to ensure the Cwm Taf health and social care community has robust plans in place in readiness for the Social Services and Wellbeing Act which will go live on 1st April 2016. The UHB will play a full and active role in the Partnership.

• Implementation of the Joint Commissioning Statement for Older People. This will have a particular focus on:

o Developing a broad range of preventative services which promote well-being.

o Building community capacity and resilience. o Providing information advice and assistance. o Developing integrated intermediate care services. o Providing a broader range of accommodation with support

(including the exploration of new models of EMI nursing care). • Developing an integrated @Home service which will support a greater

number of people in the community. • The development of Strategic Frameworks with the County Voluntary

Councils to describe how the Health Board will work collaboratively with the Third Sector to deliver the elements of the 3-Year Plan which can only be delivered in partnership by the two sectors. Continuing to build and strengthen our relationship with the third sector to ensure we deliver our services in an integrated way.

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• Review of strategic partnership arrangements in RCT and implementation of any transitional arrangements.

• Implementation of the Valleys Steps mental health model. • Identify and implement innovative models of stakeholder

engagement/involvement – reaching a wider and more diverse audience; providing them with genuine and meaningful opportunities to influence our service design/delivery.

• Engage across the Partnerships and Directorates to finalise and implement pathways for families with Neuro-developmental needs specifically ASD and ADHD, this work will include developing plans to reduce existing long waiting list within the Health Board area.

• Continue to support the Partnership through their reviews of Families First across both RCT and MT areas and maximise the opportunities to implement the programmes and ensure the health components are developed and implemented.

• Further develop plans to develop a Health Board children & young people’s engagement forum.

• Continue to provide level 2 reduction of suicide and self harm training as well as further developing the training for specific groups (eg paediatric ward staff, A&E staff, foster carers, etc).

• Develop and implement a training programme for parents / families of children with Autistic Spectrum Disorder (ASD).

• Develop a guide for families of children with Attention Deficit Hyperactivity Disorder (ADHD).

• Development of a Pilot Falls Prevention Programme in Sheltered Housing Schemes (RCT Homes).

• Continued support for the Inverse Care Project providing linkages to Communities First Cluster planning and GP Development Plans.

• Health & Well Being Events with each of the five 50+ Forums that will be open to the wider public too.

5.7.4 Staff Partnership

Employee engagement is a workplace approach designed to ensure that employees are committed to their organisation’s goals and values, motivated to contribute to organisational success, and are able at the same time to enhance their own sense of well-being.

“This is about how we create the conditions in which employees offer

more of their capability and potential.” – David Macleod

Most importantly the evidence is clear that an organisation like the Health Board can do a great deal to impact on people’s level of engagement. That is what makes it so important, as a tool for success. The approach is also about celebrating diversity, placing compassion and flexibility at the heart of everything Cwm Taf does, accepting risk and listening and trusting people to try new and innovative ways of working. Through other streams of work, patient flow; transforming safe and effective care

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together; iCARE; and the recent work around the Health Board’s response to the Andrews Report including the unannounced Executive dignity visits as well as the Welsh Government recent visits all signal that positive engagement is taking place. The role of the line manager is fundamental at all levels. The difference in having a meaningful conversation face-to-face with a senior member of the management team has had a huge cultural impact. The ‘Tell us how it is’ staff survey questionnaire was sent out in early 2013. The survey was designed to fit within a wider research context capturing information around key themes which have been demonstrated as being important for creating a positive culture of engagement. The level of participation across Wales was 27%, 25% in Cwm Taf. Overall, the Cwm Taf Staff Survey results are very close to the All Wales average and work undertaken locally has been on par with the rest of NHS Wales. Detailed breakdown of information for all areas was provided to the management teams to widen engagement with the results and to ensure that staff responses were understood. As a result, it was agreed that an employee engagement framework would be developed and key actions for the ensuing eighteen months include:

• Continuing to work in partnership with staff side representatives and trade unions; especially to co-produce the framework;

• sharing information about the Staff Survey with the organisation through the Chief Executive’s blog;

• developing a Change Management Toolkit (completed and has been successfully used for large scale change for example within mental health services);

• developing and delivering employee engagement training sessions for all line managers (already commenced);

• developing a new cascade system or team briefing system (work in progress);

• developing the use of PULSE surveys (already used across organisation), based on the all Wales information for engagement, for internal SharePoint use;

• creating a specific SharePoint site to include all information in a spirit of transparency and openness (in place);

• holding sessions with staff across the organisation in their workplace and where staff can access (currently being organised);

• Recommencing Cwm Taf choir; • Implementing Schwartz Center Rounds (first one held); • iCARE sessions and creating a culture of compassionate care

programme (for all staff at induction and roll out programme

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through train the trainers route); connection to the iCARE Compassion Code;

• Supporting the Corporate Social Responsibility group – lighting the beacons in Cwm Taf;

• Motivational interviews with Board members about staff engagement;

• Work to support the line of management e.g. develop exit and stay interview questions; develop OD plans for specific areas;

• Plan and hold an ‘Engage for Success’ workshop primarily for line managers;

Cwm Taf CaresCwm Taf CaresCwm Taf CaresCwm Taf Cares continues to develop momentum; translating what this

means in practice through working with staff at grass roots level is now underway in order that the organisational vision is owned and embedded. Additional work on having clarity around the organisational objectives in relation to how the staff can translate these to their areas of work may also be required in the development of a meaningful and trusted employee engagement framework. Finally, why focus on employee engagement? Evidence shows that effective employee engagement:

• Reduces sickness absence; • Improves patient care; • Increases productivity; • Improves health and safety at work; • Increases innovation; • Creates a happier workforce; and • Ultimately reduces costs.

5.7.5 Citizen Engagement

The Health Board is committed to creating a culture that welcomes and facilitates the involvement of patients, relatives and carers from all communities it serves in the development, improvement and monitoring of services and patient care. They can help us to develop and refine solutions to the challenges of providing high quality, sustainable services. Our community is full of examples of co-production. The Valleys communities are incredibly resourceful and mutually supportive, and they have been increasingly working more closely with us in the design and delivery of services. Our Public Forums have long been vehicles for generating better approaches to healthcare in Cwm Taf. In the immediate term we are thinking about how co-production can be strongly supported by pragmatic and concrete service developments in the following areas such as:

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• advice and support services; • self care models; • use of behavioural science. Despite keeping as healthy as possible, there will be times when everyone needs more advice and guidance to deal with health related issues. We are keen to further empower our population to access robust reliable information as the first course of action before accessing a health professional. Working with our communities, our plans for advice and support will ensure that: • the use of NHS Direct will be increased and seen as a helpful first point

of contact; • the population will access the range of services provided by the Third

Sector to provide general support and advice with the aim of reducing the stress that many people experience;

• the large ‘Carer’ population will be supported to undertake their role by accessing a carer assessment to identify what all agencies can do to sustain their role;

• the population will start to feel confident in using the 24/7 111 telephone / website advice service that will become available; and

• the Third Sector Community Co-ordinators role within each locality will be utilised fully and expanded as appropriate.

A fundamental part of our Plan is to ensure that plans are in place with our partners to ensure that our population are supported to maintain their health and to self care for minor ailments. Our plans for self care and staying healthy will ensure: • our population will have the knowledge, and confidence to look after

their own health and to prevent ill health through targeted public health interventions across all age ranges;

• our population will have an increasing healthy life expectancy so we are not just living longer but have a better quality of life;

• our population will be aware and linked into wider communities through the work of the 3rd sector to improve their health and wellbeing;

• our population will have targeted advice and support to those who already have poor health or are at high risk of ill health;

• our population will have reduced levels of obesity & smoking; • our population will have targeted support for people who are out of

work. Being out of work is strongly associated with increased overall mortality and poor physical and mental health. In the Cwm Taf area, the proportion of the population in employment is lower than for Wales as a whole;

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• our older people will have the knowledge and support needed for “active ageing”, enabling them to live healthy lives for as long as possible; and

• through all professional contacts, residents will be encouraged to take exercise, eat a healthy balanced diet, stop smoking and reduce drinking below the recommended limits. This can add a potential fourteen healthy years to life which is imperative for our population.

The organisation has started to pay significant attention to the behavioural science initiatives that have been instigated by the University of Bangor and more widely in the UK. In terms of immediate implementation, we are proposing to take forward ‘Your Medicines, Your Healthcare’ on a Wales wide basis, an approach which will feature more strongly as we develop our primary and community care strategy and further details can be found on this in Chapter 7, section 7.21. Other priorities in 2015/16 include: • Development of the Health Board’s Citizen Engagement and Patient

Experience Plans, based on agreed principles. • Regular meetings of the Health Board Stakeholder Reference Group

(SRG). The SRG ensures that a range of stakeholder views (including representatives from local authorities, Third Sector, Community Health Council, community groups, independent sector, patients and carers) are heard and can influence the planning, design and delivery of services.

• Regular meetings of the Health Board’s four Locality Public Fora to ensure continuous engagement as well as undertake any formal consultations about the design and delivery of our services. We can engage communities on a range of issues to ensure the public has a voice. Topics discussed during 2014-2015 included the South Wales Programme, Quality and Patient Experience, Stroke Services, Prince Charles Hospital Mental Health Services, proposed changes to services in Taff Ely and estate refurbishment.

• With our partners in Merthyr Tydfil and Rhondda Cynon Taf Local Service Boards (LSB), a coordinated approach to consultation activities - an online ‘consultation hub’ provides a range of tools to develop questionnaires, analyse results and create feedback mechanisms to ensure that:

o Consultations are effective; o Results are being used to improve services o Feedback is provided to the public.

In addition, a Citizens' Panel comprising of 1,600 people across Merthyr Tydfil and Rhondda Cynon Taf have signed up to give their views on consultation topics.

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• Building on the extensive engagement and formal consultation undertaken in relation to the South Wales Programme and working with neighbouring Health Boards on the next phase of the Programme. We will also work closely with the Community Health Council to ensure that engagement is timely and meaningful so that people better understand the case for change and the options being considered. As a result of the extensive work that has been undertaken, we have been able to engage with a wide range of “hard to reach” groups and develop a more robust approach to equality impact assessments.

• Involving children and young people in the planning, delivery and evaluation of services is important, not just from the perspective of improving services, but also in terms of developing confident, engaged and responsible citizens. Some of the activities undertaken during 2014-2015 included working with young people linked to our Reduction in Suicide and Self Harm Strategy to develop appropriate training materials about the issues relating to self harm. Plans are also being developed to engage with young people with an Autistic Spectrum Disorder (ASD) to inform the development of a training package for parents and carers.

5.7.6 Single Integrated Plans

The local priorities for partnership working are captured within the Single Integrated Plans (SIPs) for each County Borough Council area. Following the first year of implementation, partners have reviewed and refreshed the plans for both Merthyr Tydfil and Rhondda Cynon Taf. Merthyr Tydfil

The vision for the SIP is to strengthen Merthyr Tydfil’s position as the regional centre for the Heads of the Valleys, and be a place to be proud of where:

• People learn and develop skills to fulfil their ambitions. • People live, work, have a safe, healthy and fulfilled life. • People visit, enjoy and return.

The revised SIP for Merthyr Tydfil was approved by the Merthyr Tydfil Local Service Board (LSB) in July 2014. An Annual Report on progress made in delivering the priorities in the Single Integrated Plan was presented to the LSB in November. The priority outcomes and areas for action in 2015/16 remain the same with the majority of actions building on those from last year. Examples of new actions include:

• Mental Health - actions to tackle stigma and discrimination including

the “Time to Change” Campaign.

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• Promoting Independence - development of a single point of access across health and social care for frail elderly patients and implementation on a phased basis of integrated assessment.

• Healthy Lifestyles - increasing the number of community pharmacies who provide smoking cessation.

Rhondda Cynon Taf (RCT) The vision for the SIP is that people in Rhondda Cynon Taf are safe, healthy and prosperous. The RCT SIP also identified common themes running through the Plan:

• Early intervention - with the aim of either preventing things from worsening or, better still, occurring in the first instance.

• Inequalities - ensuring that we focus on our most deprived communities or vulnerable groups.

• A culture change within each of the partner organisations ensuring a skilled and flexible workforce.

• Better coordination - joining up of services and activities across partner organisations.

Following the review in RCT, the Annual Report approved by the Local Service Board in September 2014 concluded that whilst good progress had been made in a number of areas it was necessary to

• Focus on a smaller number of priorities which will have a greater impact.

• Target communities to try out our ideas where there is greatest need and greatest opportunity.

• Improve engagement with our communities to help inform initiatives, using the Cwm Taf Joint Engagement Strategy as a guide.

• Improve the gathering and use of information and data sharing. • Make sure staff have the skills to work in a different way.

For 2015/16, it was therefore agreed that education and employability should become the overarching priority and that changes needed to be made to the partnership structures. Cwm Taf Regional Collaboration Board

There is a significant overlap in the two Single Integrated Plans in terms of priorities, particularly relating to healthy lifestyles (e.g. smoking, obesity and substance misuse), mental health and promoting independence (e.g. preventative/early intervention services and facilitating discharge). This is helpful when working collaboratively across the Cwm Taf footprint and in ensuring alignment with the Health Board’s Integrated Plan.

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Collaboration with Merthyr Tydfil CBC and Rhondda Cynon Taf CBC to tackle priority issues common to both Single Integrated Plans is ongoing through a number of joint workstreams as agreed by the Regional Collaboration Board such as Smoking, Obesity, Integrated Localities/Intermediate Care Fund and Suicide and Self Harm. 5.7.7 Third Sector County Voluntary Councils (CVCs)

The Health Board has developed very positive working relationships with the two County Voluntary Councils (CVCs), i.e. Interlink and Voluntary Action Merthyr Tydfil (VAMT), as demonstrated by the established Merthyr Tydfil Compact Agreement and Rhondda Cynon Taff Compact Agreement and Codes of Practice that underpin them. The open and transparent approach already taken will continue to evolve and strengthen as new or redesigned services emerge. Third Sector Providers

In terms of access to services closer to home, the Health Board recognises that our Third Sector partners play an important role in delivering community based services that complement both health and social care provision. We commission a diverse range of services from over twenty organisations that are attuned and complementary to the services provided by the Health Board. The Health Board is committed to engaging with the Third Sector as equal partners in designing and delivering better services together, with improved outcomes for service users and carers. During 2015/16 we will be: • Agreeing a joint strategic framework for working with the third sector; • Building on our commissioning arrangements by implementing the

outcomes from a review of all Third Sector Service Level Agreements. 5.7.8 Cwm Taf Health and Social Care Economy

In February 2014 the Cwm Taf Health and Social Care Economy (a collaborative partnership of Cwm Taf University Health Board, Interlink, Voluntary Action Merthyr Tydfil, Merthyr Tydfil County Borough Council and Rhondda Cynon Taf Council) developed and submitted a proposal for funding from the 2014/15 Intermediate Care Fund. The proposal provided the partnership with the opportunity to consider how working together operating a ‘whole system approach’ will strengthen the foundations for further improving the outcomes for local people, providing better experiences for all people receiving services and delivering greater levels of effectiveness and efficiency.

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5.7.9 Communities First

A Community Health Development Network (CHDN) has been established to bring together representatives of Communities First Cluster Groups, Cwm Taf University Health Board, Cwm Taf Public Health Team and other community organisations who have a vested interest in reducing health inequalities across Cwm Taf. Through multi agency planning the CHDN will work towards achieving the shared health outcomes within the SIPs and the new Communities First Programme. The network has recently been expanded to include representatives from our social housing sector. The network provides a structured mechanism to allow improved communication, sharing of good practice and training for community partners. Examples of projects developed and supported by the network include the eighteen community weight management groups established across Cwm Taf. 5.7.10 Housing

The Health Board recognises that preventing homelessness and improving housing helps people, particularly the vulnerable, to lead healthy, independent lives as well as reducing inequality and poverty. A range of collaborative work is underway between the HEALTH BOARD and housing colleagues, both in the Local Authorities and Housing Providers. Priorities in 2015/16 include:

• Development of an action plan for the newly established Cwm Taf Housing Collaboration Group. It will encompass activity required as part of the WG Standards for Improving the Health and Wellbeing of Homeless People and Specific Vulnerable Groups, including a review of the Cwm Taf Hospital Discharge Protocol for Patients in Housing Need.

• Working with RCT CBC and other partners to deliver a new team around the community approach in 3 Housing and Health Action Areas, starting with Tylorstown. In addition to housing interventions, opportunities for a wider range of health and wellbeing activities will also be explored.

• Addressing the relationship between poor Housing and Asthma, including the development of stronger links between health staff such as respiratory nurses and housing practitioners; information and advice including consistent messages to tenants/residents and a best practice guide for practitioners; staff training.

• Fuel poverty initiatives including referrals from health staff to a range of projects coordinated by RCT LA’s Housing Energy Efficiency Officer such as home surveys, energy efficiency and housing grants; information leaflets and advice distributed via the Patient Support Officer in Royal Glamorgan and the piloting of information packs on one of the wards.

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• Smoke Free Homes – following a successful pilot project in two Communities First areas in 2013, roll out has continued with more Community First cluster areas and also to Registered Social Landlords.

5.7.11 Carers

Working with partners across RCT and Merthyr Tydfil, including carers themselves, we continue to implement the Cwm Taf Carers Information and Consultation Strategy and meet the requirements of the Carers Measure (CM). An Annual Report on progress in 2013/14 was submitted to Welsh Government in May 2014 highlighting significant progress across a number of initiatives. Key areas of activity which will continue and be developed in 2015/16 include: • Following a successful training day in May 2014 which was delivered to

over 150 students, we are working with the University of South Wales and Colleges in Cwm Taf to deliver Carer Awareness workshops to nurse degree students. This work has expanded to students across South East Wales and will include Social Work and Teacher students as well as Nurses and Medics.

• Further recruitment of Carers Champions across Cwm Taf. There are now nearly 200 across the partner agencies.

• The evaluation and roll out of a pilot project in 8 GP Practices (funded by the Intermediate Care Fund) to develop an accredited award for Carers Champions with AGORED

• Working with NWIS to develop a new All Wales e-learning toolkit for Carer Awareness

• Continue to promote the Carer aware e-learning package and to roll out the young Carer package. Ensure all completions are recorded on ESR.

• Cwm Taf has been involved in the development of an All Wales questionnaire to help identify the impact of the Measure. The outcomes for the first survey will be utilised as a baseline for future surveys and measuring the impact of our work.

The Carers Measure Steering Group will continue to monitor progress with the implementation of the Strategy and the annual action plan developed to support it.

5.7.12 Volunteers

The Health Board recognises the unique and valuable contribution that volunteers make in complementing our services. Their contributions enrich and extend the range of support provided to service users by providing practical help and support to enhance the patient experience.

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Work is driven forward through our Volunteering Steering Group and as a result a number of volunteering projects have been established within Cwm Taf: • Hospital radio. • Meet and Greet Volunteers (PCH). • Breast Feeding Support Group. • Chaplaincy Volunteers. • Befriending Volunteers. • Volunteer Drivers. • Audiology Volunteers. • Maternity Tour Guide Volunteers. • Stroke rehabilitation support Volunteers. • Welsh Speaking Volunteers Ward project. • Meet and Greet Macmillan Unit. Expansion of volunteering services across the organisation is not without its challenges and our key challenges are identifying funding to reimburse volunteers expenses and recruiting a co-ordinator to lead and manage service expansion. We have developed strong links with our Third Sector partners, VAMT and Interlink and we continue to work in partnership to develop volunteering opportunities. We also work with our staff side leads to develop a consistent approach to volunteering that deliver benefits both to patients and volunteers themselves. During 2015/16 we will be: • Developing a strategy for volunteering to support its expansion across

the Health Board. • Identifying funding to appoint a Volunteer Coordinator

5.7.13 Corporate Social Responsibility Corporate Social Responsibility (CSR) is about ensuring that the Health Board makes a positive impact on society and aligns social and environmental responsibility to economic goals and value for money. It seeks to raise awareness of the impact that our work has on people and our environment, and the steps being taken to reduce any negative effects. As a large employer providing public services and spending public money, our activities need to take place in the most sustainable way. We believe that by working towards the aims of corporate social responsibility we will also: • Ensure service excellence; • Make the best use of resources;

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• Provide a great place to work; • Be responsive and accountable to our communities; This can only be achieved through: - • Seeking to deliver the best and most ethical healthcare through

developing and promoting services and products that we buy that support a more sustainable way of life.

• Measuring and publicly report on our environmental impact and setting challenging targets to lower our impact on the environment.

• Seeking to foster strong positive relationships with our diverse local community and staff and meeting diverse need, promoting social mobility and tackling inequality.

• Teaming up with suppliers to minimise impacts: sourcing more sustainable and local products and services where possible, with particular emphasis on carbon emissions.

• Giving our employees information to increase their awareness of the impact of their actions on the planet both at work and at home.

• Working in partnership with our local and business communities in ways that meet their environmental, economic and social needs and has a positive effect on our business.

• Using our influence and resources to support international health development, and enrich our community through shared learning.

• Promoting healthy and sustainable lifestyles for our patients and staff and enabling them to take responsibility for their own health and well being.

We already have a number of initiatives and schemes being taken forward as part of CSR and examples of these include careers events, Job Growth Wales initiatives, work with the Prince’s Trust, the promotion of credit unions and staff support for local charities and appeals.

5.7.14 Work Experience

The Health Board has been working with Rhondda Cynon Taf and Merthyr Tydfil County Borough Council’s Bridges into Work Teams to deliver Pre-Employment programmes for a number of years. The council identifies suitable unemployed individuals who are supported by the partners to complete a two week induction/Mandatory training programme. Those who successfully complete the programme are offered a four week work placement within the Health Board. On successful completion of the work placement, the individuals are invited to apply for a position on our Staff Bank, providing participants with a pathway from unemployment through to gainful employment. Currently, approximately 50% of our Bank vacancies are filled through this route.

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For many years the Health Board has also provided local students with work placements. Each student is dealt with on an individual basis and offered work a placement ranging from one day through to a week. A further development is involving the LIFT Programme Team, a Welsh Government project targeting workless households and having assessed the suitability of using our existing pre-employment programme for LIFT trainees, we have identified the need to offer additional support to trainers and a revised plan is under development. This entails the identification of a network of volunteer mentors who, after undertaking a short coaching/mentoring training course, will be partnered with a LIFT trainee, offering advice, guidance and pastoral support. This will ensure all are better equipped and resourced to support the future share of the LIFT Trainee placement.

5.8 Integrated Assessment Process Integrated Assessment, Planning and Review Arrangements for Older People sets out a process for delivering integrated assessment processes and is a key part of implementing the Framework for Older People with Complex Needs. The Health Board is working collaboratively with its partners, Merthyr Tydfil and Rhondda Cynon Taf Local Authorities, to implement the requirements. Progress has been made in agreeing minimum core data sets and referral documentation but information sharing, given the lack of a common IT system between the partners, is proving challenging.

5.9 Equality and Diversity

The Health Board is committed to the principles of equality and diversity and the importance of meeting the needs of the protected groups under the Equality Act 2010 and the Welsh specific duties to:

• Advance equality of opportunity between people who share a relevant protected characteristic and those who do not;

• Foster good relations between people who share a protected characteristic and those who do not;

• Eliminate unlawful discrimination, harassment and victimisation. The Cwm Taf Strategic Equality Plan outlines four specific objectives, which are fundamental to the Integrated Plan:

• Better health outcomes for all. • Improved patient access and experience. • Empowered, engaged and included staff. • Inclusive leadership at all levels.

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These are currently being reviewed to reflect the changing equality agenda in terms of government initiatives and recognised good practice. A fifth ‘stand-alone’ objective is to identify gender pay difference and we are now proceeding to the second stage (action planning) of a national research project led by Cardiff University. Finally, equality impact assessment (EIA) in accordance with the ‘Brown principles’ is absolutely fundamental to service planning, whether in the development, change or withdrawal of services. Meaningful EIAs will continue to be undertaken on not only in broad terms for the integrated plan but in detail also for specific service plans. This will also necessitate engagement with relevant groups as highlighted in the recent review of NHS Service Change, Engagement and Consultation.

5.10 Bilingual Skills Strategy Welsh legislation saw the introduction of compulsory Welsh Language Schemes for public sector bodies within Wales. The Health Board continues to implement its Welsh Language Scheme and reports on progress made against national and local targets each year. The Welsh Language Commissioner is in the process of conducting a Welsh Language Standards Investigation and a new set of Welsh Language Standards will be imposed upon public bodies within Wales as part of a rolling programme in 2016. In compliance with its current Welsh language Scheme and in preparation for the Standards, the Health Board has developed a Bilingual Skills Strategy. This strategy looks at how the workforce can strategically deliver services through the medium of Welsh to the Welsh speaking public within Cwm Taf. The main objectives of the strategy are: • To carry out an audit of staff’s current Welsh language skills – finding

out where our existing Welsh speakers are based • To carry out a Welsh Language Service Needs Assessment – analysing

data to determine what Welsh service provision is needed to meet the needs of the local population

• To identify current skills gaps - within specific departments and teams across the organisation

• To bridge the skills gap – developing actions plans with team managers; using creative ways of working with current Welsh speaking staff; providing training for staff to learn Welsh; to recruit Welsh speakers.

A Welsh Language, Workforce and Organisational Development Sub-group is also the steering group for this strategy and monitors the progress made against Welsh language targets relating to Workforce and

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Organisational Development. The strategy is currently in the pilot stage within Ysbyty George Thomas, where EMI patients will benefit from strengthened Welsh language services. The Health Board also has a well established Welsh Language Group which monitors the implementation of the Welsh Language Scheme and other Welsh language initiatives. The Health Board’s Chairman is also the Chairman of this group and Welsh Language Champion for the organisation. The Welsh Language Champion and Directorate Lead for Welsh language present update reports to the Board on progress made against all Welsh Language targets and objectives. Over the next three years, priority areas for Welsh language service provision improvements include paediatrics, elderly mental health, and the implementation of the Bilingual Skills Strategy.

5.11 Ensuring Integration with Our Partners’ 3 Year Plans In developing and refreshing our 3 Year Plan, we have been very mindful of ensuring these integrate effectively with those strategic plans of our partners. As part of refreshing our plan, we have actively shared our emergent plan and priorities with our partners both in discussion and in writing, in order that we can mutually support each other in taking our mutual work programmes forward and delivering on priorities. For example, we sent a draft of our plan to organisations including WHSSC, Public Health Wales, the Welsh Ambulance Services Trust and the Shared Services Partnership in the spirit of seeking further comment and engagement. We are also considering their draft plans and are in discussion on key elements of mutual interest and priority. The following provides a short summary of some of the key areas of interface with some of our key NHS partner plans. 5.11.1 Velindre NHS Trust.

Velindre NHS Trust provides the Health Board with a range of specialised services including cancer services, blood services and others on a contractual basis. The Velindre Cancer Centre is a specialised treatment, teaching, research and development centre for non surgical oncology and treats a number of our patients with chemotherapy, systemic anticancer treatments, radiotherapy and related treatments, together with caring for some patients with specialist palliative care needs. The Welsh Blood Service is also part of Velindre and plays a fundamental role in the delivery of health care in Cwm Taf. The service works to provide blood services which allow Cwm Taf patients to improve the quality of their life and saves the lives of many people every year.

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The Trust also hosts a number of organisations on behalf of the Health Board including ourselves which include the NHS Informatics Service (NWIS); Shared Services which provide a range of high quality, customer focused support functions and services; NISCHR Clinical research Centre; National Collaborating Centre for Cancer and the Cancer National Specialist Advisory Group. A number of these services are commissioned and the Health Board is looking to constantly improve its commissioning relationship with this along with other LHB’s who provide particular services. Further detail on priorities over the next 3 year period in this respect can be found in Chapter 7 and specifically Sections 7.11 and 7.23 on our development of cancer services and commissioning priorities in the forthcoming years. 5.11.2 NHS Wales Shared Services Partnership

Hosted by Velindre NHS Trust and through our representation on the Shared Services Partnership, the Health Board has been actively engaged in the refresh of the Shared Services Partnerships 3 Year Plan. This has involved an exercise of reflecting on delivery in terms of last year’s plans and looking to priority areas for the forthcoming period, including potential areas for efficiencies, improvements, growth and investment. The Health Board shares the key objectives of the Shared Services Partnerships including ensuring value for money, the importance of customers, having an appropriately skilled and engaged workforce, developing an organisation that deliver excellence through its services and also looking at service development opportunities. In terms of priorities going forward, of particular importance to Cwm Taf in the development of Shared Services are a range of areas including:-

• Provision of an efficient and effective HR support service. • Learning lessons from the recent Oracle upgrade and support in

order to ensure a robust and consistent service for the future. • Continued close working between the Health Board and legal and

risk services. • Continued efficiency improvement through the use of new

technologies. 5.11.3 Public Health Wales

We continue to have an ongoing dialogue with colleagues in Public Health Wales (PHW) in terms of sharing our plans and also discussing mutual joint priorities that we can support each other on. We have also been involved in a peer review process which is providing access to the latest draft Public Health Wales 3 Year Plan.

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The Health Board has participated in recent workshops hosted by PHW aimed at ensuring integrated public health actions and priorities over recent months. This work has been aimed at embarking on a course of action to jointly identify agree and refine key public health priorities for the next 3 years in addition to other public health priorities both organisations may have. This is enabling us to develop a shared core set of priorities that will enable us to focus on as a whole system and ensure that our respected contributions join up. The shared priorities include:

• Improving health in the early years • Developing and supporting the public health impact of primary care • Supporting NHS Wales to improve health outcomes.

Chapters 4 and 7 of our Plan provide more detail in particular of our public health priorities and mutual support work in these key priority areas. 5.11.4 Welsh Health Specialised Services Committee. Specialised and tertiary services are those provided by a relatively small number of specialist centres to populations greater then a million people. These services are typically high cost and low volume. The Welsh Health Specialised Services Committee (WHSSC) is a joint committee of the 7 Health Boards in Wales, including Cwm Taf, and is responsible for the planning of specialised and tertiary services on our behalf. Staff from within the Health Board have and continue to be involved in dedicated discussions on the development of the refreshed Commissioning Plan for Specialised Services for Wales 2015 to 2018. This aims to set out an Integrated Commissioning Plan for these services for the population of Wales, including our own, over the coming period. Chapter 7 in our plan, and specifically Section 7.23.1 provides a summary of the priorities from a Cwm Taf perspective which we will continue to work closely with WHSSC on, to ensure the appropriate delivery of these specialist services, as well as looking at opportunities to reduce projected costs by ensuring that service growth is appropriately managed, savings opportunities are maximised, value for money is provided and high quality services are offered via the WHSSC contracts, based on sound evidence and due process. 5.11.5 Emergency Ambulance Services Commissioner and Welsh Ambulance Services Trust

Our commissioning intentions for ensuring a high quality, responsive and cost effective emergency ambulance transport service are co-ordinated

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via the Emergency Ambulance Services Commissioner (EASC) arrangements. The direct delivery of services is managed by the Welsh Ambulance Services Trust (WAST) and articulated within the WAST 3 Year Plan. Both draft plans have been shared between organisations and discussions are ongoing about priorities for the forthcoming three years. These are being framed in our contributions to the EASC Commissioning and Quality Delivery Framework, setting out the Health Board requirements for the essential clinical transport services we require as a Health Board to support our population and underpin our patient pathways. Cwm Taf is playing a very active part in ensuring that the new commissioning arrangements are robust and fit for purpose in commissioning clinical transport services for the future. Chapter 7 and specifically Section 7.23.2 provides an outline of our service requirements for clinical transportation services over the forthcoming period. This includes priorities in areas such as improving the Category A emergency ambulance 8 minute response time for Rhondda Cynon Taf and Merthyr areas, at present by trialling ring-fenced arrangements to keep local ambulances within our Health Board boundaries and ensuring a priority Health Board focus on maintaining and improving further good performance on ambulance handover rates at our District General Hospitals.

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6. QUALITY ASSURANCE AND IMPROVEMENT

6.1 Our Aim Quality and the focus on it is a ‘golden thread’ that runs through all components of our Plan. This Chapter provides the opportunity to highlight particular quality improvement approaches and includes:

The University Health Board Quality Strategy embraces the Health Board philosophy of “Cwm Taf Cares” and is supported by the Health Board’s Annual Quality Delivery Plan developed from triangulation of local and national data and patient/user/staff feedback and aligns with the requirements set out in Achieving Excellence (the Quality Delivery Plan for the NHS in Wales 2012 - 2016) and Safe Care, Compassionate Care, the National Governance Framework to enable high quality care in NHS Wales (2013). The Health Board is committed to putting patients, service users and carers at the centre of everything we do, engaging and listening to those who use our services to inform quality improvement. Our Quality Strategy focuses on delivery of safe and effective care and achieving excellent patient/user/carer and staff experience and supports the implementation of the Health Board’s 3 year Integrated Delivery Plan.

This requires effective leadership for improvement and this Integrated Delivery Plan supports the requirements set out in Delivering Safe Care Compassionate Care (2013) which requires leaders to put patients and patient safety central to all that they do promoting values and behaviours to ensure a culture of compassionate and caring staff. The Health Board is committed to listening to service users, patients, carers and our staff and acting on what is heard and seen. We will use the triangulation of the data (complaints, incidents, inquests, claims, audit, mortality reviews and Executive Walk Rounds) to inform our quality improvement priorities.

The Health Board is committed to act in ways that build accountability for quality assurance and quality improvement by applying the NHS Wales core values:

• Putting quality and safety above all else • Integrating improvement into everyday working • Focusing on prevention, health improvement and inequality • Working in true partnership

• Establishing a baseline of Quality indicators (link to AQS); • Projections of improvements; • Identification of actions required to improve.

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• Investing in our staff

The Cwm Taf Quality Strategy has adopted Darzi’s (2008) definition of quality and our improvement measures focus on:

• The safety of treatment and care provided to patients • The effectiveness of the treatment and care provided to patients • The experience patients have of the treatment and care they receive

6.2 Quality Assurance

Quality assurance is provided through our improving compliance with the 26 Standards for Health Services in Wales (Doing Well, Doing Better 2011) informing our annual improvement priorities. Key quality indicators are monitored across the services provided by the Health Board with the quality and performance dashboard providing a framework for continuous monitoring and measurement. To provide quality assurance we must consider:-

Safe Care Are patients and patient safety central to our decision making?

Effective Care Ensuring we are concerned about the quality of the care and not just the quality of the treatment

Excellent patient/user/staff experience

Are we asking “what matters to you?” rather than “what is the matter with you?”; Are we actively listening to what the public, patients and our staff are telling us?; Are we involving the public, patients and our staff in designing/improving our services?; Is the individual person and carer at centre or all that we do?

Our Quality Strategy is supported by our Annual Quality Delivery Plan, which has been developed from triangulation of our local quality data, learning from National Reports and reviews of the NHS in England and Wales. Learning from National audits (NHS Wales National Clinical Audit and Outcome Review Plan 2014/15); Confidential Enquires; feedback from Welsh Government and Inspectors (HIW); stakeholders and partners (Community Health Council, other Public service partners) also inform Health Board Annual Quality Delivery Plan. Reports on complaints, incidents, claims and inquests are scrutinised in detail by a sub-committee of the Board and all serious incidents are reported to the full Board for discussion and consideration with learning

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from this being disseminated through the organisation. In addition, we provide performance reports and quality indicators at Board and Board-sub committees for scrutiny on outcomes for patients. The ‘Trusted to Care’ report was published in May 2014 following the independent review into aspects of care and practice at the Princess of Wales and Neath Port Talbot Hospitals. The Report was commissioned by the Minister for Health and Social Services in the Welsh Government. The following key themes emerged from this review and the Minister requested every Health Board/Trust to provide assurance that where care was found to be compromised for frail older people in these hospitals, that these failings were not inherent across NHW Wales:

• In giving patients their medication • In ensuring that patients are kept hydrated; • In the overuse of night time sedation • In basic continence care

Within the Health Board we considered our position with compliance against each of the 14 recommendations in ‘Trusted to Care’ with three unannounced partnership dignity visits and quarterly unannounced visits by each Executive Director since May 2014. This has informed the following actions for improvement:

6.2.1 Actions that were already identified within our current plans, where the pace of implementation requires

acceleration;

a. Full implementation of the ward staffing establishment reviews (3 yr plan)

b. Roll out the integration model for Transforming Safe & Effective Care Together (Transforming Care & Improving Quality Together)

c. Implement Psychiatric Liaison service (recently supported by Welsh Government as Invest to Save bid)

d. Develop policy for drug administration to confused patients e. Roll out Care Rounding & Visitor Rounding f. Roll out of continence bundle g. Complete roll out of “This is Me” (patient centred care) h. Accelerate implementation and roll out of Schwartz Rounding i. Accelerate recruitment and deployment of volunteers

6.2.2 New priorities identified as a result of Trusted to Care:

a. Expand staff skills and competence in undertaking mental capacity assessments

b. Expand staff skills and competence with talking about death and dying and end of life care planning

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c. Design Question & Answer leaflet for staff re medicines management with confused patients

d. Develop a new policy for managing hydration in patients who are Nil by Mouth.

These priority areas are also being monitored via our quality improvement processes and structures. In terms of ensuring a priority focus on quality of primary and community care services, we work with all Independent Contractors using a range of approaches. There are external factors such as national contracts over which those in the front line have no control that drive change. Evidence shows us that patients generally place importance on a few key factors in relation to good quality indicators for general practice care. These included: • How care is accessed - appointments availability and times. • What care is provided - by whom and continuity. • How care is provided - communication and behaviours. • What practices achieve - outcomes and ratings. We use a range of methods to identify and spread best practice across primary and community care including clinical governance, team development, the contractor profession liaison groups, dissemination of national guidance and other evidenced based research, clinical leadership fora, appraisal process, the quarterly and monthly CPD programme, peer review, academic detailing, outcome-driven quality improvement and all the features of Cluster Network Development to review quality. Examples of our quality activities are: • Annual visits are undertaken to GP practices in order to monitor

statutory and contractual requirements as well as the quality outcomes framework (QOF) achievement.

• Detailed analysis of QOF achievement undertaken to compare to the Welsh average and to identify specific issues, outliers and concerns.

• Where issues are identified a visit from the Locality Clinical Director and the Locality Manager is undertaken to discuss an action plan.

• Post payment verification visits are also undertaken to validate the claiming of enhanced services.

• Where problems are identified advice and training is offered to the practice and other appropriate action may follow.

Analysis of the QOF data since 2004 shows: • QOF is a system of pay-for performance in which routinely collected

data from every GP practice is measured according to relevant clinical and management criteria. The data provides information about how

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many people within the practice live with the relevant Long Term Condition (the register size) and what proportions have received the relevant activity.

• There have been improvements in all domains: prudent prescribing and prudent healthcare initiatives will be developed to drive continued improvement. This will be by using other information about practices and mapping it to the relevant QOF criteria and by using the “quadrantic Improvement” method developed recently by the Health Board team in partnership with the Public Health Wales Primary Care Quality Advisory team.

• There is now considerably reduced variation both between Clusters and between Practices in QOF Achievement. This is a key performance and quality measure that the UHB has worked on and will continue to do this.

• There are a smaller number of practice teams whose achievement data could be improved when compared to the Health Board as a whole; quality improvement activities have and will continue to address the issues underlying this.

• However there is still some unexplained variation in register size; some Practices do not have as many patients on their disease registers as expected, others have more than expected; the reasons for this will be explored in partnership with the Public Health Wales Observatory.

• There are some clinical domains with ongoing variations in achievement including COPD, rheumatoid arthritis and mental health for example. The reasons for this are complex and often relate to the fact that Cwm Taf has a greater proportion of small GP Practices compared to the rest of Wales. COPD and mental health are the subject of service redesign and quality improvement projects which will start to address these issues.

• QOF data analysis has informed the inequalities work of the Health Board. This work will continue, building on the planned “Inverse Care Law Cardiovascular risk data” initiative as described above. QOF data will also be used to inform the other components of our inequalities work.

The Health Board has numerous reports available through the e-reporting system to aid the monitoring of the Dental Contracts. The Dental Quality and Patient Safety (DQPS) Group provide professional dental advice to the Health Board on quality and safety matters. The Health Board analyses the available data and works with the providers to resolve any minor issues. If any clinical or probity issues are identified, these are discussed with the dentist and an improvement plan is agreed. The Health Board implements the All Wales procedure for the management of doctors and dentists on the performers list whose performance is causing concern.

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6.3 Patient Experience The Health Board is committed to putting patients, service users and carers at the centre of everything we do, by engaging and listening to those who use our services to inform quality improvement. We continually review our practices to capture and listen to the views of patients, to ensure that our governance arrangements are robust, and to drive continuous improvement. The recent publication of the “Trusted to Care” report reinforces the importance of ensuring arrangements are in place for our Health Board to evidence how we involve service users in their care pathway and also how we capture, learn from and share the views of service users to drive continuous improvement. We are committed to using multiple approaches to seeking and understanding the experience individuals have of our services within the Health Board. The Patient Experience Plan 2014-2017 further outlines our approach to draw on a wide range of sources and information including formal, informal, real time, retrospective quantitative and qualitative approaches to obtaining feedback and data. The key is to triangulate those sources of intelligence so that they provide meaning and an understanding of what it is like to be a patient in the Health Board. The implementation and monitoring of progress against the Plan is undertaken by the Citizen Engagement Steering Group. In addition quarterly patient experience reports to Board further provide assurance that we are: • Engaging with patients to seek feedback on what their experience was

like in the Health Board • Developing measures to inform quality and performance improvements • Using the information from patients regarding their experiences to

inform and improve service provision • Meeting the requirements of the All Wales Framework for ensuring

Service User Experience

All our patient experience approaches are underpinned by principles of inclusivity to ensure a conscious focus on Co-production to deliver more effective and sustainable outcomes and improved experiences for our service users, and to meet the needs of our population through improving services.

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6.3.1 Our Commitment to Seek feedback From Patient

Experiences:

We want our patients, carers and service users to know that we care about their experiences and their interactions with all aspects of the Health Board. Our commitment has been strengthened by:

• The re establishment of our Citizen Engagement Group • Identification of Directorate/Locality Patient Experience Champions • The Patient Experience Manager contributes to Directorate

Governance Groups supporting and strengthening patient experience within local plans

• Quarterly patient experience reports are provided to the Health Board and Welsh Government

• Patient Experience is incorporated and central to:

o Corporate and local induction o F1 & F2 medical training programmes o Medical Revalidation sessions o Dignity training days o Improving Quality Together IQT. o Local Medical and Dental Committees

• A Balance scorecard has been developed to illustrate the Health Board’s compliance against the key performance indicators in the “All Wales Framework for Assuring Service User Experience” and in addition to this, patient experience activity is also measured against the Health Board’s Patient Experience Metric and Performance Indicators.

• Since April 2014 a structured approach to patient satisfaction has been implemented, with monthly patient experience audits undertaken across all areas accessing the Fundamentals of Care system. For those areas not using this approach, the All Wales Service User questionnaire is undertaken to monitor feedback.

• Patients and carers have been engaged in the key priority projects of the Health Board Annual Quality Delivery Plan e.g. dementia, patient flow and communication.

• We are encouraging GP surgeries to establish Patient Participation Groups to explore other alternative ways of gaining patient feedback to inform their service development plans.

• As part of the review of Primary Care Reporting Structure a Primary Care Committee has been established which is led by two non Executive Board members and includes patient experience focus.

• Further development of the role and contribution of volunteers has recently been undertaken with the following projects established:

o Maternity Tour Guide volunteers o Stroke Rehabilitation support volunteers o British Red Cross hospital to home scheme

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o Appointment of 5 Community Coordinators within Localities

The Citizen Engagement Steering Group monitors activity across the Health Board through updates from Directorates, Localities and Primary Care on progress against key indicators. Feedback is shared with a range of our partnership groups, including the Stakeholder Reference Group, Quality Steering Group, and Quality & Safety Committee and with the wider public through our Public forums. 6.3.2. Executive Walk Rounds - engaging and listening to patients

and front line staff to inform quality improvement

The format for the Health Board Executive Walk Rounds visits was redesigned in April 2014 with the launch of the Walk Round guide to ensure a consistent focus on patient safety.

Visits are undertaken weekly and involve visits to clinical areas across both Secondary and Primary Care by Executive Directors and Independent Members of the Board. Since the publication of Trusted to Care report, additional Executive Director unannounced visits take place quarterly. Themes emerging from the visits inform the Annual Quality Delivery Plan, for example: staffing and establishments, staff training, storage, equipment and communication. Actions to improve communication between primary and secondary care; between wards and departments; between clinical staff and patients/carers; between corporate and clinical services has been incorporated into our Quality Delivery Plan. Regular reports are presented to the Quality and Safety Committee for assurance and to the Quality Steering group to monitor trends for quality improvement.

6.4 Quality Improvement

The 1000 Lives Improvement Service and Health Board/Trusts across Wales have built national priorities for improvement into the three year integrated plans. For the Health Board these are:- The Cwm Taf Health Board Annual Quality Delivery Plan is a dynamic improvement plan which identifies detailed priorities for improvement, determined from the triangulation of data, feedback from services users, patients, carers and staff and formulated from directorate and locality patient care and safety team looking at themes and trends from complaints, concerns and incidents.

• Improving Patient Flow • Inverse Care Law • Improving Quality Together – Model for Improvement

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The quality delivery and improvement process is underpinned by a delivery structure to ensure this is progressed through the organisation. The Quality Steering Group monitors the implementation of the Annual Quality Delivery Plan and the model for improvement is applied to each improvement project through the application of Improving Quality Together Bronze and Silver training to clearly determine improvement measures and outcomes for each project team (over 1,00 staff are trained to Bronze level and over 160 to Silver level at January 2015). Progress with implementation of the Quality Delivery Plan is monitored and presented in the quarterly Quality Report to the Quality & Safety Committee. The Health Board Quality Blog promotes quality improvement work on the intranet site to share learning and best practice with staff. Health Board Quality internet Hub is currently in development for launch December 2014.

6.5 Quality Indicators

The following key indicators are monitored by the Quality Steering Group to reduce harm whilst promoting an improvement culture and safe and effective care in practice by measuring:

6.5.1 Delivery of Safe Care – “Reducing Harm”

• Timely nutritional assessment (National indicator) • Health Care Acquired Pressure Ulcers (National indicator) • Health Care Acquired Infections (National indicator) • Incident and near miss reporting clusters • Incidence of falls and falls associated with harm • Medication errors • Mortality Review –trends/themes

6.5.2. Delivery of Effective Care – “Improving Outcomes”

• Incidence of Sepsis • Incidence of VTE (compliance with risk assessment) • NEWS compliance, escalation and response – failures to act on

deteriorating patients • Incidence of lack of timely key specialist medical input to individual

patients • Incidence of undertaking unauthorised clinical procedures • Compliance with National clinical audits and Outcomes program to

inform improvements • Achievement against the Quality and Outcomes Framework • Increase in the number of patients who are diagnosed with a chronic

condition and whose care is optimally managed in the Primary Care setting.

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We will continue to focus on primary and secondary prevention of health problems with Public Health in relation to smoking, obesity and alcohol associated problems. 6.5.3 Achieving Excellent Patient (user/carer) Experience

The Health Board Patient Experience Plan provides the framework to measure patient/service user/carer feedback to inform improvement and involve patients/carers in quality improvement work. The plan applies the domains of the All Wales User Framework (2013) and supports the principles of The Listening Organisation 1000 Lives white paper as listening and learning from patient/user/carer experiences provides us with quality assurance and identifies areas for improvement. 6.5.4 Achieving Excellent Staff Experience

Staff satisfaction and commitment predict patient satisfaction. A key role of our leaders is consulting staff and learning from them. NHS staff survey results 2013 have informed an improvement plan being led by the Director of Workforce and Organisational Development. Our Fundamentals of care audits (autumn 2014) also inform the Quality Delivery Plan. The Health Board commits to weekly Executive Walk Rounds by Executive Directors and Independent Members to visit clinical areas, speak with staff and patients, observe good practice and agree areas for improvement.

6.5.5 Measuring Improvement

i. The national indicators are monitored via the Fundamentals of Care system for pressure ulcers, nutritional risk assessments and hand hygiene compliance. The Cwm Taf Health Board Integrated Performance Dashboard will continue to be developed to present the key quality indicators over time to identify good practice and to focus on areas for improvement.

ii. General Medical Services (GMS); achievement against the Quality and Outcomes Framework (QOF) is one measure used to monitor the performance of General Practitioners. An All-Wales comparison of achievement within Cwm Taf Health Board and externally against other Welsh LHBs areas is available on an annual basis. Further more detailed local analysis is undertaken annually and individual Cwm Taf practice QOF achievement is compared to identify low achievement and significant variance. This process also informs priority areas for the QOF programme of visits. Where significant variance is identified the individual GP(s) are visited by the Head of Primary Care and the Locality Clinical Director to discuss the low achievement and plans for service improvement. Our data shows that where areas have been

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identified through this process and practices have been visited improvements are made in the following year and not repeated. Overall QOF achievement has been improving year on year.

iii. Opening Hours and Appointment System within GP Surgeries; GP

Practices within Cwm Taf Localities are working hard to improve opening times and access to appointments. The annual statistical release has demonstrated year on year improvement. Where concerns are raised through patient complaints, practices are visited and action plans for improvement are agreed and implemented.

iv. General Dental Services; regular monitoring of claim trends and achievement of activity against agreed UDA (Units of Dental Activity) is undertaken. Dental Practitioner’s are advised if the practice has a percentage of claims above the average and advice is sought from the Dental Advisor in Public Health Wales. When clinical concerns or inappropriate claiming is suspected a detailed review of the clinical records is undertaken by the Clinical Policy Advisor from the NHS Business Services Authority Dental Division.

v. Optometrists; a rolling programme of Post Payment Verification visits is undertaken by NHS Wales Shared Services Partnership. Where appropriate recoveries are made and performance issues identified.

A Performance Dashboard for Primary Care has been developed and will be available shortly. Further work to encouraging practice audit, peer review and qualitative research is ongoing through the professional representative bodies and development groups.

6.6 Quality Triggers

Quality Triggers and questions are applied when triangulating the information from a variety of sources to consider the dimensions of quality to demonstrate that we are actively listening and learning: • Are we providing safe care? • Are we meeting required standards of effective care? • Are we improving user experience? • Are we providing efficient services within our resources? • Are we engaging with the workforce? • Are we providing accessible and equitable services? • Are we improving population health?

A number of key measures are regularly reviewed and triangulated by the Health Board Quality Steering Group to determine and support actions for improvement within the Quality Delivery Plan. These include:

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• Mortality Review

• Healthcare Associated Infections

• 1000 Lives work streams

• Patient/User feedback

• Staff feedback

• Executive Walk Rounds actions for improvement

• Clinical Audits – National/local

• Concerns (incidents, complaints, claims, inquests)

• NICE/Alerts compliance

• Research and Development findings

• Achievement against QOF clinical indicators

• Statistical release for GP Access Data

The regular analysis and review of data from these quality triggers to inform the priorities for service improvement is an iterative process. As part of the development of the Health Board Quality Delivery Plan, data identified from the quality triggers was reviewed and analysed, with further triangulation and interpretation of information from a range of other sources. This work formed the basis of the quality improvement priorities identified in the Quality Delivery Plan and these are described in section 5.6. The following section summarises how these priorities were developed. 6.6.1 Mortality Review

For the period November 2013 – October 2014 Cwm Taf Health Board’s Risk Adjusted Mortality Index (RAMI) demonstrated a downward trajectory, whilst remaining above the All Wales average. The significance of this is uncertain.

Stage 1 mortality case note reviews were undertaken on 1279 acute patient deaths, with 248 being referred to stage 2, and 110 community patient deaths with 6 referred for Stage 2. The review process identified the following messages:

- Accuracy & calculation of NEWS scoring and when to discontinue; - Need for Orthogeriatric care; - DNAR decision making - Monitoring of Acute Complicated diabetes - Timing and appropriateness of transfer from acute to community

hospitals

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We have developed a robust process for undertaking mortality reviews that relate to our two acute District General Hospitals and this has been rolled out to our community hospitals. This process also includes General Practitioners in additional to the hospital teams. Our challenge is to ensure the same robust process applies in our Accident & Emergency Departments and we will be focusing on this improvement. Following the independent review by Professor Stephen Palmer into hospitals with high RAMI which included Royal Glamorgan and Prince Charles Hospitals, there has been a recognition that the value of the RAMI score is limited and due to the calculation process is likely to be towards the high end for our hospitals. Accordingly we are no longer setting a target for RAMI reduction but will continue with the Mortality Case Note Review process endorsed by Professor Palmer and the Minister for Health. 6.6.2 Learning from Coroners Inquest

2014/15: The coroner has issued 3 Regulation 28`s relating to (1) frequency of neurological observations following an in patient fall and head injury in Mental Health; (2) diagnosis of meningitis and treatment (paediatrics) GP out of hours and Paediatrics; (3) prophylaxis treatment for Venous Thrombo-embolism in fractures. Many of clinical issues in these cases were already being addressed through the Putting Things Right process – the information from the inquests has served to strengthen the learning and the remedial action being taken to reduce the risk of recurrence. 6.6.3 Healthcare Associated Infections (HAI)

During 2013/14, the Clostridium difficile infection rates for the HEALTH BOARD remained the lowest in Wales at 1.58/1000 admissions in patients aged 2 and over (Wales average 3.61). This is an achievement of a 46.7% reduction of cases from year 2010/11. A revised target over an 18 month period was introduced in April 2014 which will monitor rates per 100,000 population. To achieve the national target, each Health Board is required to reduce their rate to no more than 31 per 100,000 population. A rise in numbers has been seen during recent months but a multi disciplinary root cause analysis is undertaken for every case and lessons learnt are shared with the Directorate for action. Good antimicrobial stewardship practices remain the primary prevention of Clostridium difficile infection with exemplary use of standard infection prevention and control precautions and environmental and equipment cleanliness.

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During 2014, the Health Boardbacteraemia and surpassed the 20% reduction set by Welsh Government. Again, our progress will be monitored against the new target which is no more than 2.6 cases per 100,000 popul

Across Wales, there has been an upward trend for MSSA bacteraemia which was also reflected in our numbers. The to monitor trends locally but this is no longer included as a tier 1 target. Focused improvement work is ongoing across the to achieve a zero tolerance approach to all healthcare associated infections. Out profiled performance is outlined in

6.6.4 Reported Patient Safety I

Analysis of these incidents shows that the highest category of patient related safety incidents relate to slips/trips and falls with other significant themes relating to:

• • • •

ealth Board achieved a 32% reduction of MRSA bacteraemia and surpassed the 20% reduction set by Welsh Government. Again, our progress will be monitored against the new target which is no more than 2.6 cases per 100,000 population.

Across Wales, there has been an upward trend for MSSA bacteraemia which was also reflected in our numbers. The Health Boardto monitor trends locally but this is no longer included as a tier 1 target.

Focused improvement work is ongoing across the Health Boardto achieve a zero tolerance approach to all healthcare associated

Out profiled performance is outlined in section 5.6.4

Reported Patient Safety Incidents

these incidents shows that the highest category of patient related safety incidents relate to slips/trips and falls with other significant

Admission/transfer/discharge; Pressure damage; Delays; and Communication

achieved a 32% reduction of MRSA bacteraemia and surpassed the 20% reduction set by Welsh Government. Again, our progress will be monitored against the new target which is no

Across Wales, there has been an upward trend for MSSA bacteraemia ealth Board will continue

to monitor trends locally but this is no longer included as a tier 1 target.

Health Board to strive to achieve a zero tolerance approach to all healthcare associated

section 5.6.4.

these incidents shows that the highest category of patient related safety incidents relate to slips/trips and falls with other significant

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Over the last four years incident reporting from primary care to the Health Board has been lower than within the previous Health Board structures, but following closer joint working with the Patient Safety and Primary Care teams the number of incidents being reported from GP practices has started to increase. It is the intention that learning and feedback from primary care incident reports is provided through a regular Primary Care Newsletter. It should be noted also that each practice will have their own internal system for reporting and investigating incidents to improve safety.

The highest number of reported incidents from GP practices relate to the quality and timeliness of the documentation shared between primary, community and secondary care, particularly the quality of discharge letters. A number of actions are in place to address the issues, these include:

• Encouraging all GP practices to report incidents involving poor communication or sharing of documentation;

• Encouraging all hospital doctors/nurses to report incidents involving poor communication or sharing of documentation;

• Introduction of a new system of Discharge Advice Letters; • Regular audit of the quality and communication of discharge advice

letters; • Specific training for new hospital doctors incorporated into their

induction programme; • Challenging of individuals when incidents are raised; • Improving communication between community hospitals and GP

practices when patients are transferred for rehabilitation or complex discharge.

The following key trends were triangulated from this analysis:

6.6.5 Formal Complaints

The range and volume of services provided by the Health Board is outlined in section 2.3, services provided, during 2013/14 we carried out over 1.2 million hospital appointments, operations and scans and over 800,000 face to face GP consultations.

Since the publication of ‘Using the Gift of Complaints’, (June 2014), the Health Board concerns team now contact the majority of complainants by telephone on receipt of formal complaints, with the aim of accelerating early resolution.

• Improving patient flow and care of patients with frailty • Reduction of risk in hospital and community falls • Improving the timeliness and quality of communication documentation

exchanged between primary, community and hospital services.

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During 2013/14 the Health Board received 589 formal complaints, which was an 8% decrease in the number of formal complaints received in 2012/13. Reasons for individual complaints are often multifactorial, and reflect more than one element of dissatisfaction. However, each complaint tends to have a primary subject.

An analysis22 of the top trends of complaints received from October 2013- September 2014 related to: • Patients being unhappy with their treatment (clinical practice and

diagnosis); • Delays/cancellation of appointments; • Waiting times and concerns attributed to failures in communications

standards. There is a correlation between formal complaints and clinical negligence claims. The main trends identified from this analysis can be summarised into the following themes: An extremely small proportion of these formal complaints and clinical negligence claims relate to Primary Care Professions. The trends emerging from incidents, complaints and claims were triangulated into the following key priorities for improvement:

6.6.6 Patient Experience Feedback

An analysis from patient experience and other sources of patient feedback identified the following themes:

• The way in which staff communicate with patients, relatives and carers; • Lack of involvement of carers in the care planning and discharge process; • Service users reporting wanting to be more involved in the planning and

design of services; and

22 As per the categories recorded on Datix

- Failure to diagnose/delay in diagnosis; - Failure to recognise complications; - Inappropriate treatment; - Treatment error.

• The focus on patient flow and the care of patients with frailty. • Improving the pathway for patients with fractured neck of femur. • Improving the experience of patients with cognitive

impairment/dementia. • Improving communication: consent, documentation, coding,

handover, culture of care.

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• Lack of feedback to service users when they were involved in this process;

• Difficulties with waiting times, first and follow up appointments.

6.6.7 Safeguarding The Health Board has a range of statutory obligations in relation to safeguarding (adults and children) which are summarised below: • To ensure the Health Board complies with section 28, 27(2) (a) (b) and

section 25 and section 31 of the Children Act 2004; • To ensure the Health Board complies with the Protection of Vulnerable

Adult Procedures/and strategic guidance to safeguard adults at risk of abuse and neglect;

• To ensure the Health Board complies with the requirements as the Supervising and Managing Authorities for the Deprivation of Liberty Safeguards (DOLS) as outlined in the Mental Capacity Act 2005 and amended in the Mental Health Act 2007.

• To ensure the Health Board discharges its duties as a Multi-Agency Public Protection Arrangement (MAPPA) Duty to Co-operate Agency under s325 Criminal Justice Act 2003;

• To ensure the organisation complies with safe recruitment and monitoring arrangements following Disclosure and Barring (DBS) & Independent Safeguarding Authority (ISA) guidance.

Cwm Taf has particular challenges in relation to safeguarding; measured by indicators such as rates for children on the child protection register, the number of Looked After Children and domestic abuse, Cwm Taf has rates which exceed the Welsh average. The West Cheshire Judgement made in the Supreme Court in March 2014 also has a very significant impact on the number of Health Board patients who require Deprivation of Liberty Safeguards and the changing demographics of our population with an increasingly aging population, will lead to higher rates of Vulnerable Adult referrals. The Health Board has established local governance arrangements for safeguarding led by the Executive Director of Nursing and part of this governance process is to prepare an Annual Report on Safeguarding to the Board outlining in detail the Health Board’s response to meeting its local and statutory duties.

6.7 Priorities 2015 - 2016

These emerging themes informed the year one priority high level improvement projects outlined in the 2014/2015 Annual Quality Delivery Plan. The quality measures have been reviewed and the trends have informed the 2015/16 Annual Quality Delivery Plan key priorities. It has

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also been strengthened with improvement projects across Primary and Secondary care:

As outlined above, the Annual Delivery Plan is a dynamic plan, responsive to patient, public and staff feedback and reflecting triangulation of data and emerging trends which will continually inform priorities for improvement and deliver sustainable change.

Quality measures have informed the development of the 2015/16 quality improvement priorities:

• Improving the care of elderly frail patients • Prudent Healthcare – Medicines Management. • Public Health Prudent Healthcare. • Co-production, communication engagement and learning.

These are underpinned by a range of service individual improvement projects

2015/16 – Strengthening quality improvements in Primary and

Community Care: • Improve the range and quality of General Medical Services

delivered within each cluster area of GPs. • Encourage GPs to work collaboratively in cluster groups to provide

more specialised services for the total population. • Improve the number of patients being optimally managed by their

GPs. • Reduce the gap in life expectancy between the most and least

deprived areas. • Learning from mortality reviews across community hospitals and

GP Practices • Improving flow though our community hospitals: keeping patients

independent by reducing unnecessary time spent in our community hospitals is extremely important to maintaining health and wellbeing.

• IQT (Improving Quality Together) Training: it is our aim that all Ward Managers across all the hospitals in the Localities Directorate will undertake IQT silver level training and all Band 6 Deputies will have undertaken IQT bronze by the end of March 2015.

• Increase dental activity within the Merthyr Tydfil Locality: the oral health of patients within Merthyr Tydfil is the worst in Wales. It is intended that we will commission additional units of dental activity from April 2015 in an attempt to respond and improve this All Wales position.

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6.8 Openness and Transparency The Health Board is committed to being open and transparent with the public, patients and service users with the quality of the services we provide, sharing good practice, achievements and identifying areas for improvement via:

• Cwm Taf University Health Board internet site: Quality & Performance reports, Board and Committee papers

• Annual Quality Statement • My Local Health Service – NHS Wales, quality data and performance • Public Forum events across Cwm Taf Localities The Health Board Annual Quality Statement provides our public with clarity about our commitment to Quality Improvement and confirms our performance, what we have done well and not so well and what our public, patients, service users and carers are telling us we need to improve on to inform our Annual Quality Delivery Plan.

_________________________________

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7. SERVICE CHANGE PLANS AND PRUDENT HEALTHCARE

In line with our clinical strategy, this chapter sets out our service change plans. For ease of reference, each of the sections contain links to our

performance, workforce, finance, capital/estates plans, helping to demonstrate the inter-linkage between our plans and required enablers.

Prudent healthcare examples are also provided. Cwm Taf University Health Board serves the most deprived population in Wales; 34% of our residents live in the most deprived Wards within Wales with life expectancy being one and a half years less than the Welsh average. Healthy life expectancy of Cwm Taf residents is approximately three years less for males and five years less for women than the Welsh average. However, of greater significance is that for people living in the most deprived communities in Cwm Taf, their healthy life expectancy is 10 years less than the Welsh average – meaning that local people experience ill-health for longer with the inevitable additional consequences for healthcare. The Bevan Commission publication on prudent healthcare challenges healthcare professionals to make best use of skills and resources with one of the key principles being “only do what only you can do”. This can be further extended to the patient as a partner in their own healthcare where individual responsibility for health and self-care is personally ascribed. Both of these concepts must be considered in the context of Primary Care and Community Services providing the first point of contact between an individual and a healthcare professional in approximately 90% of interfaces with health care services. Traditionally, the healthcare system can be represented by the diagram outlined in the figure below.

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The future model of care in Cwm Taf will need to continue to follow a similar relationship, however, the dynamic is likely to change to reflect the descriptors outlined in the figure below.

Whilst there are continually evolving changes and developments within all components of the model, it is within the Locality Services and the Integrated Primary Care and Community Services areas that the most

Tertiary Services

DGH Services

Community Services

Tertiary Services

DGH Services

Locality Services

Self Care

Primary Care

(Predominantly GPs)

This basic model remains largely unchanged since the inception of the NHS. The levels of care and their linear relationship remain the same although the capacity and capability for treatment, particularly within DGH and tertiary care has changed beyond all recognition over the 60+ years.

Integrated Primary Care and Community Services

Self Care and Supported Self Care

Increased focus on proactive assessment with sign-posting to a range of statutory and non-statutory services to help people stay healthy and support independent living where necessary

Joint working between all contractor professions (not just GPs) and community-based health and social care services focusing on prevention, early intervention, reablement and rehabilitation

Primary Care, Community and Secondary Care clinicians working together at locality level, in line with Prudent Healthcare principles to deliver more equitable and specialised out-of-hospital care

Hospitals and Hospital Clinicians working together across organisational and professional boundaries to deliver joined-up services but potentially in a smaller number of places. Some traditionally tertiary services devolved to DGHs in networked arrangements.

Highly specialised care delivered in a very small number of places as part of a networked approach to integrated patient care

Cwm Taf Primary and Community

Services Strategy

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significant change needs to happen to shift the balance of care. Further detail on our plans to facilitate this shift in care and develop key services can be seen later on in this chapter in section 7.21.

The Health Board has a Plan which sets out a range of inter-related, innovative service changes across the health system, which taken together will be critical enablers for achieving the priority objectives outlined at the start of the Plan, and particularly the development of primary and community care to enable a re-focussing of care towards community settings.

These enablers are also critically important to successfully deliver the South Wales Programme changes, which will have the greatest impact on Cwm Taf.

The upfront costs of this package of change are significant and it is this which requires the headroom funding of £12.4m as it cannot be afforded within the allocations already announced. This package of investment, and agreeing the additional Welsh Government funding without which it would be unaffordable, is an absolutely critical element of the Plan and further detail on the underpinning funding plan can be seen in Chapter 9. A further £2m has been set aside for internally prioritised service improvements and capacity shortfalls. In particular, we have several linked areas of change which form part of our service change priorities in this Plan, including the following:-

• Development and implementation of our Primary and Community Care Strategy, including implementation of Cluster Plans, development of our out-of-hours services and moving toward the development of a ‘hub and spoke’ model of primary care, building on the development of Health Parks across the Health Board.

• Phase 2 in the development of our Older Persons Mental Health Services, increasing the provision of community services and reducing reliance on beds where appropriate.

• Implementation of our Joint Commissioning Statement for Older People in Cwm Taf. This describes our service model for older people with complex needs/the frail elderly and will determine how the UHB and Local Authorities will either provide services or procure services from the Third Sector, independent sector or social enterprises, which will span universal to specialist needs.

• Building on the successful improvements in patient flow over last year, to extend the flow work and add additional improvements to systems and pathways of care to further reduce the requirement for acute and community beds.

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• These additional improvements include further implementation of our acute physician service, introduction of our Liaison Psychiatry Service and realising service improvement from our recently implemented stroke early discharge service and stroke centre of excellence at PCH. Such developments will help us to continue our actions on improving flow and should enable the continued incremental improvements for patients such as reducing lengths of stay in a number of areas in 2015/16, as can be seen in our demand capacity work in Chapter 5, section 5.6.5.

• Implementing the outcome of the South Wales Programme in order to ensure the sustainable development of a number of our more fragile clinical services in liaison with our partner Health Boards and Trusts, via the agreed Acute Care Alliance arrangements. Sub-section

7.22.1 provides further detail on this below.

• Relocating the Y Bwthyn Palliative Care Service and Child and Adolescent Mental Health outpatient services to the Royal Glamorgan Hospital together with other services will enable us to close and dispose of the Y Bwthyn and Tonteg sites which are two of the remaining older parts of our estate.

The following sections offer further detail in these and a range of other service change plans and initiatives.

7.1 Prevention

Key Strategic Drivers

The Welsh Government has published a range of condition-specific delivery plans to support its Programme for Government and its NHS Five Year Plan with the aim that:

• Health will be better for everyone. • Access to care and patient experience will be better. • Better service safety and quality will improve health outcomes.

Prevention of ill health and the promotion of good health feature as the first theme across all these delivery plans. Action to address modifiable lifestyle risk factors such as smoking, obesity, alcohol consumption above recommended guidelines and lack of physical exercise is fundamental to reducing the prevalence of ill-health.

Our local delivery plans will: • Highlight the key risk factors relevant to that condition, the

relationship to the Rhondda Cynon Taf and Merthyr Tydfil Single

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Integrated Plans and the role of the Health Board as a key partner in supporting this work.

• Acknowledge the contribution of national organisations (e.g. Diabetes UK) and partner organisations (e.g. National Exercise Referral in local authorities) in tackling health inequalities, their collaborative relationship and affect.

• Describe the interface between primary, community and secondary care, and impact on risk factor management.

Priorities:

i. Smoking

To make a difference in the number of people smoking in our population requires action at all levels, and is dependent on good partnership working and strong leadership. Further detail is contained within the Smoke Free Cwm Taf Strategic Action plan. We recognise that sustained work is needed to maximise the population impact of tobacco control actions, to increase the number of smokers who connect with smoking cessation services and ultimately to change social norms and the inequalities that exist within our communities. There has been a decline in the numbers of individuals being supported to quit via the established services during 2013-14 (illustrated below). This may be a consequence of the increasing popularity and heavy promotion of electronic cigarettes locally and nationally. This is being investigated and will be addressed as an emerging issue under the Smoke free Cwm Taf Strategic Action plan, but is likely to require a national solution. The Health Board will continue to work closely with Public Health Wales (PHW) to ensure that the PHW Stop Smoking service is designed and delivered around the needs of the Cwm Taf population.

774 774 774 774 774 774

122171 146 140

84

198

308

415

547

396 387

192

13 22 20 23

430

586

706

558491

413

0

200

400

600

800

1000

Q3 2012/13 Q1 2013/14 Q3 2013/14

Nu

mb

er

of

tre

ate

d s

mo

ke

rs

Number of smokers making a quit attempt via

smoking cessation services in Cwm Taf

Tier 1 Target (5% of smokers

in Cwm Taf make a quit

attempt via smoking

cessation services)

Stop Smoking Wales

(treated smoker)

Community Pharmacy Level

3 (treated smoker)

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In September 2013, Cwm Taf adopted a policy statement on reducing smoking prevalence, building on Smoke Free, Cwm Taf University HealthBoard’s Strategy established in 2012.communicates the Board’s determination to tackle this challenge and also lays a key foundation for specific action to address inequity:

Smoking cessation is a key treatment for allprofessionals should take every opportunity to:

Maximising the potential of this policy statement will involve ensuring that health care professionals systematically identify individuals who wish to stop smoking and signpost orThis approach reduces the impact of morbidity and mortality rates resulting from smoking as well as financial costs associated with accessing unscheduled care and increased length of stay. We have been working improve and shorten the referral pathway to smoking cessation services, and have plans to systematically work with other clinical leads period of 2014/15- 2016/17.

In May 2013, our MAMSS Cessation Support) research project, sponsored by Cwm Taf R&D, commenced. The aim was support established as part of maternal care increase the uptake of behavioural support and improves quit rates amongst pregnant women. On the basis of the results of the pilot, funding was “Families First” to provide this service to the Rhondda, Cynon and Taff Ely localities during 2014-15.result in an additional 150annum, with 1 in 3 being smoke free. Our Community Pharmacy Level 3 Smoking Cessation Service is well established in Cwm Taf and in January 2014 an additional 10 pharmacies joined the scheme increasing the number of participating pharmacies to 39 out of 77. We anticipate that will accessing cessation support via the scheme by 25% during 2014/15 and beyond. There has been further extension of the service during 2014/15, by April 2015, 60 pharmacies will be commissioned to provide the level 3 Smoking Cessation Service.

In September 2013, Cwm Taf adopted a policy statement on reducing , building on Smoke Free, Cwm Taf University Health

Board’s Strategy established in 2012. This statement reaffirms and clearly communicates the Board’s determination to tackle this challenge and also lays a key foundation for specific action to address inequity:

Smoking cessation is a key treatment for all smokers. Health care professionals should take every opportunity to:

Maximising the potential of this policy statement will involve ensuring that health care professionals systematically identify individuals who wish to stop smoking and signpost or refer them to appropriate local services. This approach reduces the impact of morbidity and mortality rates resulting from smoking as well as financial costs associated with accessing unscheduled care and increased length of stay.

We have been working with Cardiology, Stroke, and Respiratory leads to improve and shorten the referral pathway to smoking cessation services, and have plans to systematically work with other clinical leads

2016/17.

MAMSS (Models for Access to Maternal Smoking esearch project, sponsored by Cwm Taf R&D, was to determine if alternate models of behavioural

support established as part of maternal care increase the uptake of pport and improves quit rates amongst pregnant women.

results of the pilot, funding was “Families First” to provide this service to the Rhondda, Cynon and Taff Ely

15. Based on experience during the pilot, this could 150 pregnant mothers being supported to quit per

annum, with 1 in 3 being smoke free.

Our Community Pharmacy Level 3 Smoking Cessation Service is well established in Cwm Taf and in January 2014 an additional 10 pharmacies joined the scheme increasing the number of participating pharmacies to

We anticipate that will increase the number of people accessing cessation support via the scheme by 25% during 2014/15 and

There has been further extension of the service during 2014/15, 60 pharmacies will be commissioned to provide the level 3

Smoking Cessation Service.

In September 2013, Cwm Taf adopted a policy statement on reducing , building on Smoke Free, Cwm Taf University Health

This statement reaffirms and clearly communicates the Board’s determination to tackle this challenge and also lays a key foundation for specific action to address inequity:

smokers. Health care

Maximising the potential of this policy statement will involve ensuring that health care professionals systematically identify individuals who wish to

refer them to appropriate local services. This approach reduces the impact of morbidity and mortality rates resulting from smoking as well as financial costs associated with accessing

with Cardiology, Stroke, and Respiratory leads to improve and shorten the referral pathway to smoking cessation services, and have plans to systematically work with other clinical leads over the

(Models for Access to Maternal Smoking esearch project, sponsored by Cwm Taf R&D,

to determine if alternate models of behavioural support established as part of maternal care increase the uptake of

pport and improves quit rates amongst pregnant women.

results of the pilot, funding was secured from “Families First” to provide this service to the Rhondda, Cynon and Taff Ely

e pilot, this could pregnant mothers being supported to quit per

Our Community Pharmacy Level 3 Smoking Cessation Service is well established in Cwm Taf and in January 2014 an additional 10 pharmacies joined the scheme increasing the number of participating pharmacies to

e number of people accessing cessation support via the scheme by 25% during 2014/15 and

There has been further extension of the service during 2014/15, 60 pharmacies will be commissioned to provide the level 3

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Together for Chronic Obstructive Pulmonary Disease (COPD) is a non promotional joint working project between Cwm Taf University Health Board and GlaxoSmithKline to optimise the management of COPD patients. This project has a particular focus on smoking, and all the participating GP practices (32) have received training on the impact of smoking on the disease pathway, the importance of cessation support to improve the quit attempt, and the locally available services and referral method. As part of our work to tackle health inequalities (Inverse Care Law programme) we are prioritising smoking cessation in patients on chronic disease registers as one of our interventions. A Smoke Free Homes project has been developed in Cwm Taf. A number of our Communities First Clusters and Registered Social Landlords have received comprehensive training and resources, and further Clusters and Registered Social Landlords are scheduled for involvement. In October 2013, the Regional Collaboration Board agreed Smoke Free Public Places as a priority, committing partners to work together in delivering the Smoke Free Cwm Taf Action Plan 2011/15.

Our local performance indicators are as follows:

• Percentage of adult smokers making a quit attempt via smoking cessation service (target 5%).

• Percentage of treated adults smokers who successfully quit smoking at 4 weeks (CO verified) (target 40%).

• Percentage of pregnant smokers making a quit attempt via MAMMSS. • Percentage of pregnant women who successfully quit smoking at 4

weeks (CO verified). • Number of households signed up to ‘smoke free homes’ initiative. • Percentage of smoke free playgrounds, parks, sports grounds, council

grounds. Our population outcome measures are as follows:

• %age Adult smoking who report smoking. • %age of women smoking during pregnancy.

• %age of 11-16 year olds smoking weekly.

What will we achieve over the next three years?

• A reduction in adult smoking prevalence rates through increased use of smoking cessation services (5% of smokers making a quit attempt, with at least a 40% CO validated quit rate at 4 weeks).

• A reduction in %age of women smoking during pregnancy resulting in a reduction in the proportion of babies born with a low birth weight by increasing the number of women receiving smoking cessation support through MAMSS.

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• A reduction in of 11-16 year olds smoking weekly • An increase in the percentage of smokers on chronic disease registers

who stop smoking as part of the Health Inequalities (Inverse Care Law programme) work.

• A reduction in the exposure to second hand smoke in homes. ii. Immunisation

Immunisation uptake is increasing year on year in all our target groups. Our level of flu immunisation for patients has increased, but more work is needed to support all practices to achieve the 75% uptake in all target groups. This is detailed in action plans and will ensure that we continue to increase towards target levels. Planned action includes vaccination by midwives, Health Care Support Workers and Community Pharmacists. We have increased our staff immunisation rate from a very low base of 9% to 43% (within reach of the 50% target for 2013/14). Plans for 2014/15 and onwards to achieve and exceed this target include:

• Consolidate and build on the successful actions and initiatives implemented to date

• To secure a slot in the corporate induction programme to talk about work place vaccinations focusing on Flu, Hep B and MMR

In terms of childhood immunisations, Cwm Taf exceeds or is close to achieving the individual targets for most of the childhood immunisations and is progressing with the new challenging composite target. The composite target is more difficult as different children will miss different immunisations. Achievement of these %age targets is more difficult in a small population as one child missing their immunisation has a disproportionate impact on the %age result. All involved with providing immunisation are prioritising this work, and it can be seen that rates are continuously improving. We anticipate exceeding 90% by quarter four of 2013-14.

What will we achieve over the next three years?

• Achieve and maintain 95% uptake of routine childhood immunisations. • Achieve and maintain target uptake rates for flu immunisation in

eligible groups including the new flu immunisation programme for children and young people.

iii. Obesity

Cwm Taf Healthy Weight, Healthy Valleys Strategy identifies and co-ordinates the partnership approach to improving nutrition and physical activity and maintaining a healthy weight in Cwm Taf through:

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• Clear leadership and co-ordination of action • Improving the wider environment to encourage healthy eating and an

increase in physical activity • Improving healthy eating and physical activity levels • Supporting overweight people to reduce weight and increase physical

activity. The strategy and action plan have been adopted by the Single Integrated Plans of Merthyr Tydfil and Rhondda Cynon Taf areas. The multi-agency action required to ‘slow down’, and eventually halt, the increasing trend in overweight and obesity includes: • The development and implementation of a weight management

resource and support toolkit which offers those leading self-help community weight management groups with further guidance and practical ideas on how to incorporate these recommendations into local programme delivery. 18 groups have been established in RCT and 3 in Merthyr Tydfil. A good practice scheme is to be developed to support the groups. This could include exploring the role of community pharmacy for those patients who are prescribed weight loss medication established on the same lines as the smoking cessation model

• The public health team has facilitated a multi agency learning set on behalf of the Families First Consortium, looking at child and family overweight and obesity. The outcomes of this learning set will be used to inform the development of a childhood obesity pathway.

• An evidence based service model has been developed for the implementation of a Maternal Obesity Service, funded by Families First in Rhondda Cynon Taff.

• National Exercise Referral Scheme (NERS) – Referral from primary and secondary care into the local authority run NERS.

These contribute to the Levels 1 and 2 of the All Wales Obesity Pathway. The different levels of the obesity pathway can be summarised as:

Level 1 Community based prevention and early intervention

Level 2 Community and primary care weight management services

Level 3 Specialist multidisciplinary team weight management services run in community, primary or secondary care settings.

Level 4 Specialist medical and surgical services (including bariatric surgery

The figures given in Chapter 3 showing the high number of adults with BMI ≥ 35 demonstrate the need for future service development above Level 2 of the pathway in Cwm Taf.

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Currently, there is little provision across Wales of specialist weight management services focusing on a multi component, holistic approach to treating obesity as recommended in NICE guidance. In 2014, Health Boards’ progress against the Obesity pathway was assessed as follows: green assessment, indicates that minimum service requirements are being met; amber assessment, indicates that elements of the minimum service requirements are being met but gaps have been identified; red assessment, indicates that minimum service requirements not being met and immediate action must be taken.

All Wales Level 3 Specialist MDT Clinical Access Policy and Level 3 Service Specification documents have been developed. Welsh Government requires Health Boards to develop timetabled action plans to address identified gaps in the Obesity Pathway. As a first step, an Obesity Pathway Needs Assessment for Cwm Taf Health Board has been prepared by Cwm Taf Public Health Team and endorsed by the Executive Board. Recommendations included the development and implementation of a Level 3 service, which once implemented should take us to ‘amber’. This follows a successful pilot run in Cwm Taf in 2013, and we are now planning a further roll out of the Joint Care Programme from April 2015. We have also introduced a ‘Bump Start’ service for obese pregnant women in the Rhondda, Cynon and Taf localities, supported by Families First funding.

Our local performance indicators include: • %age of low birth weight babies. • Average weight gain throughout pregnancy. • Caesarean section rate. • Development and implementation of family weight management

programme for obese children. This will inform the development of performance indicators for the service.

• Development and implementation of targeted level 3 adult weight management programme. This will inform the development of performance indicators for the service.

Our population outcomes measures are:

• %age of adults reporting meeting the physical activity guidelines of 5 x 30 minutes in the past week.

• %age of adults reporting eating five or more portions fruit/vegetables the previous day.

• %age of children and young people meeting weekly recommendation of 60 minutes each day of moderate intensity physical activity.

• %age of adults reported as being overweight or obese. • %age of children aged 4-5 who are overweight or obese.

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What will we achieve over the next three years? We aim to halt the rising levels of overweight and obesity in the Cwm Taf population through:

• Addressing identified gaps in the obesity pathway for Cwm Taf Health Board

• Development and implementation of a childhood obesity pathway. • Increased number of referrals to the Exercise Referral programme,

particularly in the ‘Inverse Care Law’ programme areas. • Development and quality assurance of community weight management

groups. • Implementation and evaluation of the Bump Start programme to

address overweight and obesity in pregnancy leading to a reduction in low birth weight babies.

• Introduction and expansion of the Joint Care Programme to reduce the need for orthopaedic and general surgery and/or improve surgical outcomes.

• Explore mechanisms for implementing interventions equitably across Cwm Taf; a number of programmes currently operate in Rhondda Cynon Taff only and these risks increasing the inequality gap.

iv. Alcohol – priorities described in section 7.5

v. Reducing Teenage Pregnancy

The Cwm Taf Sexual Health Advisory Board (SHAB) provides a multi agency, strategic lead for sexual health work, in the Cwm Taf area. The group provides a structured mechanism to allow improved communication, sharing of good practice and resources and the development of performance management and reporting structures amongst all partners working on the sexual health agenda. A variety of work is incorporated into the sexual health action plan including the development of community profiles to target services. Ward-level data for conception rates in females aged under 18 years illustrated that across Cwm Taf, the rates of 19 wards were statistically significantly higher compared to Wales. Across the Health Board area, five wards have been identified with the highest rates of conceptions in females aged under 18 years: Gurnos, Tylerstown, Penywaun, Maerdy and Cwmbach. Work has been established with partners to increase provision and access to services, such as expanding the c-card scheme to more outlets, enhancing the provision of emergency hormonal contraception in community pharmacies and promoting young people’s clinics, in an attempt to reach our most vulnerable young people and reduce future conception rates. The 6 month Pilot through Community Pharmacists to provide information and signposting/referral to methods of long-acting reversible

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contraception (LARC) and the c-card scheme for those accessing the NHS Emergency Hormonal Contraception (EHC) Service, has now been completed. The evaluation is underway and this will collate data from the monthly monitoring forms and I this will include further qualitative data from the Pharmacists who participated via a short online questionnaire, face to face interview, or via phone contact. Conclusions will then be formed and future recommendations made by the end of January 2015.

Cwm Taf Condom Card (c-card) Scheme: The scheme works in partnership with health, schools and youth and community services to increase the availability of condoms and sexual health advice and support to young people aged 14-25 years, in Cwm Taf. Across Cwm Taf, the scheme is operated in over 70 outlets and provision has increased with the inclusion of many secondary schools, pupil referral units and additional nurse-led services. The scheme is strongly supported by the Sexual Health Outreach team and provides a valuable access point into mainstream services. To support this work, the Public Health Team will continue to deliver the Sexual Health Foundation Course on a quarterly basis, offering training to a variety of professionals who engage with young people around sex and relationships. Supporting the ‘Empower to Choose campaign’ – the Health Board is participating in the national programme managed by Public Health Wales to reduce repeat teenage conceptions by encouraging the uptake of long acting reversible contraception (LARC). Additional work to Train community based staff and improve access to services is being progressed. Work is currently underway to promote the update of Long Acting Reversal Contraception (LARC) in young people who abuse substances. This is considered a particularly vulnerable sub-set of young people due to the impact of pregnancy on those young people, their babies and services to support vulnerable families. Our population outcome measures are:

• Conception rate of young women under the age of 18. • Rate of low birth weight babies

Our local performance indicators include:

• Number and usage of Condom Card Scheme sites, including school and higher education venues.

• Increase in number of venues offering EHC and LARC, particularly in target areas.

• Increase in uptake of LARC (data development area). • Numbers of staff who have undertaken sexual health foundation

course, particularly those working with target groups. • Number of schools delivering a consistent agreed SRE programme.

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What Will We Achieve Over The Next Three Years? • Continue to reduce teenage conception rates through accessible LARC

and emergency contraception services.

Links to Performance A number of preventative performance indicators are included in the Integrated Dashboard including:

• Immunisation uptake rates. • Smoking cessation rates.

Links to Financial Plan

Provision of a total investment £12.4m is included in the financial plan for 2015/16 for recurring investment in primary & community care and innovation. This includes £0.13m for weight management services to help tackle rising levels of obesity and provide alternatives to surgery where appropriate.

7.2 Chronic Conditions


The Health Board has some of the highest levels of incidence of chronic disease in Wales, as well as an increasingly elderly and frail population. There have been historically high hospital admission rates for respiratory related admissions to hospital which are linked to the higher than average smoking rates locally and the industrial heritage of the area. With the support of our partners, Health Board aims to address some of the cultural, as well as systemic issues, in order to transform these services.

The Wales Audit Office report on Transforming Unscheduled Care and Chronic Conditions Management (2012) in the Health Board found the following: • The Health Board has made good progress in strengthening the way in

which it seeks to support people in the community and prevent unnecessary use of hospitals.

• The Health Board is beginning to test new ways to identify individuals at risk of unplanned admissions and support them in the community.

• Service redesign and investment is helping to shift the location of care from hospital to community.

• The Health Board is now making more use of primary care contracts to support patients with chronic conditions and unscheduled care needs.

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• Reliance on the acute sector to manage chronic conditions is reducing with Cwm Taf having made more progress than most other Health Boards, but multiple admission rates and lengths of stay for some chronic conditions remain above target.

• The Health Board has revised its governance arrangements for chronic conditions management and unscheduled care and is now better placed to deliver planned service changes.

Priorities

The challenge for the Health Board going forward is to develop integrated care pathways for key chronic disease areas which ensure where possible that individuals with a chronic condition have access to a range of services that support them in managing their condition. The following offers a snapshot of work underway and future priorities and needs to be read in conjunction with section 7.21 on Primary and Community Care, where specific projects are outlined:

• Self-care • Pain management • Diabetes • Heart disease • Respiratory disease.

7.2.1. Self Care


Evidence tells us that self care or self management programmes for chronic disease improve health outcomes and reduce hospital use, particularly those managing well defined conditions with clear methodology (e.g. those developed in Stanford such as the Chronic Disease Self Management Programme) and that many individuals feel more satisfied with their care and achieve a better sense of control and self efficacy through supporting self care interventions. The diagram below indicates that support for self care is needed at all stages of a patient journey, and that this includes services designed to promote healthy lifestyle choices, as well as support for helping people manage a health problem.

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Self Care as a component of Chronic Condition Management

Priorities

Mechanisms are needed to co-ordinate all this activity and to assist health practitioners to make appropriate referrals for their patients. In addition, there are gaps in service provision, particularly in relation to disease specific support classes for patients, and these should be addressed. Our priorities include:

• Signposting: healthcare professionals need to know how to refer patients to existing programmes, and robust mechanisms for ensuring that this information is to hand and up-to-date should be explored.

• Similarly healthcare waiting areas are appropriate venues for advertising the value of such programmes to patients, and the ways in which this can be used to the full should be developed. Links to telephony services should also be explored. Our Local Public Health team will work with primary and secondary care to develop centrally coordinated information systems that can be kept up to date.

• Motivational Behaviour Change: the evidence indicates that more success is achieved if health care practitioners are skilled in Motivational Behaviour Change and Brief Interventions, and use these techniques in general consultations. These techniques will be offered to healthcare professionals in primary and secondary care.

• The National Exercise on Referral programme for people with chronic conditions is similarly available in all areas, and is receiving large numbers of referrals.

• Health and Wellbeing Checks for Over 50s – Add to Your Life: roll out commenced in 2014. The over 50s Health checks programme aims to

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support and empower older people to have greater control over their own health and wellbeing.

• Referral to Stop Smoking Wales and Community Pharmacy Services to be embedded across pathways

• Increasing the capacity within our services to deliver condition specific education programmes which promote self care e.g. X-PERT, Pulmonary Rehabilitation etc.

• Further development of peer support activities across the community for those living with a chronic condition.

The Education Programme for Patients (EPP) Cymru is an NHS based self-management course for people living with any long term condition. It helps people improve their quality of life by learning different skills to better manage their condition on a daily basis. A comparison of ‘before and after’ measures showed, 4-6 months after completing the course is shown in the table below:-

Priorities

The Health Board will continue its skills training for patients; a number of generic programmes are available for patients with any chronic condition. This work will continue in 2015/16, focused on:

• Recruiting and training sufficient volunteer tutors to run the courses,

• Increasing the number of referrals to the programme • Scoping opportunities to train Health Board staff and staff from

partner agencies to deliver courses in their areas or departments to employees/clients.

• House of Care for long term condition management (see section 7.21 for further details).

Links to Prudent Healthcare

Co-production will increase the impact of all the prudent healthcare principles. One of the key features of co-production is the development and support of peer networks and self care programmes which help to build confidence of individuals and provide the opportunity to share experiences. Links to Performance

• GP consultations decreased by 7% • Outpatients visits decreased by 10% • A&E attendances decreased by 16% • Pharmacy visits increased by 18%

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The following performance measures apply:

• Tier One targets in relation to smoking cessation Links to Workforce Plan

In order to further develop the range and availability of self care programmes across Cwm Taf we are reviewing the capacity of our own services to deliver these but also importantly, exploring options for such programmes to be delivered by the Third Sector where appropriate.

7.2.2 Pain Management


Chronic non-malignant pain (CNMP) is a common pain disorder causing physical and psychological distress to patients and can occur due to conditions involving inflammatory and neurological pathways. An increasing number of patients are seeking help for chronic pain - it’s not always easy for them to get the help they need and it can place pressure on the NHS. In recent years the treatment options for chronic pain have increased, resulting in inappropriate medication usage. This has resulted in an increase in adverse events and rising costs resulting from adherence, monitoring and inappropriate therapies. Our aim has been to develop new, more accurate ways of assessing and treating types of chronic non-malignant pain and provide guidance about when patients should be referred to the chronic pain service. This will allow patients in both primary care and hospital services to be referred to the most appropriate specialists for their needs. This should ultimately mean they are treated more effectively and quickly within Cwm Taf.

Priorities

• Cwm Taf’s chronic pain service, in conjunction with pharmacy, has developed an evidence-based guideline to direct primary and secondary care clinicians in correct assessment of chronic pain, selection of cost-effective therapies and appropriate referral to the chronic pain service.

• Adherence to the guidelines will result in improved medication management of chronic pain conditions and has the potential for significant cost-savings across the Health Board. The guidelines are available on SharePoint and should be referred to by all non specialist clinicians managing chronic pain conditions.

• Further, new guidelines are also being introduced in the Health Board to improve services, with a group led by specialist pain clinicians and the pharmacy’s pain lead. This has been set up to develop further advice

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which will ensure patients are getting consistent and effective treatment. The work has recently been recognised by the Royal Pharmaceutical Society, which awarded the group the Award for Innovations in Healthcare at the national RPS conference in Birmingham.

• A further priority is the need to ensure we maintain our non-malignant chronic pain service referral to treatment waiting times within 26 weeks. This will involve consideration of further chronic pain specialism amongst our clinical workforce and there will also be a requirement to further strengthen our links with our GPs in this respect. A full service workforce review and redesign programme will need to be undertaken to assess the workforce implications and actions needed to deliver the service changes specified.


The opportunities for prudent healthcare to reach into chronic pain services were explored in the initial workshop defining prudent healthcare in Wales. Opportunities in relation to structured/routine medication reviews and a greater emphasis on co-production between clinical and patient in terms of the management of pain were identified. The move of Palliative Care service from Y Bwthyn to Royal Glamorgan Hospital presents opportunities for further collaborative working.

7.2.3 Diabetes


The prevalence of Diabetes is increasing year on year. Within Cwm Taf 5.76% of the population have diabetes compared to the all Wales figure of 4.87%. Spend on diabetes care across the UK accounts for 10% of all NHS expenditure, in Wales this equated to £500 million in 2009-10. Diabetes among adults in Wales is predicted to rise to 10.3% in 2020 and 11.5% by 2030. Together for Health - A Diabetes Delivery Plan was published in September 2013. In response to this, the Health Board’s Diabetes Planning and Delivery Group has developed a local Diabetes Delivery Plan which sets out the vision and required action for the organisation and its partners over the next 3 years. Priorities

The Health Board’s Diabetes Planning and Delivery Group have prioritised five key areas for focus in the first two years of implementation of the

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plan. The priorities are aligned to those identified at an All Wales level as follows:

i. Targeting the high risk population

The Health Board will target the high risk population - those that the pre-diabetes stage through:

• General Practice • Diabetes UK road shows • Community Pharmacy

Specifically the Health Board will:

•••• Explore opportunities to build on the annual Diabetes UK and Community Pharmacy Wales (CPW) campaigns, through the community pharmacy contract.

•••• Work in collaboration with Diabetes UK to run local campaigns signposting individuals to the range of lifestyle management information, advice and support.

•••• Via the Inverse Care Law Programme, target cardiovascular risk reduction (specifically working with General Practice to identify opportunities to signpost individuals to lifestyle management support).

ii. Improved education for individuals living with diabetes

The Health Board will focus on improving access to structured education which is provided in line with the relevant NICE guidance to ensure individuals with diabetes have the necessary information, tools and techniques to manage their condition. Specifically the Health Board will: • Develop, agree and implement a model for delivering education to

patients within primary care which complements existing structured education programmes which ensures equity of access across Cwm Taf e.g. X-Pert, DAFNE etc.

• Increase the number of patients referred to the Education Programme for Patients (EPP).

iii. Improved education for all young people with diabetes

The Health Board will prioritise the following actions within Paediatrics services: • Review current provision of education for children, young people and

their families with a view to improving access both in traditional NHS venues and in the community and schools.

• Identify opportunities to educate staff within schools. iv. Improved integration across the pathway

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Further integration of diabetes services across the patient pathway is a key priority for the Health Board. Specifically the Health Board will:

• Identify the most appropriate model for providing greater access to secondary care support for primary care.

• Review its model of outpatient services to ensure patients have timely access to specialist teams when required and reduce duplication of annual reviews.

• Seek to optimise treatment and outcomes for patients by ensuring its Diabetes Clinical Planning Group has access to the range of data and information available e.g. prescribing patterns, admission rates etc.

v. Improving foot management for all inpatients

The Health Board will prioritise foot management with the longer term aim of reducing amputation rates.

Specifically the Health Board will:

• Promote 'Putting Feet First Integrated Care Pathway across all disciplines.

• Standardise foot screening by promoting an alternative method of accessing training which is resource neutral, for example FRAME e-learning foot screening module.

• Development of a robust nursing assessment tool, with diabetes foot risk added to the Waterlow Pressure Ulcer Prevention Chart.

The Health Board’s first annual report for Diabetes was published in November 2014. The report identified that steady progress had been made across the range of priorities listed above. However the scale and pace of change will need to increase if we are to address the growing prevalence of diabetes and the associated implications of developing the condition. The key challenges for the next 12 months include:

• Ensuring we have the workforce required, with the right skills delivering services in the right place, across adult and children and young people’s services.

• The increasing prevalence of Type 2 diabetes. • Ensuring a coordinated approach and equity of access to lifestyle

advice and support across Cwm Taf. • Increasing our capacity to deliver education to children and young

people and adults with diabetes. • Reducing the complication rates for those with diabetes in the

context of our local demographics.

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There are a number of opportunities within Diabetes to take forward the principles of Prudent Healthcare. For example these include:

• Equity of access to structured education; • Re-organising the workforce across primary, community and

secondary care to ensure best use of specialist skills; • Introduction of the ‘House of Care’ approach in Primary Care for

individuals with diabetes and other chronic conditions which focuses on person centred coordinated care, developing the principles of co-production.

Links to Performance

The first Diabetes Annual Report was published in November 2014 and summarises the Health Board’s performance against the outcome and assurance measures within the Diabetes Delivery Plan. The Diabetes Planning and Delivery Group will be responsible for overseeing delivery, reporting progress to the Executive Board and producing an Annual Report for the Health Board which must then be published on our website. This will be informed by data and results of audit and peer review. Examples of good practice will also be shared, for example the following feedback as reported in the national clinical audit e-bulletin: the Paediatric diabetes unit in Merthyr Tydfil is consistently scoring very high in the audit despite being in a deprived area. Lessons should be learned from their model and best practice shared across Wales Links to Workforce Plan

In order to ensure a sustainable workforce within diabetes across primary, community and secondary care, there is a need to review current roles, skills and capacity across these sectors. The proposal for an additional 3.00wte Specialist Nurses within Diabetes is in direct response to the lack of capacity within the Health Board to deliver diabetes structured education.


Provision is included for a Locality community diabetes service and support for community diabetes specialist nurses.

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7.2.4 Heart Disease


Following the launch of the Welsh Government’s Heart Disease Delivery Plan, the Health Board has developed a local Heart Disease Delivery Plan aimed at helping to prevent avoidable heart disease and deliver well-coordinated services, where specialised care is well connected to local services, providing better patient experience and outcomes. As part of this work, the Health Board: • Carried out a local population needs assessment. • Analysed the gap between current provision and the standard of

service described in the NSF and in Together for Health – a Heart Disease Delivery Plan.

• Developed a plan to take action to close that gap. • Demonstrating through regular reporting, improved outcomes for

patients, with an emphasis on reducing health inequalities. A key element of the plan is the health needs assessment which has been undertaken by Public Health Wales and is included with the plan. This recognises the high level of morbidity and mortality from cardiovascular disease in the Cwm Taf area. The key messages are:

• Deaths from cardiovascular disease (all ages) are higher than the rest of Wales.

• Death rates from cardiovascular disease are highest in the most deprived populations. Thirty six percent of the resident population live in areas which are among the most deprived 20% (fifth) in Wales (WIMD 2011). Whilst the rates overall have decreased since 2001, the inequality gap has widened.

• Rates of premature mortality (under 75 years of age) from cardiovascular disease are the highest in Wales; death rates are highest in the most deprived areas and twice as high in males than females.

• Premature mortality from coronary heart disease is the highest in Wales.

• The General Practice prevalence of hypertension and coronary heart disease (QoF 2012) is highest in this Health Board (12.9% and 2.9% respectively). This is statistically significantly higher than the Wales prevalence for hypertension and CHD (11.1% and 2.6%)

Priorities

The Delivery Plan sets out the following:

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i. Delivery Theme 1: Promotion of Healthy Hearts

Aim: To ensure people are aware of and supported in minimising their risk of premature heart disease through healthy lifestyle choices and medication where appropriate.

ii. Delivery Theme 2: Timely detection of heart disease

Aim: To ensure risk is managed and heart disease is detected quickly when it does occur, allowing timely progress to treatment.

iii. Delivery theme 3: Fast and Effective care

Aim: People with heart disease receive fast, effective treatment and care so they have the best possible chance of living a long and healthy life.

iv. Delivery Theme 4: Living with Heart Disease

Aim: That whether in the community or in hospital, people are placed at the centre of heart care and their individual needs identified and met so they feel well supported and informed and able to manage the effects of heart disease.

v. Delivery Theme 5: Improving Information

Aim: Ensure information systems support high quality care and performance, clinical audit and review information to drive service improvement.

vi. Delivery Theme 6: Targeting Research

Aim: Ensure a commitment to research, delivering improved prevention and treatment options and outcome.

Our plan identifies the significant challenge that this brings and recognises the importance of developing a comprehensive prevention agenda. It is expected there will be a long lead time in seeing the planned outcomes from this work and in the interim, we also need to address the increasing demands and challenges this places on services, as the number of patients requiring treatment rise across the pathway from primary to tertiary care.

Many of the underlying determinants of heart disease are also the same for other disease groups such as stroke and diabetes and the Health Board is planning to address many of these in a single work programme, linked to reversing the Inverse Care Law, will underpin all three delivery plans, as can be seen above. The initial focus of this work will be cardiovascular disease, which is a key driver for theme 1 of the action plan, promoting healthy hearts. Further detail on this programme can be seen in section 7.21. In terms of our secondary and tertiary care, our priorities include:

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•••• Delivery of our Referral to Treatment Time targets including outpatients and diagnostics.

•••• Investment in a greater diagnostic unit capacity to accommodate ‘one stop assessment’ and allow services such as physiologist led treadmill testing, physiologist led pacing and defibrillator clinics to run parallel to consultant clinics.

•••• Development of a pacing service at Prince Charles Hospital. •••• Repatriation of cardiology activity from Cardiff and Vale ULHB. •••• Expansion of our cardiac catheterisation laboratory capacity.

Our local plan also seeks to address the four national priorities identified by the all Wales Heart Disease Implementation Group which focus on:

• Delivering the cardiac waiting time target through putting in place

effective pathways

• Developing and piloting component or differential waiting time targets.

• Develop a consistent model for the delivery of cardiovascular risk

assessment.

• Review workforce capacity and consider new models of delivery that

release capacity.

• Improving participation and case ascertainment in National Clinical

Audit.

Links to Workforce Plan In terms of the Inverse Care Law Programme pilot, leading to Cardiovascular Risk Identification and reduction in the over 40 year old population – from a workforce perspective this will require Clinical Nurse, HCSW, Project Manager and Public Health Specialist input. It is also likely that the plan will identify a shortfall in consultants, specialised cardiac nurses and physiologists to meet the delivery requirements set by the Welsh Government. The full extent of this is being developed in the next stages of our action and workforce plans and will require service redesign and prioritisation. Links to Financial Plan

Investment has been identified to support the Inverse Care Law Programme as part the development of the Primary Care Support Unit and Cluster Hub priorities. Within the secondary care element of the pathway, a service and workforce review and redesign will need to be undertaken, resulting in a clear plan of what can be achieved within existing resources and what cannot, with the additional resource required identified and clearly evidenced.

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The Cardiac Planning Group is responsible for overseeing delivery, reporting progress to the Executive Board and producing an Annual Report for the Health Board on implementation of the actions within the Heart Disease Delivery Plan which must then be published on our website. There will also be an increase in the number of heart disease related indicators that we will be reporting as part of our Integrated Quality and Performance Dashboard over the coming months to ensure greater visibility at Board level including component waiting times. Capital / Estates requirements

It is acknowledged that the Cardiac Catheterisation Laboratory is reaching the end of its life and plans are in place at an all Wales level to engage potential suppliers in a national procurement exercise to replace equipment. There are also local capital equipment replacement requirements built into our local discretionary capital programme.

7.2.5. Respiratory Disease

Chronic Obstructive Pulmonary Disease (COPD) and Asthma are a particular focus for the Health Board with approximately 8,000 patients registered as having COPD (2.67%) and 19,738 individuals living with Asthma (6.5%) in Cwm Taf. Respiratory disease is a very common cause of death, severe acute illness, A&E attendance and a major cause of emergency hospital admissions. Chronic Obstructive Pulmonary Disease is generally the most frequent cause of an emergency admission to hospital. In 2012-13 Cwm Taf University Health Board spent £42.7m on respiratory services (7.65% of our total expenditure) which equated to £145.2 per head of population - higher than the Welsh average of £117.7.

In response to the national Respiratory Delivery Plan for Wales published in April 2014 Cwm Taf Health Board developed its local Respiratory Delivery Plan (October 2014). The plan sets out how the Health Board will address the actions identified within the national plan thereby improving the care and support, experience and outcomes for people living with a Respiratory condition. Our work programme is focussed four key themes which are underpinned by a range of specific actions:

• Preventing poor respiratory health • Early detection • Prompt effective treatment • Patient education and support services

The Health Board is currently awaiting the publication of an addendum to the national plan which focuses specifically on services for children and

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young people (CYP) with respiratory conditions. Our local priorities for improving services for CYP include:

• Reduce the number of children exposed to passive smoking, and reduce the number of teenagers smoking.

• More focus on health promotion/education sessions in schools. • Establishing better working relationships between primary

care and paediatric team.

COPD is to be the first target area for the Rhondda Locality providing a specialist team and a dedicated clinic accessed by patients who have COPD. This is a project to trial an intensive team who will work with a small cohort of mild-moderate COPD patients in order to try and change their behaviours. (This would be a cohort with the evidence for intervening early to prevent progression to severe COPD) Links to Prudent Healthcare

The Respiratory Planning and Delivery Group are applying the principles of Prudent Healthcare across their work programme. This is also linked in to the national ‘Making Prudent Healthcare Happen’ programme. Examples of specific actions include:

• Triangulation of prescribing, QOF and admissions data to identify variation in practice and outcomes for those living with COPD.

• Developing referral pathways between our services and local smoking cessation support.

• Piloting an electronic discharge system to ensure appropriate reconciliation and prescribing of medication for patients with respiratory disease

• Developing a cluster hub service to support practices, linked to secondary care

• Piloting spirometry in community pharmacies It is anticipated that this work will facilitate earlier discharge, with a goal of a reduction of two days in ALOS, supporting appropriate patients so they no longer need admission and also deliver more value by ensuring that prescribing is optimal. Links to Workforce Plan

The Respiratory Planning and Delivery Group are currently reviewing the service and workforce model for COPD services in light of the Plan and known capacity issues in relation to capacity of the workforce to deliver education programmes for example Pulmonary Rehabilitation. Later in this chapter under our primary care plans, detail is provided on the cluster hubs workforce, which is likely to include respiratory nurses, therapists, and access to support for the mental health issues that accompany respiratory disease

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Links to Finance Plan

Investment has been identified as part the development of the Primary Care Support Unit and Cluster Hub priorities. Links to Performance

The plan and its associated actions will form the work programme for the Respiratory Planning and Delivery Group, progress against which will be monitored on a quarterly basis and reported to the Executive Board and Board annually.

7.3 Adult Mental Health


During the early part of 2013 the Health Board reviewed its Strategic Framework and Local Action Plan to align it with the recently published Together for Mental Health – A Strategy for Mental Health and Well-Being in Wales. This work builds upon the considerable improvements made to mental health service provision in Rhondda Cynon Taf and Merthyr Tydfil over the past decade and to progress phase two of the Five Year Strategic Framework to address any remaining inequities, service gaps and modernisation needs.

Priorities

The Strategic Framework for Mental Health in Cwm Taf (2011 – 2016) presents a number of objectives for improving the lives of people with mental health problems and has three phases. The first phase, adults of working age, was reviewed, planned and implemented this year and we are now in phase two examining older persons’ services. A key aspect of the strategy was not to treat components of mental health as separate as we aim to develop an ageless service which is supported within the new all-Wales Strategy. However, to ensure we can manage the strategic intention appropriately, it has to be phased. Linking key components of our service into a seamless pathway is essential to success. Phase 2 of implementing the recovery model for older people involves significant service and workforce redesign. A paper was submitted to the Health Board in January 2014, giving approval to proceed to an engagement phase with patients/service users, staff, Community Health Council, statutory partners and other stakeholders on the newly proposed service redesign. We have now successfully completed the first phase of this redesign in October 2014.

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Over the next two years we will redesign older person’s mental health services, shifting the focus of treatment and care from in-patient settings to the community and improve the quality of patient care. Our aim is for patients to have high quality treatment and care in the right place, at the right time, without delays, with a high level of expertise. In particular, we expect in-patient assessment to be progressive, continual assessment to be consistent and liaison services to be enhanced. In 2015/2016 we will focus further upon in-patient care and building a sustainable model, ensuring we have robust community and liaison services and 2016/2017 will see better outcomes overall compared to our current baseline across a range of key performance indicators. The main challenge to delivering this objective in OPMH will be the availability of specialised nursing home places in the local area. Continuing to achieve a reasonable level of savings in Continuing Health Care for Adults of Working Age has also been increasingly challenging for a number of reasons, one being the lack of good housing provision for moving people on from in-patient settings. We aim to examine the opportunities for major improvement in this area in partnership with local authorities, non-profit organisations and third sector. A reconfiguration of in-patient services is only one part of the redesign programme. We would also aim to improve liaison services to reduce the length of stay in the general hospital wards and improve primary care liaison services. As the population ages, the demographic nature of general ward populations is changing. A snapshot survey of Cwm Taf beds (excluding Obstetrics, Paediatrics and Palliative Care) in September 2012 revealed that almost 3 in 4 general hospital beds in Cwm Taf were occupied by patients over 65, 1 in 4 beds occupied by someone identified as suffering from dementia and 1 in 12 by someone identified as suffering from a solely mental health problem. We have successfully gained monies through the ‘Invest to Save’ initiative to implement a Psychiatric Liaison Services commencing in early 2015. The combination of reconfigured in-patient mental health services for the elderly, enhanced liaison services and reinvestment from increased productivity will provide better outcomes for patients and the community. On the basis of change we predict: • Shorter in-patient stays for assessment. • Reduced lengths of stay in continuous assessment beds. • Safe high quality patient environments. • Reduced delays in acute general settings. • Early identification of preventable illness. • Improved community service provision.

Over the next three years our wider priorities including the above include:

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• The review and further development of memory clinic services; first priority for 2015

• Build on the ‘Recovery Model’ redesign, examine the development of locality based services and revised medical model working alongside GP Clusters. Part of reviewing the medical model will be examining the role of the Nurse practitioner to cover areas where we are experiencing long standing recruitment difficulties in middle grade cover

• Ensure the planned workforce model is delivered and further work is completed in relation to the development of acuity tools which measure workload and complexity for both in-patient and community settings

• Introduce a new Psychiatric Liaison service to deal with increasing mental health problems in acute hospital services. This is a key area identified in our 5 Year Strategic Plan for Mental Health and requires frequent monitoring of its impact against investment

• Develop a local strategy for psychology services and plan to rationalise the prescribing of anti-psychotics and to examine the further use of ‘talking therapies’/‘psycho education’ in partnership, to reduce the use of prescribing of anti-depressants.

• Shift to more community based services and work jointly with QUERY • Support the roll out of the Rhondda Cynon Taf Reduction of Suicide

and Self Harm Strategy and Multi Agency Immediate Response to Critical Incident Protocol into Merthyr Tydfil and make connections to the ‘Talk to Me 2’ Strategy.

• Review needle exchange and supervised consumption schemes and revise current specifications to reflect best practice. In relation to needle exchange, this may involve the procurement of supplies and services from alternative providers.

• Continue to improve performance against the Mental Health Act Measures.

• Potential use of Intermediate Care Fund in partnership for OPMH and working in partnership with Local Authorities

• Further development of Primary Care Mental Health services and Tier 0 to reduce the use of prescribing of anti-depressants.


• More effective use of resources; preventing hospital admission, reducing the unnecessary prescribing of anti-depressants linked to ‘Valley Steps’.

Links to Workforce Plan

• Following a review of the phase 1 of the OPMH redesign, further inpatient capacity could be released, following investment of 16 wte in community services. This is dependent upon developing the strategic capacity for more specialised nursing home places in the local area and successful evaluation of Phase 1.

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• Also part of these changes, investment has been secured to recruit 8 wte into the DGH Psychiatric liaison team and recruitment is underway.


Areas of planned investment in 2015/16 include:-

• Liaison Psychiatry Services. • Phase 2 Community Older Persons Mental Health Service redesign. • Valley Steps Tier Zero Mental Health Services Project.

Estate/Capital Implications

• Transfer of a CMHT and OPMH service from Y Bwthyn • Potential redesign of ward 35 at PCH to support new service model


The Mental Health Directorate has its own Performance Dashboard in addition to a number of indicators presented as part of the Corporate Integrated Quality and Performance Dashboard. These indicators include performance against the Mental Health Act Measure. The service redesign outlined above should lead to the following improvements in quality and performance:

• Improved health outcomes through early identification and treatment. • Reduced acute length of stay. • Increased admission avoidance. • Reduction in the number of bed days.

7.4 Child and Adolescent Mental Health


The Health Board provides Child and Adolescent Mental Health Services (CAMHS) to its own resident population together with the populations also of Cardiff and Vale and Abertawe Bro Morgannwg University Health Boards. CAMHS are undergoing a number of changes to develop services and minimise risks at all tiers of service. Work has commenced to review our core business within a limited funding stream, in line with the requirements of the Mental Health Measure and the recently released guidance on definitions to be used, the ‘National Service Guidance for Planners’. In that respect, it is a specialist service dealing with significant mental health problems and complex co-morbid mental health. This work demands a strategic approach and a longer-term strategy in close

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partnership with all sectors in both Cardiff and Vale and ABM University Health Boards. Currently in the CAMHS Network, specialist CAMHS provide the majority of the health requirements for children and young people with neurodevelopmental disorders. Neurodevelopmental disorders are disabilities in the functioning of the brain that affect a child’s behaviour, memory or ability to learn. This includes the conditions of Attention Deficit Hyperactivity Disorder (ADHD), Autistic Spectrum Disorder (ASD) and Tourette’s Syndrome. The increasing demand created by neurodevelopmental disorders has had a detrimental effect on the provision of specialist services available for those children and young people with mental disorders, particularly those subject to the provisions under the Mental Health (Wales) Measure. The current neurodevelopmental model of working requires children and young people to be referred separately to individual services, with different criteria and each with their own waiting lists. The aim across the Cwm Taf CAMHS Network is to develop comprehensive neurodevelopmental services with partner agencies that will be strongly embedded in primary and community care services.

Priorities As a CAMHS service we have commenced work to examine what our core business is through the development of a service specification and within the limited funding available, in line with the requirements of the Mental Health Measure and the national service planning guidance. In that respect, it is a specialist service dealing with significant mental health problems and complex co-morbid mental health. It is important that we work closely with our partners in delivering these priorities, including Local Authorities’ delivery of the Mental Health Measure, also with support from the Third Sector

Priority areas for consideration for the CAMHS Network areas include: • The implementation of a care and partnership approach (CAPA) in order

to provide quality care for the treatment of moderate to severe mental disorder. CAPA is a service transformation model that combines collaborative and participatory practice with service users to enhance effectiveness, leadership, skills modelling and demand and capacity management. CAPA improves services to clients by:

o Focusing on engagement, therapeutic alliance, choice, strengths, goals and care planning;

o Improving access by ensuring timely appointments that are fully booked, i.e. no waiting lists;

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o Ensuring service users are seen by a clinician with the right skills.

o Use of Outcome measures. o Facilitates commissioning and provision of services by

transparency of capacity and care packages.

• Development of neurodevelopmental services to develop a multi-disciplinary neuro-developmental team which would aim to ensure a commitment to excellence in providing care so that professionals work together to pool their skills and knowledge to achieve the best possible outcomes for the child young person and their family. Families would be supported at all stages and would be empowered to work and bond with their child as opposed to the current situation where families are often on a waiting list for over a year before assessment and intervention is offered.

• CAMHS are currently undertaking an exercise across each of the LHB areas within the CAMHS Clinical Network that it provides services to, in to develop clear and concise service specifications for the NHS provision of specialist CAMHS. This has been prompted by both financial pressures, and also the new service delivery pressures arising from implementation of the Mental Health (Wales) Measure.

• Further development of psychological therapies.

• Strengthening dietetic support in tier 2/3 services for eating disorders.

• A significant element of CAMHS, particularly Tier 4 services, is commissioned by Welsh Health Specialised Services Committee (WHSSC).

• Working with WHSSC and the other Health Boards in South Wales, we will assist commissioners in developing the Community Intensive Treatment Team model further so that it is equitably provided throughout South Wales. In addition, work with WHSSC to formally commission the five additional beds in Ty Llidiard and repatriate patients from high cost placements at a cost neutral basis.

• The Tier 4 Inpatient Service is commencing work through implementation of STEAM (System to Escalate and Monitor). STEAM was designed to track in-patient acuity through accurately measuring it. It is being piloted in response to WG plans to identify and develop an occupancy level target between providers and WHSSC that could be reflected in the performance monitoring and contracting process.

• To assist operational delivery and performance, build upon the locality model and review the structure around the management and administrative teams to support the localities and improve communication.

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Over 2013 the management team in CAMHS have developed a performance dashboard and it currently includes the following data: • Activity/Waiting List • MHM Part 2 Information • In-patient bed days/acuity • Sickness • Concerns/compliments • Incidents/Sentinel events • Finance

The Dashboard is presented and discussed in the Clinical Business Meetings within the Health Board regularly and is utilized by local clinical teams to check variances and improve performance. Our current priorities for improvement include: DNAs; Mental Health Measures; PDRs and Medical Appraisals.

Links to Workforce Plan • Although still under development, the core components of the neuro-

developmental service have been identified as being a multi-disciplinary team which anticipates an increase of 8 wte across the service.


• In process of agreeing a plan with both C&V and ABM Health Board’s to close the funding gaps over a 18 month period.

• Recurring investment in Tier 4 CAMHS services funded by commissioners.

• Investment has been identified to support the development of neuro-developmental services.

Capital/Estates Requirements

• Reduction in number of CAMHS bases – relocate service based at Tonteg to RGH.

7.5 Drug and Alcohol Services


Established in 2010, the Cwm Taf Area Planning Board (APB) supports the planning, commissioning and performance management of substance misuse services.

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Priorities

The APB will continue to develop and commission services that respond to local need. In partnership with key stakeholders, including local authorities and third sector providers, a broad range of integrated substance misuse services are already in place. Priorities for 2015/2016 include: • Regular and coordinated reviews of drug related fatal and non-fatal

drug poisonings in order to develop appropriate and affective interventions to reduce harm.

• Improve needle exchange provision across Cwm Taf. • Implementation of the Blood Borne Virus screening pathway • Implementation of the Drink Wise, Age Well Programme, which is

Lottery funded. The programme aims to:

o Inform policy and practice about preventing alcohol related harm in later life;

o Improve health and well being for people age 50 and over who are at risk of developing alcohol related harm;

o Ensure more effective services are delivered to prevent alcohol related harm amongst the ageing population.


The Area Planning Board applies the principles of prudent healthcare by ensuring the services commissioned are in accordance with the Recovery Oriented Integrated Systems of Care (ROISC) framework. This means that: • A wide range of evidence based services, interventions and aftercare

are offered to enable service users to engage in appropriate support and treatment.

• Local partnerships promote access to mutual aid networks and on-going peer-led community support which include self-help and mutual aid.

• Services are monitored on the basis of meaningful outcomes with service-user experience and goals at the centre of this.

• Services commissioned range from prevention to psychosocial/pharmacological to diversionary interventions; all set within the context of the Recovery Oriented Integrated Systems of Care (ROISC) framework model.


Performance is monitored by the Area Planning Board (APB) against the following five Welsh Government key performance indicators (KPI):

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• KPI 1: Increase the number of clients who engage with services between assessment and [planned ending of treatment by reducing the incidences of clients who do not attend (DNA) or respond to follow up contact post assessment date. Welsh Government target: less than 20%

• KPI 2: Achieve a waiting time of less than 20 working days between referral and treatment. Welsh Government target: more than 80%

• KPI 3: Substance misuse is reduced for problematic substances between start and most recent review / exit Treatment Outcome Profile (TOP). Welsh Government target: show continual improvement against baseline and Welsh benchmark figure of 67% 13-14

• KPI 4: Quality of life is improved between start and most recent review / exit Treatment Outcome Profile (TOP). Welsh Government target - show continual improvement against baseline and Welsh benchmark figure of 56% 13-14

• KPI 5: Number / percentage of cases closed (with a treatment date) as treatment completed. Welsh Government target - show continual improvement against baseline and Welsh benchmark figure of 72% 13-14


Each year, the APB receives funding from the Welsh Government to commission services that will tackle the harms associated with the misuse of drugs and/or alcohol. During 2014/2015 the SMAP revenue allocation was £2,686,376 and the capital allocation was £584,802 for. The Health Board received £1,102,201 for the provision of services. In addition the Health Board is required to spend a minimum of £2,523m annually on substance misuse services as a ring fence within its overall allocation from Welsh Government. As with other Health Boards across Wales; Welsh Government withholds this sum until confirmation is received from the respective APB that it is satisfied that the ring fenced funding has been spent in accordance with its strategic priorities. This requirement ensures a co-ordinated approach in channelling the combined revenue funding of £5,209,376 towards tackling the needs of the local population. Capital/Estate Requirements We are currently investigating the availability of capital to support service change via the substance misuse capital fund.

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7.6 Learning Disabilities


Services for Learning Disability are provided by Abertawe Bro Morgannwg University Health Board (ABMU) in partnership with the University Health Board, Local Authorities and partner agencies. The Health Board attend a strategic group led by ABMU to ensure there is delivery of key objectives. ‘Forward Together: Strategy for the South Wales Learning Disability Collaborative (Adult Services) provides an action plan for future development of learning disability services which we support and will implement as we strengthen our commissioning arrangements together with our partners.

Priorities

This Strategy set out to achieve, through incremental steps, the following:

•••• Creation of (managed) health teams leading to integrated health and social care teams.

•••• Development of services on the ‘Tiered Approach’ •••• Fully integrated services and formal partnerships utilising mechanisms

as Section 33.

As most people with a learning disability will access health care through a variety of different means, it is important that all health care staff are aware and trained to deal with their needs. Training is available to all staff and the revised Learning Disability Care Bundle as recommended by Welsh Government has been implemented to improve the patient and care journey when in general health care.

Improving the patient experience

During 2015 the Health Board will continue to introduce the Learning Disability standards bundle for hospital care in our District General Hospitals (DGHs) and Community Hospitals.

This collaborative protocol has been developed to support the care of patients with a learning disability when they access acute hospital services. The guidance places the patient firmly at the centre of care and the aims of the collaborative protocol are to:

1. Enable the wards to audit their delivery of care standards against the Healthcare Standards and care bundles

2. Enhance communication between the patient, carers and range of health care professionals

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3. Ensure a high standard of care is provided throughout the patient’s journey

4. Highlight issues of consent and advocacy for people with a learning disability and how health care professionals can facilitate this

5. Highlight the role of the Community Support Team (CST) for people with learning disability in relation to assessment of need, planning of an individual’s care requirements, education and support

6. Promote the use of ‘Information and Assessment’ tools in order to reduce risk and vulnerability and also identify the additional care needs and resources that may be required to support an individual patient with learning disabilities

7. To promote good practice by applying the principles laid out in the “Good Practice Framework for People with a Learning Disability Requiring Planned Secondary Care” (Public Health Wales, 2011)

Within the Health Board, preliminary training of Ward Managers on both DGH sites commenced in early 2014. It is expected that all in-patient areas who have patients with learning disability will fully adopt this system, led principally by the Ward Manager but for all professionals.

We have introduced key criterion within the Fundamental of Care Audit to provide regular and on-going monitoring of the Learning Disability bundle implementation and it is anticipated that it will significantly reduce the possibility of unmet need in this area of care.

During 2013, Health Board participated in a national audit of Learning Disability treatment and care (The National Audit of Learning Disabilities) and the Feasibility study began in May 2013 and was completed in April 2014. The study aimed to determine:

• Whether a national clinical audit could feasibly generate reliable data about the quality of care provided by health organisations to people with learning disabilities

• Whether a national clinical audit is an effective way of driving improvement within NHS organisations

The feasibility study included a small number of primary and secondary care sites (general acute and mental health). Results of the feasibility study (involving 12 GP practices, 9 acute hospitals, and 7 mental health services across England and Wales) indicate that the quality of care for people with learning disabilities falls below recommended standards.

In primary care, there was reported to be a low uptake of annual health checks, unsatisfactory physical health monitoring and health promotion. Secondary care services were found to have difficulty identifying people with learning disabilities. Learning disability was not included in

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mandatory training programmes and some staff reported feeling out of their depth when caring for this patient group.

This report reinforces the constant need for monitoring in this area and continued updating of all staff groups through high quality training.

Next Steps

The need for more on-going mandatory training in this area of treatment and care is essential and there will be continued monitoring of standards in this area from 2015 onwards. The following highlights some examples of the areas which require further discussion and development. We will be undertaking further work with both corporate and clinical Directorates to develop an action plan for further endorsement;

• Development of an internal specialised training officer • Buying in training or e-learning • Core subject audits in all specialities • Spot visits • Consider a “lead” Directorate • Innovative developments with GMS contract • Develop intelligent system on Myrddin to monitor admissions • Review clinical coding for Learning Disability

7.7 Oral Health


The National Oral Health Plan (NOHP) for Wales outlines a series of actions for improving oral health and reducing oral health inequalities in Wales over the next five years and beyond. The Plan fits in well with the Welsh Government’s vision for the NHS in Wales outlined in ‘Together for Health’. Cwm Taf University Health Board, through its Oral Health Advisory Group (OHAG), has developed its local Oral Health Delivery Plan to respond to each of the actions identified in the NOHP in order to address the oral health needs of the residents of Merthyr Tydfil and Rhondda Cynon Taf. Sharp differences remain between individuals with the best and worst oral health in Wales and in Cwm Taf and our performance lags behind in similar areas in some important aspects. Prevention is at the core of the plan and reducing the risk factors that lead to oral disease is only possible if the delivery of dental services and oral health improvement programmes are oriented towards primary health care and prevention.

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Priorities

The Health Board aims to deliver the actions outlined in the plan within five years. Full implementation of the actions will lead to an improved provision of dental services and signs of improvement in the oral health of the population of Merthyr Tydfil and Rhondda Cynon Taf.

This Strategy sets out to achieve, through incremental steps and while all the actions outlined in the plan are important, we are following a phased approach to their implementation. One of our major goals must be to help people take responsibility for ensuring their own good oral health. By working together, we believe we can make a real and sustainable difference to the oral health of our population. Links to Workforce Plan

Workforce issues identified in local plans include:

• Within Orthodontics, there are issues about the supply of SpR staff – the supply from the University is uneven year on year at present, discussions are underway to resolve this.

• The Orthodontic Department are currently considering options for replacing medical staff, including in restorative dentistry.


• The Oral Health Delivery Plan highlights that the majority of the

actions will be taken forward by making the best use of the current resource whether that is a staff, facility or financial resource.

• Funding has been identified to support restorative dentistry developments.


The Plan and the associated actions will form the work programme for the OHAG for the next five years and progress will be monitored through the quarterly meetings of the Group with reports presented to the Executive Board as appropriate.

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7.8 Family Services


Building on our achievements of planning and delivering services in partnership, we are working with our staff across the partnership to increase their skills and abilities to maximise every opportunity they are presented with to make a positive difference to children and families. We are working to support the needs of the whole family as well as the problems of the child or young person.

This in turn will empower families and raise awareness amongst parents on how best to meet the needs of their children, enabling effective engagement with the family earlier in line with programmes such as Flying Start and Families First which aim to reduce the numbers of family related problems escalating and requiring more specialist support.

Linked in with this work, maintaining safe and sustainable maternity and newborn care is a priority for the Health Board and remains a challenge. Paediatric and Maternity services continue to develop, linked with the South Wales Programme, local paediatric service plans and our Maternity Services Delivery Plan. For neonatal care this challenge is shared across the South Wales area. Priorities • •••• Continue to implement the plan to achieve standards outlined in the

Welsh Government document, ‘Delivering a Strategic Vision for Maternity Services in Wales.’

•••• Work with partners to full implement the Continuing Care Framework for Children and Young People.

•••• Implementation of Paediatric Assessment Unit at RGH. •••• For obstetrics and neonatal services all opportunities for innovative and

new models are being pursued within the Alliance to retain as much care locally as possible on the RGH site.

•••• Ensure mechanisms are in place to meet the new requirements for Adoption & Fostering Medical Services.

•••• Enhance community paediatric services including the development of Community Paediatric Nursing to prevent admissions or readmissions and deliver care closer to home when appropriate.

•••• To enable children who are unwell and their families to be supported and observed without the necessity of being formerly admitted to a children’s ward.

•••• Redesign of Community Midwife Service. •••• Redesign the Hysteroscopy service to improve access and efficiency.

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•••• Over the past few years, the sexual health service has undergone modernisation. The service has also had the benefit of new Health Park and Community Hospital premises in order to allow further developments to take place. As a result of modernising, which has also included restructure and development of the operational workforce, the service is in a position to propose further changes that will enhance services for clients as well as be cost effective.

•••• Increase access to home termination and early medical termination services.

•••• Work with our partners to consider how health needs of Looked After Children are met.

•••• Robust community children’s nursing service to care for children with complex needs in an appropriate environment


• A range of performance information exists in order to support the development of family services including the development of maternity dashboard.


• Redesign of Community Midwife Service linked with the South Wales Programme implementation work.

• The development of Advanced Neonatal Nurse Practitioner roles. • Maintenance of paediatric medical and midwifery rotas on two DGH

sites as far as is possible, pending implementation of the South Wales Programme.

• Contingency plans in place should the above become unsustainable including interim arrangements to introduce rotation schemes between Health Boards.

• Further skill mix change including development of band 3 midwifery support worker workforce.

• Paediatric Assessment Unit workforce model being finalised.


• Service and workforce models are being finalised with financial implications outlined in Chapter 9.


Design work to expand neonatal facilities at Prince Charles Hospital in Merthyr Tydfil has already begun at Cwm Taf University Health Board as part of the South Wales Programme outcome, with the aim of completing the build in early 2016. Work is also underway at the University Hospital Wales on their associated capital scheme.

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7.9 Frail Elderly


In recent years, health and social care partners in Cwm Taf have sought to strengthen the services provided to the frail elderly population by seeking to work collaboratively and increasing the range of services provided in communities. Particular successes include:

Despite the progress made above, our current system does not function as effectively as we would like and services do not always offer the right quality. We want to deliver services that are:

To address these issues the Health Board established a Frail Elderly and Rehabilitation Project Board involving key partners to provide direction and energy for the continued development of services for this population group.

Following a review of current practice, the work of NHS Sussex and Birmingham and Solihull Frail Elderly Programme was highlighted by colleagues as resonating with the vision for services in Cwm Taf. The diagram below sets out the principles that will govern the development and delivery of our services in Cwm Taf in the future (adapted from Birmingham and Solihull).

• Person centred. • Dignified. • Flexible. • Co-ordinated/joined up. • Integrated between health and social care.

• Development of @Home services including:

o CIAS. o Community IV Service. o Community Ward. o Reablement & Intermediate Care.

• Mental Health service developments.

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Priorities

• Review of current service models for chronic disease management to ensure patients are proactively managed in the community:

o Acute management of frail elderly patients in inpatient settings: where individuals do require admission to hospital we must ensure that frail patients are assessed in a timely manner by the appropriate multi-disciplinary team. The time spent in an inpatient setting will be minimised due to proactive management and discharge planning.

o Develop a single point of access to all assessment service for frail elderly patients (acute and community based).

o Development of a frail team/assessment model at the front door. o Implement an in-reach model for complex discharge planning. o Implementation of integrated assessment.

• Work with Local Authority and the independent sector providers to ensure the implementation of the National Outcome Focused Framework and robust funding arrangements.

• Work with Partners to fully establish the local Adult Safeguarding Board, contributing to the work plan priorities.

• Increase the breadth of support available in the community and provide additional population will be delivered through an integrated

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enhanced @Home service the name for our core and enhanced community services.

• Provide support services to care homes and ensure people are cared for in the most appropriate environment, for example, end of life care pathway and advanced directives.

Key characteristics will include:


The increase in the breadth of support available in the community and provision of additional robust alternatives to acute admission and support people coming out to assist patients coming out of hospital and being maintained in their own home or alternative non hospital setting will contribute towards reductions in non elective and elective admissions; improvement in outpatient productivity; reductions in hospital admission avoidance where appropriate and assist with a reduction of non elective admissions and readmissions as can be seen in our demand capacity planning in Chapter 5, Section 5.6.5.

Links to Workforce Plan •••• Further development of the @home service in association with partners

including the Local Authority and Third Sector. •••• Investment in enhanced district nursing and complex discharge

functions. Links to Financial Plan

Investment plans are linked to improvements in a number of areas including:

• Enhanced district nursing support to nursing homes.

• Proactively identify and care for frail elderly at every stage of the pathway.

• Integrated health and social care team with one single point of access.

• Wrap care around the patient through care co-ordination; • Care Coordinator role is a key function and must be performed

by the right team member with the ability to advocate and influence.

• Care planning is owned by the patient and their carer. • Ability to provide an acute response to those patients with short

transient medical issues whose care/treatment could be provided in a community/home setting.

• Support patients to be safely ‘discharged’ from acute hospital; • Early identification of frail elderly patients in primary care.

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• Respite care in nursing homes. • Development of a single point of access for services at home and in

the community. • Increased access to intermediate care. • Further hospital based senior social worker support. • Complex discharge team

7.10 Urgent & Emergency Care


Much of the work within urgent and emergency care (unscheduled care) continues to focus and build on the work undertaken in the past 18 months on patient flow. This work is complex and varied and requires continued focus and change to overcome the numerous blockages and changes in the system. This work has been key to improving outcomes and quality for patients, whilst maintaining elective activity within the Health Board. The Health Board submitted its Unscheduled Care Delivery Plan to Welsh Government in June 2014 and its Winter Plan in September 2014. Delivering sustainable unscheduled care services remains a top priority and key challenge for the Health Board.

Together with its key partners in Merthyr Tydfil County Borough Council and Rhondda Cynon Taf County Council, the Health Board has been making a concerted effort to implement plans and tackle any delays in the system. Work has been focused on understanding the components of the pathway and their relationships and interdependencies. The plan is targeting improvements predominately in the length of stay, bed days released, impact on occupancy and emergency department performance with a collective focus on patient flow across all four main hospital sites by incorporating the ‘Improving Quality Together’ model with quality improvement coaches and a buddy system for adult inpatient wards. The aim is to reduce lengths of stay and enhance patient safety, effectiveness and the patient experience across all services.

The development and implementation of the community IV service and virtual ward have been key enablers to the process and further development work to improve the discharge processes are ongoing within the locality team, including the development of a home medication scheme. In response to the evidence gained over recent years the Health Board has invested in a front door model that ensures patients are seen by a

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senior clinician (Acute Care Physician) as soon as possible. The model has had a positive impact enabling increasing numbers of patients to be managed on an outpatient rather than inpatient basis via responsive ambulatory care and 48 hour clinical decision unit. These services are supported by therapy services that are closely linked with reablement enabling speedy supported discharge. It is envisaged that this service model will be extended in the future to cover both evenings and weekends and is a key pillar of the new medical service model.

Priorities

Work to maintain patient flow will continue and be driven by the key challenges within the system. The focus of this work includes:

• Provision of sustainable Accident and Emergency service at both PCH and an innovative acute medicine model at the RGH.

o Appointment of extended hours’ acute physicians at the ‘front door’.

o Implementation of the new medical model. o Communications campaign re minor injuries service.

• Redesigned GP out of hours services (see section 7.21 for further detail on the new model). This work will also be linked to the introduction of the NHS 111 service for Wales, which is aiming to improve 24/7 access to timely urgent healthcare with the integration and expansion of the existing out of hours and NHS Direct Wales services. In particular, where Health Boards have been asked to prepare for the implementation of NHS 111 by ensuring that current out of hours services are robust and is it acknowledged that many of the areas for further improvement to out of hours can will be further addressed through the ongoing work to deliver NHS 111 services for Wales.

• The development of a sustainable service model for acute surgery. o Considering acute assessment services and the potential for

new service models. • Proactively manage patient flow:

o Daily multidisciplinary ward rounds. o Daily deep dives by senior nurses o Enhanced deep dives weekly by senior managers o Continue to monitor the key USC performance measures to

ensure early identification of potential issues o Embed Anticipated Day of Discharge Model on all sites o Continue the roll out of live bed management system to

specialty areas. o Identification of areas of Surge capacity on each DGH site.

• Reduce demand on GP Out of Hours Services. • Influencing the way the public access services. • Promoting clinical engagement across the healthcare system.

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• Evaluate the impact of the agreed work programmes on outcomes that reflect patient experience, patient care and quality.


• Further develop the Acute Physician model to provide extended hours and weekend cover.

• Development of extended nurse practitioners in defined areas – acute medicine, paediatrics, neonatology.

• A redesigned Out of Hours service will look to new and innovative roles to support the new model.

• Appointment of Emergency Care Flow Co-ordinators.


The improved flow in unscheduled care has reduced reliance on inpatient beds. The reduction in beds has facilitated the co-location of ortho-geriatric rehabilitation services with the acute trauma / orthopaedic ward. Co-location of these services will further reduce length of stay of this patient group. The ability to deliver core elective activity throughout the year has also reduced the need to out source activity in many specialties during this financial year with its corresponding savings. The key changes planned for 2015/16 are set out in Chapter 9, section

9.7 - whole system redesign and include:

• Emergency care flow co-ordinators. • Extending acute physician service to evening and weekends at RGH. • Acute medicine specialist nurses.

Estates/Capital Requirements

Capital is required to redesign the acute medicine services at the RGH site as this will significantly enhance the quality of patient care and productivity and will support the outcome of the South Wales Programme. Plans are currently under development.

Performance

The Health Board has made good progress on improving patient flow through our unscheduled care services, which is demonstrated in the graphs below. Graph 1 below shows the improved 15 minute ambulance handover performance across the Health Board, with the subsequent reduction in lost hours.

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Graph 2, below provides an overview of the 4, 8 and 12 hour A&E performance.

Although the above information demonstrates significant improvements, the system remains fragile and variable. One of the continued main focuses for the forthcoming year is the elimination of 12 hour waits. Many of the challenges continue to relate to the smooth transition to most appropriate setting when medically fit and joint work with LA colleagues remains the key to this. The following continue to be the key drivers for each area:

• Avoiding A&E attendances through more admissions direct to

CDU/MAU.

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• Greater turnaround on day 1 in CDU/MAUs (extended medical cover, bed reconfiguration at RGH).

• Increased ward round and “board” round frequency from physician medical time released by improved CDU turnaround, including increased weekend ward rounds.

• Re-alignment of beds between medicine and surgery, and re-allocation within medicine. Avoiding A&E attendances through maximising use of MIUs (phone first etc).

• Avoiding A&E attendances through improved WAST protocols and practice and implementation of paramedic pathfinder.

• Avoiding A&E attendance through better use of CIAS/review of CIAS model.

• An overall resulting reduction in attendances through the PCH and RGH A&Es of 5%.

• Optimise and integrate CIAS, therapy assessment teams and in reach reablement to provide the maximum contribution to reducing acute and community hospital bed-days.

• Reduction in length of stay in community hospitals.

7.11 Cancer Services


In summer 2012, the Welsh Government published a national Five Year Cancer Delivery Plan which provides a framework for action by Local Health Boards and NHS Trusts working together with their partners. It sets out the Welsh Government’s expectations of the NHS in Wales to tackle cancer in people of all ages, wherever they live in Wales and whatever their circumstances.

Priorities

The Cancer Implementation Group led by Welsh Government have developed and agreed a set of well defined priorities. These priorities will ensure that there is a national focus and a clear sense of direction for the next 12 months. Health Boards, Trusts, Welsh Government, Cancer Networks and advisory structures are expected to work together to ensure these priorities are delivered. There was also the expectation that these priorities are included within this plan. In summary the 5 national priorities are as follows: • Organisation of cancer support services to ensure improved services,

delivery, planning and performance. • Primary care oncology. • Develop and pilot a single urgent cancer pathway. • Patient experience.

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• A National focus on lung cancer. Focusing on these 5 areas will drive services and performance across Wales over the next 12 months. However, the prioritisation at a national level in these areas does not mean that other work will not continue. Delivering high quality cancer services that result in good clinical outcomes and improved survival rates is a key priority for us. Our Cancer

Local Delivery Plan (LDP) for 2014/15 was launched at the end of April 2014. In addition to delivering the national priorities within our LDP we are focusing on a range of priorities which include the following: •••• Continuing to sustain and improve compliance for All Wales Cancer

Standards; •••• Treating patients as efficiently and effectively as possible, in particular

striving towards achieving cancer waiting times targets. •••• Responding to the outcomes of Peer Review processes undertaken

during the year. •••• The production of our Annual Report for Cancer Services in line with

Welsh Government requirements; •••• Responding to the recent patient experience findings. •••• Developing the Macmillan funded Acute Oncology Service across Cwm

Taf which is a pilot project for 3 years.

Prudent Health Care

Within Cancer Services there is a lot of scope to move from principles to practice in relation to prudent health care and the quote from the Minister for Heath & Social Care, Mark Drakeford “just applying the label of

prudent healthcare in a post-hoc fashion to the world as it has always been would be a very disappointing outcome” resonated with the service. With the priorities and service changes we have identified within our Local Delivery Plan we have opportunities and the funding, made available from cancer charities, to change the way services are current used and provided and to embed prudent health care in practice which promotes suitability in the future. For example our three year Macmillan funded Acute Oncology Project cuts across the 5 principles of prudent health care in the following ways;

- Ensuring avoidance of unnecessary investigations for cancer patients when they are admitted as emergencies.

- Fast tracking cancer patients back to their relevant Multi Disciplinary Teams following emergency admission.

- Reducing the avenge length of stay for cancer patients. - Identifying patients quickly with symptoms of metastatic spinal

cord compression and ensuring they progress on their pathway as a matter of urgency in a co-ordinated approach.

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- Identifying and treating patients with neutropenic sepsis in line with new guidelines and protocols.

- Ensuring patients with Cancer of Unknown Primary are fast tracked onto their pathway, avoiding unnecessary investigation and delays.

Our work undertaken with all stakeholders, including patients, to develop and agree our priorities with our Local Delivery Plan demonstrates the sense of shared and joint decision making as well as co-production around the implementation of the Welsh Governments Cancer Plan.

Links to Workforce Plan Over the life of this Plan the Health Board have agreed to the development of the following where we anticipate funding from Macmillan Cancer Support:

• 2 wte Acute Oncology Nurses – pilot project 3 year period. • 1 wte Upper GI/Pancreatic Clinical Nurse Specialist – permanent

post. • 1 wte Head and Neck Specialist Dietician – permanent post. • 1 wte Patient Centred Care Manager for Cancer. Funded for 2 year

period by Macmillan, fixed term appointment.


• Acute Oncology Service full project costs received from Macmillan over 3 year period.

• 1 wte Upper GI/Pancreatic Clinical Nurse Specialist, received over 3 years from Macmillan.

• 1 wte Head and Neck Specialist Dietician = funding received from Macmillan over 3 years.

• 1 wte Patient Centred Care Manager, fixed term funding received from Macmillan over 2 year period.


The Health Board has given a commitment to Welsh Government that, in over 90% of cases, non complex urgent suspected cancer (USC) referrals for which the complete investigation and treatment pathway is delivered within Cwm Taf, will be treated within its target date. Similarly the Health Board expects that all non urgent suspected cancer (NUSC) referrals will be treated within 31 days of a decision to treat, although this also depends on delivery within the timescales in tertiary centres. In terms of percentage of our patients referred as non-urgent suspected cancer seen within 31 days, our position is often above our profiled position and achieves the 98% target, a position we plan to maintain. In terms of the percentage of our patients referred as urgent suspected

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cancer seen within 62 days, we have been below our profiled position for the first part of this financial year, however recent months have indicated improvement, which we are working hard to sustain.

There has been a renewed focus on ensuring that patients are seen more quickly at the outpatient and diagnostic stage together with increased clinical engagement in cancer performance. Both have been contributory factors in the improved position.

As a commissioning Health Board, we will ensure that referrals are made to partner LHBs/Trusts following a decision to treat/diagnosis within the first 31 days of the pathway. However, it must be appreciated that the diagnostic pathway for some cancer patients can be complex, involving a number of investigations, and on these occasions obtaining a decision to treat within the first 31 days is not always possible. This is particularly true of lung cancer patients who have multiple investigations before a definitive treatment pathway is agreed.

We will continue to manage the interface with our tertiary providers and receive a weekly report on progress with the tertiary element of the pathway; there is an agreed escalation process and where necessary Medical Director to Medical Director dialogue. In general 99% of all NUSC referrals are treated within 31 days of a decision to treat and the Health Board will expect to maintain this level of performance.

Capital/Estate Requirements

• Office accommodation for the above mentioned posts. • IT Equipment etc to be funded by Macmillan as start up costs.

7.12 Stroke Services


Our updated Stroke Delivery Plan builds upon the considerable improvements made to stroke service provision in Rhondda Cynon Taf and Merthyr Tydfil in recent years, by continuing to progress the development and redesign of stroke services. Aligning with the National Stroke Delivery Plan, our local plan focuses on the whole pathway of care from stroke prevention, to detecting stroke quickly, delivering fast, effective treatment and care, and supporting life after stroke. This is underpinned by improving information and targeting research.

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Our local plan also addresses the four national priorities identified by the all Wales Stroke Implementation Group, i.e.:

• The identification of individuals with Atrial Fibrillation (AF). • Awareness campaign for stroke prevention, including AF. • Reconfiguration of stroke services in Wales including the

development of hyper-acute services. • Community Rehabilitation.

Priorities

Following extensive stakeholder engagement during 2012 to 2015, our proposals to redesign stroke services in Cwm Taf, incorporating the centralisation of the acute and rehabilitation stroke units and creation of an Early Supported Discharge service have been recently implemented. This redesign has been driven by the need to meet ever more challenging quality standards and to make best use of specialist stroke resource. The key features of our new model for stroke care are:

• Centralisation of acute and early rehabilitation stroke services into a stroke centre of excellence at Prince Charles Hospital.

• Centralisation of longer term stroke rehabilitation services at Ysbyty Cwm Rhondda.

• Creation of a community based stroke Early Supported Discharge service.

The impact of our redesign of stroke services will be closely monitored and carefully evaluated during 2015 to ensure it is helping to deliver the improved performance and outcomes intended for our stroke patients. We will also continue to develop the Business Justification Case for the capital development of an integrated stroke unit on the Prince Charles Hospital which will maximise our potential to provide therapy intensive treatment and care on the acute site. Links to Workforce Plan

• Our Stroke Services Redesign project has involved using our specialist stroke resources differently in a reconfigured model of stroke care, by bringing the specialists who are currently spread out across various hospital sites into a stroke centre of excellence and to create a multidisciplinary team to support patients to return to their home and family life as soon as possible.

• Centralising our stroke specialist resources enables us to provide more equitable access to stroke specialists, particularly consultants and therapists, several of whom currently work single-handedly and cannot be covered when on leave.

• Therapies staff have been required to either rotate, or relocate, to different sites

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• Staffing levels are now closer to clinical guidelines although shortfalls remain with medical and nursing staffing, which will be closely monitored.

• Next steps include consideration of moving to seven day working.


• In terms of contracting implications – the impact of the redesign of stroke services by Cwm Taf and neighbouring Health Boards on patient flow has been considered. There will be a small outward flow of south Cwm Taf stroke patients to UHW and Princess of Wales Hospital if hyper-acute stroke services continue to be provided there. This is likely to be offset by additional inward flow of stroke patients to Prince Charles Hospital from the Powys and ABUHB areas, once hyper-acute services are taken out of Nevill Hall Hospital. The predicted net financial impact of this is being analysed and are being monitored.

• Early Supported Discharge (ESD) Service – the stroke ESD service has been developed with pump-prime funding from the Intermediate Care Fund which we are looking to continue into 2015/2016.

Estate/Capital Requirements

The next phase of stroke service redesign requires capital to facilitate the required moves. A Business Justification Case will be developed during 2015/16.

Performance

Performance is monitored and reported against the:

• Welsh Government acute care bundles and shadow bundles - monthly.

• Royal College of Physicians Stroke Sentinel National Audit (SSNAP) - clinical audit reported quarterly.

• Royal College of Physicians’ Organisational Audit – annual.

7.13 End of Life Care


A Strategy for Palliative and End of Life Care Services was developed by a clinically led multi-disciplinary team and has formed the basis of the Cwm Taf local End of Life Care Delivery Plan published in September 2013 and updated in December 2014

Priorities

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• The redesign of palliative care services in Cwm Taf focuses on the development of a locality wide model which addresses both the estates provision and improving the quality and co ordination of palliative care services in Cwm Taf.

• A key element of this work is being developed through stakeholder engagement on the future provision of specialist palliative care services currently provided at Y Bwthyn, with a view to relocating the service onto a purpose designed facility on the Royal Glamorgan Hospital site. This is being progressed in 2015/16.

• This will enable improved access to acute interventions for palliative care patients, whilst also offering a suitable environment for end of life care.

• The model identifies a range of health and social care services already delivered within the community and wishes to strengthen the @Home model for palliative care aligning this with the @Home service.

• The model also provides the opportunity to integrate teams, develop new pathways, work with the Third Sector providers and reduce duplication to achieve better outcomes for patients and service users.


• Maintenance of robust District Nursing Service to provide community

based palliative care. • Staff will be required to relocate when Y Bwthyn moves to the Royal

Glamorgan site. There is no anticipated wte or skill mix change.


The release of Pontypridd Cottage Hospital in 2015. Links to Performance

An outcome framework to accompany Welsh Government’s Together for Health - Delivering End of Life Care provides the main mechanism for annual performance reporting. The first Cwm Taf End of Life Care Annual Report was submitted to Welsh Government in June 2014. It measures the following outcome indicators:

• Residence at time of death • The numbers of emergency admissions for palliative care patients

amongst our population • The number of people recorded on a primary care palliative care

register prior to death • The number of people receiving specialist palliative care

Estates/Capital Requirements

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• Capital funding is required to support this development and built into our plan. Macmillan Cancer Support has indicated that they may be willing to help support this development financially.

• Following a move of the Y Bwthyn palliative care service and other services located at the Pontypridd Cottage Hospital, the site would become free for potential disposal.

7.14 Liver Disease

Work is being led nationally to develop a Liver Disease Delivery Plan for consultation. The Health Board will respond to the consultation when it is published by Welsh Government.

7.15 Eye Health Care


The Health Board’s Local Eye Health Care Plan has been developed in response to the Welsh Government’s Together for Health: Eye Health Care Delivery Plan for Wales 2013-18. The vision set out in the Eye Health Care Plan is to develop a high quality, patient focused, integrated service to improve the eye health of people living in Wales, so they can benefit from better sight throughout their life. For those who develop sight impairment, to ensure they receive appropriate care, support and rehabilitation. The key priorities are:

• Preventing avoidable sight loss and improving eye health. • Early identification of poor eye health and sight problems. • Providing high quality, efficient, accessible services. • Providing care and support for people living with sight/dual sensory

impairment.

This Plan is designed to focus on the requirements for the population served by Cwm Taf Health Board Priorities

The Health Board’s Local Eye Care Plan is structured around the 3 key themes set out in Welsh Governments Together for Health: Eye Health Care Delivery Plan for Wales.

• Raising awareness of eye health and the need for regular sight tests • Early detection of eye health and sight problems – targeted for

people at risk

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• Providing access to high quality, integrated services and support.

Prudent Healthcare

Promoting the importance of regular eye tests is key in maintaining good eye healthcare and the Health Board will work with all of the relevant stakeholders to achieve this. The Health Board’s strategy is to ensure that patients’ eye healthcare is delivered in the most appropriate setting. To this end, we have recently received funding from Welsh Government to undertake three schemes that will allow us to move eye care from secondary to primary care.

• Cyclo- refraction for children • Post operative cataract care • Monitoring of Patients with Glaucoma or Ocular Hypertension

The Health Board wishes to continue these schemes into 2015/16 and beyond, utilising the additional funding available for Primary Care and will also explore all other opportunities to develop service in optometric practices. There are also plans in place to introduce an optometrist led triage system for all new ophthalmology referrals. This will ensure that patients are seen in the most appropriate setting. In addition, the Health Board will continue to expand the provision of Ophthalmic Diagnostic and Treatment Centres (ODTC). This will involve an increase in the number of sessions currently provided from Ysbyty Cwm Rhondda and establishing a new service in Ysbyty Cwm Cynon to serve the population of Merthyr Tydfil and the Cynon Valley. The Health Board has already taken a decision to increase the number medical photographers to support the planned introduction of virtual clinics for patients with medical and diabetic retinopathy. We will also look to establishing the same for some patients with macular disease.


Additional staff are required to support the redesigned ophthalmology service model including:

• Hospital based optometrists. • Ophthalmic technicians. • Medical photographers to support virtual clinics. • Administrative and clerical support.

Further work is also underway to develop more sustainable ophthalmic medical nursing capacity.

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Investment has been identified to support the implementation or our Eye Care Plan including priorities such as:

• Development of post-operative cataract services. • Development of glaucoma assessment service. • Development of child refraction service. • Re-designed ophthalmology service model.

Performance

Reduction in new and follow up waiting times together with reduction in the number of patients awaiting an appointment past their planned follow up date.

7.16 Organ Donation & Transplantation

In January 2014 the Welsh Government published “Taking Organ Transplantation to 2020 – Wales Action Plan” with the overall objective that Wales will become one of the best performing countries in the world for donation and transplantation. The plan sets out the actions and outcomes up to 2020 to enable this to be achieved. The Health Board also has a local Strategy and Action Plan.

The responsibility of the Cwm Taf Organ Donation Committee is to ensure that organ donation within the Health Board achieves its potential, to examine aspects of the processes which may be hindering that aim and implement changes to improve organ donation rates. The Wales Transplantation Advisory Group provides national leadership and will monitor progress made within the Health Board with compliance in implementing UK and Welsh strategies, and deliverance on actions required from the Wales Action Plan.

7.17 Rare Diseases

The draft Welsh Government Implementation Plan for Rare Diseases has been prepared by a Task Group that brought together the NHS in Wales, the Welsh Government, the Third Sector and the research community. The Task Group has also worked with those preparing plans in other UK countries. The Welsh Implementation Plan for Rare Diseases sets out the Welsh response to the commitments in the UK strategy for rare diseases published in November 2013 which sets out 51 commitments to

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improvement information, services and research in relation to people with rare diseases. The consultation closed on 23rd May 2014. The Health Board will respond to the final plan when it is published by Welsh Government.

7.18 Neurological Conditions


In April 2014 Welsh Government published “Together for Health – a Neurological Conditions Delivery Plan” which builds upon the outcome of the Adult Neurosciences Review and associated reports, and complements the quality requirements endorsed in the Report of the Task and Finish Group on Care Pathways for Long Term Neurological Conditions. All Health Boards have been required to develop with their partners a local Neurological Conditions Delivery Plan in response, by 31 January 2015. Priorities

Neurological services are provided for Cwm Taf mainly by Cardiff & Vale Health Board. Cwm Taf patients are able to access services at UHW and Rookwood, and also at the Royal Glamorgan and Prince Charles Hospital thanks to the provision of consultant outreach services. During 2014/15 and the early part of 2015 priority is being given to addressing current waiting lists and clarifying commissioning arrangements in conjunction with Cardiff & Vale Health Board and WHSSC. The Cwm Taf local Delivery Plan focuses on the following priorities:

• Raising awareness of neurological conditions – particularly with staff in primary and secondary care

• Timely diagnosis – by improving demand management and referral mechanisms

• Fast and effective care – ensuring best use of our valuable specialist resources

• Living with a neurological condition – improving access to multi-disciplinary condition specific support and neuro-rehabilitation services

• Improving information – management of information for performance management and commissioning purposes, as well as improved systems to enable appropriate access to clinical records for cross-organisational working.


Outcome measures are being determined by the all Wales Implementation Group, and will be reported upon via Annual Reports. Meanwhile, Cwm

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Taf is liaising with Cardiff & Vale UHB to clarify waiting list information and improve performance against RTT targets. Links to Workforce Plan

Development of the Delivery Plan has highlighted workforce shortfalls in neurological services, for example in consultant levels, specialist nursing (epilepsy), interventional neurology, neuro-rehabilitation and brain injury services. Specific plans to address priority needs will be developed during 2015/16.

7.19 Accessible Healthcare Standards


The recently launched Welsh Government standards focus on the needs of people with sensory loss. This includes people who are deaf, deafened or hard of hearing; blind or partially sighted; or deaf/blind whose combined sight and hearing impairment cause problems with communication, access to information and mobility.

Priorities

Our work as a Health Board will look to encompass actions to ensure that: • All frequently used information leaflets and documents intended for

patients and the public should be available in accessible formats for patients with sensory loss;

• All public and patients areas should be accessed in order and understand their needs and this process must involve and engage with people with sensory loss and ensure that their views are reflected in any proposals to design, develop or change a service. Capital funding will be required to support this development.

We have an established project group with Executive leadership which has developed an agreed action plan with timescales and actions for delivery. This includes the review and development of appropriate policies, procedures and protocols in order to effect the changes required to deliver the standards. There is also a significant training agenda. Progress on the delivery of the plan is monitored and reported formally to the Board.

7.20 Medicines Management

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Medicines use by patients is the most common and frequently occurring healthcare intervention in the developed world. Pharmaceutical Care is the responsible provision of drug therapy for the purpose ofdefinite outcomes that improve a patient’s quality of life. Ensuring that patients have the best outcomes from their medicines through excellent pharmaceutical care is a key challenge and an opportunity for the Board and its Medicines Man The health benefits for both our patients and economic opportunities for our healthcare system that can be derived from effective pharmaceutical care are significant. As part of this approach, pharmaceutical care already works alongside the principles of pavoid waste and harm, apply the minimum intervention, maximise the benefit of interventions and encourage cowith patients. This will translate into a whole system culture change with respect to the way medicines are used and is the basis for the Cwm Taf project “Your Medicines Your Health”. A particular challenge for pharmaceutical care is the public health anddemographic changes linked to an aging population and the associated increase in need in terms of chronic condition management identified in chapter 3. The “over 65” age group constitutes 12% of the population but consumes 40% of the primary care medicineover 60yrs take 4 or more medicines compared to 7% below 60yrs. “over 65” age group is growing in Cwm Taf

We believe that maximising the benefits from medicines, whilst minimising the potential harm, can deliver the and vulnerable in society.

Medicines use by patients is the most common and frequently occurring healthcare intervention in the developed world. Pharmaceutical Care is the responsible provision of drug therapy for the purpose ofdefinite outcomes that improve a patient’s quality of life. Ensuring that patients have the best outcomes from their medicines through excellent pharmaceutical care is a key challenge and an opportunity for the

and its Medicines Management Team.

The health benefits for both our patients and economic opportunities for our healthcare system that can be derived from effective pharmaceutical care are significant. As part of this approach, pharmaceutical care already

principles of prudent healthcare, where we aim to avoid waste and harm, apply the minimum intervention, maximise the benefit of interventions and encourage co-production and self reliance with patients. This will translate into a whole system culture change with

to the way medicines are used and is the basis for the Cwm Taf “Your Medicines Your Health”.

A particular challenge for pharmaceutical care is the public health anddemographic changes linked to an aging population and the associated increase in need in terms of chronic condition management identified in chapter 3. The “over 65” age group constitutes 12% of the population but consumes 40% of the primary care medicines expenditure. over 60yrs take 4 or more medicines compared to 7% below 60yrs. “over 65” age group is growing in Cwm Taf

We believe that maximising the benefits from medicines, whilst minimising the potential harm, can deliver the most benefit to the frail and vulnerable in society.

Medicines use by patients is the most common and frequently occurring healthcare intervention in the developed world. Pharmaceutical Care is the responsible provision of drug therapy for the purpose of achieving definite outcomes that improve a patient’s quality of life. Ensuring that patients have the best outcomes from their medicines through excellent pharmaceutical care is a key challenge and an opportunity for the Health

The health benefits for both our patients and economic opportunities for our healthcare system that can be derived from effective pharmaceutical care are significant. As part of this approach, pharmaceutical care already

rudent healthcare, where we aim to avoid waste and harm, apply the minimum intervention, maximise the

production and self reliance with patients. This will translate into a whole system culture change with

to the way medicines are used and is the basis for the Cwm Taf

A particular challenge for pharmaceutical care is the public health and demographic changes linked to an aging population and the associated increase in need in terms of chronic condition management identified in chapter 3. The “over 65” age group constitutes 12% of the population but

s expenditure. 36% of people over 60yrs take 4 or more medicines compared to 7% below 60yrs. The

We believe that maximising the benefits from medicines, whilst most benefit to the frail

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Another important driver is continuing the work to reduce antimicrobial resistance as part of the UK Antimicrobial Resistance (AMR) Strategy. The antimicrobial stewardship programme has commenced and is delivering in secondary care. There is now a significant need to extend this out to primary care to include clinical staff and the public in recognising the need to apply the principles of prudent prescribing to the use of antimicrobials. There is the need to apply the principles of Prudent Healthcare and, in particular, Prudent Prescribing. Cwm Taf Health Board is already well placed and is leading this agenda across Wales in medicines management. The response to the ‘Trusted to Care’ report in 2014 influenced and re-prioritised the directorate planned developments. A number of actions required immediate progress and will continue to influence the future plans. The response to this report is a key driver for the Medicines Management Quality agenda. The achievements in 2014 have provided a good foundation e.g. The development of a medicines safety dashboard has provided a means of monitoring key areas going forward, the review and update of key policies and procedures to support good medicines governance and a refreshed approach to patient centred professional care with staff undertaking appropriate training and becoming dementia friends etc. However, there could be further improvement required in education and training of clinical staff and improved medicines storage and security at ward level. The development of primary and community care aimed at ‘supporting people to live independent, healthy and fulfilled lives’ is outlined in section 6.15. This reinforces the necessary shift of both focus and support to the Primary care sector and identifies the added value that can be achieved in this model using a range of healthcare professionals including the increased role of community pharmacy in primary healthcare delivery. Community pharmacy is a primary care resource which has a presence in all areas of the Health Board (70 pharmacies in Cwm Taf). The recent pathfinder Choose Well scheme in the Cynon Locality has enabled further developments such as the MTeD link for DMRs by community pharmacists. The predicted requirement from WG will be to roll out this service across the Health Board. Realising the potential of community and primary care based pharmacists to deliver patient care aligned with the primary care cluster priorities and freeing GP time applies the Prudent principle of “only do, what only you can do.”

Priorities

Promoting medicines safety, improving quality and ensuring cost effectiveness by applying the prudent healthcare principles will continue

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to be the cornerstone of the work of our medicines management team. In 2015/2016 our priorities will include: • The implementation of MTeD system to pilot wards in January 2015

will reduce patient harm across the interface, reduce medicines related admissions and minimise waste through inefficiencies in paper transfer to GPs. It is the key service change again in 2015-16 with a planned roll out to all Health Board wards.

• To pilot NWIS project to connect the Choose Well Pharmacies in the Cynon to the MTeD system to enable and support the Discharge Medicines Review (DMR) service by community pharmacy

• To fully develop and extend the Your Medicines Your Health programme as a large scale intervention aligned with Prudent Healthcare that will change the culture of patients and the wider public with respect to the use of medicines.

• To extend the Antimicrobial Stewardship Programme into primary care as a multidisciplinary, cross sector programme of initiatives to ensure the best clinical outcome for treatment or prevention of infection, to minimise unintended consequences of antimicrobial use, including antimicrobial resistance and to minimise healthcare costs without compromising quality of care.

• To provide an integrated medicines management service with an increasing focus in primary care. The recent ICF has enabled the Medicines @ Home concept to commence i.e. a care home pharmacist and the HMAS plus scheme (HCA administering medicines in patient’s homes). The initial evaluation is encouraging and warrants including these initiatives in the 2015-16 plan.

• The Cynon Valley project - to implement the use of IP pharmacists as part of the cluster team at locality levels to support the delivery of the primary care identified health priorities. A three year delivery plan to include community pharmacist IP pharmacists roll out phased over 3 yrs. The Cynon Valley Community Pharmacy plan is innovative, collaborative and builds on new IT infrastructure which is seen as best practice.

• To sustain and develop the quality issues of the Medical Director e.g. sustain the IPFR support, improve medicines related education for nursing and medical staff as a Trusted To Care response

• To deliver the financial challenges of the prescribing expenditure saving targets through schemes at the local, Health Board and Welsh Government levels.


• Cwm Taf Health Board leading on the Prudent Prescribing work in

Wales.

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• The implementation of the MTeD system in January 2015 will reduce patient harm across the interface, reduce medicines related admissions and minimise waste through inefficiencies in paper transfer to GPs

• Prudent use of antimicrobials through the antimicrobial stewardship programme: minimising waste from inappropriate prescribing, minimising harm from healthcare associated infections and adverse medicines effects and involving the public in reducing antimicrobial use.

• The Your medicines Your Health scheme has already engaged with over 2500 people to promote the responsible use of medicines

• Realising the potential of community and primary care based pharmacists to deliver patient care aligned with the primary care cluster priorities and freeing GP time applies the Prudent principle of “only do, what only you can do.”


There is a well developed medicines management Key Performance Indicators (KPI) dashboard which includes financial and patient quality and medicines safety indicators. This also links to the C-Difficile rates and Anti Microbial Stewardship (AMS), patient flow indicators and discharge communication (MTeD).


• Service redesign to support the Acute Care Alliance changes and the shifting focus to primary care.

• Roll out of MTeD. • Development of the Antimicrobial Stewardship Programme. • Medicines@ Home initiatives • Increased use of independent prescribing pharmacists. • The development of Consultant Pharmacist posts and Advanced

Practitioners. Links to Financial Plan

• Acute and primary care prescribing savings plans delivery. • NICE and AWMSG approved medicines planning and control. • The extension of the Antimicrobial stewardship programme into primary

care. • The continuation of the Your Medicines, Your Health campaign • Implementation of MTED.


• Discretionary capital funding to support the continued roll-out of MTeD has been allocated.

• £160k to replace existing medicines management technology is required to sustain and improve services; these include replacing part

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of the automated pharmacy system in RGH and updating the aseptic unit equipment.

• £60k has been allocated for modernisation of the management of medicines will include more ward based automated storage units.

7.21 Primary and Community Care


For Wales to realise its ambition to deliver a primary care and community-led NHS, the current systems for commissioning and delivering services must change. Prevention, early intervention and avoidance of hospital admission need to form the basis for redesigning integrated systems of health and social care. Managing increasing demand in the context of existing and future resource and medical manpower constraints requires an innovative approach to the development of new models of care and workforce planning. The Health Board has recently commenced engagement on the development of its 3 Year Strategy for primary and community health services Creating Healthier Communities which outlines Cwm Taf University Health Board’s plans to deliver safe, high quality, equitable and sustainable primary and community services for the people of Merthyr Tydfil, Rhondda, Cynon & Taff Ely. ‘Setting the Direction’ is a key policy driver in ensuring that services can be provided safely within peoples own homes, or as close to home as possible. Our Strategy has been developed based on local need, but also taking into account the newly published Welsh Government document ‘Our Plan for a Primary Care Service in Wales up to March 2018’, as well as the ‘Social Services and Wellbeing’ (Wales) Act 2014. The Health Board already has a track record of working with partners in primary care, Local Government, WAST and the Third Sector to develop and deliver joined-up systems and pathways of care. Success is evidenced through evaluation of specific schemes and particularly through the contributions made to the NHS Award-Winning “Patient Flow Programme” which has enabled Cwm Taf to more effectively manage demand and deliver against key performance targets (e.g. Ambulance Handover). Whilst the focus on development of integrated care pathways will continue to be an important feature of service and quality improvement, transformational change is urgently required to meet the challenges of the future. Further incremental shift of services from hospital to

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community-based delivery, or indeed simply extending the role of enhanced services within the GMS contract will not deliver the scale or pace of change necessary to meet demand. This is the focus of the Cwm Taf Primary and Community Services Strategy and the basis for this Plan. The Health Board has thought hard about the model for taking this work forward. In broad terms the Health Board has reflected strongly on its experience of serving this population since its inception and has focused its strategy and delivery plan on five areas: • Clusters and Cluster Hubs: introducing the best possible strategic

approach and organisational form to link local needs to the full range of Health Board services;

• Performance: managing core primary care services to ensure that we deliver against our standards, drive out variation and aspire to improve;

• Co-production: building the best possible relationships with people to help them stay healthy;

• Research, evaluation and development: ensuring that we work from an evidence base and constantly learn and reflect on our day to day practice and the outcomes it achieves for people in their communities.

Written through these areas for activity is an absolute commitment to reversing the impacts of the Inverse Care Law and we are proud to be one of the Health Board partners that is explicitly working on the development of a social model to address the inequalities that have such an impact on our population. The following diagram sets out our five areas for focus:

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In this coming year, the Health Board’s Plan is strongly focused on building the correct strategic approach to drive primary care activities at every level. The following diagram sets out the outline model for our Primary and Community Services Strategy and it is explained below.

17

The historical footprint for the delivery of primary care has been the GP Surgery, Dental Practice, Community Pharmacy or Optometric Practice delivered principally through independent contractor arrangements. Traditional core community services such as District Nursing, Health Visitor and School Nursing Services are provided by Health Board salaried staff on the basis of defined community footprints with strong alignment to General Practice and primary health care teams Additionally, Local Authority partners have replicated the locality model with joint working and close collaboration between teams. Whilst true integration of primary care services is rare, some communities have the advantage of co-located services where more than one of these practices is housed within the same building where it makes economical sense to share overheads and provides patient convenience. The contractual arrangements with Health Boards provide minimum quality assurance safeguards. However, the variation in practice size and the range of enhanced services available to each patient population varies greatly. This variation is often aligned to the “inverse-care-law” – where those with greatest need experience poorest access.

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Under the GMS contract, the delivery of ‘enhanced’ services by GPs is voluntary and dependent on GPs having identified needs for their patient population and having acquired the necessary skills to deliver the service. As a result, not all GPs provide the same range of services, with larger practices often having the ability to provide more extended services than their smaller counterparts. Over recent years, in the context of the GMS contract, attempts have been made to reduce variation and drive up standards through incentivising enhanced services to be delivered within federated arrangements across GP Practices. However, collaboration is, to a large extent, limited by the business consequences for the independent contractor. Where there are incentives to share services, this can work well but where there could be a threat to practice income, opportunities can be restricted. More recent amendments to the GMS Contract provide further incentives for Locality or cluster-based working but the likely impact on variation is assessed as being marginal in the overall context of independent contractor status. There has been considerable debate at a national level (UK and Wales) regarding the development of salaried services versus independent contractors within primary care. Given the complexity of the issue and the practicalities of any such changes, it is argued that a mixed economy approach, if effectively introduced and managed, can provide the optimal solution to improve quality, capacity and reduce variation. Our strategy takes into account these factors and aims to build on the strengths of the existing systems and skills whilst building capacity and capability to address growing demand. The key objectives of the strategy are: • to consolidate services at GP Practice level so as to strengthen

local provision. In some instances this might include rationalisation of premises (including closure of Branch surgeries) and supporting voluntary practice mergers;

• to reduce variation in access to core and more specialised services at GP Practice level; this may include one Practice within a cluster providing enhanced services through federated arrangements to the wider cluster population;

• to develop four Cluster Hubs as centres for delivering more enhanced services and to transfer services out of the acute DGH; this will involve Contractor GPs from within the Cluster and PCSU salaried GPs working together with link secondary care consultants and the wider multi-disciplinary team to deliver a broader range of out-of-hospital services.

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• to develop new systems of integrated community working that deliver greater prevention, ensure early intervention and avoid unnecessary hospital admission; one of the key collateral benefits of the new models of care will be the release of high cost clinical time in secondary care to increase in-hospital efficiency thus improving waiting times and unscheduled care performance;

• to develop further the Primary Care Support Unit that already provides a flexible and multi - disciplinary workforce to support GP Practices and the Cluster Hubs; this will require the development of new roles in community nursing, pharmacy and therapies as well as paramedic practitioners, clinical support worker roles and salaried GPs;

• to develop an Academic Primary Care Unit to enhance research, development and teaching; this will include appointing an academic chair and developing bespoke training opportunities for Doctors and other Allied Health Professionals wanting a portfolio career across community and hospital-based medicine and could also potentially be a key component of the future recruitment and retention strategy for primary and community staff in South East Wales.

Organisational Form: Cluster Hubs

With this strategic direction in place, the Health Board has been developing an appropriate delivery model for services and this has led to the design of Cluster Hubs. The development of Cluster Hubs is a new concept designed to provide a vehicle for interfacing and integrating primary and secondary care services at a Locality level. The Cluster Hubs will serve as a focus to develop a range of out-of-hospital services which aim to: • make best use of skills in an equitable way across all practice

populations; • provide opportunities for Independent Contractors to develop specialist

services, according to community need and in conjunction with the Health Board, at no detriment to the core primary care function they must deliver;

• provide new portfolio career opportunities for Doctors, Nurses and AHPs across primary and secondary care;

• create a system which will reduce unnecessary hospital admissions; facilitate direct access to a greater range of diagnostics; enable protocol-driven access to inpatient waiting lists reducing overall RTT; reduce outpatient follow-ups; improve patient experience; and

• defined outcomes for cluster hubs will be aligned to those service areas identified to as needed for each locality.

Work is being progressed and we would envisage these being part of the cluster plans by beginning of June 2015.

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The outline Cluster Hub model is represented by the following diagram:

Each Cluster Hub will support a range of services delivered across the whole of the Locality linked to secondary care services in the designated District General Hospital, as outlined in the figure below.

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This organisational form will make connections between the Health Board, Localities and Clusters organisationally; connect local consolidations and federations, primary care support activities, integrated community activities and academic research and support the reach into and out from secondary care. It will also allow for the emerging, innovative service provision which is being developed through the South Central Alliance to be connected to primary care – whether that be the new acute medicine model, the Diagnostic Hub or the Paediatric Assessment Unit. Inverse Care Law Programme The Health Board is committed to reducing health inequity in Cwm Taf. We recognise that our services need to be at their best where they are needed most, with more support provided to our most deprived communities.

As part of our work with GPs in particular, we have a dedicated programme targeted at reducing early deaths from cardiovascular disease in Cwm Taf. Cardiovascular disease (CVD) is a major cause of premature mortality in Cwm Taf and is the highest in Wales (see Chapter 3 population health and challenges). The Programme forms part of disease prevention and early intervention through primary care and community services which will realise benefits across the whole pathway. It is proposed that investment upstream in primary and community care will realise in time reduced demand on services in secondary and tertiary care.

The Inverse Care Law Programme is central to the Health Board’s commitment to driving up standards through service remodelling based on the needs of the population and the best available evidence of clinical and cost effectiveness. A structured approach to cardiovascular disease risk identification and management is being piloted in practices serving our most deprived communities, which will be evaluated and rolled out across Cwm Taf in a phased approach from April 2015. A pilot project progress report has been produced and reported to the Welsh Government. An evaluation report will be available at the end of the extended pilot. Reducing the burden of cardiovascular disease in Cwm Taf will increase the number of years lived in good health, free of disability and limiting long term illness. This will enable the working age population to remain economically active and improve outcomes for families and the community. There will also be benefits to the health and social system realised through the reduced burden of ill health and disability. As a commitment to addressing health inequalities in the Cwm Taf Population and reversing the Inverse Care Law, the Primary Care Action

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Plan (which has been informed by the cluster plans and population needs assessments), identifies prevention and early intervention as priority areas. Encouraging healthy lifestyles and behaviours as part of this programme and related projects will not only reduce risk of CVD, but also cancer and dementia as illustrated in the Caerphilly Cohort Study. During 2015-18, the Inverse Care Law Programme will be implemented across Cwm Taf and will dovetail with other projects identified in the primary care and the 3 Year Plan. House of Care Model for Long Term Condition Management

Many people who have one long term condition (LTC) commonly suffer from another (known as multi-morbidity) and yet opportunities to identify and manage these conditions are often missed. Patients often receive care from multiple different teams in a disjointed way. This results in uncoordinated care, multiple different healthcare contacts and in some cases, confusing and contradictory information. We know that in less than half of routine consultations do people get any help to manage during daily life and we also know that people would like more support to enable them to have the knowledge, skills and confidence to do this. A recent focus group with patients from a Rhondda General Practice (January 2014) confirmed this. A more co-ordinated and integrated approach is needed to assessment, treatment and care to improve outcomes, including patient experience and patient safety. The House of Care is a direct service response to this. It starts with making better use of service contact time – by what we call “care and support planning”, which links traditional clinical care with support for self management. It then ensures that the service people need in their daily lives, to support the goals and plans they have identified during care planning, are available in the community, known as “more than medicine”. In this way, care planning ensures that people with LTCs can have a uniquely personalised, individual response, embedded within an overall approach. The Cwm Taf LTC model places the individual at the centre of their health whilst developing skills such as motivational interviewing and coaching amongst those interacting with the individual, allowing them to direct the individual to the support they require. It promotes team working across healthcare and other sectors and follows the House of Care Model supported by patient activation23.

23The Kings Fund explains “patient activation” as the knowledge, skills and confidence a person has to manage their own health and healthcare. Patient Activation Measurement (PAM) scores correlate with the ability to participate in own health care. This validated tool determines initial activation levels, enabling a tailored approach to improving activation levels, enabling a person to develop knowledge, skills and confidence to

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Developing a Social Model of Health

Evidence suggests that many of our health problems have their origins in society. We know that socio-economic circumstances can drive inequality in health. In response, we need to have a range of options to offer when people seek help for symptoms and illness that arise from these situations. As part of our work on the Inverse Care Law Programme and the House of Care model, we will strive with our partners to develop a ‘social model of health in primary care’. Such a model will involve stakeholders from across health and social care, housing, leisure and the Third and Independent sector, all working in an integrated and person centred fashion. The model will pick up on the themes outlined by the Minister in the last Primary Care Conference: • Developing a distributed model for leadership where all take

responsibility for what they can improve. • A remodel of the current workforce and service toward one that is

multidisciplinary and based on a social model of health. • Developing primary care clusters as the engines of delivery for local

health and social care. The partnership opportunities within Cwm Taf are, and always have been strong and these principles will be used to test all of our development work moving forward. Priorities for 2015/2016

The consolidation of core primary care services and the first step in the reduction in variation between practices within clusters must be addressed as part of individual Practice agreements and cluster plans, as required by the GMS contract. Further transformational change needs to be delivered through innovation and the development of new models of care; new workforce solutions; new funding models; and new systems of alignment of secondary and primary care. The following offers an outline of each of the core elements identified in the outline delivery model covering: • Primary care core services. • Community Care core services. • Reversing Inverse Care actions. • Clusters and Cluster Hub core commitments.

embrace positive behaviour change and management of LTCs. Using patient activation in delivering healthcare can reduce health inequalities, deliver improved outcomes, better quality of care and lower costs.

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Primary Care Core Services

Our priorities for primary care core services will ensure:

• Quality Standards such as improved access will be fully developed and understood for every GP practice, with improvements where indicated.

• Each GP practice will have a well established ‘practice development plan’ which feeds into the ‘Locality Cluster Plan’.

• Quality and Outcome Framework (QOF) will be maintained and enhanced in some practices to ensure achievement is comparable to Wales.

• Target the recruitment of a number of salaried GPs to support workforce development and aid recruitment.

• Develop and support GP mentoring schemes. • Support backfill of acute care nurses to work within GP settings. • Support practice nurses to undertake advanced community skills

training. • Dental Practices will target the actions developed by the Cwm Taf Oral

Advisory Group, as outlined in its ‘Local Oral Health Plan’. This plan sets out the priorities over the next three years.

• Increase access to dental care within the Merthyr Tydfil Locality. • Development of a sedation services for dental patients in primary care. • The Health Board will work with local optometric practices to deliver

the key actions as outlined in the Wales Eye Care Plan. Examples of where opportunities exist to transfer care to optometrists include discharge of post operative cataracts, provision of a refraction service and provision of a glaucoma assessment service.

• Develop and deliver the key actions within the Health Board Three Year Community Pharmacy Strategy which covers the following five key themes: Public Health, Integrated Workforce, Medicines Management, Finance & Resources.

• Implement the new model for district nursing which will ensure that a wider skilled workforce is available with enhanced capacity to support new community development.

• Targeted interventions at GP level for cardiovascular disease to support the Inverse care programme.

• GP Practices will play an active role in indentifying patients in vulnerable groups who would benefit from the enhanced services available from the Intensive Community Services. This team will work across the four localities to create a strong, multidisciplinary approach focused on supporting patients with complex needs in the community.

This proactive approach will lead to the:

• Maintenance of independence and wellbeing; • Avoidance of unnecessary hospital admissions; • Timely hospital discharge; • Improved management of chronic conditions;

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• Active rehabilitation and reablement. Community Care Core Services

Our priorities for extended community services will ensure: • There will be no gaps in community services ensuring that patients will

not be admitted to hospital because there are limited alternative services in place.

• There will be no duplication of services between the professionals or organisations that provide services making care easier to navigate.

• We will pursue a single point of access across health and social care. • Review of @home services with our partners, to ensure that it is

meeting the current need and demand. • Development of the Care Home support services and the Respite Care

provision. • Palliative care beds from Y Bwthyn will be re-located to the Royal

Glamorgan site in a dedicated facility. • Re-design the Continuing Health Care Team to facilitate more rapid

change. • Further detailed work will be undertaken to reduce the ALOS further to

reduce dependency. • The rehabilitation of patients within the community hospital beds will

be modernised with new ways of working. • Flexible skill enhancement of staff will be developed to promote wider

community working. Reversing Inverse Care Law Actions

Our priorities for reversing inverse care will be as follows:

• The project will continue to monitor the patients identified in the 8 practice pilots over the next 6 months as well as plan for a phased roll-out drawing on the experience so far. This extended pilot period will allow a more robust evaluation in collaboration with academic partners.

• The ICL programme roll-out is incorporated in the Primary Care Action Plan and the programme will be re-named for the roll-out to a more meaningful brand name that will engage our population.

• Academic Fellows Scheme - there will be ongoing discussions with Cardiff University School of Medicine to engage GPs in the Academic Fellow Scheme to support the next phase of the Programme, starting in August 2015.

• There will be prioritisation of the permanent employment of key dedicated staff to accelerate the programme within the scope of any further funding.

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• Additional staff will be recruited to the ICL CVD team, linking closely with other projects within the Primary Care Plan, exploring for example the possibility of joint project management arrangements with Lifestyle service development at cluster hubs

• There will be identification of the next round of practices through the cluster meetings and through the dissemination of the outcomes of the pilot for further roll out. This will be targeted at the more deprived populations/practices i.e. intervention will be proportionate to need.

• There will be agreement from the evaluation on which health check system/risk tool will be used going forward.

• We will complete the annual review on the program with an emphasis on the outcomes of the evaluation.

• We will consider if there are other community venues or primary care outlets that could be explored to identify other at risk patients i.e. dental practices for cohorts of patients that may rarely visit the GP but may attend the dentist.

• Establish robust on-going evaluation of the programme and establish research links as appropriate.

Clusters and Cluster Hubs

The Minister has made his priorities for primary care going forward very clear. His main drive is for activities that will achieve: • sustainability of services and the workforce; • access to services for the population; • shift of services out of hospital into primary and community settings; • a strong focus on innovative new approaches to care. In light of this, the Minister has also given a steer on priority areas for focus at the local cluster level, to target:

• Prevention and early detection of cancer; • End of life care; • Minimising the harms of polypharmacy; • Access.

GP Cluster Plans are a new requirement for primary care from 2014/15 This requires the GPs in each locality i.e. Rhondda, Cynon, Taff Ely and Merthyr Tydfil to agree the top priorities that need to be addressed collectively as determined by the locality needs assessment. Locality Clinical Directors have worked hard with the primary care team and the wider clinical and administrative body of colleagues in Cwm Taf to isolate the following projects as priorities for 2015/16 across four major domains: • local projects at Cluster/Cluster Hub level;

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• enabling projects that will support delivery of the local plans; • corporate projects that will enable delivery of local plans and link to

other organisational functions; • projects with a focus on inequalities and social outcomes that will

require a cross organisational approach to be operationally successful.

These programmes of work are outlined in the diagram below and Annex

A4 provides further detail of the local projects by cluster area:

As part of our priorities for 2015/2016, there are a number of enabling and corporate projects as can be seen from the below: Enhanced Primary Care Support Unit

The new PCSU model builds on current resources and a robust evaluation in 2009. It is designed to address the needs and demands of contemporary general practice and primary care. The PCSU is a multi-professional team with an administrative support structure that will maximise efficiency, equity, flexibility, safety and governance. The team will be linked to the Cluster Hub teams so that there are economies of scale, sharing of resources and expertise and appropriate targeting of services. The key outputs of the scheme will be: • Attractive and flexible working arrangements to recruit a highly

motivated workforce. • Securing a workforce from home grown health professionals. • Portfolio careers linked to Education, Training Academic and Research

for all professions. • Academic Fellows/Clinical Fellows supporting general practice teams. • Support for opportunities in specialism.

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• Support and mentorship for health professionals’ also clinical support for practice development.

• Alignment to clusters and generic teams. • Direct delivery or support to back fill GP practices to provide specialist

services within a ‘cluster hub’ at each locality. • Providing an environment for secondary care staff to work in a

community setting. • Support multi-professional undergraduate training placements. • To support the testing of new models e.g. triage of acute calls in hours

or alternative professionals for minor illness. • Rapid response team to step in with immediate support or to

undertake the service as a ‘managed practice’. • Supply of affordable primary care workforce for short to medium term

as alternative to expensive locum cover. • Provision of HCAs with advanced skills in cardiovascular disease risk

assessment and behavioural change/counselling as a cluster resource. • Mental health practitioners and lifestyle coaches providing behavioural

change and support at cluster level. • Generalist Pharmacy support at GP and cluster level in delivering

medication reviews and specialist advice re long term conditions and poly-pharmacy. Specialist Pharmacy support to address areas such as antimicrobial prescribing within primary care.

• Therapy provision to address specific interventions at cluster hub level i.e. MSK also to support the growing needs of care homes and the growing demand on GP provision.

Building Cluster Hubs

The building of cluster hubs is a major theme in all of the four localities. Two of the localities specifically Rhondda and Taf Ely have described their initial models and initial areas for immediate focus. These are described in the tables below, aligned to each of these cluster areas. Rhondda is described as ‘cluster hub development’ and Taff Ely is described as ‘development of Dewi Sant’. Research Capability

All of the schemes that we develop will need robust evaluation, audit and associated learning. Others will lend themselves to research methodology. Clarity is forming on the areas that will lend themselves to a more formal research approach one of which is aligned to the work in the Rhondda and is a research proposal linked to the development of a COPD Intensive Intervention Team. This is a project to trial an intensive team who will work with a small cohort of mild-moderate COPD patients in order to try and change their behaviours. Culture and Communications

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One of the key themes from each of the clusters has been that of improved communications across secondary and primary care. The Merthyr cluster has taken a lead on developing this through ‘Optimising Care by Improved Communication’ this is highlighted in the section below. The aim is to improve relationships and therefore communication between primary and secondary care. The emphasis is on removal of artificial boundaries, prejudices, mistrusts and therefore rebuilds relationships. It also includes electronic systems that will aid communication for discharge advice and referral advice. Primary Care Prescribing Investment Scheme The Primary Care Prescribing Investment Scheme (PCPIS) will stimulate and drive improvements in primary care prescribing. It will release funds that would otherwise be used to underpin the growth in prescribing expenditure. These funds will then be re-directed to augment the delivery of Locality and GP-practice plans. Out of Hours

We will be introducing a new out of hours model in three phases during 2015/16. In the first phase, we are most likely to consolidate services on our two acute sites and supplement this with a transport solution as a temporary measure. Following consolidation we will test new workforce, team based models for delivering OOH and consider a new approach to packaging shifts with practices. Finally, in light of what we learn in the first two phases, we will consider a longer term approach to integration. The diagram below outlines our implementation approach:

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Neurodevelopmental Services. The Neurodevelopmental Community Team features in the CAMHS & Paediatric plans, but is also highlighted here, as there is a core GP component to deliver the service differently. The core components of the service would be provided by CAMHS/Paediatrics/lead GPs for each cluster. The GP element is the provisions of medication and associated physical review along with prescribing as part of a shared care Locally Enhanced Services. A multi-disciplinary neurodevelopmental team would aim to ensure a commitment to excellence in providing care so that professionals work together to pool their skills and knowledge to achieve the best possible outcomes for the child young person and their family. Families would be supported at all stages and would be empowered to work and bond with their child as opposed to the current situation where families are often on a waiting list for over a year before assessment and intervention is offered. Your Medicines, Your Health

Your Medicines, Your Health (YMYH) is a holistic approach straddling health, social care and education. Focussing on some areas of deprivation (e.g. social housing) it will work to improve equity and reduce variation in care. It will make better use of the resource consumed by medicines and thereby contribute to improved sustainability of services. YMYH is both person-centre and population orientated. Preliminary work in Cwm Taf has demonstrated a high degree of public ownership and intuitive endorsement to the underlying approach of YMYH. An evolving programme of proven interventions techniques will be applied and evaluated via action research. YMYH has the full support of the Welsh Government’s Prudent Prescribing Implementation Group & the all Wales Chief Pharmacists Committee.

Timescales for delivery

The following diagram sets out the phasing for delivery of the above local, enabling and corporate primary and community care projects which have been set out above:

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Our primary care projects will break across the year in three major phases. First, an enabling phase running between March and July to put in place solid foundations in terms of capability and support for ongoing project delivery. This will be followed by a project set up phase between July and October, which will see prioritised corporate projects (OOHs and neurodevelopmental services) coming into place alongside our major projects which have drawn from our clinically led workshops in recent weeks. This will then be followed by an implementation review phase in the final third of the year, where project delivery will be driven and assessed for continuation into 2016/17. The total programme of work will be reviewed monthly by the Primary Care Committee and within the scrutiny arrangements provided by the Board and our sub-committee arrangements, as can be seen later in Chapter 11. Links to Workforce

The proposed changes to the service delivery model, in particular the development of cluster hubs and the PCSU, will result in significant changes to the way the workforce is employed, utilised and developed. The key features of the new workforce model will see the recruitment of a number of directly employed staff including salaried GPs, pharmacists

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(both general and specialist), and nursing staff to back fill practice staff. Further detail is outline in Chapter 8. Links to Financial Plan The outcomes of the work associated with the primary and community care funding has been reviewed along with other programmes of work and two major development days to develop our financial priorities for 2015/2016 as outlined within our financial plan in Chapter 9.

Investment is included for areas such as:

o Development of the PCSU and locality hubs including additional pharmacists, GPs and specialist nurses

o Inverse care lay programme expansion o Medical Practitioners to support independent prescribing o Your Medicines, Your Health Campaign o Cluster Hub priorities o Primary and Community Eye Care development o New GP Out of Hours model o Primary Care premises development o Risk stratification tool to support GPs o Investment in primary care team to support arrangement of

change, GP and practice management leadership.

Estates & Capital Requirements

Priorities include new developments, linked where relevant with the development of cluster hubs and ensuring allocation of improvement grants. Specific areas include: • Llanharan, Taff Ely - Primary Care Medical Practice and Premises • Mountain Ash, Cynon, Primary Care Medical Premises • Aberdare, Cynon, Primary Care Medical Premises • Tonteg, Taff Ely, replacement branch premises.

7.22 Secondary Care

In addition to the elements of secondary care services in the service plans above, clearly the outcomes of the South Wales Programme has a significant impact on the development of the Health Board’s clinical strategy as we move forward.

7.22.1 South Wales Programme

The South Wales Programme (SWP) was a joint programme of work between five health boards providing healthcare services in South Wales

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and South Powys – Abertawe Bro Morgannwg, Aneurin Bevan, Cardiff and Vale, Cwm Taf, and Powys – and the Welsh Ambulance Services NHS Trust (WAST). The services reviewed through the programme were consultant-led maternity and neonatal care, inpatient children’s services, and emergency medicine (A&E), due to their ‘fragility’ in terms of their ability to deliver safe and sustainable models of care. Extensive work was undertaken over a two year period to prepare plans for the future configuration of services, central to which was clinical leadership, engagement and professional advice, complemented by broader stakeholder engagement and formal periods of engagement and consultation. Decisions on the outcome of the programme were taken by Health Boards and WAST at special board meetings held in February 2014 and the collective position of all partner organisations was confirmed in March 2014. This included the following: • Inpatient Paediatric services will not be delivered from the Royal

Glamorgan Hospital (RGH) site in the future but implementation will be dependant upon a new local assessment model being in place, before, or at the same time as the changes take place, to ensure that the majority of children continue to have their care delivered locally.

• 24 hour consultant-led A&E services will not be delivered from the RGH

site in the future but implementation will require the proposed new model for a local A & E service and acute medicine (aligned to an appropriate surgical and critical care system) to be in place before or at the same time as the changes take place.

• For Obstetric and Neonatal services, the Board sought a firm

commitment that in the context of a wider networked service, all opportunities for innovative new models would be pursued through the South Central Alliance to retain as much care locally as possible. The Board sought that centralisation will only happen in the genuine absence of a viable alternative as tested through the transition arrangements and recognised that other LHBs considered that it would not be possible to retain any Consultant-led Obstetric and Neonatal services in RGH, and that if this was proven to be the case, the Board would agree that it would have no alternative other than to accept that these services would, in the longer-term, not be present on the RGH site.

• The Royal Glamorgan Hospital will also develop a significant role in

diagnostics and ambulatory care supporting the wider network of hospitals within a South Wales Central Alliance.

• The Royal Glamorgan Hospital will become a beacon site for developing

innovative models of care in acute medicine and diagnostic services.

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The South Wales Programme outcome also confirmed the strategic importance of Prince Charles Hospital (PCH) in preserving access to services for the residents of South Powys and the wider heads of the valleys communities. Recognising some of the critical mass challenges this hospital faces, Cwm Taf in association with other Health Boards is accelerating the network arrangements requiring support from both the South Central and South East Alliances in delivering services in Prince Charles Hospital in the medium and long-term. Whilst we do not have a detailed costing of the impact of implementing the SWP at this stage, as there remains a degree of uncertainty as to the detail of the final service moves their phasing, we have made financial provision in the Plan for some of the key secondary care innovations and new model enablers for the service changes and moves, and high level provision for the likely transitional costs. More detail will be added to the Plan as the detailed implementation emerges over the coming weeks and months Further background information on the SWP, including post consultation documentation, is available via the SWP website http://www.wales.nhs.uk/SWP/home with the following sub-sections offering further detail on the implementation programme. South Central Acute Care Alliance In terms of implementing the outcomes of the SWP, all SWP partner Health Boards and WAST supported the creation of three Acute Care Alliances (ACAs) across South Wales and South Powys. Hywel Dda Health Board also supported the introduction of the ACAs. The ACAs aim to ensure that hospitals no longer work in isolation but instead work more closely together across Health Board boundaries as part of a network providing care to patients. In September 2014, the Cwm Taf Health Board approved the proposed arrangements for the establishment of the South Central Acute Care Alliance together with its partner Health Boards and WAST. The South Central ACA’s primary focus is on the acute hospital services provided by Prince Charles Hospital; Royal Glamorgan Hospital; University Hospital of Wales Cardiff; University Hospital Llandough, and the Princess of Wales Hospital (POWH). Whilst POWH is included in the South Central ACA due to its geographic position to the alliance and its close working relationships with hospitals in Cwm Taf, the commissioning responsibility for the Bridgend population and the accountability for the delivery of services within POWH remain with ABM University Health Board.

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Prince Charles Hospital, whilst part of the South Central ACA, will also work closely with the planned SCCC, Nevill Hall Hospital and Ysbyty Ystrad Fawr to serve the population of the Heads of the Valleys and South Powys and maintain clinical relationships across this area. At ACA level, the governance structure has three levels: ACA Chief Executives’ Delivery Group, ACA Implementation Team and ACA Clinical Implementation Group/s. The ACA structure also links with that of the South Wales Health Collaborative (SWHC) through the SWHC Board and SWHC Executive Steering Group. The SWHC works on behalf of six Health Boards - Aneurin Bevan, Abertawe Bro Morgannwg, Cardiff & Vale, Cwm Taf, Hywel Dda and Powys – and undertakes work programmes with a regional focus as directed by Health Board Chief Executive Officers. The SWHC provides objective input into change programmes and in supporting the ACAs in delivering agreed changes. Implementing the SWP Outcomes

For the Health Board, as part of the South Central Alliance, the following outlines the key elements of further detailed and implementation work now underway, either within the Health Board, Alliance, or SWHC as appropriate.

Emergency and Acute Medicine

As part of the outcome of the SWP, it was agreed that 24 hour consultant-led A&E services will not be delivered from the Royal Glamorgan Hospital (RGH) site in the future but implementation will require the proposed new model for a local Accident and Emergency service and acute medicine (aligned to an appropriate surgical and critical care system) to be in place before or at the same time as the changes take place. It was also agreed that RGH will be a ‘beacon site’ for developing a new and innovative model of acute medicine that maximises the opportunity of delivering the widest range of medical care in a local hospital setting.

The developing role of the University Hospital of Wales (UHW) as a major trauma centre will become increasingly important to the population of Cwm Taf in the future. In this context, it is recognised that the most seriously ill patients and injured patients will not receive their care in Royal Glamorgan Hospital in the future. The Health Board is therefore working closely with the SWHC who are taking forward this work and is also developing its local acute medicine

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model in this context, including an assessment of capital works required to facilitate the introduction of the new model. The Alliance has established an Emergency Medicine Clinical Implementation Group with representatives from across the Health Boards and indications from the Deanery highlight that that the training posts for the Foundation and GP Trainees will be withdrawn from the RGH from August 2015. This means that new models and capital works will need to be in place aligned to this timescale and across the Alliance, with clear transition and/or contingency arrangements in place as required. The SWHC has established an Acute Medicine Clinical Reference Group and work is currently underway on the implementation of an audit of the composition of the acute medicine take for the SC ACA hospitals. This exercise will provide some clinically-based evidence on which to develop an approach for modelling of acute medicine activity. This audit is being undertaken in the South Central Alliance. These changes require a significant improvement in the local emergency ambulance response together with the development of a robust retrieval and transfer system to mitigate risk. Recognising its own responsibility for commissioning of ambulance services, Cwm Taf and the SWHC are working closely with partners including the Welsh Ambulance Service to develop a retrieval and transfer system that will function within the to safely manage patient flow. Paediatric/Obstetric/Neonatal Care As part of the outcome of the SWP it was recognised that inpatient paediatric services will not be delivered from the RGH site in the future but implementation will be dependant upon a new local paediatric assessment model being in place, before, or at the same time as the changes take place, to ensure that the majority of children continue to have their care delivered locally.

For Obstetric and Neonatal services, the Board sought a firm commitment that in the context of a wider networked service, all opportunities for innovative new models would be pursued through the South Central Alliance to retain as much care locally as possible.

The Board sought that centralisation will only happen in the genuine absence of a viable alternative as tested through the transition arrangements and recognised that other LHBs considered that it would not be possible to retain any Consultant-led Obstetric and Neonatal services in RGH, and that if this was proven to be the case, the Board would agree that it would have no alternative other than to accept that

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these services would, in the longer-term, not be present on the RGH site. An Alliance Clinical Implementation Group for these clinical specialities has been established and has been meeting over recent months in order to develop plans for implementing the required changes in these fragile service areas across the Alliance area. This includes finalisation of the detailed service models, analysis of the activity and redefined patient flows and detailing the required capital programme of work, as to accommodate these changes an expansion of the facilities (particularly delivery suites and neonatal cots) are needed in University Hospital of Wales (UHW) and Prince Charles Hospital (PCH). The Health Board is currently finalising discussions with Welsh Government to release the remaining funds for Cwm Taf to invest in creating an expanded neonatal unit, extra delivery rooms and maternity theatre at PCH. In this context, in January 2015 at its Public Board meeting, the Board agreed a way forward on implementing this element of the South Wales Programme. It was noted that the building programme for the expansion of the neonatal and obstetric unit in Prince Charles Hospital, will take around 9-12 months to be completed, therefore a transition plan is needed until that time to ensure that safe services can be delivered and to minimise disruption to patients and staff in the short-term. It was therefore decided that the Board needs to do everything possible to maintain the services at both PCH and RGH until the capital developments are completed in PCH and UHW. However it was noted that the Health Board’s ability to keep the two sites working in this way will be heavily reliant on locum doctors at significant cost. The additional cost of these locum doctors is something that the Board has committed to finding a way to manage but it was acknowledged that if the doctors are simply not available, then the Board may not be able to sustain this transitional plan until the new Units are ready. It was therefore agreed that if, at any time during this transitional phase, the safety of services cannot be assured because of a lack of doctors, the Board decided that as a contingency, the consultant-led deliveries, neonatal cots and paediatric inpatient beds will be temporarily centralised on the RGH site. This is because the facilities are already available in RGH and would ensure that the building works to secure the long-term future of these services in PCH, as determined by the South Wales Programme, is not compromised. A contingency plan to this effect has since been developed and is ready to be implemented, should it be required. It is important to note that should this contingency move be necessary for patient safety, consultant-led ante-natal services, midwifery-led care

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including a midwife-led birthing centre and a Paediatric Assessment Unit would operate from Prince Charles Hospital during this period. Capital works are now underway on developing the Unit in PCH and as soon as the building works are completed at both PCH and UHW, the South Wales Programme outcome for Paediatric, Neonatal and Obstetric services should be implemented and services would move back to PCH. Within Cwm Taf, work has also been progressing well on the development of the Paediatric Assessment Unit in the Royal Glamorgan Hospital with detailed plans being finalised, the model has been piloted in situ and discussions have also taken place with the Community Health Council.

Diagnostic Hub

As part of the SWP, it was agreed that the Royal Glamorgan Hospital will develop a significant role in diagnostics and ambulatory care supporting the wider network of hospitals within a South Wales Central Alliance.

The Health Board received £2m of funding from Welsh Government in June 2014 to start developing the concept of the Diagnostic Hub. A Project has been established in order to take this work forward and is currently developing the work programme. A Stakeholder Group is also being established to ensure partners such as the Welsh Government, LHB and Trusts are also involved in the development of the project. The first phase in developing the Hub includes the expansion of further MRI and CT capacity, with a business case recently submitted to the Welsh Government. Subsequent phases are also being developed, which could see the service model potentially extending to pathology and other diagnostic services in the medium to longer term. For example, there are options that exist in Cwm Taf to support developments such as cellular pathology redesign, with real opportunity to align the regional pathology work with the Diagnostic Hub development. Strategically, looking at the Royal Glamorgan Hospital site and/or the surrounding area, there are already a good number of co-located services based here already such as the screening services, blood transfusion service and the wound innovation service. There are also service changes outlined above, planned for the Royal Glamorgan Hospital as part of the South Wales Programme, which may well present some accommodation opportunities. This area has well established transport links already in place for screening services, provided from the estate adjacent to the hospital and provides some exciting development options for the future. Surgery

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The South Wales Collaborative also has a Clinical Reference Group established to look at surgical specialties. Draft clinical models have been produced for general surgery, urology, vascular, gynaecology, ophthalmology, ENT and oral maxillo-facial surgery (OMFS). Within Cwm Taf and building on the work of the Collaborative, work is underway on the development of the local surgical models required to support the acute medicine model and paediatric surgery requirements. There are assumptions regarding clinical service co-dependencies within surgical service models which are currently being considered with clinical colleagues particularly from acute medicine, anaesthetics, critical care and diagnostics and joint discussions are also underway. Arrangements for a ‘Getting It Right First Time’ (GIRFT) review in orthopaedics are also being progressed locally and by the Collaborative. Our financial plan has identified additional resources to enable primary care changes needed to support the South Wales Programme changes, utilised initially on South Wales Programme changes. In terms of key areas of change and investment, strengthening core primary care; developing primary care cluster hubs and using them to help achieve a shift from secondary care to primary and community care; greater integration with social care, Local Authority and Third Sector partners; implementing new secondary care models to improve effectiveness and critically to enable RGH to play a full part in the health system without the full range of A&E, paediatric and obstetric services and developing new workforce roles and models to facilitate all of the above are critical enablers to successfully deliver the South Wales Programme changes, which will have the greatest impact on Cwm Taf.

South Wales Health Collaborative

• Major Trauma Network

In late 2012, a workshop was held to consider how major trauma services should be provided for people in South Wales and South Powys. The report from that workshop was reported to the South Wales Programme Board in January 2013 and February 2013, and the minutes of the latter record that the Programme Board approved the actions arising from the workshop and, specifically, the creation of a formal Trauma Network in South Wales, with administrative support,

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and the appointment of an independent South Wales Clinical Director for Trauma and lead clinicians from LHBs.

The South Wales Health Collaborative hosted a major trauma development forum on 7th April 2014, to progress work to plan for and establish a major trauma network for South Wales and South Powys. Since then a Project Board and a Clinical Reference Group have been established to consider the options to deliver a Major Trauma Network and develop a business case for consideration by Chief Executives in early 2015. This work is linking closely with the Emergency Medical Retrieval and Transfer Service Cymru Programme Board to ensure alignment.

• South Wales Pathology Collaborative

Current andrology services in Wales are very fragile with some services becoming increasingly unsustainable. The SWPC has made recommendations to the CEOs on a future sustainable model for andrology Services by focusing on a national service and this has been developed into a business case for consideration and approval. This does currently suggest a very modest investment across Wales, in order to create an all Wales national andrology service, wholly provided within the NHS in Wales, fully accredited and providing a high quality, sustainable service.

Current cellular pathology services within South Wales, especially in the West, are fragile and fragmented and considerable work has already been undertaken to identify options for the future provision of these services. In order to sustain the service, concentrate expertise and enhance efficiency the SWPC will develop proposals for reconfigured Cellular Pathology services within South Wales. This review will take into account the progress in North Wales to create a regional centre with the introduction of new technology via the Health Technology Fund. Synergies will be maximized to ensure a National approach is adopted. Pathology transport services within Wales are currently provided by a variety of means e.g. WAST, hospital transport and private couriers/taxis. However it has been identified that this service is not sufficiently resilient or reliable to support transport of samples to reconfigured laboratory services delivered from fewer sites. The SWPC has considered the possibility of a managed single dedicated transport service for pathology across Wales but in view of the transfer of Health Courier Services to Shared Services and the difficulty disaggregating the pathology service from the HCS, it has been agreed that pathology transport will be provided by Shared Services in the future. A detailed service specification with associated performance indicators is being

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developed to ensure the effective commissioning and monitoring of the service from Shared Services.

Advances in automated microbiology testing means that microbiology services within South Wales have an opportunity, through use of new technologies, to accelerate improvements in the quality and efficiency of the service provided. This technology could deliver significant workforce savings which would be maximised if implemented as part of reconfiguration of an integrated microbiology service across South Wales.

It has been agreed by the SWPC that in order to progress the work Public Health Wales would lead in developing the project. They will deliver a clear specification with clarity on the level of service for a national microbiology service in Wales and a draft Strategic Outline Case is expected by the end of 2014/15.

• Sexual Assault Referral Centre (SARC) Services

Over the last two years, work has been undertaken through the SARC national planning group to review the current provision of SARC services in South Wales and to consider options for a regional service model. Welsh Government had approached the SWHC Director to request that this work was taken forward through the collaborative and, in July 2014, Chief Executives agreed that, given the fragility of the service, SARC services would be included in the SWHC work programme. A Project Board and Task & Finish Groups have been established to oversee and progress the work required to develop proposals for a sexual assault service for South, Mid and West Wales. The service model will address the needs of men, women and children of all age groups but will differentiate between children less than 13 years of age, those aged 13 to 15 years of age and 16/17 years of age, and adults (18+ years of age). It will consider the acute phase (delivered by Sexual Assault Referral Centres (SARCs) and follow up (sexual assault services) with the initial priority to address the acute phase and establish core/statutory services on a sustainable basis. Whilst this work is progressing, the potential for resource and funding implications need to be recognised within IMTPs.

• Vascular Services – South East Wales

The South East Wales Vascular Network is comprised of Cardiff and Vale Health Board, Aneurin Bevan Health Board and Cwm Taf Health Board and has been established to strengthen the delivery of a 24/7 high quality, consultant led vascular surgery and vascular related interventional radiology (IR) service, to deliver optimal patient care across South East Wales. The model will complement the network arrangement already established in South West Wales and extend this

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to become a fully integrated network, including IR and centralisation of arterial surgery. The output of the project will include the production of a business case to support a proposal outlining the way in which the agreed clinical model for consultant-led vascular surgery and vascular related IR services will be delivered. The development of the South East Wales Vascular Network is being delivered through a Steering Group, supported by an Advisory focused Group. Building on work previously completed, but which only on required surgery following AAA screening, regarding potential options for the delivery of a network model across the region, formal project management arrangements have now been established to take forward the work, for all vascular surgery and vascular related interventional radiology services. The Advisory Group has considered and agreed a service model based on a hub and spoke approach and a non-financial appraisal has resulted in the University Hospital of Wales being the preferred option for the hub in South East Wales. A robust capacity/demand assessment and financial appraisal will now be undertaken to complete the business case and provide recommendations to the Chief Executives.

• Acute Medicine

The Clinical Reference Group (CRG) for Acute Medicine has produced a service model for acute medicine in response to the changes to services proposed through the South Wales Programme. The service model defines the services that will be deliverable on a ‘local’ or level 2 hospital site in the context of the service changes recommended through South Wales Programme and also identifies those specialist acute medicine services that should be provided only on ‘regional’ or level 3 hospital sites. In developing this model the CRG has taken account of proposed and foreseeable changes to other acute services as well as current and emerging guidance and policy on the provision of acute care in hospitals.

The work of the CRG is continuing to refine the service pathway and supporting algorithm for the delivery of acute medicine services. An audit is currently ongoing on South Central ACA to test the viability of triaging to the proposed acute medicine pathway based on presenting symptoms and to assess the composition of the acute medical take against the proposed ‘levels’ of care i.e. levels 1- 4 or local, enhanced-local, regional and supra-regional. The data from this exercise will enable the testing of the impact of the proposed service model on possible service configuration options in line with both the outcome of the South Wales Programme and the

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emerging findings of the clinical planning work ongoing under the direction of the South Wales Health Collaborative.

• Emergency Surgery

It was recognised that the service pressures and drivers for change associated with the specialties under consultation in the SWP applied also to other acute specialties and the sustainability of further hospital services were becoming increasingly fragile.

The CRG for Surgery was therefore established and has developed draft service models for surgical specialities for the South Wales Health Collaborative. These service models will define the core requirements for the safe and effective provision emergency and elective services for ‘local’ (levels 1 & 2) and ‘regional’ (level 3) hospital sites.

Consideration has been given to how the service models will support each other and the range of other services at both local and regional hospitals. The following surgical specialties have been considered within the scope of the surgical CRG:

• General Surgery • Vascular Surgery • Urology • ENT • Ophthalmology • Oral and Maxillo-Facial Surgery • Trauma and Orthopaedics

The service models for each of the specialities above have been drafted to identify the surgical inpatient and day case provision that can be delivered on both an emergency and elective basis at each level of care. The elective casemix has been assessed and mapped to each level of care in order to describe the types of procedures and supporting service requirements that are potentially deliverable at each level.

It is anticipated that the ten acute hospital sites in South Wales currently providing full emergency general surgery (EGS) will need to reconfigure the emergency service pathways to develop a networked or ‘hub and spoke’ model of care with 24/7 emergency surgical admissions concentrated on far fewer sites in order to provide safe and sustainable services that meet core standards and to provide the best outcomes for patients.

Work is ongoing under the direction of the SWC to model the potential impact of options to reconfigure surgical services to inform the planning process prior to wider engagement with all appropriate

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stakeholders to further develop integrated plans across Acute Care Alliances and Health Boards.

• Finance Workstream

Alongside providing professional finance leadership, advice and support from constituent Health Boards and WAST for each of the above workstreams falling under the NHS Wales Health Collaborative (SWHC), the finance workstream is also progressing work on developing the required changes to the financial frameworks needed to support significant service change and collaborative working.

Whilst this is being progressed incrementally, in each of the above areas by exploring what is required in terms of a financial framework and funding flows to deliver change in each area, this will now need to be brought together to form an agreed national approach. This work will need to include the input and involvement of Welsh Government finance colleagues and may need to be aligned with any changes in terms of resource allocation. This will be further explored and progressed with NHS Directors of Finance and Welsh Government.

7.22.2 Planned Care


The Health Board submitted its Scheduled Care Delivery Plan to Welsh Government in June 2013 and developed a similar internal plan for 2014/15. These plans describe the action necessary meet the target trajectories for Referral to Treatment (RTT) targets and cancer targets. The plans acknowledge that achieving and sustaining the required cancer targets and RTT position in all specialities will continue to be a major challenge for us, in particular ophthalmology.

Our Board clearly recognise the benefit of early assessment and treatment on health outcomes and place a high priority on achieving the national access targets, which as part of planned care system includes looking across primary care, community and hospital services. Our primary and community care section shows that we are committed to re-balancing planned care pathways and through our cluster plans we are seeking to develop appropriate components in primary and community care to reduce reliance on secondary care and reflecting the principles of prudent healthcare.

We continue to take positive steps to improve our performance, including implementing a range of ‘enabling’ measures that are linked to improving patient flow and process efficiency that are all contributing to the

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development of a sustainable service model. We remain committed to our journey of continuous improvement necessary to develop a sustainable service model for planned care.

Delivering Service Priorities

Whilst the Health Board has not been able to meet its original target of zero breaches by November 2014, our expectation remains that with the exclusion of ophthalmology for the reasons described above, there should be no 52 week breaches at the end of March 2015 and that we will deliver a year end figure for 36 week waits below that of the 638 achieved at the end of March 2014. The graphs below show the 36 week position for the end of February 2014, with and without Ophthalmology.

We recognise the importance of demand and capacity planning and the need bring these into balance in the organisation and our demand and capacity plans in this respect can be seen in Chapter 5, section 5.6.5.

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We have developed more sophisticated local demand and capacity planning tools, designed to help us articulate recurrent demand and capacity levels, including understanding and assessing any backlogs and identifying capacity gaps. This has contributed to the development of more robust plans at local directorate level to meet these gaps to ensure the delivery of safe and sustainable services. This work is ongoing and our ambition is to continue to build our capability and capacity in this area to ensure that we understand how our planning for planned care is aligned within the overall capacity plan in our Health Board, including understanding the impact on our infrastructure requirements such as theatres and beds. Using our more sophisticated modelling systems we are better able to understand our business processes, including how we manage the core stages of delivery, in oral surgery, for example, we are now identifying alternative treatment pathways for patients, we have commissioned external capacity for MRI, as the first step to improving diagnostic waiting times in radiology and similar strategies will be employed for other radiological modalities where necessary. Our focus on improving efficiency and patient flow remains a key tenet of our improvement plans. Key enablers are the expansion of overnight stay capacity, improved treat in turn rates and pre-operative assessment in addition to work being undertaken across the pathway to offer alternative to inpatient, or consultant led hospital delivered care. In addition we will improve day of surgery admission rates. In addition we have established a programme of theatre quality improvement to improve overall theatre efficiency, safety and productivity. The programme objective is to improve theatre utilisation rates and to achieve financial and productivity improvements as can be seen in Chapter 9. This programme is supported with a new Theatre Productivity & Management Tool which has developed by the Health Board. Recently piloted in oral surgery to support surgical teams, it has already been shown to improve theatre utilisation. Maintaining our strong emphasis on theatre quality improvement is an important driver for achieving efficiency in the scheduled care system and since April 2013 our utilisation rate has maintained an improvement trajectory. The average theatre utilisation rate at present is 86%, however taking into account the funded sessions and reflecting the take up rate of these sessions, the rate falls to 70% for the Health Board as a whole.

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We have some recognised challenges in relation to outpatients and in some specialities the waiting time for a first outpatient appointment has grown to an unacceptable level. This is due in part to long standing capacity issues, in particular, ophthalmology. We have developed an outpatient improvement programme and in this respect we are regularly reviewing the situation both at the individual service level and organisation wide. As well as driving efficiency and maximising capacity within the current system, in parallel through our primary care strategy we are also looking at ways of developing services in primary care and identifying alternative pathways and patient management. Examples of this are the Muscular Skeletal (MSK) Triage service within orthopaedics. This has reduced demand for outpatient consultation by 50%, with patients being seen more appropriately within therapy services. Within oral surgery, the development of a community based minor oral surgery service is also beginning to reduce demand for consultant led services and weight management programmes. We have further examples of moving some outpatient activity has back in to primary care, particularly in diabetes, cardiology, oral surgery and ophthalmology. This needs to be further integrated with the referral management project, supported with improved referral criteria and referral management systems to improve demand management. Moving forward we will continue to look for opportunities to manage demand via alternative sources across the health and social care economy. Priorities

With the improvements we have seen in unscheduled care and patient flow, far fewer operations have been cancelled this year resulting in improved theatre utilisation. As outlined above we will seek to increase our current day case and short stay surgical rates, thus reducing the need for patients to stay in hospital for less than a day; 23.59. There is also a focus on theatre start times trying to ensure lists start on time, including the pre-lists briefing times.

The focus of our work in 2015/16 will continue to include the following, including systems to manage referrals and to direct people to the most appropriate setting:

• Reducing unnecessary overnight stays, maximising the use of the Overnight Surgical Stay Units and the throughput of elective cases on a day case basis.

• Increasing theatre productivity and efficiency, and developing measures and processes to monitor improvements.

• Optimising core outpatient and inpatient capacity and improving patient flow.

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• Reducing bed days and length of stay using evidence based models such as ADD, Enhanced Recovery after Surgery (ERAS) and a standardised Health Board wide Pre-operative Assessment Screening Service.

• As part of our outpatient redesign, we are investing in information technology systems within outpatients to communicate with our patients.

• One area is the implementation of a text and remind service reminding patients about their new or follow up outpatient appointment the day before.

• The other area of current implementation is in self serve patient check in system. Patients can book themselves into an outpatient clinic without having to go through a receptionist. This has significant savings identified for outpatients.

• Developing our primary and community care strategy to develop opportunities across the pathway to offer suitable alternatives to inpatient, or consultant led hospital delivered care.


• Key service and workforce potential change areas (some of which are under going further work) include:

o Centralisation of breast services – plans are currently under development to identify the implications.

o Ophthalmology (see workforce detail in the Eye Care section at 7.15)

o Orthopaedics – linked with the GIRFT review o Urology Diagnostic and Treatment Unit o South East Vascular redesign including nurse specialist roles o Work underway as part of the South Wales Collaborative and

Surgical Services Clinical Reference Group (see section 7.2.22 for further detail)

• Therapies have introduced demand led working across 7 days with the aim of:

o Reduced LOS o Increased admission avoidance o Improved patient flow

This is requiring redesign and enhancement of the workforce to deliver services across seven days.

• Investment in ICT to support the more effective and efficient running of outpatient services will lead to a need for a review of clinical and non-clinical support services to the outpatient function.

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The key changes planned for 2015/16 are set out in Chapter 9, section 9.7. Performance

There are a range of indicators related to scheduled care in the Integrated Performance Dashboard including: • Referral to treatment time • Theatre efficiency • Average length of stay • Delayed transfers of care • Surgical site infection rates

7.22.3 Critical Care


In June 2013, the Welsh Government published a national Five Year Delivery Plan for the Critically Ill. It was designed to provide a framework for action by Local Health Boards and NHS Trusts to guide them in the organisation and prioritisation of services for people who are critically ill. It set out Welsh Government’s expectation of the NHS in Wales in delivering high quality critical care ensuring the right patient has the right care at the right time.

The plan focuses on maximising efficiency and effectiveness, tackling variation in access and reducing inequalities in service provision. Our local plan was launched at the end of September 2013 and our first progress report was published in June 2014. Our progress report in particular reflects on our achievements and outlines the opportunities and challenges ahead.

Priorities

There is a clear expectation from Welsh Government that the development of local plans will include the national priorities and our plan is therefore a blend of the national and local priorities. In summary, the five national priorities are as follows and these will continue to be our priorities for 2015/16 and beyond:

• Patients and clinicians to discuss and agree appropriateness of critical care and level of escalation of care in time of need.

• Patients to have timely access to (where appropriate for their condition and needs) and discharge from critical care.

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• Patients to be cared for in the correct facility with highly qualified specialists.

• Patients and carers to be as involved in their care as they feel appropriate.

• Patients to receive care that is clinically effective.

We recognise that focusing on these areas will play a pivotal role in helping NHS Wales understand this unmet need and will also support the service reconfiguration aligned to the Welsh Government’s vision for services for the critically ill.

We continue to make good progress on the delivery of our local plan, and in particular our performance against the Welsh Government Assurance Measures shows that there is evidence that our performance is improving in a number of key areas and that we compare favourably to the rest of Wales. The major challenge for the Health Board in the coming year and beyond will be the expectation and ability of critical care to support the acute medicine model for RGH within the South Central Acute Care Alliance.


• The Critical Care Outreach Team (CCOT) are supporting the roll-out of SEPSIS 6 and is working with ward staff to ensure all patients are screened for Sepsis.

• Evidence from early intervention by the CCOT is that admissions to critical care can be prevented.

Performance

Analysis our performance against key Welsh Government measures shows that our performance is improving in a number of key areas and that we compare favourably to the rest of Wales. This is outlined in detailed in our current progress report as well as local and national reporting through the Critical Ill Scorecard and the Intensive Care National Audit and Research Centre (ICNARC).


• Priority Themes 2 and 3 require investment in medical staffing to achieve full compliance, in particular in relation to intensivist cover. Clinical Psychology provision is also identified.

• There may be difficulty recruiting middle grade Anaesthetic doctors in the future, which will need to be closely monitored.

• Opportunities to train Anaesthetic Critical Care Practitioners such as Band 7 Nurses, or ODP staff to take on some of these responsibilities will be given further consideration.

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• Work is currently being undertaken to work through the implications of the South Wales Programme on critical care services and further detail will be available soon.


• To meet the current standards, further investment will be required in

Consultants specialising in Intensive Care Medicine. A Business Case will need to be developed.

• Tier of medical staff in Prince Charles Hospital, along with an increase in the number of Consultants specialising in Intensive Care Medicine. This requires more detailed planning work and again as in the RGH scenario, will need to be linked to implementing the outcomes of the South Wales Programme.

A review of all investment proposals will be undertaken prior to the start of the financial year to agree the key priorities for 2015/16, the levels of investment and phasing decisions. Further information is provided in Chapter 9. Capital/Estates Requirements

• There are no immediate requirements. However there are likely to be

future implications, in particular related to implementing the outcome of the SWP, particularly at PCH which will need to be kept under review as part of the PCH Ground and First Floor Project.

7.22.4 Clinical and Non-Clinical Support Services


We continue to maximise opportunities to utilise clinical and non-clinical support services to support service re-design, develop new ways of working and to maximise capacity within the healthcare system. These services include:

• Pathology • Diagnostics • Medical Records, Clinical Coding & Patient Care Administration • Facilities • Patient care administration • Procurement • Corporate services

Priorities

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i. Pathology

• Introduction of Blood Science department: currently Biochemistry, Haematology, Immunology and Transfusion are separate departments with individual management and staffing skill mix structures; plan is to amalgamate the services into one department.

• Regionalisation of Microbiology & Histopathology Services: potential redesign of Health Board microbiology service into Public Health Wales and the regionalisation of Histopathology and other pathology services. The intention is to regionalise the testing but leave consultants in situ to maintain the clinical link. This could lead to a single microbiology and Histopathology service in South East Wales region and is dependent upon further redesign work and agreement.

• In terms of the Diagnostic Hub, subsequent phases of development work are being developed, which could see the service model potentially extending to pathology and other diagnostic services in the medium to longer term. For example, there are options that exist in Cwm Taf to support developments such as cellular pathology redesign, with real opportunity to align the regional pathology work with the Diagnostic Hub development.

• Strategically, looking at the Royal Glamorgan Hospital site and/or the surrounding area, there are already a good number of co-located services based here already such as the screening services, blood transfusion service and the wound innovation service. There are also service changes outlined above, planned for the Royal Glamorgan Hospital as part of the South Wales Programme, which may well present some accommodation opportunities. This area has well established transport links already in place for screening services, provided from the estate adjacent to the hospital and provides some exciting development options for the future.

• Clinical Haematology service redesign: utilising new technologies • Electronic referrals: building on the introduction of LIMs, development

of electronic test requesting and results reporting. • Repatriation of haematology/chemotherapy from Cardiff. • Point of care expansion - Introduction of POCT INR service. This

service is part way complete. As part of the change to better INR service provision, we will introduce self testing service. This plan is to provide point of care testing in the community with the aim of reducing admissions. Screening patients prior to symptoms has already been proven.

• Autopsy service - The impending change to the Coroner’s Act will herald the introduction of Medical Examiners. All deaths will involve the ME which will likely increase the number of autopsies. Whilst currently this service is provided for the Coroner by HB consultants in below the line job plan activity the increase will impact on the current staffing ability to manage. A plan to provide this service has been produced and is to be discussed with the Medical Director, HM Coroner and Local Authority.

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ii Radiology

Development of phase 1 of the Diagnostic Hub: building on increased direct access, increased capacity required and as a linked part of implementing the outcomes of the South Wales Programme.

Radiology service redesign: further role redesign and skill mix work is being developed in conjunction with the workforce plan. Single site for breast radiology is a preferred option.

• Radiology capacity / geography is dependent on the clinical support required for each Health Board site and will also be dependant in part on the outcome of the South Wales Programme.

• Rolling programme for replacement equipment - facilitate the IT infrastructure and equipment replacement programmes that underpin diagnostic provision.

• Review equipment decontamination arrangements for community services.

• MRI capacity will also need to be increased as figures are based on the present, with increased staffed time. Increased demands with technological advance (e.g. all prostate cancers imaged with MRI and an increased need for stroke management etc). This will require further MRI capacity. CT Colonography is projected to require additional time and is a clinical cancer requirement.

• Additional CT capacity will be required to address increasing capacity requirements and also help address difficulties with acute on call imaging associated with breakdown, equipment service and eliminates patient transfer. Further high end CT Scanner capacity will also permit development of Cardiac CT which is another necessary clinical development.

Medical Records and Patient Care Administration

• Roll out of partial booking within Medical Records: all patients should receive a letter six weeks before their outpatient appointment which confirms the time and date. The patient then rings the call centre to confirm that they are available and happy with the appointment. This is also sometimes called patient focused booking and is recommended as part of guide to good practice. As the roll out of partial booking to the remaining follow up specialties is progressed, the work of the admissions office will reduce due to the introduction of the live bed management to the wards.

• Engage with management, staff and staff side about possible job redesign at an early stage in planning.

• Live bed management rolled out fully to all the wards in RGH. • Move some of the admissions office staff to Ty Elai to increase partial

booking. • Review of Health Records standards, linked in with the Royal College

of Physicians standards.

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• Implementation of the Health Records Storage Project. • Development of the Health Records Digitisation Projects. • Focus on improved Health Record data quality. • Improved clinical engagement in Health Record improvement.

Facilities

• Implementation of income generation opportunities.

o Laundry services. o Central Production Unit (cooked freeze products).

� Ready meals. � Textured modified meals.

• Facilities services re-design including:

o Housekeeping: review of cleaning standards for low risk areas as outlined in the Cleanliness Standard and audited by Credits for Cleaning Audit Tool.

o Catering: review of restaurant services. o Portering/security: service review to in-source current security

contract. o Feasibility into the centralisation of switchboards. o Development of the atrium in the Royal Glamorgan Hospital to

provide a commercial offering.

Procurement

• Procurement savings review to continue linked with cross cutting theme.

Corporate Services

• Complete corporate services review • Identifying opportunities for support services to improve process

efficiency and quality of care. • Identifying opportunities for support services to improve process

efficiency and quality of care.

Links to Workforce

Pathology

• Potentially a significant number of staff will not wish to relocate and will therefore need to be redeployed or released. Work is ongoing in modernising laboratory careers through skill mix redesign.

• Development of alternative roles for POCT e.g. HCAs undertaking some phlebotomy duties.

• Potential introduction of more nurse led clinics to increase the capacity of consultants.

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• Recruitment to a new consultant for the autopsy service. However this is an area where there are recruitment difficulties.

Radiology

• Service redesign and additional MRI and CT capacity requirements all have implications for further investment in radiographers and reporting radiologists or radiographers.

• New service to move to CT colon from barium scans. • Diagnostic Hub – further work is underway to determine the workforce

models to support this development.

Medical Records and Patient Care Administration

• The Health Records Storage and Digitisation Projects include a staff

investment of temporary wtes, supported by an Invest to Save bid,, with an eventual release of administration posts.

• There is also a requirement for staff to relocate over the duration of the project.

• Further detailed work is required to understand the potential benefits of increased use of technology on administration systems.

Facilities • Rebalancing the workforce across the Health Board sites, re-sizing in

line with national benchmarking and investment in new models will result in a small reduction in the workforce over the life of the Plan.

• There is a need for significant relocation and potential role change which anticipates a release of capacity in year one.


The financial plan includes provision for recurring investment in radiology activity uplifts to meet demand and maintain 8 week targets, including partial to CT and colonoscopy.

Capital/Estate Requirements

• Pathology reorganisation: there will need to be some capital money

available to redesign departments, yet to be estimated. • Radiology rolling programme for replacement equipment - facilitate the

IT infrastructure and equipment replacement programmes that underpin diagnostic provision.

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• Income generation opportunities within facilities may require capital expenditure as an enabler.

• The developing plan for the digitisation of patient health records will require significant capital investment but will avoid premises costs, and support the move over time to a digital health record, significantly reducing medical records staff costs.

• The creation of a diagnostic hub at RGH will improve patient flow (and hence reduce bed requirements) at Cwm Taf by reducing A&E and inpatient waits for diagnostics, while providing additional capacity for scans across South Wales to provide cheaper alternatives to the current use of premium rate capacity.

7.23 Commissioning

Commissioning is the means by which the Health Board aims to secure the best value for local citizens and taxpayers i.e. the best possible health and wellbeing outcomes, within the resources available. It is an on-going process within the Health Board that applies to all services, whether they are provided internally, by other Health Boards, NHS Trusts, Local Authorities, other public agencies, or by the independent sector. The Health Board commissioning function recognises the key functions of an effective commissioning process and these are described in the model below.

In addition, there are also key enablers for effective commissioning as follows:

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• Clinical Engagement and Leadership • Information • Whole System Approach and Involvement from primary care

through to Specialist Care – planning on a pathways basis

The Health Board has developed a commissioning strategy and our local commissioning intentions are underpinned by ten key principles that are outlined in our Commissioning Framework. These are: -

• Applying the NHS Core Values. • Patient Centred. • Inclusive Stakeholder Engagement. • Needs based. • Whole System. • Services should be provided as locally as possible. • Services will be evidence based using best practice and fostering

innovation wherever possible. • Achieving Value for Money. • Performance Managed to ensure services deliver high quality care

efficiently, effectively and in a timely manner • Commissioning decisions are based on ‘good decision making’

guidance.

Over the last year the Health Board has continued to develop its commissioning agenda and develop its underpinning commissioning processes. This is operating on two levels: a) Understanding what we should and should not be commissioning

(this is based on the whole system model). This will be underpinned by the principles of Prudent Healthcare.

b) Ensuring services we do commission are delivering is what they should be so that they are commissioned in such a way that is more clinically and cost effective, with a key focus on quality and excellent clinical outcomes.

Commissioning Prudent Health Care

As we move forward over the next three years, it will be important to clearly understand the services we currently provide that may not have a strong evidence base and the extent to which they can demonstrate their value as clinically and cost effective treatments. Whilst we have fully supported the work that Public Health Wales has done in developing the schedule of services of Interventions not Normally Undertaken (INNU), we recognise that there is more work that is required in this area. Cwm Taf Health Board have been involved in the work being led by WHSSC on evaluation of the clinical and cost effectiveness of a range of specialist service interventions, modality of treatments and clinical access

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criteria over the last two years and believe that this type of work needs to be emulated across the whole of the service pathway, including what happens in both primary care and secondary care service to ensure we focus the health boards resources to achieve the maximum outcomes for patients in Cwm Taf. From the work we have been involved in, we recognise that evaluating our services in such a way is both time consuming and does require a very high level of skill, both of which are not readily available currently within Cwm Taf. Going forward Cwm Taf Health Board believe given the skill base and resource to undertake such work is very limited across the NHS in Wales, consideration should be made to undertaking this on a single basis for the Whole of NHS Wales either collaboratively or by a single entity.

This will ensure:

• We gain economies of scale in developing this work and

• We avoid postcode lottery, so the outputs apply to NHS Wales and not to just a single Health Board.

If done once for NHS Wales, we should end up with a clear service specification for NHS Wales that is clear and transparent to the service and patients alike.

Effective Commissioning of Services External to Cwm Taf Health

Board

The Commissioning and Contracting delegated budget manages both the outflow of monies to other providers to deliver a range of services for Cwm Taf residents and the inflow of monies from other LHBs for Cwm Taf to provide services for other LHBs residents. These flows of monies are supported by Contracts/Long Term Agreements(LTAs).

In summary for 2014/2014, the forecast outturn of these ‘flows’ is as follows:

Inflow Outflow

£m £m

Aneurin Bevan 19.369 0.819 ABMU 4,230 4.522 Cardiff and Vale 5.908 20.167 WHSSC 4.706 55,304 Velindre - 6,630 Powys 1,034 - Hywel Dda 0.180 0.290

Total 35.427 87,732

Source: Cwm Taf University Heath Board Commissioning Plan 2015 -2018

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Moving forward over the next three years Cwm Taf will be concentrating ensuring what it currently commissions externally is commissioned in the most clinically and cost effective way within the principles of Prudent Healthcare.

A key focus for commissioning has been on understanding the patient flows between LHBs and the impact on the historical contracts that underpinned these flows. Our ambition for this work has been to ensure that patients who need care outside Cwm Taf receive appropriate and timely services which represent good quality and value for money. This has enabled Cwm Taf to improve its contracting arrangements. Through clinical engagement in the commissioning process, it has also led to a range of improvements, which include developing appropriate services that are closer to home for patients.

We aim to build on this work and in this context we will:-

• Ensure the services provided to our residents are evidence based for clinical and cost effectiveness, ensuring best practice and innovation are fostered.

• Provide services, whenever clinically appropriate and cost effective, locally within Cwm Taf. Where services are provided within Cwm Taf, they will be provided, as far as clinically appropriate, within a community/ out of hospital setting and as close as possible to peoples homes.

• Commission services we cannot provide within Cwm Taf from neighbouring LHBs to reduce travelling times for patients, recognising that a small number of patients requiring more specialised treatment may be required to travel to a UK specialist centre in England.

• Maximise value/mitigate risks in our external contracts; including to avoid/reduce additional Referral to Treatment spend.

In addition we will be looking to ensure that the services we provide for our neighbouring LHBs patients are provided to the high standards we aim to deliver, offering quality of access according to clinical need. Going forward we will be working collaboratively with neighbouring LHBs to explore opportunities to provide a wider range of services for their residents.

The commissioning and contracting team have identified a range of opportunities to make changes in the way we commission our services from neighbouring LHBs as well as change the way we may want to provide services for our neighbouring LHB residents in the next three years. This will result in a service change across a range of services with the aim of developing services colder to peoples’ homes and at the same time delivering high quality patient care in a more cost effective way.

The key themes underpinning our planned commissioning changes in 2015/16 are to:

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• Maximise opportunities for repatriation of Cwm Taf patients from hospitals outside Cwm Taf where appropriate.

• Ensure effective demand management and prioritisation of specialised services.

Priorities include:

• Developing commissioning and contracting capacity. In line with the health Boards commitment to improving the quality of its commissioning the health board has acknowledged its importance and the need to develop its capacity to undertake a greater range of work

• Developing local services with the aim to repatriate services from neighbouring LHB services, to allow patients to receive their care closer to home and at the same time develop more sustainable services locally. Areas identified include: o Haematology, allowing more patients to have their haematology

and chemotherapy in local hospitals and avoid unnecessary travelling at times when they are at their sickest.

o Rheumatology, expanding local services will allow more patients to avoid numerous travel journeys

o Trauma and orthopaedics, a number of areas within Trauma and Orthopaedics have been identified where services could be expanded locally to avoid unnecessary travelling, the opportunities include:

- Repatriation of hand surgery - Remodelling of the spinal pathway, especially looking for

spinal outpatients to outreach into Cwm Taf - Remodelling spinal outpatients to include utilising Cwm

Taf Pain Management services. - Repatriation of low/medium complexity work across a

number of sub specialties • Cardiology. Developing local services and remodelling pathways to

support a hub and spoke model, where as much of patients pathway would be provided locally. Key to this area will be to repatriate a larger proportion of the interventional cardiology work from the tertiary centre, allowing local skills and facilities to be maximised and to support the cardiology Delivery plans that Cwm Taf has developed.

• Improving access to Neurology Services: whilst not a provider or a commissioner of neurology Services, Cwm Taf will be looking for the commissioning responsibility of neurology services to be transferred to it and then to work with the provider to look to remodelling the services to achieve greater access in support of the Cwm, Taf Neurological Delivery Plan.

• Improving the Quality and Performance in Commissioning: During 2014/15 Cwm Taf Health Board has started working on developing a quality Dashboard for commissioning, to provide assurance that the services we commission externally are of the quality and standards we

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expect of internally provided services. Moving forward further development of a commissioning performance and quality dashboard is a high priority for the organisation.

• Improving the Quality of Contracts: whilst much work has been undertaken over recent years in understanding contracts in terms of activity and value for money, moving forward more work is now required to rebase contracts so they reflect the range of services we will want to commission going forward.

• Specialist commissioning: we will continue to work with and support the WHSSC commissioners in the commissioning of highly specialised services.

• Whole system Commissioning: during the next three years the Health Board will be looking to improve the integration of planning services across LHB boundaries by firstly involving the Cwm Taf Directorates in the commissioning of services externally to Cwm Taf. The aim would be that these services would then be planned, managed and commissioned under a single budget, to strengthen the patient pathway between LHBs and maximise any benefits that this may bring.

• Developing services to support neighbouring commissioning decisions: work has already commenced with Powys Health Board to explore opportunities for Cwm Taf to provide in reach services into Powys where appropriate to provide services to Powys residents more locally and shorten their travelling times, especially in the way services will be changing across the South Wales as part of major service redesign and in particular the South Wales programme. Whilst we already provide a range of services including general surgery, rheumatology and soon to be gynaecology and acute stroke services, there is also an opportunity to further expand the range of services and opportunities.

• Commissioning and Contracting for South Wales Programme: over the next three years, as work progresses and service models change as outcomes of the South Wales Programme and Alliance work emerge, there will be impacts on the way services are commissioned and contracted with our neighbouring LHBs. Impacts on existing contracts and pricing mechanisms will need to be identified and reflected in ongoing contract arrangements. The full extent of the impact of this work is yet to be fully understood

7.23.1 Specialist Services

Specialised and tertiary services are those provided by a relatively small number of specialist centres, to populations greater than 1 million people. These services are typically high cost and low volume. The Welsh Health Specialised Services Committee (WHSSC) is a Joint Committee of the seven health boards in Wales, and is responsible for the planning of specialised and tertiary services on their behalf.

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The Commissioning Plan for Specialised Services for Wales 2015/2018 sets out an integrated commissioning plan for specialised and tertiary services for the population of Wales for this financial year. On behalf of LHBs including Cwm Taf, the aim of WHSSC is to ensure that these services are planned and secured from providers that have the appropriate experience and expertise; are able to provide a robust and sustainable service; are safe for patients and are cost effective for NHS Wales. The seven Health Boards in Wales have agreed a three year commissioning strategy in order to:

The strategy also aims to raise awareness and understanding of specialised services and to ensure that specialised services help meet the Institute for Healthcare Improvement ‘Triple Aim’ to: • Improve the health of the population; • Enhance the patient experience of care (including quality, access, and

reliability); and • Reduce, or at least control, the per capita cost of care. The key priorities for the six programme areas are set out in the following work programmes: • Mental Health • Cancer and Blood • Cardiothoracic • Neurosciences and Complex Conditions • Renal • Women and Children During 2015/16, Cwm Taf University Health Board will continue to work with WHSSC to look at further opportunities to improve the management of pathways between secondary care and tertiary services. In particular, one of the key issues for Cwm Taf in 2015/16 will be the repatriation of ICD work from Cardiff & Vale University Health Board to Cwm Taf University Health Board. This will expand the range of interventional cardiology services within Cwm Taf and improve access for patients.

7.23.2 Clinical Transport Service

“Ensure equitable access to safe, effective, and sustainable specialised services for the people of Wales.”

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Ambulance response targets remain challenging across the Cwm Taf locality. There are a number of contributory factors for this including:

• Geography/topography. • Increased activity. • The increased acuity of calls. • Flow of ambulances out of the area. • Resource levels to meet demand.

Performance against the 8 minute standard (Red/Category A) within Cwm Taf locality for the year 2013/14 (April/December) was at 54.7% against the 65% standard. Performance against the 8 minute standard for Merthyr Tydfil UA was at 58.4% Year to December. Performance against the 8 minute standard for Rhondda Cynon Taf UA was 53.8% Year to December. The following factors are key influences to current performance achieved:

Activity Life threatening calls rose by 17% (an

additional 2,408 incidents in January-December 2013 compared to January-December 2011).

Activity Green call volume increased by 8% (an additional 1,626 incidents January-December 2013 compared to January-December 2011).

Acuity 999 calls showed a 2% increase in life threatening calls (January-December 2013 compared to January to December 2011).

Flow There is a significant net flow of ambulance resources out of Cwm Taf, particularly into the Aneurin Bevan and Cardiff and Vale areas.

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During 2012/13 the top 5 chief complaints alone accounted for 40% of all emergency (AS1) activity. Health Care Professional (Card 35) accounted for 19% of all AS1 activity. Both Chest Pains and Breathing Problems accounted for 10% each of all emergency (AS1) activity.the Rhondda Cynon Taff locality of Cwm Taf has the third highest level of demand within Wales, behind Cardiff and Swansea:

(Jan 2013 to April 2013)

Acuity, or the total of immediately life threatening calls as a percentage of all 999 calls received showed a 2% increase in life threatening calls (January-December 2011 compared to January to December 2013). In 2011, 40.1% of 999 calls received were catethreatening. In 2103, this increased to 42.1% of 999 calls.

The graph below demonstrates that Cwm Taf had the second highest level of life threatening calls in Wales (January to April 2013). This is reflective of the demography of the population of Cwm Taf.

The conveyance rate in Cwm Taf is often the highest across Wales. The current work programme on alternative pathways of care should reduce

Health

Board

Locality

Cardiff & Vale

Cardiff

ABM Swansea

Cwm

Taf

RCT

Hywel Dda

Carmarthenshire

Aneurin Bevan

331

the top 5 chief complaints alone accounted for 40% of all emergency (AS1) activity. Health Care Professional (Card 35) accounted for 19% of all AS1 activity. Both Chest Pains and Breathing Problems accounted for 10% each of all emergency (AS1) activity. the Rhondda Cynon Taff locality of Cwm Taf has the third highest level of demand within Wales, behind Cardiff and Swansea:

Acuity, or the total of immediately life threatening calls as a percentage of all 999 calls received showed a 2% increase in life threatening calls

December 2011 compared to January to December 2013). In 2011, 40.1% of 999 calls received were categorised as immediately life threatening. In 2103, this increased to 42.1% of 999 calls.

The graph below demonstrates that Cwm Taf had the second highest level of life threatening calls in Wales (January to April 2013). This is reflective

of the population of Cwm Taf.


Locality Category

A

Red 1

Category

A

Red 2

Green

1

Green

3

746 5,834 5,256 3,806

Swansea 515 4,124 3,678 2,646

474 4,151 3,557 2,594

Carmarthenshire 333 3,093 2,509 2,080

3,124 2,479 2,086 8,020

the top 5 chief complaints alone accounted for 40% of all emergency (AS1) activity. Health Care Professional (Card 35) accounted for 19% of all AS1 activity. Both Chest Pains and Breathing Problems

Activity within the Rhondda Cynon Taff locality of Cwm Taf has the third highest level of

Acuity, or the total of immediately life threatening calls as a percentage of all 999 calls received showed a 2% increase in life threatening calls

December 2011 compared to January to December 2013). In gorised as immediately life

threatening. In 2103, this increased to 42.1% of 999 calls.

The graph below demonstrates that Cwm Taf had the second highest level of life threatening calls in Wales (January to April 2013). This is reflective


Green

3

Total

3,806 15,642

2,646 10,963

2,594 10,776

2,080 8,015

8,020

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the conveyance rate further and ensure that patient care is delivered in the right place at the right time by the right person. However the ratio of Category A / Red calls to the overall workload within Cwm Taf is reflective of the demographic profile and subsequent health needs of the population of the area.

Good operational working relationships between the Health Board and WAST are in place and together with the Emergency Ambulance Services Commissioner work programme on behalf of LHBs, will be the foundation to support an improving unscheduled care system moving forward.

One of the key priorities for the Health Board is to ensure the implementation of successful and effective commissioning arrangements under the EASC arrangements. The Health Board is currently developing an agreement on key areas of service and performance between NHS Wales Health Boards and WAST through this transitional year (2014/15) before full implementation of a new Commissioning & Clinical Quality Delivery Framework in 2015/2016. Within the Health Board there have been a number of actions taken to achieve this improvement in patient handover performance; these actions have included:

• System wide "focus on flow" project, which has concentrated on reducing delays in discharge across all inpatient bed settings.

• Review and implementation of an organisational escalation policy that is responsive to pressures in any aspect of the service.

• Acute hospital wide ownership of pressures at the front door. • Zero tolerance approach to delay in ambulance handover. • Close working relationship with WAST colleagues to develop and

implement pathways to avoid hospital transfers. • Senior clinical decision maker at the front door to avoid delays and

facilitate early discharge.

The Health Board continues to develop further initiatives in conjunction with WAST to build on this success; two of these key initiatives are described below:

• Ring fencing of Cwm Taf WAST resource, preventing travel across boundaries other than in emergency situations - it is hoped that this pilot will improve the category A response times in the Cwm Taf area. This pilot is being tested during March and will be in place for a 6 week period from 30th March 2015.

• Use of alternative vehicles to transfer General Practitioner admissions - it is envisaged that this will improve the timeliness of these admissions and will facilitate further improvement in the category A response times. This pilot commenced on 16th March 2015.

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The continued work to improve patient flow within the organisation, complimented by the above joint working initiatives, is anticipated to maintain and further improve our ambulance handover rates within the next three months so that we can achieve the 95% target. We are very committed to working in close partnership with Welsh Health Specialised Services Commission, the Emergency Ambulance Services Commissioner and Wales Ambulance Services Trust to continually improve specialist services, reduce any delays experienced within the hospital setting and also to improve the overall ambulance response times. This is an area which the Health Board is keeping under very close review and is a priority for improvement. We are looking to invest further in capacity to support improvements developing our commissioning and contracting agenda. Links to Financial Plan

WHSSC growth trends in the cost of specialist services have run at between 1% and 2% in recent years, and this has previously been reflected in WHSSC advice as regards future plans. This equates to an estimated cost pressure for Cwm Taf University Health Board of £1.2m in each year for inflation and growth, and this is the provision made in each year of the 3 Year Plan, before the impact of commissioning prioritisation and savings. The savings plan includes planned savings of £0.6m in 2015/16 and in each subsequent year to mitigate this £1.2m gross cost pressure to a net provision of £0.6m per annum. An additional provision of £0.4m is also included in 2015/16 for EASC. It is a major concern that emerging plans for WHSSC and EASC at present appear to be assuming additional investment by Cwm Taf of around £1.2 to £2m in 2015/16. This level of investment would be unaffordable to Cwm Taf, and is a significant risk to the plan. Further detail on this can be seen in Chapter 9.

_____________________________

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8. WORKFORCE AND ORGANISATIONAL DEVELOPMENT

8.1 Workforce Profile The Health Board’s workforce is clearly its most significant asset and it is through the commitment, professionalism and dedication of our staff that we are able to deliver high quality services to our population. The way in which the Health Board plans, recruits, supports and develops, deploys and utilises its staff, is vital to its ability to meet the increasing service and financial challenges it faces. Our average WTE is 6,900 which represent’s a reduction of approximately 100 WTE over the previous 12 months and the average number of contracted staff in post is 8,100. The total pay-bill is circa £297m per annum which represents approximately 66% of ‘controllable’ budget. The pie chart below shows our current workforce profile by profession.

We are the second largest employer within the area and a large proportion of our workforce will be our patients and be in receipt of our services. The level of deprivation within our community is likely to be a contributing factor to the high average sickness percentages of our workforce. Sickness rates remain a challenge for the Health Board and the rolling average sickness percentage is 5.75% (as at September 2014), which is 0.25% higher than for the previous year. The graph below shows the month on month position.

4%17%

18%

6%11%2%

9%

33%

0%

Breakdown of FTE by Staff Groups as

at September 2014

Add Prof Scientific and Technic Additional Clinical Services

Administrative and Clerical Allied Health Professionals

Estates and Ancillary Healthcare Scientists

Medical and Dental Nursing and Midwifery Registered

Students

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The Health Board has a challenging age profile with a high proportion of groups of staff aged 51 and over within our total workforce. The top three staff groups with a high proportion of staff aged 51 and over are Nursing & Midwifery, Estates and Ancillary and Administration and Clerical. The pie chart below shows the age profiles within the Health Board by profession.

1% 9% 10%

2%

9%1%

3%15%

50%

Cwm Taf Staff Group of Employees aged

51 years and Over by FTE

Add Prof Scientific and Technic Additional Clinical Services

Administrative and Clerical Allied Health Professionals

Estates and Ancillary Healthcare Scientists

Medical and Dental Nursing and Midwifery Registered

Grand Total

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The Health Board currently employs 653 doctors and dentists, on average this is represented by 588 full-time and 65 part-time posts. 59% of this workforce is currently male and 41% are female. There are particular challenges with this staff group which relate to recruitment and retention, some of which are national challenges and some of which reflect local changes in the allocation of Deanery training posts. This means that we are heavily reliant on locum cover to manage some of our services.

The charts below show the breakdown of staff by Agenda for Change pay band and medical grade:

18.00137.59

1359.21765.86

493.301397.91

1022.24695.94

190.8859.7145.47

17.405.803740.5

125.5565190

244.6

Ad-Hoc

Band 2

Band 4

Band 6

Band 8 - Range A

Band 8 - Range C

Band 9

FP 2

SAS

Cwm Taf Skill Mix Profile for Staff in Post as at 30th

September 2014 by WTE

0.26%2.01%

19.85%11.19%

7.20%20.42%

14.93%10.16%

2.79%0.87%0.66%

0.25%0.08%0.54%0.59%

1.83%2.77%

3.57%

Ad-Hoc

Band 2

Band 4

Band 6

Band 8 - Range A

Band 8 - Range C

Band 9

FP 2

SAS

Cwm Taf Skill Mix Profile for Staff in Post as at 30th

September 2014 by percentage

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The workforce profile has remained largely unchanged over the past 12 months with small contracted WTE reductions in all staff groups except Allied Health Professionals. The current turnover rate is 3.8%, excluding retirements and Voluntary Early Release turnover, 6.8% in total. Against a target of 85% for all Agenda for Change staff, 60% have currently had a Personal Development Review within the past 12 months, with the monthly trend provided in the table below.

Changes to the review cycle for consultant and SAS doctors job planning from 18 to 12 months has seen a significant reduction in compliance which is discussed further in section 8.5.2. Primary Care Workforce

Within core primary care provision there are four practitioner services, medical (GPs), dental, pharmaceutical and optical. These practitioners are independent contractors and are not employed by the Health Board. There is currently no requirement for there practitioners to provide workforce data however the current profile for the Health Board is as follows.

• There are 46 GP practices, supported by a total of approximately

170 general practitioners. The primary care healthcare team

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consists of GPs, practice nurses and healthcare assistants, phlebotomist, practice managers and reception staff.

• There are currently 35 dental practices supported by 107 dentists. In addition to dental services being provided by independent dental practitioners, there are two community dental services practices, a dental teaching unit and 10 community dental clinics.

• There are 28 optician premises in the Health Board supported by 69 optometrists.

• There are 77 NHS community pharmacies. There are significant differences and therefore challenges specifically within our General Practice workforce and the issues that this creates both for in-hours and out of hours services. Some specific details associated with our GP workforce is outlined below: • We have the highest percentage of single handed partnerships,

18.75% compared to a Welsh Average of 10.21%. • We have the lowest percentage of GPs per 10,000 population, 6.01

compared to Welsh Average of 6.59. • We have the lowest number of WTE GPs per 10,000 population, 4.21

WTE compared to the Welsh Average of 6.19. • Female practitioners as a percentage of GP workforce is 44.07%

compared to Welsh average of 46.59%. • Percentage of the Cwm Taf GP workforce aged 55 and over is the

highest at 31.07% compared to a Welsh average of 23.15. It must be noted that since 2004 there is no mandatory retirement age for GPs and therefore many decided to work beyond 55.

• Reported GP vacancies are high across the 4 Localities totalling 14 in all and include 5 in the Cynon Valley, 7 in Rhondda, 2 in Taff Ely and none in Merthyr Tydfil.

The recruitment and retention problems facing the GP workforce both in hours and Out of Hours is a result of a number of factors. There are a growing number of experienced GPs leaving General Practice, mainly due to retirements but also for other reasons. Approximately a third of our GPs over the age of 55 are likely to retire over the next two years. There is also a shifting pattern in more and more GPs on completion of their training are choosing not to join practices as Partners but instead become either salaried or ‘locums’. As locums the GPs can command a much higher remuneration than they would if they were salaried or Partners. They also have the freedom and flexibility to work how much and as little as they wish. We are fortunate in that we already have a Salaried GP Service and we have been expanding this team. We will continue to work with practices to plan retirements and to support succession planning so as to ensure there is additional support and to give more GPs the experience of

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working in what is often challenging but very rewarding environments which is the Cwm Taf Valleys.

8.2 Key Workforce Assumptions The key workforce assumptions for the Health Board for the next three years are as follows. Pay cost pressures have been assessed to include:

• An assumed overall wage award of circa £2.5m per annum for each of the three years. This is based on the confirmed funding for 2015/16, which covers the confirmed A4C staff award and the quantum assessment, based on 2% non consolidated Top of Scale, for medical and dental staff.

• Agenda for Change incremental drift which has been evidenced to still be impacting upon and increasing the cost of the workforce. The increases in recent years have been slowing down - £0.7m has been assumed for 2015/16 and £0.5m and £0.3m for subsequent years.

• Incremental drift for medical staff is projected at £0.2m in each year. • Commitment awards for consultants are projected at £0.2m in each

year. • Provision for the additional costs resulting from increased employer

pension contributions from 2015/16 and from the end of “contracting out” from 2016/17 have been made at £0.7m in 2015/16 and £5.6m in 2016/17.

• The anticipated turnover rate for staff during 2013- 14 was 4.75%. The actual turnover rate as of September 2014 was 6.8% including retirement and VERs.

• The predicted turnover rate for 2015/2016 is 6.8% including retirements and VERs).

8.3 Key Workforce Challenges

As described in more detail in Chapter 7, the approach to planning incorporates Directorate and Locality plans together with cross cutting themes. The workforce implications have been developed as an integrated part of these local plans and the key implications have been identified throughout the plan.

At this stage, the workforce plan does not specifically take account of the South Wales Plan. With the programme of work now moving to implementation stage, the participating Health Boards and Welsh Ambulance Trust have established a workforce project group which is overseeing the development of integrated workforce plans associated with the development of new service models within the South Central Acute Care Alliance. This project group reports in to the wider programme structure and is currently finalising a set of principles which will support the programme of work and the retention, redeployment, rotation and

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recruitment of staff within and across the alliance. It is also co-ordinating the development of collaborative workforce solutions to ensure contingency plans are in place in the event of any rota failure and managing the development of local and alliance workforce plans for each service.

In the meantime, there are significant pressures in maintaining a viable medical workforce to support some of these ‘fragile’ services and local contingency measures continue to be developed and implemented in liaison with the Wales Deanery. Services across the alliance within Paediatric, Neonatal and Obstetric services are currently the most fragile with significant risks within three health boards and heavy reliance of local staff in all three. Within Cwm Taf, a detailed contingency plan has been developed and one to one discussions with staff are underway to address the potential need for urgent relocation of services within the Health Board until the building works in PCH and UHW are completed (see section 7.22.1). Local workforce plans for these services are anticipated to be completed by the end of March with an alliance plan to follow in April. The scope of the work currently also includes emergency and acute medicine, surgery and the diagnostic hub and the workforce plans for these services are under development and will be the next priority.

The other key challenges facing the Health Board in the lifetime of the plan are as follows:

• The sustainability in junior doctor rotas which has been and will continue to be exacerbated by the reduction of training places provided by the Deanery. In addition to specific challenges faced in the specialties considered as part of the South Wales programme, the Health Board has found recruitment to the Trauma and Orthopaedics and Surgery rotas challenging and has had to rely on locum doctors to cover these slots.

• In the context of a UK shortage of general practitioners, the Health Board with an aging GP population faces significant challenges in sustaining primary care services.

• The Health Boards Primary Care and Community Services Strategy (see Chapter 7) identifies our plans to address these challenges through the development of a different workforce model across in primary and community care which will provide greater opportunities for the entire workforce to develop extended skills and specialist practice working in a more integrated service delivery model across the Health Board. (See section 8.5.1 below)

• The shortage of GPs and consequent fragility of the GP ‘Out of Hours’ Service has been an ongoing challenge for Cwm Taf for several years; this is no different to the position across Wales and the rest of the UK.

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As a consequence we are now regularly in the situation of not having enough doctors to staff all four existing OOH service centres. The current contingency when rotas cannot be delivered is to consolidate the service into our two OOH centres at PCH and RGH. Plans are currently being developed to re-model the out of hours GP service on a more sustainable basis, in the first phase consolidating services into two centres at PCH and RGH supplementing this with a transport solution. The workforce associated implications include the redeployment of staff to two sites, consolidation of rotas for staff, expansion of Advanced Nursing Practitioners and Advanced Paramedic Practitioners and increased multi professional working. The use of a wider multi disciplinary team is a key feature of the model.

• Further service change and new models of working, e.g. 24/7 working, more care provision in the community and in patients’ homes, consolidation of services to fewer sites and the proposed closure of inpatient beds associated with new service models. The implications of these developments for our workforce are that staff will need to adapt to different working patterns, in different locations and in different roles. Given that over 80% of our current workforce is also our future workforce, this will require significant development and change management programmes and effective staff engagement and partnership working.

• Continuing to realign the nursing workforce to meet the agreed establishments to meet the safer nursing recommendations. This involves the rebalancing of the nursing workforce across our wards and hospitals and an associated reduction in bank and agency usage. This is to be achieved in a time of increasing difficulty in recruiting qualified nurses across the UK. The UHB has not encountered significant difficulties in nurse recruitment in previous years given the preference for working locally of many of the newly qualified nurses from the local university. However, recent recruitment drives have seen a change in this position with the UHB only recruiting to approximately one third of the advertised vacancies. New approaches to recruitment will need to be developed.

• Balancing the need to ensure safe staffing levels are sustained to enable the provision of high quality care, with the need for a reduction in the pay bill.

• The low turnover of staff currently running at 6.80% • The high sickness rates (as above, linked to the poor health of the

local community). • As shown, the age profile of the workforce within the UHB highlights

that there are several areas where an aging workforce could present a problem to the sustainability of the service provision. There has been no significant change to the workforce profile in respect to the age profile of our workforce since last year. The concerns expressed in last year’s plan remain. A new change however is the request by senior staff within both medical and other clinical professions, to retire

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and return, often to lower banded, part time posts. This poses opportunities and challenges in respect of skill mix redesign and our ability to retain experience at the same time as recruiting novices.

• Balancing the need to drive workforce modernisation and efficiency at the same time as widening access to employment and protecting jobs for the community and promoting our corporate social responsibility.

8.4 Workforce Savings As noted above, given our turnover is running at 6.80% per annum the maximum reduction that could be made in any one year is estimated at around 1-1.5%. This is because some posts will need to be replaced. Therefore, reductions through turnover and vacancy control will need to be supplemented by initiatives such as the use of interim or temporary staff, the release of staff through other mechanisms such as redeployment out of the organisation and/ or exit strategies such as VER programmes. As a last resort redundancy would need to be considered as an option. Between April and January 2015, a total of 37 staff have taken VERs. Further applications are currently under consideration. During 2014, a review of the cross cutting themes resulted in the previous three separate workforce themes (medical, corporate back office and nursing) being combined into one overarching theme, Workforce Productivity Improvement. Developments to date include the realisation of £1.0m worth of savings primarily through the corporate back office workforce savings workstream.

8.4.1 Projected changes over the three years 2015 – 2018

Based on our corporate and directorate plans, a total paybill reduction is projected at circa 347 paid WTE over 3 years. Provision for investment in new service and delivery models has been made within the finance plan and this reduction will be offset by a projected increase of 376 paid WTE, following the introduction of new service delivery models and other quality and safety investments. The net increase of 29 paid WTE of current workforce is shown in table below:-

Workforce Plan 2015-

16 to 2017-18

Savings

Plans*

Cost

Pressures &

Investments

Investments

dependant on £12.4m

Primary & Community

Care funding**

Net

Movement

2015/16 -117 75 201 159

2016/17 -118 50 0 -68

2017/18 -112 50 0 -62

Total -347 175 201 29

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* Further details in Chapter 9 ** Highly dependant on delivery of the Financial Plan

Further details of the year 1 impact by staff group and the expected model of workforce reduction is shown in the following table. The table below reflects this position for both financial and workforce plan movements:-

Workforce

Plan 2015-16

Staff Group

Savings

plans

Investments

and Cost

Pressures

£12.4m

Investments

Total

Add Prof Scientific and Tech

-6 4 12 10

Add clinical services

-26 22 30 26

A&C -8 1 34 27

Allied Health Profess

-5 3 11 9

Estates and ancillary

-13 0 0 -13

Healthcare scientists

-4 3 3 2

Medical and dental

1 4 23 28

Nursing and midwifery

-56 38 88 70

Students 0 0 0 0

Total -117 75 201 159

These workforce changes have been identified within the context of the planned investments and savings set out in Chapter 9.

8.5 Rebalancing the Workforce; the Health Board’s approach to workforce change

Our approach to rebalancing the workforce continues to be as described in our previous plan. As above, we recognise that the current configuration of the workforce is not sustainable in terms of ensuring that we have the right people and skills in place to deliver the service changes we are planning. Additionally the difficult financial context means that at the same time as we need to invest in new roles and new service models, there is a need to maximise the efficiency of our current workforce and deliver significant savings through control of the pay bill. Given the context of our local labour market, the wider public sector financial

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challenges and potential workforce changes, and our social responsibility, a key driver is where possible to protect the low paid and to save jobs and we will continue to seek to re skill and redeploy staff wherever possible in order to avoid redundancies.

The proposed changes to the workforce in 2015/16 both investments in new posts and reductions in workforce numbers, have been identified by service scheme/change programme and plotted in terms of when the scheme is likely to deliver the changes. This is explained in more detail in Chapter 9, Finance.

Significant progress has been made in year with close working between finance, planning and workforce teams supporting the Directorates to analyse the current workforce and agree establishment and pay budgets. From this basis, the local plans are fully integrated and incorporate the change management processes to be utilised including use of turnover and retirement, redeployment, investment and growth and finally use of voluntary exit mechanisms. Compulsory redundancy has not been utilised in the past year and will continue to be considered only as a last resort should these fail to deliver the changes planned.

The Health Board’s approach to rebalancing the workforce is based on three complementary strategies all of which will need to be utilised simultaneously. These are:

The following section provides further detail on the planned workforce initiatives and change programmes associated with each of these work streams. More detail on the change programmes themselves are detailed in Chapter 7 on Service Change. 8.5.1 Workforce Redesign to support Service Change

The service change plans in Chapter 7 identify a range of schemes which have implications for the workforce design. A summary of the significant workforce changes is provided below.

i. Service Design and Site Rationalisation

Proposed service redesign and where appropriate site rationalisation will necessitate the physical movement of staff across the organisation, role change and WTE reduction. We are assuming the ongoing phased reduction of beds/wards as a result of improvements in patient flow will

1. Workforce redesign; skill mix change and new roles.

2. Maximising workforce efficiency.

3. Reducing the size of the workforce.

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release capacity of approximately 36 WTE, primarily these will be nursing and healthcare support workers and facilities posts.

The ongoing realignment of nursing workforce across sites and the reduction of the workforce resulting from the improvements in patient flow will remain within the parameters of the CNO standards (see below). Pontypridd Cottage Hospital & Y Bwthyn Palliative Care Unit

Palliative care services currently provided from Y Bwthyn will be transferred to Royal Glamorgan Hospital in 2015, with an increase in beds from 6 to 8. It is anticipated that other services based within the hospital will relocate to Dewi Sant Hospital or the Maritime Resource Centre, for example Tonteg Day Unit, Therapy staff, etc. There is no anticipated WTE or skill mix change.

Tonteg Hospital

The proposal to relocate CAMHS from Tonteg Hospital to Royal Glamorgan Hospital will result in no net change in the workforce as the services is relocating in its entirety. Stroke Redesign

The objective of the proposed service redesign is to improve the quality of stroke services across the Health Board in line with national clinical standards, through the redesign of our stroke care delivery model. This will involve the rationalisation of stroke services onto fewer sites and the development of community based rehabilitation services. Workforce implications include consolidation of specialist staff through relocation on different sites, a move to 7 day working which is currently being trialled for therapy staff. There will be no significant change to WTE. Staffing levels are now closer to the clinical guidelines, although shortfalls remain in medical and nursing staffing. Investment in the early supported discharge as part of our integrated care priorities includes 8 WTE therapists. Mental Health Service Redesign

In October 2014 Older Person’s Mental Health Services was redesigned, which included investment into community services and transport, the centralisation of assessment services at Royal Glamorgan Hospital and the closure of Ward 1 at Dewi Sant Hospital. This major change commenced in February 2014 and affected approximately 25 staff. The planning and implementation phases have been effective and the service will be evaluated. An assessment of the change management toolkit utilised to support the change is currently being reviewed via a pulse survey.

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Part of this redesign saw the change in function of Ward 35 at Prince Charles Hospital from an assessment ward to a continuing health care ward. This is turn requires a different skill mix and a reduction in and redeployment of 4 WTE Healthcare Assistants

As part of these changes, investment was secured to recruit 8 WTEs into the DGH Liaison Team and recruitment is underway.

Further inpatient capacity could be released, following investment of 16 WTE in community services. This is dependent upon developing the strategic capacity for more specialised nursing home places in the local area and successful evaluation of Phase 1. Acute Medicine Service Model

The revised service model introduced last year included the introduction of Acute Physicians and emergency care flow co-ordinators to improve the flow of patients through unscheduled care systems and to facilitate increased capacity for ward round. Building on this, the Health Board is planning to increase the number of Acute Physicians by 9 WTE to enable the provision of weekend cover and to appoint 4 WTE emergency care flow co-ordinators. The model also assumes the development of 6 WTE specialist nurses and ANPs in acute medicine. The redesign of GP OOH services will also afford the opportunity for innovative integrated workforce redesign. Facilities Service Redesign

Last year, the Facilities Directorate undertook a comprehensive review of portering, housekeeping and laundry and catering services and utilised benchmarking data to assess the scope for modernisation and driving efficiency. An ambitious programme of service reconfiguration commenced which will continue to balancing the workforce across the Health Board’s sites, resizing the workforce in line with the national benchmarking and investment in new models of service which in years one and two largely through income generation schemes with the laundry service and CPU. In addition, plans are underway to centralise the main Switchboard to provide a 24 hr service later in 2015. Additionally, the impact of the changes to site and ward configuration will require further assessment of the facilities workforce requirements. The net impact over the three years will be a small reduction in the workforce. However, in year one of the plan, there is a need for significant relocation and potentially change of roles for many staff couples with the release of capacity equivalent to 18 paid WTE staff.

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Pathology Service Change The Directorate is undertaking a change to provide a blood science laboratory initially on both DGH sites which it is anticipated will enable skill mix change, relocation and some WTE reduction. Additionally as electronic requesting increases, especially in primary care, there will be reduced staffing requirement over the next 2 years. In year one of the plan there is an anticipated reduction of 7 WTE. Additional developments within the service include the development of alternative roles for Point Of Care Testing e.g. HCAs undertaking some phlebotomy duties and the potential introduction of more nurse led clinics to release the capacity of consultants. These nurse led clinics will replace PCH Consultant led clinics to provide anticoagulation services to YCC/Kier Hardie. An administrator/co-ordinator will also be required. Work is ongoing in modernising laboratory careers through skill mix redesign. There is currently an established model in Biochemistry for Clinical Scientists. As regionalisation of pathology services progresses, there will be increased opportunities in other specialties. There are already 2 staff commencing on this pathway (Microbiology and Immunology) and others expressing interest. These roles would reduce the clinical impact on hard to recruit consultants by performing clinical duties. A new consultant for the autopsy service will be recruited; however this is an area where there are national recruitment difficulties.

Radiology

Service redesign and additional MRI and CT capacity requirements all have implications for further investment in radiographers and reporting radiologists or radiographers. Analysis of demand and capacity of sonography shows the requirement for additional resources and the development of the new service to move from barium scans to CT colon will require investment on 3 WTE staff. Further work to determine the workforce models to support the proposed Diagnostic Hub is underway. Critical Care Service Development

To meet the clinical & quality standards for critical care and address the lack of junior doctors available to facilitate an out of hours 3rd tier to address this shortcoming, there will be the need for investment in SAS Doctors, Consultant Intensivists and Clinical Psychology sessions for the critical care patients. A phased approach to the recruitment of these staff

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over the next 3 financial years will be employed, to address immediate concerns but also recognising the change across south Wales. Opportunities to train Anaesthetic Critical Care Practitioners such as Band 7 Nurses, or ODP staff to take on some of these responsibilities will be given further consideration.

The development of outreach services for the care of patients at ward level who have either been in a critical care environment or those who have the potential to need that level of care in the near future requires investment in Band 5 nurses. This would enable a 24/7 service at both Prince Charles Hospital & the Royal Glamorgan Hospital.

Work is currently being undertaken to work through the implications of the South Wales Programme on critical care services and further detail will be available soon. Surgery and Planned Care

The key service change areas for the directorate are the centralisation of breast services and the creation of a urology diagnostic area both of which will have implications for the workforce but these are not yet known. Further work is underway to determine the detailed finance and workforce implications. As part of the South East Vascular service redesign programme, the development of nurse specialist roles is under consideration. Work to determine the future of surgical services and the associated workforce implications is underway as part of the South Wales Collaborative and Surgical Services Clinical Reference Group (see section 7.2.22 for further detail). Investment in ICT to support the more effective and efficient running of outpatient services, e.g. the introduction of test and remind services and self check in will lead to a need for a review of clinical and non-clinical support services to the outpatient function. Ophthalmology Service Model

To support the Ophthalmology and Diagnostic Treatment Centre development, there will need to be investment and recruitment to a number of additional roles including 1 WTE Optometrist, 3 WTE band 3 helpers (HCSW) and 1 WTE A&C support. Additionally, investment in Medical photographers to support virtual clinics is required. Further work is also underway to develop more sustainable ophthalmic medical and nursing capacity.

Primary Care development

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As identified in the workforce challenges above, there are significant workforce challenges within primary care. As identified in chapter 7, the current service model with a heavy reliance on the traditional GP practice, requires modernisation. Significant workforce risks are associated with the long standing and increasing difficulties in recruiting general practitioners to provide both the core general medical services and also to provide cover for the out of hours service. The proposed changes to the service delivery model, in particular the move to the cluster model of service delivery will result in significant changes to way the workforce is employed, utilised and developed. The new workforce model will have a number of components a key element of which is the expansion of the Primary Care Support Unit, PCSU through the recruitment of a number of directly employed staff including a salaried GPs, pharmacists, both general and specialist, and nursing staff to backfill practice staff, working across practices. Further details of the WTE requirements and scale of investment in the new models are provided in the finance section in Chapter 9. The key features of the new workforce model will include: a) Skills Enhancement and Alternative Roles for Primary Care

Staff • The recruitment of extra salaried GPs to the Primary Care Support Unit

to provide backfill support into GP practices, to aid professional development and provided capacity for new developments i.e. Cluster Hub working and to release GPs with special interests to work within the cluster hubs.

• GP Mentoring schemes to align highly skilled GPs with newly qualified GPs to enhance their scope.

• Sessional support for GPs and Practice Managers to enhance their leadership skills in Cluster Plan development.

• Using directly employed nursing staff to backfill and enable practice nurses to develop advanced primary care skills education to enable them to undertake ANP roles within practices and release GP capacity. Recruitment of ANPs has not been successful previously and developing our existing nursing staff is vital.

• Utilisation of primary care nurses who have undertaken the Diploma in Minor Illness and working to Patient Group Directives as an addition/alternative to ANPs. This would be a quicker route whilst ANPS are being developed/recruited

• Directly employed pharmacists who will undertake medical reviews to enable the release of GPs

• Integration of GP OOHs with A&E will enhance the skills of all involved. b) Skills Enhancement and Shift from Acute to Community

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The above funding has also seen some opportunity to consider the skills needed to support acute staff to work in community settings:

• Back fill opportunities to acute areas offered to release Nursing staff to

work in community settings. • Increasing the number of advanced nurse and therapy practitioners

supporting the management of chronic conditions • On-going plans to align some specialist nurse provision with

community settings and teams providing in reach rather than acute focussed providing outreach.

• Planned movements of identified services around Optometry from acute staff provision to primary care staff provision.

c) Skill Mix Reviews and Opportunities

Skill mix reviews and opportunities for Health Visiting and District Nursing as Well as Ward staff have been on-going in localities for the last 2 years. This year the focus is on:

• Implementing the District Nurse review with a significantly lower

number of band 7s to enhance dedicated leadership with an appropriate skill mixed team for each locality.

• Development of HCAS at band 3 to undertake programmed work i.e. Inverse care programme on Cardiovascular Disease and Home Medication Service. Development of band 4 practitioners and increase band 2 HCSW

• Further progressions of the skill mix on the Rehabilitation Wards Other features of the workforce modernisation to support the developments identified in chapter 7 will include: • Working with the Medical schools to support the development of

portfolio careers for doctors in training to enable them at an early stage in their career to have a footprint in both hospital medicine and primary care

• Working with universities and education colleagues to support the development of portfolio careers for other non medical professionals including nurses, therapists and scientist

• Working with Welsh Government and National Public Health Services to create a Chair in Primary and Community Care in Cwm Taf to facilitate academic research and access to associated funding opportunities

• Extending the utilisation of electronic management systems into primary and community care – e.g. ESR and e rostering.

• Development of an OD programme to build effective management capacity and collaborative relationships between primary and secondary care staff focussed around the needs of patients.

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Out Of Hours Workforce Modernisation

As identified above, to address the GP shortages in OOH, the proposed remodelling of the service through consolidation on two sites will be supported by a range of workforce modernisation. This includes, the utilisation of a wider multi-professional team including Advanced Nurse Practitioners (independent prescribing as an essential component), advanced paramedic practitioners, currently used in times of escalation to support the home visiting service, nurse triage and pharmacists. There are limitations to the use of Advanced Paramedic Practitioners in terms of prescribing and other governance issues; also the numbers APPS currently available are very low across south Wales. The new model will be introduced in three phases during 2015/16. The first phase is likely to consolidate services on our two acute sites and supplement this with a transport solution as a temporary measure. Following consolidation new workforce, team based models for delivering OOH will be tested together with the development of new approaches to packaging shifts with practices. Finally, in light of what we learn in the first two phases, we will consider a longer term approach to integration alongside the development of our acute medical services. ii. Development of new/extended roles

Advanced/Specialist and Extended Scope Practitioners

In its previous plan the Health Board identified the need to develop of 15 additional Advanced Nurse Practitioner (ANP/AEP) posts by 2017 to improve the quality and safety of care as a consequence of increased continuity of staffing. Currently due to shortages in the supply of junior doctors a substantial proportion of junior doctors are short term agency staff, with inherent problems with staffing resilience and continuity. The aim was to train and develop 10 existing registered nurses to be Advanced Nurse Practitioners ANPs and to directly recruit 5 ANPs who are already able to operate at ANP level. The period of formal training is generally 2 years, which needs to be followed by 1 year of developing competence in the roles before being able to fully undertake the ANP roles. By year 4, 15 agency junior doctors could be replaced by the trained ANPs. The key clinical specialties where it was proposed these roles would be introduced would be paediatrics, neonates, acute medicine, surgery and mental health. Further development of our plan has identified the scope to increase our plans for these roles in the areas identified above and also for the use of ANPs across nursing, therapies and health sciences in a wider range of settings addressing both the need for advanced depth of specialist practice and more generalist/broader based advanced practice. In

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particular, we are seeking to develop a cohort of enhanced roles within the following specialties and services: • Our proposed primary care cluster hubs, supporting chronic conditions

management and frailty, as first point of contact within our developing paediatric and acute medical assessment services and within our new OOH services. Final numbers are still being indentified but conservative estimates of year one are the requirement for 5 posts within each of these settings.

• Advanced practice for radiographers due to recruitment difficulties for radiologists. This would be a new development area and again at this stage the numbers are low looking at 1-2 posts over the next two years

• There is currently an established advanced practice model in Biochemistry for Clinical Scientists. As regionalisation of pathology services progresses, there will be increased opportunities in other specialties. There are already 2 staff commencing on this pathway (Microbiology and Immunology) and others expressing interest. These are currently funded internally – to assist in progressing this model further funding opportunities through WEDS will be explored. These roles will reduce the clinical impact on hard to recruit consultants by performing clinical duties.

• Within our trauma wards to improve DOSA and ALOS to support our work on patient flow.

• Pharmacy to support our work with primary care along with the increase in independent prescribing pharmacists. The health Board also intends to increase consultant pharmacist posts.

• Increasing the Diabetes Specialist Nursing resource which will span primary, community and secondary care with the aim of increasing capacity for structured education and improving inpatient care. This should lead to a reduction in emergency admissions for diabetes, a reduction in average length of stay for patients with diabetes, a reduction in complication rates and reduction in prescribing costs

• From the work done to date, it is likely that the plan will identify a shortfall in consultants, specialised cardiac nurses and physiologists, as well as a shortfall in equipment to meet the delivery requirements set by the Welsh Government. The full extent of this is being developed in the next stages of our action and workforce plans and will require service redesign and prioritisation.

We are currently updating a central register of advanced, extended scope and specialist practitioners to include each individual practitioner advanced practice qualifications and the scope of their role and updating ESR. Succession planning is also key to ensure where there is an advance practice role, there is future sustainability and where there are risks, these are highlighted and monitored. This work is being overseen by the recently formed Clinical Professional Practice Board established to oversee the planning and development and governance of these roles. The Health

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Board is also represented on the national forum supporting work on the development of Advanced Practice roles. Physicians Assistants

The Health Board has also commenced dialogue with colleagues in the Midlands and Powys regarding the potential development of Physicians Assistant roles to support care delivery in a range of settings including emergency medicine, primary care and community care. Discussions are at an early stage. Support Worker Development

The Director of Nursing established a task and finish group in 2014 to progress the development of the HCSWs workforce to identify where these can be utilised to greater effect to support qualified staff. A key priority for the group is the identification of potential service areas for development of these roles together with determining the competencies, training and development required to deliver these. The working definition of the HCSW group of staff has been categorised by those who provide care and those who support the provision of care. This will ensure that the development of the wider HCSW is addressed. In year role development has included the following which will continue to be progressed. • The development of ophthalmic practitioners with Optometrists and

Orthoptics taking on some medical and nursing tasks (BP and prescribing).

• Orthodontic technicians. • Health care support worker in Oral Maxillo Facial services. • The introduction of Maternity Support Workers to facilitate the release

of qualified midwives to undergo additional training in order to undertake the examination of new born babies which is currently done by junior doctors thus in part helping to reduce the pressure on junior doctor rotas. 8 MSW per year are being recruited and trained on a phased basis as the qualified midwifery workforce is rebalanced.

In addition, the Health Board has a number of staff who have already been developed to level 4 practice, but has not fully utilised the skills of these staff by developing practitioner roles. The development of band 4 practitioner roles will be a key priority for the Health Board in 2015/16, with a particular focus on non ward environments (in part due to the CNO nursing establishment principles), including primary and community care. Discussions have taken place with the new Head of School at the University of South Wales to support the work.

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The Directors of Nursing and Workforce are currently undertaking roadshows with directorate managers and clinical leads to explore further opportunities for workforce modernisation and new role development which will be factored in to ongoing workforce plans. Recruitment Difficulties Recruitment difficulties are a primary driver for skill mix change and workforce modernisation but also clearly post a significant risk to the Health Board in delivering safe and effective services. The use of agency and locum staff is a major financial and quality risk. The recruitment of medical staff within the four services covered by the South Wales Programme are well rehearsed, in addition, a summary of the key areas where the Health Board is experiencing particular difficulties is provided below: • Primary care – the recruitment of general practitioners for core general

medical services and out of hours services. • Consultant Restorative Dentistry • Dual trained Oral Maxillo-Facial nurses • Dental laboratory staff – in house training might be only avenue • Audiologist and advanced level • Ophthalmology nursing and medical staff. • Radiologists. We have been unable to recruit fully in 2014-15 and the

age profile of our workforce poses a major risk. • Pathology - Consultant staff in all specialities but particularly

Haematologists. • Following the introduction of the shift system to replace on call, we

have been unable to recruit 2014-15 band 5 radiographers. • Band 5 physiotherapists – this is a recent deterioration across the

region which we are monitoring closely. • Registered nurses. 8.5.2 Maximising Workforce Efficiency

Maximising the efficiency and productive contribution of the workforce is a key component of our workforce plan. The priorities range from ensuring our operational and management systems and process are robust and facilitate the effective management and deployment of our staff, to the utilisation of e- employment systems to minimise waste. This requires the Health Board to ensure that it develops best practice employment policy and practice, benchmarked with comparable organisations. The Health Board will continue to utilise the resources developed through the ‘Working Differently Working Together’ programme to ensure that it maximises the flexibilities afforded in the range of employment contracts and terms and conditions.

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As described in Chapter 9, there will continue to be a workforce productivity cross cutting work programme to oversee a range of actions to support efficiency and productivity to support service improvement and release savings from the paybill. i. Workforce Productivity Programme

General Workforce Productivity

In 2014/15, within the general workforce productivity theme focused on a range of areas including a review of the corporate departments establishments, the introduction of the MEDACS Vantage Tax efficiency scheme for the employment of locum doctors, introduction of the car leasing salary sacrifice scheme, and reducing travelling expenses. Additionally the Health Board fully rolled out e-expenses from 25% to 97%.

The key focus of activity for 2015/16 will continue as in 2014/15 including further efficiency from our corporate functions; efficiency in the travel and expenses budgets through changes in practice such as more use of technology, use of pool cars, car sharing etc; the introduction of further salary sacrifice schemes (under consideration IT equipment/pcs, professional subscriptions); and the embedding of the MEDACs vantage scheme for recruiting locum doctors.

A new area for efficiency will be the use of planned retire and return initiatives to facilitate supportive retirements, skills retention and interim support for new staff from experienced practitioners and skill mix change. This will apply to all staff groups and is managed through our vacancy control panel.

Medical Workforce Productivity

Our medical workforce productivity group will continue to focus on a range of activities in order to maximise the deployment and utilisation of our medical workforce. Key actions include implementing effective job planning and ensuring that all consultants and SAS doctors have an agreed job plan to support appraisal and revalidation and improving the management of leave, study leave and sickness absence and minimising the associated requirement for additional duty hours (ADHs) and short term locums.

An additional area of activity is associated with addressing levels of additional locum and agency cover to support gaps in cover where individuals are not able to fulfil their contractual commitments.

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Consultant and SAS Appraisal and Job Planning

Following a revitalisation of the job planning process two years ago, the Health Board saw a considerable improvement in the number of job plan reviews. Over 80% of our consultants have taken part in job planning meetings and we achieved a 98% compliance rate with appraisal during 2014.

As part of wider all Wales discussions it has now been agreed that the reporting period should be set over a rolling 12 month period. This has resulted in a significant impact on the compliance figures reported by the Health Board as it adjusts to a shorter review timeframe. Currently 27.2% of consultants have a current signed plan (with 1.15% being unsigned) and 10.83% of SAS doctors have a current plan (January 2015). The introduction of the electronic job planning and medical e-rostering (see below) will address this and the first stage of the e-job planning project is to ensure all job plans are up to date.

Work has also been undertaken to analyse the use of and operational management processes for annual leave, sickness and other forms of absence which require cover. Revised guidance has been issued to consultants and Clinical Directors following discussion at the LNC, supported by roadshows.

To support this work the Health Board piloted the ESR job planning record module and was successful with an ‘Invest to Save’ bid to procure an electronic job planning and clinical activity management system. The latter will enable more efficient rota management including the management of annual leave, study leave, and sickness which are core priorities for the group. A project manager has been appointed, a preferred provider indentified and the final procurement process is underway. In addition to reducing the requirement to appoint locums to cover short term gaps, this programme of work should ensure a range of quality and capacity benefits are delivered. A further programme of work which has commenced but will require implementation in 2015/16 is the implementation of a Rota Office to undertake roster management and the provision of cover for medical staff which will free up both clinical staff allowing them to undertaken clinical work and directorate staff to concentrate on other priority work. A successful Invest to Save Bid will enable us to set the office up within the year. Over the following year it is anticipated that the benefits of reduced cost of agency and locum staff and the increased capacity for management and clinical staff will enable the office to fund itself on a recurrent basis. The potential to establish an integrated resource office to oversee the delivery of the rota office, e-rostering for all staff groups, the bank and the Medacs service in the longer term would also be considered under this programme.

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ii. Nursing Productivity

The Nursing Productivity group was implemented following the work undertaken to review the nursing establishment across the acute and community wards. A report was produced outlining the position in relation to the Chief Nursing Officer recommendation for safe staffing levels. The main aim of the group is to:-

• Development of a comprehensive nursing Workforce Plan. • Assess and review flexibility and deployment of staff • Review ways of working and effective shift patterns • Review of Ward, Mental Health and Nursing Establishments outside of

ward areas.

Following extensive work, agreed establishments which were broadly consistent with the CNO recommendations were finalised, ward manager role to be 50% supernumerary rather than 100% as per the recommendations. An analysis was undertaken to match this to the current staffing levels on the wards.

The decision was taken to establish the current wards within the Health Board to 95% with the ability to use 5% bank flexibility. The review of the wards highlighted there were areas of both over and under establishment of registered Nurses. Where under establishment occurred, this was being compensated by nurse bank/agency usage to ensure safe levels of care.

During this time there has also been work to rebalance the establishments between over and under established areas. This piece of work has been affected by the recent service redesign/bed remodelling which has changed the establishment profile as staff have moved and been redeployed.

The establishment review highlighted a significant under establishment of Health Care Support Workers (HCSW) in both Royal Glamorgan Hospital and Ysbyty Cwm Cynon. The bank usage was significant in these areas which supported the findings. A recruitment campaign was launched in July 2014, which resulted in total 36 HCSW being employed (27 RGH acute and 9 YCC community). It is expected there will be a reduction in bank/agency usage and this will be monitored through the workforce tracker and finance. In order to improve the consistency of patient care in the acute medicine and surgical wards a different more innovative workforce strategy is being employed. Rather than relying totally on bank and /or agency staff to cover gaps in the rotas a decision has been taken to appoint externally to a pool of 8 WTE qualified nurses that could be deployed to different wards on a longer term basis than the usual bank cover in order to cover more long term absences, e.g. to cover long term sickness and maternity leave.

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To aid the Heath Board to monitor the workforce plan for Nursing a workforce tracker has been developed, which is based on the work undertaken by our Facilities Directorate last year. A screen shot of the tracker is provided below.

This tracker enables the Health Board to rebalance the ward back to the establishment by turnover, retirements and also monitor the impact this should have on nurse bank spend. The Health Board can then make an informed decision regarding moving qualified staff if the workforce plan doesn’t show the movement needed. The tracker and that for Facilities are used to inform decisions by the Vacancy Control Panel.

Further work has been undertaken to review the establishments in A& E and the Health Board has agreed an establishment for both the A&E departments and the Clinical Decisions Unit. There have been some challenges in implanting this and work is ongoing with Medical colleagues and staff side to progress this.

The Nurse Director has met with the Directorate for Mental health and professionally agreed the recommended staffing for acute and long term Mental Health wards. Further impact on nursing establishments will result from any reduction in in-patient beds and the rationalisation of some services as outlined in section 8.5.1 above. Detailed workforce plans are being developed by service scheme, however mapping the changes and their impact across the organisation

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will informing our approach and will maximise choice and opportunity for the staff affected. The work is complex and incorporates utilisation of turnover and retirements, redeployment and relocation, reducing bank and agency usage, supplemented by access to VERs should the former fail to facilitate sufficient workforce change and cost reduction. The current levels of sickness absence on some of the wards will need to be reduced significantly to enable the targeted bank utilisation to be achieved and these areas are being targeted for increased intervention and support. The Health Board currently has 41 registered nursing vacancies and 36 HCSW vacancies which it is seeking to recruit to. Initial recruitment has resulted in offers of employment being accepted by 13 qualified staff, however disappointingly, several staff have had offers from several Health Boards. The Health Board is now discussing how it can implement more innovative recruitment campaigns. Alongside the introduction of the new ward establishments, the Health Board is continuing to implement a programme of change to standard shift patterns of 12 or 6 hour shifts through a consultation and engagement process. This process is central to our implementation of e-rostering. A further programme of work to re-invigorate our nurse bank has commenced. The Health Board is participating in the joint work being undertaken by Directors of Finance, Nurse Directors and Workforce Directors to address medical and nurse bank, locum and agency usage in the face of increased use of high premium agency nurse and locum staff. A key aspect of this work is to review the all Wales Bank Worker contract. In addition to this work, the Health Board is keen to develop its nurse bank (and widen to other professions) on a more sustainable and reliable basis. At this stage, one of the actions which the Health Board is keen to develop is to increase the opportunity for bank workers to access level 2 NVQ development. This would enable better retention, succession planning and career progression for our current and future workforce and would also support the development of a higher skills base to support the care of our population. This also supports our work on our Corporate Social Responsibility. Effective management practice

A range of actions will continue to be improved to ensure that all staff are effectively and fairly performance managed, throughout their employment. Key priorities in respect of developing management capacity and capability include the management of training and development, managing employee health and wellbeing, managing attendance across all domains of leave and performance management

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including undertaking regular development reviews (PDRs), and appraisal for medical staff.

Personnel Development Reviews

The current rate of PDRs undertaken within a rolling 12 months is 62.43% as at 1st December 2015 against a target of 85%. The profile by organisation and directorates is provided below for the year to date and month respectively.

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Directorates Managers regularly receive a suite of the latest PDR information as described below, requesting that they routinely check the recorded data, identify any anomalies in PDR recordings and ESR structures and also to prioritise those staff approaching 2nd gateways.

These simple checks ensure accuracy of reporting and a reflection of true compliance. An analysis of the rates over the past three years demonstrates a similar profile whereby the compliance with the 85% target increases and decreases on a cyclical basis. However, we have sustained an ongoing upward trend with each year progressively better that the previous year. The incorporation of PDRs into the performance management framework has resulted in a steady improvement in 2014/15.

The Learning & Development Department continue to support Directorates in the following ways to improve PDR compliance:- • Providing a comprehensive suite of reports to DMs on a monthly basis

providing the latest PDR compliance data, contextualising each Directorate’s performance; what to do to improve compliance; where to seek further help and guidance

• Supporting the PDR agenda at the Clinical & Corporate Business Meetings through preparation of summary reports in advance of each CBM and attendance where necessary

• Assigning L&D officers to individual Directorates to assist in the identification and rectifying of report anomalies; develop compliance plans; provide 1:1 support to managers; raising awareness at briefing and department meetings

• Training Reviewers to enable them to record PDRs via ESR Self Service; offering on-going support and guidance.

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• PDR training for Reviewers is an accredited 1-day programme offered on a twice monthly basis to all Directorates. Uptake of this programme is excellent.

The rate is now improving and is monitored via the monthly clinical and corporate business meetings. An action plan has been developed to improve the delivery of PDRs which includes improved recording and reporting mechanisms. Achievement of the target will be a core objective for line managers in 2015/16, managed through their own PDRs. An associated area for priority which commenced last autumn is the active management of gateway increments and where appropriate ensuring that staff on protection are managed effectively and deliver value for money in respect of the scope of their duties. iii. Health and wellbeing and reducing absence attributed to

sickness.

The Health Board’s current sickness absence profile is illustrated in the chart in section 8.1 above. Maximising attendance at work is a key priority for the Health Board. Performance is reviewed monthly at business meetings and is reported through the integrated dashboard which is presented at every meeting of the Board and scrutinised monthly at Executive Board. A quarterly detailed analysis of absence levels and the actions to address these are discussed by the Director of Workforce and OD at the Finance and Performance Committee. The Health Board has set itself a challenging target of reducing sickness by 1% by the end of the financial year to March 2015 from a starting position of 5.5%. The Minister for Health and Social Services instigated a similar target during the year. This would require a sickness absence level of 4.5% at the end of March. The target is not on course to be met with the current rolling rate at 5.8%. A Health and Wellbeing action plan has been developed and submitted to the WG to address a range of activity focussed on improving the health and wellbeing of the workforce through the five themes: • Health and wellbeing initiatives via the Corporate Health Standard

work – the Health Board achieved platinum status in October 2015. • Improved reporting and recording of sickness and data quality and

analysis. This is associated with the roll out of ESR self service below. Managers are being trained in business intelligence function on ESR.

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• Ensuring managers actively and appropriately manage all episodes of sickness absence utilising the policy. The WOD team are undertaking deep dives and audits into the sickness levels and the management processes in targeted areas of high sickness absence. These audits are demonstrating the level of compliance with the sickness absence toolkit for managers. Where this is low, this is being escalated to senior managers and additional support and intervention is provided. Line managers are receiving bespoke support to manage cases.

• Improving our Occupational Health Service through the introduction of a nurse led case management model, development of KPIs, improved processes and stabilising our clinical workforce. We successfully appointed a senior nurse manager who commenced on 1 March and through joint working with ABMU UHB, secured a stable medical commitment from an experienced consultant OH physician and newly appointed consultant. Improvement to access and the operational processes have been implemented and feedback on the changes has been very positive. However, access to the service remains challenging.

The Health Board recognises that the management of sickness absence will remain an ongoing challenge. The programme of work outlined above will continue supported by a move away from a centralised sickness absence team to a business partner model aligning a team of WOD professionals with directorates. This will enable WOD staff to work with line managers on a consistent basis aligned to the wider issues within a directorate or team that can affect absence rates. This will remain a high priority.

Recent successes include the introduction of a system where all ward based nurses in the RGH report any sickness directly to the senior nurse. This is being evaluated but initial analysis indicates that there has been a 2% reduction in absence rates. Within the Facilities and Mental Health Directorates, robust enforcement of return to work interviews with every employee routinely has resulted in a reduction in absence levels.

iv. E- Employment systems

ESR roll out

The roll out of ESR Manager Self Service is enabling us to maximise the efficiency of staff and to ensure that managers are taking the necessary accountability and responsibility for the staff they manage. A key element of the roll out programme is to raise awareness and the use of the Business Intelligence elements of ESR to enable line managers to access comparative management data and reports from

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their desktops. As identified in last year’s Plan, we have refreshed our project arrangements for the roll out of ESR and associated systems to accelerate implementation. E-rostering

The roll our of e-rostering within the Health Board is a key way of maximising the efficiency of the Workforce and ensuring that wards are covered safely and within budget by the introduction of the e rostering system to manage the rotas electronically. Our implementation process commenced in 2013. The rollout plan for e-Rostering is on target and we are due to complete the second phase in June 2015. Currently all wards on the PCH site are rostering and are live to payroll. By spring 2015, all wards at RGH, YCC and YCR will also be live to payroll. Consultation with the Mental Health Directorate has commenced. It is anticipated they will complete training and go live to payroll April/May 2015. There is a third phase on the plan that includes Facilities, Pathology and Radiology. The plan indicates that rolling out to these areas will extend the programme to November 2016. Consideration now needs to be given to identifying benefits realisation of the programme. During the consultation phase in any new area, a staffing profile is created based on the information the ward manager provides. The information gathered includes all staff in post, band, individual hours of work, and working preferences. The roster trainer collates the information, and at a later date, returns to the manager with a staffing profile of the team. Where staff have been identified as having preferences or set working patterns, the manager is required to meet with the staff member, along with a HR manager and staff side rep (if appropriate). At this meeting a discussion should take place to review working preferences, working patterns and restriction, with a view to either formalising an arrangement, or advising the staff member they should request particular requirements in line with the Roster policy. In a number of areas, this work has been successful in encouraging some staff to review their working patterns and return to making shift requests. In areas where there are family friendly arrangements or custom and practice situations these, often restrict the roster manager from creating the most cost effective roster, and can lead to gaps in shift fill resulting in a request for Bank or Agency cover. Closer scrutiny of rosters will take place at the point of sign off of bank and agency by the Senior Nurses to ensure where gaps in cover are identified, that effective rostering has taken place, before the request for Bank or Agency is made.

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v. Other measures

The Health Board has reinvigorated its vacancy control mechanisms managed to ensure that vacant positions are properly scrutinised and alternatives to direct like for like replacements are considered routinely. The panel uses the workforce trackers identified earlier to inform decisions and ensure that these are made within the context of delivery of the Directorates workforce plans and are consistent with decisions made to release staff on VERs. The VCP also scrutinises retire and return applications and monitors temporary and fixed term appointments and secondments. The Vacancy Control Panel VCP meets to discuss all vacancies on a fortnightly basis. The Health Board will continue to participate and contribute to the discussions regarding national changes to terms and conditions of employment 8.5.3 Reducing the Workforce

Detailed alignment of service, workforce and financial plans has been undertaken and the scale of the workforce challenge identified requires a reduction in 2015/2016 of the workforce of approximately 117 paid WTEs. Although the net impact of all planned service investment will result in an in year increase in WTE of 159 WTE, these will not all be existing staff. There will be a requirement to release or not replace some staff as well as the opportunity to redeploy, retrain and develop others.

Delivering the scale of workforce change identified will continue to be challenging and will require a co-ordinated and staged change programme. The elements of the approach the Health Board has used in 2014/15 and proposes to continue to utilise and has modelled, is as follows:

• Actively planning a reduction in the workforce through the use of

turnover from natural wastage and retirement and the non- replacement of leavers

• Restricting bank and other non-contractual work such as overtime and additional hours to limit the need for actual reductions in substantive posts.

• Cease and/or restrict recruitment based on required reduction of staff groups ( All recruitment is processed via the Vacancy Control Panel)

• Use of retire and return to facilitate skill mix change and flexible retirement.

• Redeployment of staff to suitable alternative posts via the OCP process • Termination of fixed term contracts where appropriate

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• Utilisation of VERS (see below) • Seeking voluntary redundancies • Make compulsory redundancies where services/posts have become

redundant.

There is a risk in employing some of these strategies in terms of loss of essential skills and the impact on patient care but a robust risk assessment process will be employed in order to minimise any risks, e.g. compulsory redundancies would be a last resort and would require robust consultation and engagement.

i. Turnover

The low turnover of staff within the Health Board is currently running at 6.8% (3.8% voluntary movement and retirements at 3%) is a challenge and we cannot rely on natural wastage to achieve the identified workforce reductions and skill mix change. The age profile of the organisation has been mapped by staff group and service, and assumptions have been made that a significant proportion (but not all) of staff who reach the age of 65 will retire. Given the assumption that 50 – 66% of all leavers will need to be replaced (given that they occupy front line posts) and factoring in the distribution of turnover across the 12 months of the year, it is assumed that the realistic projected turnover will deliver approximately 240 WTE reduction full year impact which reduces to 120 when the phasing of turnover throughout the year is taken into consideration. Any further reduction is therefore to be achieved through VER. ii. Reducing variable pay costs

Excluding temporary workers, agency work, additional sessions and on call which has recently been reviewed as part of the national changes, the current variable element of the paybill is around 8%. The changes to the nursing establishment assumes a proportionate reduction in the use of bank working as detailed above. The UHB has seen a recent increase in its agency and locum costs partly due to increased demand but also due to the increased use of high, off contract agencies due to shortages of staff. The UHB is represented on the joint working group established to address this with DOFs, WODs and NDs. iii. Controls on recruitment and replacement of staff

As indicated above, the Health Board introduced robust vacancy control processes in 2013.

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Invoking the OCP and seeking redeployment options

Where possible, staff who may be displaced and wish to remain in employment, will be offered redeployment into suitable alternative posts. An active redeployment register is managed by the WOD department and will continue to be routinely referenced by the vacancy control panel prior to any appointment being approved for advertisement.

All vacancies will continue to be advertised internally first unless there are exceptional circumstances where it is clear that the required skills are not available within the organisation. Staff who do not accept suitable alternative posts will be managed in accordance with the provisions of the policy. Additionally, displaced staff will be afforded the option to apply for VER.

iv. Proposed Utilisation of Future VER processes

To support the ongoing need for the Health Board to change the way we deliver our services over the next few years, and to ensure that the VER scheme is used as an enabling tool to support this flexibility to address service re-design, the Voluntary Early Release (VER) scheme is open for individuals to submit applications on an ongoing basis and for the Health Board to invite groups of staff associated with specific change programmes to apply for VER. The Health Board will continue to seek support via Invest to Save monies to maximise its capacity to utilise VERs and is reliant upon securing the funding within its current bid to enable it to deliver its projected workforce reductions in 2015/16. The Health Board has utilised VERs successfully for a number of years and ahs now developed a well established process guided by agreed principles signed off by it RATs Committee:

• Staff can submit a VERs application at any time to their line manager or the HR team.

• It is made clear that staff who submit applications do so in full understanding that there is no ‘right’ to VERs nor a guarantee that where a line manger supports an application, it will be approved or the funding available.

• The Health Board may decide to run a targeted or general campaign to promote and invite applications as part of a corporate intention to reduce headcount.

• Staff are asked to consider VERs in support of a specific organisational change process as a routine first step prior to commencing any slotting in and selection process under the all Wales Organisational Change Procedure.

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• Remuneration Committee is provisionally booked to coincide with all Board and Board development meetings and will proceed if and when there are fully supported business cases for employees who apply for VER.

• Remuneration Committee will be asked to support cases in principle on the basis that when and if the financial position allows, the approved applications will be released. This will allow staff to be released quickly when funding becomes available.

• Clear messaging via sharepoint, staffside and other communications has been reinforced to indicate that VERs is not a right and staff must not assume or plan on the basis that an application will be successful. The application form will be amended to reinforce these messages.

• Confirmation that the application has been approved will only be communicated to the employee at the point in which funding becomes available.

The anticipated contribution from VERs to workforce reduction is 40 WTE in 2015/16. A significant majority of these are assumed to be facilities and administrative staff, but given the level of reduction required this is likely to include some frontline staff. This is based on a number of factors including:

• The current cohort of applications which are predominantly from these groups

• The scale of savings required from these two groups of staff associated with the facilities service redesign and the back office review of corporate department

• The capacity to release staff from support functions without the need to backfill or replace is greater than for front line staff.

However, should the assumptions about turnover or the level of reductions in variable pay not materialise, or be delayed in taking effect, there may be a need to increase the number of staff who are approved for VERs. Given both the age profile and scale of change and physical relocation/movement required over the next three years, we anticipate that the number of applications for VERs will exceed the Health Board’s capacity to release staff. v. Voluntary or compulsory redundancy

In the event that it has not been possible to redeploy any displaced staff and that there is little prospect of any suitable employment arising in the near future, as stated, individuals will be asked to consider applying for VER. However, VER is by its nature a voluntary scheme and an individual cannot be compelled to access the scheme.

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In these circumstance, in accordance with the provisions of the OCP, the Health Board would need to consider offering voluntary redundancy and as a last resort compulsory redundancy. Before embarking on such a course of action, clear change management principles and engagement with staff side colleagues would be of paramount importance.

viii. Investments in workforce change 2016 - 2018

There is a continued balance between planned investment in new service models and workforce change resulting in reductions to headcount. Investment is predicted to require the appointment of 50 new posts in both 2015 and 2016 respectively. The main projected areas of growth include primary care services, acute medicine, community staff associated the management of chronic conditions, community mental health services, and investment in diagnostics and therapies and electronic employment systems. These developments will be dependent upon the prioritisation process prior to the start of each year.

ix. Projected reductions in workforce 2015 – 2018

A net reduction of 130 paid WTE is anticipated over years 2 and 3 of the Plan. x. Delivery

The strategies to deliver these changes will continue as in year one. However, our capacity to drive further efficiency from our variable pay bill particularly in respect of overtime and bank will be limited as a result of our actions in year 2015/16. With lower projections of age retirements and an assumption of continued turnover at around 6- 7%, the need for accessing voluntary or compulsory exit processes is likely to be greater. xi. The Key Risks/limitations to Service Change

In order for the successful transformation of services to become a reality all of the above strategies and implications on the Workforce should be considered and carefully evaluated. Any service change would need to be implemented with the total buy in of the organisation and within legal and best practice frameworks.

The main risks/limitations to the transformation of services being delivered is as follows:

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• Lower staff turnover levels than predicted will reduce our capacity to deliver pay savings

• Delays in delivering the service and workforce change in the earlier part of the year will necessitate greater levels of workforce savings in the latter part and may require blunter measures to be utilised, e.g. vacancy freeze, etc

• Our ability to manage the proposed reductions are dependent on rebalancing the nursing and facilities workforce and effective management of all leave including containing sickness absence

• Risk of not achieving the changes in service provision and workforce modernisation to enable safe and sustainable services to be provided.

• Breakdown in partnership working • Fragility of medical workforce • Management capacity and capability to deliver. • Impact of the South Wales Programme is still unknown and it is

difficult for managers to plan in this context • Risk that staff who had planned to retire will delay their retirement

plans and wait for an option to take VER.

Communication and Engagement with Staff

A range of mechanisms have been developed to support our communication with our staff and their representatives and to engage them in shaping the service changes. A draft communications strategy has been developed which will be finalised and published in 2015. The communications team has a page on SharePoint which is accessible to all staff and explains how the team works and how it can help the organisation. Employee Engagement The Workforce and Organisational Development department has undertaken research into “best practice” in relation to promoting and improving employee engagement. As a result of this an employee engagement action plan was devised, its aim was for this to be used as a guide when working with directorates. The tool has been used as a base line in working with staff within WHSSC to improve how staff feel about there workplace. Through consultation with staff and management, the action plan has now been implemented and employee engagement is moving in the right direction. An employee engagement awareness training session has also being devised and pilot sessions have been delivered throughout the HB. Feedback from these sessions, which included W&OD, Trade Unions, Senior Management and Team Leaders has been very positive. The

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training rolled out to all Directorates in the new year, with HR Business Partners being the constant link to support managers. Many pulse surveys have now been carried out throughout the HB and feedback is being used effectively in driving and supporting change. The change management toolkit which has been devised has resulted in service change being planned and implemented in a consistent, open and transparent way. So we will continue to use and develop the toolkit, the principles and leaflet for staff. Agreement has been reached to undertake a pulse survey for staff who have been subjected to the redesign of services at Dewi Sant Hospital. The Employee Engagement Group are currently drafting a leaflet for all staff to raise awareness and a EE strategy is in the process of being devised. Partnership Working

We have active engagement with our staff side colleagues via the formal partnership arrangements at the monthly meeting of the Joint Advisory Group (JAG) and Working in Partnership Forum( WIPF). These meetings are attended by the Chief Executive, Directors, service managers and WOD. Major service changes, e.g. the SWP are shared on the agenda with our staff side colleagues. However in order to support the level of change outlined in the three year plan for the Health Board; these partnership arrangements are being reviewed and will need to be refreshed in order to ensure that the level of change needed is delivered in partnership. There are also a number of other informal and formal fora for joint working within the Health Board where staff side play a key role and which will ensure that service change is delivered

8.6 Organisational Development

The NHS Leadership Academy in the 2012 publication ‘Help’24 shaped our plans for developing outstanding leadership in health outlined the case for change, the evidence for change and the direct link to leadership.

‘If the NHS is to meet the challenges of the coming years,

we need to be more coaching and facilitative in our approach, supporting NHS leaders and their organisations to

take risks, innovate on an industrial scale and completely transform many of our services. Building relationships with

all parts of the health and social care system will be key to making this happen.

24 The Tayside Centre for Organisational Effectiveness

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Tweaking around the edge won’t deliver what’s needed. We

need to transform the whole system, supporting each other to take risks and innovate and engaging our staff and the

public in difficult conversations. The fundamental difference between success and failure will be the calibre of our

leadership.’

This evidence takes on an even higher profile in the context of post Francis and the Andrews Report ‘Trusted to Care’ which highlighted the importance of leadership in the creation of a culture of clinical compassionate care. Progress is being made against this three year plan which began in January 2014, some areas are progressing quicker than others and the aim is to adapt the plan to ensure we are responding to the emergent requirements within Cwm Taf. As we enter the second year of the plan the emphasis is on management fitness for purpose so that the development stream can compliment the fitness to practice work. We are expecting further progress as the organisation matures through its development journey.

• Building leadership capacity and capability - examples of progress include the completion of development programmes for clinical directors; assistant directors and directorate support managers. A further programme for senior managers has been drafted with a view to implementation in early 2015. A network of coaches is also being utilised across the organisation supporting effective engagement and personal and service change. Discussions at Board and Executive Team level have been taking place with a view to starting a programme in the forthcoming year.

• Engaging our workforce in service change – work has continued following the South Wales Plan and with the Alliance; buzz events with a wide range of clinical staff have been held as well as the Quality Summit; R&D conference and Clinical Conference. Developing a culture of compassionate care has been an area of focus; iCARE sessions have been held with over 500 staff with wide ranging impact; opportunities for staff to care for themselves have also been started such as within the Schwartz Center Rounds.

• The University Health Board have also approved the development and implementation of an Employee Engagement Framework which builds on the work developed in partnership following the last staff survey. This forum has led work to improve communication mechanisms, use of pulse surveys which are followed up by action planning and management of change effectively. The latter programme has seen the development of a toolkit for managing change which has been utilised with the Mental Health changes and service rationalisation in 2014/5 and is currently being assessed via

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a pulse survey. There have been no related sickness or grievance cases which is a significant change.

• Change-ability and performance enhancement – work has started to embed the All Wales NHS Manager competency framework within all internal learning and development programmes; Cwm Taf’s management structure and arrangements have been under review to ensure sustainability and assure performance.

High Level Priorities for the organisational development approach

over the next three years

Building Leadership

Capacity and Capability

1. Development programmes for clinical directors, assistant directors, directorate support managers and for heads of nursing;

2. Senior manager programme for staff in operational and corporate roles;

3. Internal secondments and development for key players to broaden their skills and experiences in different service and organisational areas;

4. Coaching network across the Health Board to support effective engagement in service change and delivery;

5. New leadership programmes for newly appointed consultants and GPs, nurses and therapists and health scientists;

6. Working in partnership with Academi Wales to access programmes and resources to enhance leadership capability;

7. Board and Executive level development programme to incorporate Aston-based approaches to leadership and team development; specific conversations have taken place with Academi Wales to enhance Board skills on scrutiny and governance.

Engaging Our

Workforce in Service Change

1. Implementation of a staff engagement framework; 2. Specific nursing workforce engagement

programme; 3. Building the momentum around medical

engagement (following on from the Doctors Debating Series; Medical Leadership Forum; medical and leadership development programmes and succession planning; implementation of the medical engagement scale;

4. Building momentum and connection within the Cwm Taf leadership community through a series of ‘Buzz events’ hosted for specific staff groupings

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e.g. senior leadership; nurses; therapists and health sciences; medical and multidisciplinary;

5. A multi disciplinary conversation series around service innovations which create a culture of clinical compassionate care;

6. Awareness of leaders impact in culture creation, including these themes in our monthly business meeting discussions;

7. Reflective practices in quality improvement through the use of critical incident learning; appreciative inquiry; story circles and Schwartz center rounds

Change-Ability and

Performance Enhancement

1. Series of development centres to access talent and potential to feed a succession planning pipeline;

2. Implement the all Wales NHS Manager competency framework;

3. Regular review of the organisation’s structure; management arrangements and process to ensure fitness for purpose;

4. Re-shaping the Workforce and OD functions; 5. Roll out IQT (Improving Quality Together) as the

service improvement framework; 6. Robust commissioning framework for all OD

workstreams to ensure executive sponsorship for each one; and alignment with corporate priorities.

7. Utilisation of impact assessment tools and techniques to evaluate outcomes from OD commissions

8. 10.Appropriate participation; learning and sharing at 1,000 Lives+ events

9. Bringing together clinical education; learning and development departments to offer a cohesive one stop shop development service which meets development needs which have been identified as corporate priorities.

10. Development of Performance Management framework

11. Drive Consultant and SAS doctors appraisal and PDR compliance to ensure development needs are addressed on an individual and collective basis.

____________________________

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9. FINANCE

9.1 Overview of the financial plan

The financial plan builds on the current 2014/15 to 2016/17 plan, and also the delivery in 2014/15, the first year of the plan. The Health Board is projecting breakeven in 2014/15 which will be a success given the challenging nature of the plan and a lower than average share of additional Welsh Government allocations. During 2014/15 there has been slippage in the delivery of savings plans and also lower recurring savings achieved. In 2014/15 the forecast breakeven position has only been achieved through slippage on investments and developments and other non-recurring measures. A recurring deficit of £9.4m is projected going forward into 2015/16 and this is the starting point for the 2015/16 – 2017/18 plan.

In 2015/16 significant additional resources of £29.1m are anticipated from Welsh Government. £16.7m of this is relatively certain, but the remaining £12.4m is subject to exactly how the total £80m unallocated Welsh Government resource is allocated to Health Boards.

The Health Board has been developing in recent months a plan for a range of inter-related innovative service changes across the health system which taken together will be critical enablers for achieving the priority objectives outlined at the start of the plan, and particularly the development of primary and community care to enable a re-focussing of care towards community settings. These enablers are also critically important to successfully deliver the South Wales Plan changes, which will have the greatest impact on Cwm Taf. The upfront costs of this package of change are significant and it is this which requires the head room funding of £12.4m as it cannot be afforded within the allocations already announced. This package of investment, and agreeing the additional Welsh Government funding without which it would be unaffordable, is an absolutely critical element of the plan. There is a major question as to whether the Health Board would be able to properly meet the challenges it faces over the plan period without this funding.

A further £2m has been set aside for internally prioritised service improvements and capacity shortfalls.

After meeting the costs of inflation and pay rises together with unavoidable cost and service pressures, £19.7m of savings are required to supplement the increased resources from the Welsh Government in order to deliver a balanced budget in 2015/16. This is around 4.3% of the controllable budget. £5.1m can be delivered through non-recurring means, and £14.6m through recurrent changes. The investment in service improvement outlined above is as critical in delivering key elements of the

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savings programme as it is in delivering improved care, a re-balancing towards the community and the South Wales Plan changes.

The financial plan is necessarily ambitious and challenging, given the financial environment the Health Board is operating in, and so it does have significant risks which are described in the plan, together with the associated mitigation plans.

9.2 Quality and Safety

The Health Board is committed to continuously take account of the context of the Triple Aim requirements as the 3 Year Plan for 2015/16 – 2017/18 is developed and assessed. These principles have been used in the development and implementation of cost improvement plans where triangulation of quality, performance and cost has meant that informed decisions have been made to manage risk and prioritise investments as well as deliver cost reductions.

9.3 Update on Financial Performance in 2014/15 The Health Board has recently submitted its M11 Monitoring Returns to Welsh Government. This showed a year to date (YTD) deficit of £1.9m and a forecast breakeven position for 2014/15. Our forecast recurrent deficit going into 2015/16 is £9.4m and the key elements are summarised below:

£m

Planned recurrent deficit going into 2015/16 as per the approved 3 year plan

6.8

Less: Assumed non recurring WG allocation in original plan that is now confirmed to be recurrent.

(8.0)

Add: Shortfall in assumed recurring terms and conditions savings in original plan (£5.5m in 2014/15 that is agreed to be covered non recurrently by WG)

4.8

Forecast recurring deficit against the approved plan (many of the measures taken in 2014/15 to achieve balance are non-recurring)

5.8

Total 9.4

The £9.4m forecast underlying deficit at the end of 2014/15 is the starting point for our medium term financial plan for the three year period 2015/16 to 2017/18.

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9.4 Summary of the Financial Plan For 2015/16 to 2017/18

The key assumptions driving our financial plan for the next three years are summarised below: • An underlying deficit at the end of 2014/15 of £9.4m.

• Additional recurring allocations from Welsh Government of £29.1m in

2015/16 and also a further £17.0m in 2016/17 and £11.7m in 2017/18 (See Section 9.5 for breakdown).

• Provision for recurring inflation, cost and service pressures of £19.0m

(4.2%) in 2015/16, £19.3m (4.2%) in 2016/17 and £19.2m (4.2%) in 2017/18. This includes pay increases from 2015/16 at circa 1% per annum plus incremental drift and non-pay increases from 2015/16 in line with projected inflation.

• Provision for the additional costs resulting from increased employer

pension contributions from 2015/16 and from the end of “contracting out” from 2016/17 have been made at £0.7m in 2015/16 and £5.6m in 2016/17. We have assumed that additional ‘consequentials funding’ of £5.6m will be received from the Welsh Government to meet the additional costs of the pension changes in 2016/17.

• Recurring investment in new service and delivery models of £2.0m per

annum for 2015/16, 16/17 and 17/18. Plus a further investment in 2015/16 of £12.4m in Primary & Community care & Innovation subject to Welsh Government funding.

• Non recurring costs and investment in change totalling £5.65m for

2015/16 reducing to £1.5m in 2016/17 and £2.0m in 2017/18. In 2015/16, £1.9m of this investment is linked to agreed new invest to save funding from the Welsh Government and £2m relates to the projected cost of retrospective CHC claims.

• Availability of Welsh Government strategic capital funding to support

the capital costs of the key changes included in the plan. Our 3 year capital plan includes a number of schemes in which are critical to deliver key service changes within our plan, many of which are key enablers for saving included in the plan. Without this funding, the relevant revenue savings within our plan could not be fully achieved.

• £43.2m of re-design and efficiency savings over 3 years (9.3% of

controllable expenditure) plus £5.1m of non recurring savings in 2015/16.

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• It is assumed that the depreciation costs of all future capital schemes are fully funded by the Welsh Government, in line with current policy. These additional costs and consequent non-cash backed allocation changes are not included in the financial schedules pending clarity on approvals.

The medium term plan is shown in the table below, with costs and deficits shown as positive numbers and income and surpluses as negative numbers. Based on the assumptions outlined above, this plan will deliver a break even position over the three year period.

The elements of the plan are described in further detail below.

Medium Term Financial Plan 15/16 to 17/18

Total

R= Recurring and NR = Non Recurring R NR Total R NR Total R NR Total

£m £m £m £m £m £m £m £m £m

Brought forward recurring deficit/-surplus 9.4 9.4 -0.2 -0.2 -2.9 -2.9

Share of further 2014/15 growth -14.2 -14.2 -17.0 -17.0 -11.7 -11.7 -42.9

Primary and community care & innovation -12.4 -12.4 0.0 0.0 -12.4

Pay inflation funding -2.5 -2.5 0.0 0.0 -2.5

New invest to save 15/16 -1.9 -1.9 -0.5 -0.5 -0.2 -0.2 0.0

Invest to save repayments 3.1 3.1 2.7 2.7 1.5 1.5 0.0

Income from commissioners -0.9 -0.9 0.0 -0.9

Income changes -30.0 1.2 -28.8 -17.0 2.2 -14.8 -11.7 1.3 -10.4 -58.7

Cost pressures and investments

Pay rises, incremental drift and inflation 5.7 5.7 6.5 6.5 6.3 6.3 18.4

UK national NI and pension changes 0.7 0.7 5.6 5.6 1.5 1.5 7.8

Service and demand pressures 13.3 13.3 12.8 12.8 12.9 12.9 39.0

Primary & community care investment 12.4 -1.5 10.9 2.0 2.0 2.0 2.0 16.4

New service and delivery models &

infrastructure2.0 2.0 2.0 2.0 2.0 2.0 6.0

Invest to save expenditure 1.9 1.9 0.5 0.5 0.2 0.2 0.0

Other non-recurring costs 3.8 3.8 1.0 1.0 1.8 1.8 0.0

Provider investments funded by

commissioners0.9 0.9 0.0 0.0 0.9

Sub total 35.1 4.2 39.2 28.8 1.5 30.3 24.6 2.0 26.7 88.6

Efficiency and re-design savings -14.6 -5.1 -19.7 -14.5 -14.5 -14.1 -14.1 -43.2

Sub total -14.6 -5.1 -19.7 -14.5 0.0 -14.5 -14.1 0.0 -14.1 -43.2

Total change on previous year -9.6 0.3 -9.4 -2.7 3.7 1.0 -1.2 3.3 2.2 -13.4

Revised surplus/deficit -0.2 0.3 0.0 -2.9 3.7 0.8 -4.1 3.3 -0.7 0.0

2015/16 2016/17 2017/18

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9.5 Allocation changes and other income changes

Guidance from the Welsh Government has identified three planning Scenarios for the period of the 3 year plan:

• Scenario 1= Base case - Flat in real terms – 2% cash increase per annum in years 2 &3

• Scenario 2 = Worse case – Flat cash – 0% cash increase per annum in years 2 & 3

• Scenario 3 = Best case– Flat in real terms plus funding to cover the ending of the Employers’ contracted out 3.4% rebate for salary –related pension schemes

The Cwm Taf Plan is based on Scenario 3 and the impact of moving to Scenarios 1 and 2 is explained in Section 9.11 – Key risks to the Financial Plan in Years 2 and 3. A summary of our assumed allocation changes and other income changes are shown in the table below.

Recurring allocation changes

2015/16 over

2014/15 £m

2016/17 over

2015/16 £m

2017/18 over

2016/17 £m

Further general allocation growth

(14.2)

(17.0)

(11.7)

Pay inflation funding (2.5) 0 0 Primary and community care & Innovation

(12.4)

0

0

Sub total (29.1) (17.0) (11.7)

Non recurring allocation

changes

Existing Invest to Save repayments

3.1 2.7 0

New Invest to save funding & repayment

(1.9) (0.5) 1.3

Sub total 1.2 2.2 1.3

Other income changes

Tier 4 CAMHs income from commissioners

(0.9) 0 0

Total (28.8) (14.8) (10.4)

The key points to highlight are as follows:

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• An additional recurring allocation is assumed (over and above the £8.0m in 14/15) of £14.2m in 2015/16. This is based on an 11.1% Cwm Taff share of total general allocation growth of £200m (i.e. £22.4m) in line with the allocation letter. We are also assuming Pay award funding of £2.5m for 2015/16 as per the Welsh Government letter of 6 February 2015, plus a further allocation if actual costs exceed £2.5m.

• An additional recurring allocation of £12.4m in 2015/16 for Primary and Community care development, continuing intermediate care investment and investment in innovation and technology to deliver the Health Board’s vision for transformation and enable the South Wales Plan changes. The Health Board has flagged up for some time the criticality of investment in these areas to enable the whole healthcare system in Cwm Taf to provide an appropriate and innovative response to rising demand and the specific requirements for greater pre-hospital differentiation and primary care resilience for the South Wales plan changes to be successful. No further allocation growth specifically to support transformation is assumed in 2016/17 or 2017/18.

• New income of £1.9m in 2015/16 is planned from agreed Cwm Taf bids

against the 2015/16 round of Welsh Government Invest to Save funding, and that this will be matched by equivalent spend in 2015/16, with repayment in part in 2017/18 (some repayment assumed in later years). Repayment of previous invest to save funding is scheduled; £3.1m in 2015/16 and 2.7m in 2016/17.

• New income of £0.9m has been agreed with WHSSC for Tier 4 CAMHS

in 2015/16, subject to delivery of agreed service levels.

• A total cash allocation of £17.0m has been assumed for 2016/17. This is based on 2% of our Total Revenue allocation (including primary care contracts) of £568m (£11.4m) plus a further £5.6m ‘consequentials funding’ to meet the additional costs arising from pension changes in 2016/17.

• A total cash allocation of £11.7m has been assumed for 2017/18. This

is based on 2% of our Total Revenue allocation (including primary care contracts) of £579.4m (i.e. £568m plus £11.4m).

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9.6 Inflationary and Service Demand and Cost Pressures The table below shows the projected inflationary, demand and other cost pressures for the next three years.

Table 1 - Recurring 2015/16 £'m

2016/17 £'m

2017/18 £'m

Inflation: Pay inflation and incremental drift

3.6 3.4 3.2

UK national NI and pension changes

0.7 5.6 1.5

Non pay inflation 1.3 1.3 1.3 Continuing Heath Care 0.7 0.9 0.9 Funded Nursing Care 0.1 0.1 0.1 Primary care contracts 0 0.7 0.8

Sub Total 6.4 12.0 7.8

Service demand & cost pressures:

NICE and new high cost drugs 1.7 1.7 1.7 Specialist Services and EASC 1.0 0.6 0.6 Continuing Heath Care 0.6 0.5 0.6 Funded Nursing Care 0.2 0.2 0.2 Primary care prescribing 3.5 3.5 3.5 Community pharmacy 0.3 0.3 0.3 Primary care contracts 0 0.8 0.7 Claims 1.2 1.2 1.2 Local cost, demand and service pressures

4.8

4.0 4.0

Sub Total 13.3 12.8 12.8

Total 19.7 24.8 20.6

The basis for the above estimates is outlined below.

i. Pay cost inflation

Pay cost pressures have been assessed to include

• An assumed overall wage award of circa £2.5m per annum for each of the three years. This is based on the confirmed funding for 2015/16, which covers the confirmed A4C staff award and the quantum assessment, based on 2% non consolidated Top of Scale, for medical and dental staff.

• Agenda for Change incremental drift which has been evidenced to still be impacting upon and increasing the cost of the workforce. The

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increases in recent years have been slowing down - £0.7m has been assumed for 2015/16 and £0.5m and £0.3m for subsequent years.

• Incremental drift for medical staff is projected at £0.2m in each year.

• Commitment awards for consultants are projected at £0.2m in each year.

ii. National Insurance and pension changes There are three separate cost pressures over the term of the three year plan:

• HM Treasury has published the final valuation and employer cost cap regulations and directions for the NHS Pension Scheme. This valuation measures the full cost of paying pension benefits and will inform the future employer contributions to be paid into the scheme. These results indicate a 0.3% increase of the employer contribution rate from 14% to 14.3% effective from 1 April 2015. This will equate to a cost pressure of £0.7m for Cwm Taf University Health Board in 2015/16.

• The introduction of the Single Tier State Pension in April 2016 will

coincide with the end of contracting out arrangements for salary related pension schemes. This change will result in the removal of the National insurance rebate for both employees and employers. NHS employers estimate that the impact of this change will be a rise in costs in excess of 2% of the pensionable payroll increase. This would equate to a potential cost pressure of circa £5.6m for Cwm Taf University Health Board in 2016/17.

• We have also included a cost pressure of £1.5m in 2017/18 in

respect of the additional costs associated with auto enrolment.

iii. Non Pay inflation

Following the approach taken in previous years, a matrix largely based upon the Health Services Cost Index (HSCI) has been developed and applied to 2012/13 accounts expenditure heads to derive an assessment of non pay inflation. To provide a more accurate assessment, colleagues from Welsh Health Supplies have provided estimates of inflation on medical and surgical consumables, provisions and external general service contracts. The assessed impact is £1.3m per annum over the three years of the plan.

iv. NICE and new high cost drugs

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The cost of NICE technical appraisals and nationally adopted high cost drugs has been a significant cost pressure in recent years. We have assumed annual increases of £1.7m for each of the next three years. This estimate includes £1.2m per annum for internal Cwm Taf growth plus a further £0.5m per annum for the anticipated growth in NICE costs at Velindre Trust and other Health Boards for Cwm Taf residents. It is important to note that no provision has been made in the Plan for the potential additional costs associated with new Hepatitis C treatments in 2015/16.This is included as a risk in Section 9.10- Key Risks to the 3 Year Financial Plan.

v. Specialist services and EASC

WHSSC growth trends in the cost of specialist services have run at between 1% and 2% in recent years, and this has previously been reflected in WHSSC advice as regards future plans. This equates to an estimated cost pressure for Cwm Taf University Health Board of £1.2m in each year for inflation and growth, and this is the provision made in each year of the 3 year plan, before the impact of commissioning prioritisation and savings. The £1.2m has been split between £0.6m assumed to be due to unavoidable demand pressures and £0.6m assumed to relate to discretionary service improvements, including those to address quality concerns or issues. The savings plan includes planned savings of £0.6m in 2015/16 and in each subsequent year to mitigate this £1.2m gross cost pressure to a net provision of £0.6m per annum. An additional provision of £0.4m is also included in 2015/16 for EASC. It is a major concern that emerging plans for WHSSC and EASC appear to be assuming additional investment by Cwm Taf of around £1.2 to £2m in 2015/16. This level of investment would be unaffordable to Cwm Taf, and is a significant risk to the plan.

vi. Continuing Health Care (CHC) We currently spend circa £27m per annum on external CHC placements. The anticipated cost increases for 2015/16 have been based on price inflation of circa 2.5% per annum (£0.7m) and volume growth of circa 2.5% per annum (£0.6m). Our plan also includes £0.3m for NHSFNC. It is important to note that no provision has been made in the Plan for any potential additional costs associated with the recent judicial review of the approach taken to FNC increases across Wales. This is included as a risk in Section 9.10- Key Risks to the 3 Year Financial Plan.

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vii. Primary Care prescribing

Trend data for 2014/15 and the previous 2 years is summarised below:

Gross PAR

Costs

CAT M and PPRS price

savings

Net PAR

£m £m £m

Actual out-turn 2012/13 69.1 (16.0) 53.1

Actual out-turn 2013/14 71.5 (17.4) 54.1

Forecast out-turn 2014/15 74.0 (18.5) 55.5

PLAN 15/16 (net of savings)

75.7 (18.1) 57.6

2013/14 growth over 2012/13- after savings

2.4 (3.4%)

(1.4) 1.0

2014/15 growth over 2013/14- after savings

2.5 (3.5%)

(1.1) 1.4

2015/16 growth over 2014/15 – after

planned savings

1.7

(2.3%)

0.4 2.1

The average growth in Gross PAR costs over the past 2 years has been circa £2.45m (3.5%). It is important to note that this is net of estimated savings of circa £1m (1.2%) per annum, and so the growth excluding the impact of savings average around 4.7% per annum. The financial plan for the next three years is based on similar continued growth before savings of £3.5m (4.7%) per annum. Our savings plan includes planned primary care prescribing savings of £1.8m in 2015/16 to mitigate the £3.5m gross cost pressure down to £1.7m. This equates to net growth after savings of £1.7m (2.3%), in comparison with an average the £2.45m (3.5%) over the last two years. The Full Year effect of CAT M and PPRS price changes made in 14/15 has resulted in a £0.4m reduction in the anticipated price savings in 2015/16 to £18.1m. No further CAT M or PPRS savings have been assumed for 2015/16 and subsequent years.

viii. Community Pharmacy

The anticipated cost increases for the next three years have been estimated at £0.3m for 15/16 and £0.3m for each of the subsequent two years. Our savings plan includes planned Pharmacy savings of £0.55m in

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2015/16 from the full year effect of 2014/15 price changes which will fully mitigate this £0.3m gross cost pressure in 2015/16 (but not in future years).

ix. Primary care contracts

The assumed cash allocations of £17m in 2016/17 and £11.7m in 2017/18 are based on 2% of our Total Revenue Allocations, which include allocations for General medical services, community pharmacy and dental services. The primary care element of the total allocations equates to circa £1.5m per annum in 2016/17 and 2017/18. This is matched in the plan with an equivalent spend on primary care contracts, split equally between inflationary pressures and service demand and cost pressures.

x. Welsh Risk Pool (WRP)

The cost of clinical negligence and other claims currently met by the Welsh Risk Pool will be met by LHBs in 2015/16. It has been agreed that the each LHB will receive an additional budget reflecting its share of the current Welsh Risk Pool budget and a risk sharing arrangement will be put in place such that all costs are shared between LHBs proportionate to their shares of the devolved budget. Claims are on a rising annual growth trend of around 10% per annum with an estimated All Wales cost pressure of circa £10m for 2015/16. A provision of £1.2m per annum has been included within our financial planning assumptions for each of the next three years.

xi. Local cost, demand and service pressures

Provision of £4.8m, £4.0m and £4.0m has been made over 2015/16, 2016/17 and 2017/18 respectively. A summary of the key components in 2015/16 is as follows:

Local cost, demand and service pressures £k

Agency costs within A&E and Pathology 1237

Demand increases (ageing population, 2014/15 trends) 896

Ward nursing cost pressures (regarding recuitment,

agency, absence management) 626

Reductions in 2014/15 income streams (eg RTA) 311

Trend increases in non-pay relating to demand

pressures & new drugs 300

Other 1430

Total 4800

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9.7 Investment in Change and New Service and Delivery Models The following table sets out the planned recurring and non recurring investments in change for the three year period:

2015/16

£'000

2016/17

£'000

2017/18

£'000

Non recurring costs including CHC retrospective claims and enabling of change

5.7

1.5 2.0

Recurring internal investment in new service and delivery models, quality & infrastructure

2.0

2.0 2.0

Recurring WG funded investment in Primary and Community care & Innovation

12.4 2.0 2.0

Recurring investment in Tier 4 CAMHs services funded by commissioners

0.9 0 0

Total 21.0 5.5 6.0

Non-recurring investment in change

Provision of £5.7m has been made in 2015/16 for the non-recurring costs of the change programme and to meet non-recurring cost pressures. The 2015/16 investment plan is summarised below and is partly funded through an agreed £1.9m Invest to Save allocation from the WG:

Table 2 – Non Recurring 2015/16

£'m

2016/17

£'m

2017/18

£'m

Invest to Save schemes 1.9 0.5 0.2

Retrospective CHC claims 2.0 0 0

Other non-recurring costs and transitional change costs

1.8 1.0 1.8

Total 5.7 1.5 2.0

Recurring investment in new service & delivery models, quality and infrastructure

Provision of £2.0m for new recurring investment is included in the plan for 2015/16 and also for 2016/17 and 2017/18. A high level summary of the key priorities for 2015/16 is provided below, which links with the Health

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Board priorities and service changes outlined earlier in the Plan, particularly in Chapter 7.

Recurring investment in Primary and Community Care & Innovation

The Health Board has been developing in recent months a plan for a range of inter-related innovative service changes across the health system which taken together will be critical enablers for achieving the priority objectives outlined at the start of the plan. Key areas of change and investment include:- • Strengthening core primary care. • Developing primary care cluster hubs and using them to help achieve a

shift from secondary care to primary and community care. • Greater integration with social care, and local authority and third

sector partners. • Implementing new secondary care models to improve effectiveness

and critically to enable RGH to play a full part in the health system without the full range of A&E, paediatric and obstetric services.

• Developing new workforce roles and models to facilitate all of the above.

These enablers are critically important to successfully deliver the South Wales Programme changes, which will have the greatest impact on Cwm Taf.

Proposals for investment in new service and delivery

models £k

WHSSC developments 600

Restorative dentistry 341

Radiology activity uplifts to meet demand and maintain

8 week targets, including partial move to CT

colonoscopy 300

Contracting & Commissioning - capacity 100

Consultant microbiologist 90

INR service review 80

Deprivation of liberties standards 71

Gastro posts 80

Rheumatology repatriation & service to Powys 75

Other 263

Total 2000

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The upfront costs are significant and this requires head room funding which cannot be afforded within the allocations recently announced. The Health Board has therefore brought these developments together into an integrated investment package, and is seeking Welsh Government funding for that package. Provision of £12.4m for new recurring investment is included in the plan for 2015/16 with a further £2m per annum for 2016/17 and 2017/18. The main areas of investment required for 2015/16 are summarised below. This package of investment, and agreeing the additional Welsh Government funding without which it would be unaffordable, is an absolutely critical element of the plan. There is a major question as to whether the Health Board would be able to properly meet the challenges it faces over the plan period without this funding. This risk is highlighted as a key risk in Section 9.10 - Key Risks to the 3 Year Financial Plan.

The detailed investment plans for 2015/16 are shown below for each of the categories described above: • Primary & community care. • Integrated Care • Innovation, technology and other required investments to support

whole system changes (including service and disease plans). Further information on what these schemes deliver and how that aligns with key objectives is given in the relevant sections of the plan. The 2015/16 Plan assumes non recurring slippage of £1.5m against the planned recurring investment of £12.4m.

Cwm Taf whole system innovation development plan Wte £k

Primary & Community care 97 7021

Integrated Care 54 2220

Innovation , technology and other required

investments to support whole system changes ( Inc

service and disease plans)

50 3159

Total 201 12400

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Primary & Community Care Wte £k

Development of the PCSU and locality hubs- GPs ,

pharmacists and specialist nurses13 1220

Inverse care law expansion 6 300

Medical practioners to support independent prescribing 1 50

Your medicines your health campaign 1 100

Cluster Hub priorities 6 260

Valley Steps Tier Zero Mental Heal Service 0 300

Community OPMH 16 480

Data warehouse and BI development 0 20

Weight management services 0 130

Primary & community eyecare service development 4 100

New GP Out of Hours model 0 492

Implement MTED 1 30

Audiology support to ENT to improve waiting times 4 115

CAMHs and Neuro development services 8 500

Primary care premises development 0 276

Risk stratification tool to support GPs 0 20

Investment in primary care team to support

management of change5 250

Support 5*band 5 practice nurse training via backfill of

acute nursing staff4 150

Support backfill for 2 band 2 practice nurses to gain ANP

qualification2 84

GP & practice mgt leadereship 0 56

Development of post operative cataract service 1 47

Development of glaucoma assessment service 2 64

Development of child refraction service 0 8

Change in INR costing model 0 42

LAC safeguarding 1 42

Volunteers co-ordinator 1 35

Research & development 3 100

Management capacity for change - additional posts

and/or external support3 100

Additional resources to enable primary care changes

needed to support the SWP changes,utilised initially on

SWP changes 15 1650

Total 97 7021

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Integrated Care Wte £k

Reablement from cognitive impairment(inc LA element) 2 120

Early supported discharge for stroke 8 308

Dietetic support for nursing homes 1 45

Therapies investment in PCH medicine 4 101

District nursing support to nursing homes 10 356

District nursing mobile working support 0 90

HMAS 5 160

Respite care in nursing homes 1 37

Development of single point of access 0 52

Increased access to Intermediate care 9 271

Training requirements for single handed equipment 0 20

Five ways to well-being 1 50

Community Co-ordinators 8 265

Neighbourhood Capacity Grant 0 100

Contribution to hospital based senior social worker

support0 100

Complex discharge team 5 145

Total 54 2220

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9.8 Medium Term Savings Plan 2015/16 to 2017/18 Summary

2015/16

£'m 2016/17

£'m 2017/18

£'m Total £’m

Efficiency and redesign savings

17.7 17.4 17.2 52.3

Contingency (3.1) (2.9) (3.1) (9.1)

Total recurring savings 14.6 14.5 14.1 43.2

Total non recurring savings

5.1 0 0 5.1

The total planned savings over the 3 year period of £43.2m represents a reduction of around 9.3% of the Health Board’s controllable expenditure (excluding capital charges and primary care contracts), around 3.1% per annum.

Innovation , technology and other required

investments to support whole system changes ( Inc

service and disease plans)

Wte £k

Data warehouse and BI development 0 25

Outpatient self check-in support 1 45

Emergency care flow co-ordinators 4 80

Extending acute physician service to evening and

weekends at the "warm" site9 968

Diagnostic hub transitional costs 0 100

E rostering for medical staff 1 85

Increased preassessment nurses 1 45

Endoscopy - demand and caapcity JAG, WG standards,

Decontamination requirements5 442

PCH -ANP T&O 1 43

New service to move to CT colon from barium scans 3 140

Better use of ESR including self-service 1 40

New approaches to HCA recruitment 0 40

Diabetes community specialist nurses 3 110

Liaison psychiatry 8 560

Acute medicine specialist nurses 6 186

Re-designed ophthalmology service model 7 250

Total 50 3159

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When developing our three year efficiency and re-design savings plans, we have been mindful of the requirement to phase in programmes of work to ensure a whole systems approach is being adopted and to target work on improvements where there is the biggest opportunity. To facilitate this, we have identified eight cross-cutting themes which we have used to plan and prioritise the development of the overall plan. This work is being informed by the benchmarking and other data referred to earlier in the plan. The eight cross cutting themes, as outlined earlier in the Plan are:

• Planned Care/Urgent & Emergency Care/Frailty • Service Redesign & Site Rationalisation • Outpatient Improvement and Patient Care Administration • Prescribing • Contracting & Commissioning • Workforce Productivity Improvement • Non Pay • Prudent Healthcare

For the purpose of the medium term savings plan, these have been identified within four categories of change:

• Whole Systems Re-design • Commissioning & Contracting • Service Productivity & Efficiency and; • Non Pay

Our medium term savings plans are summarised in the following two tables which show firstly the savings by overarching category/ theme for each of the three years, and secondly by the estimated impact on pay, non-pay, income and workforce.

2015-16 2016-17 2017-18 Total

Medium Term Savings plan ( 3 years from 2015/16 to

2017/18) £k £k £k £k

FYE of 2014/15 Savings schemes 1806 1400 1300 4506

Whole systems Redesign 2500 3000 2900 8400

Commissioning schemes 1151 1500 1500 4151

Service productivity & efficiency 7891 7000 6900 21791

Non pay management 4365 4500 4600 13465

Non recurring savings 5100 0 0 5100

Contingency -3067 -2900 -3100 -9067

Total 19746 14500 14100 48346

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The detailed savings plans for 2015/16 are shown below for each of the categories described above:- • Full Year effect of 2014/15 savings schemes • Whole systems re-design • Commissioning • Efficiency and productivity • Non-pay management • Non recurring savings Full Year effect of 2014/15 Savings schemes The 2014/15 savings schemes which will have a significant full year effect going into 2015/16 are show in the table below. The four main schemes are as follows:

• Bed reductions following significant improvements in patient flow. • Community pharmacy reimbursement scheme – full year effect of

Nov 2104 price changes. • Estates and facilities savings following the changes in service

provision at Dewi Sant hospital. • Facilities schemes linked to workforce redesign and productivity.

2015-16 2016-17 2017-18 Total

Medium Term Savings plan ( 3 years from 2015/16 to

2017/18) £k £k £k £k

Pay 8760 8600 8510 25870

Non pay -traditional and CHC 5288 5190 5130 15608

Non Pay - primary care prescribing 1800 1770 1750 5320

Non pay - acute prescribing 160 150 160 470

Non pay -other health boards 975 960 950 2885

Income - other health boards 176 180 170 526

Non clinical Income generation 555 550 530 1635

Non recurring savings 5100 0 0 5100

Contingency -3067 -2900 -3100 -9067

Total savings 19746 14500 14100 48346

Total WTE reduction from savings- before contingency 181 177 175 533

Total WTE reduction from savings- after contingency 117 118 112 347

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i. Whole systems re-design

The individual schemes for 2015/16 are set out in the table below.

The key changes are explained below:

• Patient flow £1.4m - we are building on the successful improvements in patient flow in 2014/15 and adding additional improvements to systems and pathways of care to further reduce the requirement for acute and community beds. These additional improvements include further improvements in implementation of the flow methodology, introduction of the Liaison Psychiatry Service and various improvements in community services funded non-recurrently from the Intermediate Care Fund in 2014/15, and extension of the acute physician service. This will enable bed numbers to be reduced in 2015/16 with planned savings of £1.4m.

Savings Plans Start Month Pay Pay Non Pay Income Total

FYE of 14/15 Savings schemes WTE £k £k £k £k

Bed changes made in 2014/15 1 0 600 0 0 600

Community pharmacy re-imbursement scheme 1 0 0 550 0 550

Dewi Sant site rationalisation 1 0 190 190 0 379

Facilities 1 0 92 31 0 122

Medacs Vantage scheme for agency doctors 1 0 80 0 0 80

Lease car flexible benefits 1 0 75 0 0 75

Total 0 1036 770 0 1806

Savings Plans

Start

Month Pay Pay Non Pay Income Total

Whole System Redesign WTE £k £k £k £k

Admission avoidance and length of stay reduction from

further flow improvements and community investment

and enablers 1 36 1200 200 0 1400

Planned care productivity (non core spend red'ns and/or

list reductions) 1 0 600 200 0 800

Maximising patient value from healthcare - prudent

medicine 1 7 200 50 0 250

Site rationalisation of Tonteg hospital 7 0 0 50 0 50

Total 43 2000 500 0 2500

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• Planned care productivity improvements of £0.8m- this comprises reduction in premium rate RTT spend and in theatre capacity, driven by improvements in theatre productivity and utilisation.

A number of these key enabling service improvements are assumed to be funded from the assumed Welsh Government funding for primary and community care development and innovation described above.

ii. Commissioning

The changes planned are shown in the table below.

The key themes underpinning our planned commissioning changes in 2015/16 are to: • Maximise opportunities for repatriation of Cwm Taf patients from

hospitals outside Cwm Taf where appropriate. • Ensure effective demand management and prioritisation of specialised

services.

iii. Efficiency and productivity

A wide range of schemes for achieving savings through improvements in efficiency and productivity have been developed, which are set out in the table below. This includes: • Shortfalls in delivery of 2014/15 directorate savings targets • Cross cutting themes • New directorate schemes for 2015/16

Savings PlansStart

MonthPay Pay Non Pay Income Total

Commissioning schemes WTE £k £k £k £k

ICD repatriation 7 0 0 150 0 150

Haematology repatriation 1 0 0 50 0 50

Rheumatology repatriation 1 0 0 75 0 75

CAVOC repatriation of simple T&O cases 1 0 0 100 0 100

Powys flows to PCH 1 0 0 0 176 176

WHSSC demand management and prioritisation 1 0 0 600 0 600

Total 0 0 975 176 1151

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Savings Plans Start Month Pay Pay Non Pay Income Total

Service productivity & efficiency schemes WTE £k £k £k £k

Recover 2014/15 savings target shortfalls

Acute Medicine 1 4 112 0 0 112

ACT 1 4 124 0 0 124

General surgery 1 0 5 0 0 5

Head & Neck 1 1 31 0 0 31

Localities 1 0 0 298 0 298

Children & Young people 1 0 9 0 0 9

O&G 1 0 16 0 0 16

Radiology 1 0 0 9 0 9

CAMHS 1 0 11 0 0 11

Mental Health 1 5 166 166 0 331

Medicines management 1 1 41 0 0 41

Estates 1 1 37 0 0 37

Corporate back office 1 7 273 0 0 273

Cross cutting themes

Outpatients 1 3 100 0 0 100

Patient care administration 1 2 70 0 0 70

Medical staff productivity 1 0 450 0 0 450

Specialist nurses and other non ward nurses 1 4 150 0 0 150

Salary sacrifice schemes & lease cars 1 0 100 0 0 100

General workforce productivity 1 0 150 0 0 150

Travel expenses 1 0 0 150 0 150

Directorate schemes

Facilities - workforce redesign, commercial

opportunities & productivity 1 18 603 340 555 1498

Acute medicine 1 3 100 100 0 200

General surgery 1 9 285 0 0 285

Head & Neck 1 2 86 0 0 86

Localities - Community nurse productivity 1 13 400 0 0 400

Localities - operations productivity 1 2 50 50 0 100

CYP 1 2 65 65 0 130

O&G 1 8 180 0 0 180

Pathology - recruitment of haematologists to replace

agency staff 1 -2 200 0 0 200

Pathology- operations productivity 1 7 200 0 0 200

Radiology - operations productivity 1 7 200 0 0 200

Therapies- operations productivity 1 8 250 0 0 250

Mental health -operations productivity 1 10 400 400 0 800

Mental health - community productivity 1 16 480 0 0 480

Medicines management - pay savings 1 1 50 0 0 50

ICT - capitalisation of staff costs 1 0 145 0 0 145

Estates- capitalisation of staff costs 1 0 150 0 0 150

Estates - 2% saving on balance of budget 1 1 35 35 0 70

Total 138 5724 1613 555 7891

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iv. Management of non pay

The Health Board has an established record of delivering non-pay savings. This will continue into 2015/16 and will focus on the following key areas: • A cross cutting theme on non pay management- £1.2m. • Bed lease contracts- £0.4m • Energy efficiency and awareness- £0.3m. • Potential switch between Lucentis and Avastin- £0.4m. • Primary care prescribing - £1.8m.

The individual schemes are shown in the table below:

v. Non recurring savings in 2015/16

Our financial plan assumes that the successful outcome of a number of non recurring income opportunities will yield net savings in the region of £5.1m in 2015/16.

Savings PlansStart

MonthPay Pay Non Pay Income Total

Management of Non pay WTE £k £k £k £k

Non pay management - cross cutting theme 1 0 0 1200 0 1200

Bed lease contracts 1 0 0 400 0 400

Energy efficiency from investment return, energy

awareness and underlying position 1 0 0 280 0 280

Voluntary sector SLAs 1 0 0 85 0 85

Acute prescribing- cross cutting theme 1 0 0 100 0 100

Acute prescribing - National procurement opportunities1 0 0 60 0 60

Potential to switch between Lucentis and Avastin 1 0 0 400 0 400

Primary care prescribing - Incentive schemes plus other

savings opportunities 1 0 0 1350 0 1350

Primary care prescribing - rebates for consumables in

the community 1 0 0 0 0 0

Primary care prescribing - use of stoma products in the

community 1 0 0 50 0 50

Primary care prescribing - use of enteral feeding in the

community 1 0 0 50 0 50

Use of diabetic consumables in the community 1 0 0 150 0 150

Use of urinary catheters in the community 1 0 0 200 0 200

Primary care - Home oygen contract 1 0 0 40 0 40

Total 0 0 4365 0 4365

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Efficiency and re-design savings in 2016/17 and 2017/18

While detailed plans have focussed on 2015/16, plans are also being developed for the latter two years, developing on the framework already in place. The key schemes in each of the overarching categories of change are as follows. These are reflected in the three year financial savings plan set out above.

i. Whole systems re-design

• Further improvement in patient flow and systems of care. • Using the planned 2015/16 investment in primary and community care

to reduce dependence on secondary services, and release resources. • Development of the role of outpatient consultations within patient

pathways. • An increased contribution from the application of prudent medicine

principles. • Further development of the Older Persons Mental Health model,

improving community and liaison services, enabling reductions in continuing assessment beds.

• Rationalisation of some services on to a single site, linked to the outcome of the South Wales Plan. Examples would include Pathology Regionalisation where the principal would extend outside the Health Board boundary.

ii. Commissioning

• Further development of prioritisation and development of models of

care for specialist services, including pathways and care models • Looking at the opportunity to concentrate specialist services on single

sites where appropriate • Further repatriation of services provided for Cwm Taf patients by other

Health Boards where appropriate.

iii. Efficiency and productivity

• Further development of productive working across a wide range of

settings - including in particular inpatients, theatres, outpatients, endoscopy, diagnostics, facilities and community services. This will require appropriate management capacity and technology as outlined previously.

• Further development of back office improvements, including salary sacrifice schemes (bringing the provision of salary sacrifice schemes within Shared Services), improved use of ESR and E rostering for a wide range of staff groups.

• Continued development towards an electronic medical record and increased use of electronic systems for referrals, order requesting and

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results reporting, enabling improved clinical information and reduced administrative staff costs.

• Systematic review of the banding of posts and the harmonisation of banding across the Health Board

• Further development of commercial activities for other health boards • Further improvements in energy efficiency, subject to securing the

necessary capital investment.

iv. Non-pay management

• Ongoing work on procurement, non-pay management including

prudent clinical selection of products, prescribing and management of continuing health care placements.

9.9 Balance Sheet and Cash Flow The Health Board is forecasting to have a positive cash balance at the end of 2014/15. The PSPP compliance for 2014/15 is projected at 88% over the whole year. This is below the target of 95% due mainly to systems and process issues early in 14/15. It is planned that monthly compliance will be back at 95% by April 2015. The projected working capital balances over the next three years are as follows:

2014-15 2015-16 2016-

17

2016-

17

£m £m £m £m

Inventories 3.6 3.6 3.6 3.6

Receivables 36.4 36.0 36.0 36.0

Payables (58.9) (55.0) (55.0) (55.0)

Provisions (31.6) (31.6) (31.6) (31.6)

Cash 0.5 0.1 2.9 2.9

Total (50.0) (46.9) (44.1) (44.1)

Delay in paying non-NHS

invoices at year-end

(£m/wks)

nil

nil

nil

The above projections assume that any movements in working balances not associated with a I&E deficit will be funded via cash assistance from the Welsh Government. It also assumes that there will not be a material change in payment patterns of other Health Boards to Cwm Taf. Clearly, this may be a risk should other Health Boards experience cash pressures.

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9.10 Key Risks to the 2015/16 Financial Plan The following outlines the key risks to the 2015/16 financial plan:

Risks to be managed by the University Health Board: The key risks to be managed by the Health Board include: • Shortfall in savings delivery against £17.7m target (see below) • Recurring deficit brought forward • WHSSC and EASC • Other In year unavoidable cost pressures We are assuming a further improvement in recurring savings delivery in 15/16 with a stretch target of a £3.4m shortfall against the £17.7m target. This expected improvement is dependant on our assumed £12.4m planned investment in new service models funded from new WG monies. This is because these new models are critical to releasing resources from the current patterns of care and spend. As shown above, a shortfall of £3.4m can be accommodated within the 2015/16 plan, provided the

Risk assessment of 2015/16 financial plan

Baseline

assumption

Action required to

achieve target

position

£kTarget

position

Downside

position

Worst

case

position

£k £k £k

Savings delivery short of plan -17700 Cwm Taf 3,400 6,800 10,000

Non recurring income opportunities -5100 Cwm Taf with WG 0 0 5100

Cost of developments assumed to be funded by WG but

not funded and still needing to proceed0 Cwm Taf with WG 0 3800 4800

New treatments for hepatitis C 0 Cwm Taf with WG 0 2500 3500

FNC rate increases 0 Cwm Taf with WG 0 ? ?

Recurring deficit brought forward from 2014/15 9400 Cwm Taf 0 500 1000

WHSSC commissioning (excluding EASC) 600 Cwm Taf 0 400 1600

EASC commissioning of WAST 400 Cwm Taf 0 400 400

In year unavoidable recurring cost pressures not

budgeted0 Cwm Taf 400 1000 1500

Slippage of expenditure from new WG funding -1500 Cwm Taf with WG 0 250 500

Surplus/deficit before contingencies 3,800 15650 28400

Recurring general contingency 0 Cwm Taf 0 0 0

Recurring savings contingency 3100 Cwm Taf -3100 -3100 -3100

Potential for inflation costs lower than budgeted Cwm Taf -700 -700 -700

Contingencies -3800 -3800 -3800

Surplus/deficit after contingencies 0 11850 24600

Scenarios

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£3.1m (0.5%) contingency is earmarked entirely for shortfalls against savings targets. This approach has been agreed with the Board.

Risks that require further discussion with Welsh Government

The earmarking of the contingency against savings risks means that there is no contingency available against the other key risks shown above:

• Risk that the allocation to Cwm Taf from the £80m additional funding to WG is lower than the £12.4m assumed in the plan, or is not able to be committed to the schemes which have been prioritised in the plan. This risk is assessed to be at least £3.8m.

• Risk that the £5.1m non recurring income opportunities will not be

realised in 2015/16.

• Risk of unplanned costs of new Hepatitis C treatments over and above the £1.9m provision already for additional NICE costs in the plan. An assessment has been made that this cost could be at least £2.5m.

• Risk of changes to FNC rates, including potentially retrospective changes, resulting from the judgement at the recent court hearing.

There are also a number of other potential risks which would require further discussion with Welsh Government if they materialise in 2015/16:

• The risk around the South Wales plan changes. We are increasingly clear about the planned changes and their cost, but there remains some uncertainty around the fine details and also a degree of delivery risk.

• The final cost of the 2015/16 pay awards remains within the plan assumption of £2.5m based on the Welsh Government letter of 6 February 2015.We are assuming that any additional financial consequences from awards made for medical and dental and other staff in 15/16 will be funded by Welsh Government.

• Securing approval for capital funding to deliver the schemes which are key to the achievement of re-design and productivity savings over the 3 year period.

Financial Risk Management Plans for 2015/16

The key elements of the approach within the Health Board to minimise these risks are as follows:-

• Further development of the capability and capacity to plan and deliver service improvement and change, including :-

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o Restructure of corporate departments to better align with and

support directorates in the delivery of change and savings, plus investment in the information team and in business intelligence tools.

o Continued development of the approach and infrastructure to plan and deliver cross-cutting savings programmes, including implementation of a Programme Management Office (PMO)

o Investment in management and clinical support within the primary care team

• Provision within the plan for the non-recurring costs of change,

including VER, pump priming and other transitional costs.

• Further increasing the rigour of requiring clear expected outcomes to be demonstrated before investment in re-designed services is approved.

• Development of more detailed options and plans for reconfiguration of services within the South Wales Plan and ensuring that value for money is maximised in those plans, including more detailed clinical models, patient flow predictions, staffing models and resultant financial plans.

• A savings shortfall contingency of £3.1m has been established within the financial plan, which equates to around 0.5% of total Health Board expenditure.

As regards the second category of risks which the Health Board cannot manage alone, the key actions regarding the 2015/16 risks are as follows:-

• To continue to engage with the Welsh Government to ensure that the planned Cwm Taf programme of investment will be funded through the additional resources available to the Welsh Government.

• To keep the Welsh Government closely informed on the Health Board’s progress to secure the £5.1m non recurring income opportunities in 2015/16 and to negotiate brokerage with the Welsh Government if these opportunities were to slip into 2016/17.

• To work up options for taking forward the new Hep C treatments and to work with the Welsh Government to agree a phased implementation plan and how any additional costs can be financed.

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• To liaise closely with the Welsh Government on the potential impact on FNC rates following the court judgement and how any increased costs can be financed.

• To continue working with other Health Boards to develop a single integrated plan for service reconfiguration under the South Wales programme, and to liaise with the Welsh Government regarding the service and capital and revenue consequences of that plan.

• To continue working with other Health Boards through the Management Group and the Joint Committee to improve the effectiveness of WHSCC commissioning.

• To progress capital business cases and seek approval decisions from Welsh Government in a timely way.

9.11 Key Risks to the Financial Plan in Years 2 and 3 As noted in Section 9.5, Welsh Government guidance has identified three planning Scenarios for the period of the 3 year plan:

• Scenario 1= Base case - Flat in real terms – 2% cash increase per annum in years 2 &3

• Scenario 2 = Worse case – Flat cash – 0% cash increase per annum in years 2 & 3

• Scenario 3 = Best case– Flat in real terms plus funding to cover the ending of the Employers’ contracted out 3.4% rebate for salary –related pension schemes

The Cwm Taf Plan is based on Scenario 3 and the impact of moving to Scenarios 1 and 2 is shown below:

Scenario 3 Scenario 1 Scenario 2

Best case Base case Worse case

(surplus)/deficit (surplus)/deficit (surplus)/deficit

£m £m £m

2015/16 0 0 0

2016/17 0.8 6.4 17.8

2017/18 (0.8) 10.4 44.9

Total 0 16.8 62.7

The other key risk for Years 2 and 3 is the risk of inflationary pressures in 2016/17 and 2017/18 not remaining within the assumed levels in the plan, and in particular the level of pay awards for these two years.

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There is relatively little Cwm Taf can do as an individual Health Board to influence the funding and inflation risks in the latter two years of the plan, but the Health Board will continue its dialogue with the Welsh Government on the management of these risks.

A summary of the financial impact of a worst case scenario for each and all of these risks is shown below in the format in which the Health Board is required to report risk to the Welsh Government. Because this reflects the worst case position on all risks it does very much exaggerate the real level of risk. After mitigation of these combined worst case risks the net risk for 2015/16 is £24.6m, and by 2017/18 it is £65.7m.

Summary of risks and mitigating actions 2015-16 2016-17 2017-18

£k £k £k

Savings delivery short of Plan 10000 18,000 24,000

Unavoidable recurring cost pressures 1500 2,500 3,500

Impact of not fully securing £11.9m additional WG

investment in 2015/16 . 4800 4,800 4,800

WHSSC and EASC service pressures exceed provision in

the plan 2000 3,000 4,000

Legal claims settlement slips to 16/17 5100 -5,100 0

Legal claims settlement not at level assumed in plan 0 2,000 0

Potential cost of New HEP C drugs not included in our

NICE forecast 3500 3,500 3,500

Slippage of expenditure from new WG funding less than

provision in Plan 500 0 0

Recurring deficit b/fwd from 14/15 1000 1,000 1,000

Potential cost implications of NHSFNC Judicial review ? ? ?

Actual pay increases in 2015/16 exceed Plan assumption

of £2.5m ? ? ?

Costs of South Wales plan service changes exceeds

provision in the plan ? ? ?

Insufficient Capital funding to meet service change reqs

reduces savings ? ? ?

Assumed WG cash increase in 16/17 to meet increased

pension costs not achieved 0 5,600 5,600

Assumed WG cash increases in 16/17 & 17/18 of 2% not

achieved 0 11,400 23,100

Actual pay increases in Years 2 & 3 exceed assumed

increase by 1% pa 0 3,000 6,000

Sub total : Downside risks 28400 49700 75500

Actions to mitigate risks -3,800 -6,700 -9,800

Total Net risk 24600 43000 65700

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10. ENABLERS

10.1 Information and Communications Technology Cwm Taf University Health Board IM&T Strategy and 3 Year Workplan was approved by the Board in December 2012. The strategy builds upon the strengths of the existing infrastructure and systems as enablers to our service redesign and improvement programmes. The strategy describes how IM&T can be utilised to support the challenge of delivering new ways of working to provide safe and effective care, streamline management processes, cut across traditional boundaries and support integration between Health Services, other Public Sector bodies and the third sector. The University Health Board recognises the real benefits of IM&T in terms delivering efficiencies and/or return on investment opportunities. The IM&T Strategy is based on the following 9 principles:

During the first 24 months of the workplan we have: • Improved the infrastructure allowing planned new systems to be

implemented more easily. • Provided Internet access to all Staff, Students and Patients through

use of “the cloud” • Moved all Wide Area Network services to PSBA with consequent

savings and improvements in resilience and speed. • Deployed Welsh Clinical portal, and working with NWIS to develop and

improve the system ensuring that speed and functionality has continued to improve.

• Upgraded the North and South Voice systems, expanding IP and telephony and replacing systems that are nearly 20 years old.

• Implemented an electronic CTG recording system, established from 2013 Health technology funds.

• Continued to replace older hardware and remove XP legacy systems.

• Achieving system rationalisation and consolidation; • Ensuring best use of resources; • Delivering innovation; • Effective partnership working; • Effective risk management; • Obtaining financial sustainability; • Demonstrating Value for Money and Quality; • Effective governance; • Improving data quality and performance measurement

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• Improved the use of Myrddin across all areas. • Deployed a single PACs imaging system (Fuji). • Completed major improvements to the Theatre system including

collaborative work with ABMUH.

Over the three years of the 2015/16 to 2017/18 plan we will increase the focus of IM&T in supporting improved clinical care, including both the quality and efficiency of care processes. This will include, in particular, the introduction of new technologies to support the move towards electronic health records and providing electronic systems and information availability which support the delivery of care in real time and across care pathways.

We will continue to focus on the deployment of national systems, reviewing the proposed new national strategy, but also ensuring that, where there is a local requirement that is not addressed, we ensure that the Health Board is not disadvantaged and make appropriate arrangements to resolve. Planned work for which resources have already been made available includes:

• Developing and deploying mobile solutions for Community staff including the provision of 250 Netbooks with mobile access to the Board desktop, and to develop increased access to appropriate systems from the desktop e.g. GPs systems., supported by Health Technology Funds.

• Continued major infrastructure refresh programme including: o Server rooms, investigating moves to a National data centre. o Servers. o XP and 2003 eradication. o Local hardware. o Expansion of MDFs project to release printer resource savings o Transfer of Adastra to hosted solution.

• WCP: o Deployment of Medicines Transcription and Electronic

Discharge (MTED) across a number of pilot areas. o Deployment of IHR, with the implementation of National audit

system. o Interfacing to Cardiology, Endoscopy, Maternity. o Increased Clinical documentation including Clinical letters

from Myrddin. o GPTR deployment of requesting from within GPTR within

Primary care. • Myrddin:

o Completion of Real time PAS. o Deployment of Text and remind service. o Deployment of full electronic referral and HERS2. o Clinic self booking booths.

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o Access to Clinical information via WCP. o Integration with TOMS to facilitate improved theatre

scheduling and use of theatre capacity. • Care records including the development of the national Welsh Care

Records system and localised improvements to the existing service including centralisation and digitisation.

• Business Intelligence: Improvements to the existing performance and Information systems and the development of a greatly improved Information data warehouse with inputs from all appropriate systems within the Board. Developing the business intelligence systems already procured (Qlikview, Qliksense and Microsoft) to facilitate the sharing of dynamic performance and information dashboards across the breadth of the Health Board, including to individual clinicians regarding their own clinical practice.

• Consolidation of single Radiology Information System. • Community Care Information System; working with NWIS on the all

Wales procurement of a system for Health and Social services. • Further Theatres system development with the addition of ABMU

Health Board to the collaboration. • Child Health; moves to a new 2015 version and consolidation. • Switchboard rationalisation, in concert with Facilities. • Review of Microsoft Office replacement requirements in future.

We will also develop business plans and capital funding proposals to deliver on the increased focus on the move towards electronic health records outlined above, including :-

• Selective digitisation of health records • Document management technology for making digitised records

available to clinicians at the point of use • Digital dictation • Clinical systems in specific areas (e.g. diabetes, ophthalmology) • Electronic prescribing

In terms of supporting our primary and community care plan, there are a number of key areas which require technology as a key enabler, some of which are identified in Chapter 3, section 3.5 under ‘Innovation’. These include: • an on-going need for easily accessible information/advice and

signposting to services for health, social care and voluntary sector services in one place;

• a system for better scheduling of the work of community teams; • systems for sharing of appropriate information across health and social

care services; • need to facilitate routine use of CVD risk assessment tool in practice

and in time extend to wider community venues;

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• a single point of IT access for health and social care services; • rapid access to ordering and test results needs to be evaluated to

ensure that it continues to meet current needs; • wider use of social media and mobile applications along with tele-

health; • mobile devices for community staff need to be the norm; • maximise the opportunity to use IT to improve communications

between secondary care and general practice and community pharmacy;

• in association with NWIS, Cwm Taf as the development bed for a link between MTeD and Community Pharmacies to support the discharge medicines use review service.

The scale of cost involved means that this is subject to securing Welsh Government strategic capital funding, but it is a critical enabler for the health board’s development plans. £12m has been included in the planned capital programme over the 3 year plan period. We will also continue to seek funding for individual elements of the programme through specific funding or bid processes, such as the Health Technology Fund, but given the inter-related nature of the planned developments, a strategic funding programme over several years would be the preferred approach, potentially starting with a Strategic Outline Case. The University Health Board will continue to use a structured approach to the development of our core infrastructure to lever the maximum benefits from existing equipment and systems, as well as allowing us to build capability and support the delivery of new systems that ultimately improve patient care and safety.

10.2 Capital & Estates 10.2.1 Estates

The Estate is one of the Health Board’s largest assets, and consists of a range of facilities and services which support all the Health Board’s activities in the delivery of healthcare for its catchment population. The Health Board agreed its Estates Strategy in 2014, updated from an interim strategy agreed in October 2012. The strategy describes the Health Board’s existing estate and broadly outlines known and potential changes proposed to it over the next 5 years. At the end of March 2014, the Health Board managed two District General Hospitals, five occupied community hospitals, and 27 health centres/clinics/support facilities. Within Primary Care, GPs own and

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manage a large number of premises, many of which the Health Board shares or utilises to some extent. The Estates Strategy describes the current condition of the estate, supported by a wealth of data that is submitted as part of the annual Estates and Facilities Performance Management System (EFPMS) returns. A summary of the key issues is outlined below: • Major improvements have been made in the condition of the estate

over the last few years, with 61% now built post-1995 and only 3% built pre-1945,

• Overall compliance against fire safety standards has improved considerably (86% of the estate compliant in 2012/13, compared with 74% in 2011/12), but work is still required to ensure that compliance against fire standards is improved at Prince Charles Hospital,

• The overall levels of risk adjusted backlog maintenance have reduced over the last few years with the sale of a number of old community hospitals. However,

o the data suggests that a significant maintenance backlog has built up at the Royal Glamorgan Hospital, which is now 15 years old, with increasing pressures on the building and the accommodation in terms of overall space, functional suitability, and life span of major areas of plant / equipment,

o Dewi Sant Hospital also requires work to bring this up to standard if it is to continue to be a major site in the Health Board’s portfolio,

o A significant increase in expenditure is required to reduce the overall backlog maintenance costs,

• There are a number of primary care practices in poor condition which will need to be addressed as part of the Primary Care Estates Strategy. In the past, the development of new Primary Care premises has been achieved largely through the use of third party developers with funding support for any increased revenue costs met by Welsh Government. This funding is no longer available and work on primary care premises has been on hold for some time pending agreement of an alternative funding model.

In terms of energy management, the Health Board recognises that the consumption of energy and water is necessary for the provision of healthcare services, but that it also has a responsibility to be energy and resource efficient by minimising unnecessary energy usage. The Health Board has already invested in various low or zero carbon technologies which will help drive it to a zero carbon emitting organisation. However, the current level of consumption (436 kWh/m2) is rated as an amber performance nationally and improvements are required to reduce consumption to at most 410 kWh/m2.

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The Health Board has therefore agreed an Energy Management Plan which commits the organisation to a 7% reduction in consumption year on year. This includes the introduction of an energy awareness campaign together with a range of capital schemes identified to reduce usage. Much of this plan is dependent on capital becoming available. The Health Board’s 3 Year Integrated Plan sets out a number of service changes, many of which will have a significant impact on the estate. The Estates Strategy sets this out in more detail, but some of the more major impacts include: • A major redesign of services provided from the Royal Glamorgan

Hospital, which will require capital refurbishment as an enabler. This will include the development of the Diagnostic Hub, transfer of palliative care services onto the site, centralisation of breast services and a number of changes arising from the South Wales Programme including the introduction of a Paediatric Assessment Unit and Acute Medicine model.

• Establishment of a ‘health park’ type facility on the Dewi Sant site, with a mix of primary and community health care, social care and third sector partners using the site for ambulatory care. Again, capital will be a major enabler.

• Service remodelling which will see Tonteg Hospital and Pontypridd and District Cottage Hospitals becoming surplus to requirements, and further reviews on-going to determine whether any further community premises may be vacated in future.

• Recent purchase of a building to provide a centralised medical records storage facility.

Over the coming three years, the strategic objectives for our estate are to ensure that: • The estate is developed to meet emerging service models. • All statutory and safety obligations are achieved. • Backlog maintenance levels are reduced year on year to a nominal

amount by 2017/18. • Performance against the 6 national targets is improved, with the 90%

target achieved by 2017/18. • The cost per square metre is reviewed each year, reducing it if

possible, taking account of the safety of the service.

10.2.2 Capital

The Health Board recognises the importance of ensuring that strategic links are made between significant service change plans and capital

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investment. The capital programme is therefore fully aligned to the service and estate priorities set out in this plan. Availability of Welsh Government strategic capital funding to support the capital costs of the key changes included in the Plan are key. Our 3 year capital plan includes a number of schemes in which are critical to deliver key service changes within our Plan, many of which are key enablers for saving included in the plan. Without this funding, the relevant revenue savings within our Plan could not be fully achieved. The Health Board has received approval of the Outline Business Case for the major capital scheme to refurbish the ground and first floors at Prince Charles Hospital. This scheme is fundamentally designed to ensure that the organisation can meet its strategic aim to deliver statutory and safety compliance, and will meet the requirements of the outstanding fire enforcement notice in that area. However, the scheme also provides the opportunity to redesign patient flows, deliver service efficiencies and transform the patient experience. Work is now on-going on the development of the Full Business Case. Major capital investment is required to implement many elements of the Health Board’s 3 Year Plan. The Health Board has submitted to the Welsh Government a set of priorities for capital investment for the coming years, with schemes that enable service model changes, facilitate performance and efficiency improvements and maintain the Health Board’s assets (estate and equipment) to a high standard. Specific schemes include:- • Prince Charles Hospital ground and first floor refurbishment. • Schemes to enable service model changes:

o Palliative care remodelling to facilitate the move of palliative care services currently at Pontypridd and District Cottage Hospital (P&D) to RGH and close P&D.

o Redesign of the Royal Glamorgan Hospital to facilitate the outcome of the South Wales Programme, including the development of a Diagnostic Hub and suitable accommodation to meet the emerging requirements of emergency/acute medicine.

o Creation of a new, expanded paediatric, obstetric and neonatal service at Prince Charles Hospital to enable the outcome of the South Wales Programme

o Reconfiguration of the Dewi Sant site to enable the development of a Health Park facility.

o Strategic programme to develop the primary care estate.

• Schemes to facilitate improvements in performance and efficiency: o Major ICT investment to enable the move towards electronic

health records, for example including electronic prescribing, document management technology, digital dictation and digitisation.

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o Energy management improvements to secure revenue reductions.

o Centralisation of medical records storage. o Centralisation of switchboards across the Health Board.

• Major radiology and catheter laboratory modernisation programme. • Discretionary Capital Programme.

A number of these proposed schemes relate specifically to the organisation’s quality and financial plans with capital funding required to facilitate the changes in service models that will lead to achievement of cost reduction plans. Work is on-going to ensure that the appropriate business cases are developed and submitted. Elements of this investment plan are already acknowledged by the Welsh Government and included in the future All Wales Capital Programme, including the refurbishment of the ground and first floor at Prince Charles Hospital. The Welsh Government provided a significant level of additional capital funding in 2014/15 which could be used at the Health Board’s discretion. This has allowed the Health Board to address a number of high risk areas through significant medical equipment and ICT replacement, and has also enabled the implementation of a number of corporate priorities aimed at improving performance including an outpatient self check in system and a business intelligence system. The Health Board will continue to take advantage of any other funding opportunities or routes which become available, such as the Health Technology Fund, ‘Invest to Save’ and Integration Funds. The Health Board’s Capital Plan assumes at the moment that there will be an uplift of nearly £1m of discretionary funding in 2015/16, as announced recently by Welsh Government. The primary use of discretionary funding will be to replace equipment and maintain the estate to ensure future sustainability of service. There will however be an element that will be used as an enabler to support other aspects of the Estates Strategy, including the energy management plan, and smaller service/estate improvement plans. In summary, the following reflect the specific priorities for the coming year outlined in the Capital Plan and the Estates Plan:- • Commencement of the refurbishment of ground and first floors at

Prince Charles Hospital (PCH) to meet the requirements of a live Fire Enforcement notice, but also to redesign and relocate service departments to improve quality of services and meet modern accommodation standards,

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• Creation of a new and expanded paediatric, obstetric and neonatal service at PCH in line with the outcome of the South Wales Programme,

• Significant changes to the Royal Glamorgan Hospital (RGH) site, - developing a programme for plant / equipment replacement to

ensure that the hospital remains at physical condition and statutory compliance category B

- creating a site development plan for the hospital to accommodate all of the changes outlined - developing a suite of business cases to secure capital to enable these changes to be implemented,

• Agreement of a Primary and Community Care Estates Development Plan, supporting the delivery of a Primary and Community Care Strategy, including urgent consideration and agreement with Welsh Government on a funding model,

• Development of the Dewi Sant site into a Health Park facility, with consideration being given to how Ysbyty Cwm Cynon (YCC) and Ysbyty Cwm Rhondda may also be able to contribute to this service model in their respective communities,

• Continued review of office accommodation, with the introduction of an agile working policy to improve space utilisation and to facilitate the transfer from YMH in 2016,

• Continuation of a disposal programme, with disposal of Pontypridd and District Cottage Hospital and Tonteg Hospital planned for next year, and a review of community premises to determine whether there are further opportunities for site rationalisation,

• Development of a recently procured new site to facilitate the centralisation of medical records storage,

• Continuation of benchmarking of costs against English and Welsh providers,

• Negotiations with WG to secure the significant levels of capital to enable change.

• Review priorities for the Discretionary Capital Programme, taking into account the needs of the organisations 3 year plan;

• Undertake a range of actions as outlined in the energy management plan, including in particular continuing to seek capital funding for the major schemes required to reduce consumption.

___________________________

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11. DELIVERY, STEWARDSHIP & GOVERNANCE

11.1 Planning Approach The integrated planning approach that the Health Board has used to prepare its Plan, builds on the strengthened processes introduced over the last two years, marking a significant change from the approach used in previous years. This approach recognises that the Health Board has three main areas of focus in planning and monitoring improvements over time:

• Developing clear long term strategic objectives for the Health Board which will frame the development of short and medium term service improvement plans.

• A clear (and rolling) set of priorities for improvement over the next three years.

• A clear understanding of the steps which are required in the short to medium term (1-3 years), to underpin the successful delivery of the Health Board’s longer term objectives and priorities, aligned with those of NHS Wales.

The planning approach for the development of our Plan has been designed as a two-fold process; developing Directorate/Locality/Corporate ‘bottom up’ and owned plans within a Local Planning Framework (LPF) and in parallel, developing plans based on cross cutting themes & other organisation wide plans. The building blocks of our Local Planning Framework (based on the national planning work) involved the development of organisation wide ‘opportunities’ using benchmarking and closer integration between service, quality, performance, workforce and financial plans.

Using this structured model of integrated planning, we are driving our local planning process to ensure that we achieve ‘read across’ for the expected outcomes we identify and their impact not only measured in terms of workforce, finance and performance, but specifically to assess their impact on patient experience, quality and the principles of prudent healthcare.

As part of the ongoing development of integrated planning in the Health Board, we have further developed our LPF to build on our local Directorate, Locality and Corporate plans to ensure that we continue to strengthen and develop plans that are realistic, measurable and attainable. In particular for this planning cycle, we maintained our focus on:-

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• ‘What are we doing that could be done better’? – e.g.

productivity & efficiency

• ‘How do we change the way we do things’? – e.g. service shifts,

prudent healthcare

• ‘How we fundamentally change what we do’? - e.g. whole

systems change across a health economy; working with partners

and the public/patients (co-production).

In addition, we have continued our focus on delivery through the development of a local planning assurance and approvals process for our local plans and cross cutting theme plans. Maintaining our strong delivery focus, we have further developed our formal assessment and approval process for our local plans with our focus on assessing them using a ‘maturity matrix’ structure. This year’s process built on the previous year and consisted of structured feedback sessions to inform final Directorate & Cross Cutting Themes Plans. This feedback process took place during January, February and March in order to inform final plans. As part of the planning a delivery arrangements, there is a formal ‘sign off’ process off by the Operational Directors, supported by a corporate Executive Board approval process. This is an area of our planning process that we will continue to develop and in particular, we are using opportunities to use a peer review approach and Directorate learning sessions to share best practice. Our intention is to further strengthen our planning and delivery approach as part of our journey of clinically led transformation. Chapter 7 on our service change plans demonstrates how we have developed this planning model using our pathways based approach, providing the structure for the presentation of our service plans and deliverables. The development of the Plan has been an iterative process underpinned by a comprehensive formal and informal engagement process led by Executive Directors, predicated on open and honest discussions which reflect the challenging environment in which we are operating. As an iterative process, we have developed our plan using this formal and informal feedback. In addition we participated in the NHS Led Peer Review process which was facilitated by the Good Governance Institute in early December 2014 and we have responded to this feedback in our Plan. We will continue to use this formal and informal approach to underpin our communication, engagement and consultation processes and a copy of our Engagement Plan can be found at Annex A5.

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The Health Board is committed to principles of genuine citizen and staff empowerment and we will continue to work with our partners to develop and strengthen the planning and prioritisation process. We will also continue to evolve our planning processes by learning from the experiences of the last year and reflecting on feedback from all those involved. In addition to the Engagement Plan, our local planning timetable is described in the table below:-

Table 1 Local Planning Timetable

Cycle Component

Key Milestone

Date

Plan

Development

Local Planning Framework developed by Core Planning Group and issued to Directorates (Clinical, Localities & Corporate).

27 October

First ‘corporate’ refresh of the current 3 Year Plan (2014 – 2017) in accordance with National Planning Framework.

31 October

Updated Health Board 3 Year draft Plan 2015 – 2018 discussed with Health Board Executive Board.

19 November

Updated Health Board 3 Year draft Plan 2015 – 2018 discussed with Finance & Performance Sub Committee

27 November

All Clinical & Corporate Directorate Plans and Cross Cutting Theme Plans received.

28 November – 13 March

Updated Health Board 3 Year draft plan 2015 – 2018 discussed at Board development session.

5 December

NHS Peer Review 15 December

Health Board 3 Year draft Plan 2015 – 2018 discussed with Health Board Executive Board.

17 December

Plan Approval

Final 3 year draft Plan 2015 - 2018 to Board for approval

21 January

Submit ‘Final draft Plan 2015 – 2018 to Welsh Government

30 January

Welsh Government assurance and scrutiny process

February – March 2015

Respond to feedback from scrutiny process and amend plan accordingly.

March 2015

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Board to approve final version and submission to WG

31 March 2015

Plan Delivery

Delivery agreements for approval Health Board 3 Year Plan 2015 – 2018 detailed in Directorate & Cross Cutting Theme Plans

February – March 2015

Approval of Directorate & Cross Cutting Theme Plans

March 2015

Executive Programme Board & Clinical Business Meetings

Monthly ongoing

11.2 Delivery Model The Health Board has a very strong delivery focus, which has developed year on year since the original turnaround programme. The turnaround approach was highly intensive, but principally financially focused, which has limitations in an NHS setting. Over the last three financial years we have developed our governance in relation to delivery and we now have a more blended approach to quality, safety, performance and finance, which retains the intensity, pace and focus of our initial recovery but has moved into delivering a much more transformational agenda. Over the last two years the Health Board has sharpened its focus on a number of key priorities. This means that the Health Board’s significant investment in day to day governance is being appropriately utilised to gain maximum return for the communities we serve. Our focused approach to delivery will continue by the development (and where appropriate use) of: • More sophisticated benchmarking data; • More clarity on the further opportunities that each directorate has for

improvement; • Cross cutting activities that can be pursued with executive led

projects; • A matrix/programme management model that tracks directorate and

locality performance against their plans, as well as cross cutting activities undertaken by several directorates;

• A reinforced approach to managing these activities with robust governance and focused performance management; and

• A delivery framework that supports delivery through our directorates and localities, underpinned by specialist advice and a programme infrastructure.

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11.2.1. Benchmarking

We maintain our focus on benchmarking as a business intelligence tool and we intend to continue to: • Develop clear information on the comparative spend per head of

population on the services (commissioned and provided) by the Health Board and key drivers for that comparative spend in terms of both activity levels (relative access rates) and unit costs (relative productivity). The comparative cost per head would ideally be based on cost per head of population weighted for age and deprivation. However, there is not currently an agreed basis of defining weighted population for each Health Board in Wales this way and certainly not one that would allow comparisons across the UK. We are therefore comparing our spend per ‘un-weighted’ head of population for each service with those of identified Primary Care Trusts (PCTs) in England with comparable population characteristics – Durham, Middlesbrough and Sefton.

• The volume and productivity drivers for variations in overall cost are planned to be developed as follows: volume in terms of activity per head of population for each service will be compared with the average for the three PCTs above. This is currently being undertaken for the Health Board by CHKS. We have asked for this to be broken down, for example, by specialty, patient type, Healthcare Resource Group (HRG).

• Productivity at an overall specialty/service level will be assessed initially by comparison of Cwm Taf reference costs and unit costs with those of other LHBs. However, we will then go on to consider how to compare reference costs with those in England, including what adjustments are necessary to achieve this.

The aim of this process is to build a picture of the relative spend on each specialty or service and the extent to which variances against comparable organisations are driven by volume as against productivity.

11.2.2 Opportunities for Improvement We will continue to use an “opportunities register” approach that will utilise comparative (performance, quality, workload and cost) statistics covering all of the Health Board’s clinical and support services. The aim is to encourage the use of benchmarks and other comparative data to develop efficiency and effectiveness within the organisation, including potential savings opportunities. This approach is to strengthen evidence based planning and build the momentum for ongoing improvement in the organisation. This will also support the Health Board to strengthen its business intelligence.

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11.2.3 Cross Cutting Themes

Directorate and Locality Plans on their own are likely to achieve less if they are drawn up and delivered without integration with the rest of the organisation and with partners. We are therefore committing ourselves to a further year of cross cutting plans. There are two particular ways in which cross cutting plans can add value:

• Economies of scale and expertise in looking at difficult problems being faced by some or all directorates and localities (e.g. outpatient productivity improvement).

• Avoidance of ‘silo’ working which is sub-optimal for the organisation as a whole.

When developing medium terms savings plans as a Health Board, we have been mindful of the requirement to phase in programmes of work to ensure a whole systems approach is adopted and to maintain equity across the Health Board. To facilitate this, as can be seen earlier throughout the Plan, we have identified those cross cutting themes where we believe there is greatest gain from a focussed cross cutting project process. This year and into next year, are eight themes are as follows: • Planned Care/ Urgent& Emergency Care/ Frailty • Service Redesign & Site Rationalisation • Outpatient Improvement and Patient Care Administration Prudent

Healthcare • Prescribing • Contracting & Commissioning • Workforce Productivity Improvement • Non Pay • Prudent Healthcare In terms of delivery and governance, the approach we are following is based on a programme management approach and is essentially the way in which we create a linkage between the directorates and localities service change plans and the cross cutting themes; and keep track of quality and finance and performance targets to support delivery. This is described in the diagram below:

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This model is designed to ensure that we utilise a ‘whole system’ approach to the delivery of our three year efficiency and re-design savings plans. It recognises that we will need to phase in programmes of work, as well as targeting work on improvements where there is the biggest opportunity. This includes the importance of assessing the impact on quality and patient experience using our Quality Impact Assessment Tool. As outlined above, this ‘programme planning and delivery approach’ is a key part of our local planning and delivery cycle which will prioritise deliverables and establish a clear delivery framework with performance management arrangements. This has already identified: • Directorate and Locality integrated business plans with delivery

managed through Clinical Business Meetings; • Cross-cutting themes that are underpinned by clear programme

management and project implementation plans, led at Executive level with Executive level oversight;

• Model of Continuous Improvement e.g. using business intelligence; reflecting benchmarking;

• Continued process of communication, engagement, consultation and approvals, including the development of a robust assurance and approvals process for our local plans.

11.2.4 Governance for Delivery

The Health Board has four important set pieces that will ensure the activities outlined above are appropriately managed, these are: • Clinical Business Meetings – where a small core of Executives meet

on a monthly business with the clinical and managerial leads of each directorate to provide oversight and performance management of the entire operation;

• Corporate Business Meetings – where a small core of Executives meet on a bimonthly basis with the managerial leads for each major

Cross Cutting Themes 2014/15 and beyond

ACT

Acute

Medicine Surgery

Head &

Neck

Obs &

Gynae Paeds Therapies

Mental

Health CAMHS

Localities

& Primary

Care

Clinical

Support

Facilities &

Estates

Other

corporate

directorates

Outpatient Improvement & Patient Care

Admin

Prudent Healthcare

Prescribing

Workforce Productivity & Improvement

Scheduled/Unscheduled/Frailty

Service Redesign & Site Rationalisation

Contracting & Commissioning

Non Pay

Key

Directly relevant

Indirectly relevant

Largely irrelevant

Directorates

Cross Cutting Theme

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corporate function to provide oversight and performance management;

• Operations Board – where the Chief Operating Officer oversees his cluster of cross cutting themes and associated activities to achieve medium to long term improvement trajectories;

• Executive Programme Board (EPB) – where all the Executives meet on a monthly basis to give oversight and coordinate all of the performance and improvement activities in the organisation. The EPB reports on a quarterly basis to the Executive Board.

Our performance management arrangements outlined in the table below provide further synergy to this delivery model:-

Forum Performance Management University Health Board - Integrated Performance Dashboard

- Quality and Finance Reports - Annual Service Delivery Reports - 3 Yr Plan Progress Report - Sub-Committee Reports - External Audits and Reviews

Integrated Governance

Committee

- Sub-Committee Reports - External Audits and Reviews

Board Sub-Committees - Integrated Performance Dashboard - Quality and Finance Reports - External and Internal Audits and

Reviews

Executive Board - Integrated Performance Dashboard - Quality and Finance Reports - Annual Service Delivery Reports - 3 Yr Plan Progress Report - Business Case Approval

Executive Programme Board Delivery Programme Highlight Report Project/Cross-cutting Theme Highlight Reports Overall plan delivery tracking

Clinical Business Meetings Local Dashboard monitoring Progress / Highlight reports

Corporate Business Meetings Local Dashboard monitoring Progress / Highlight reports

To further support delivery, we aim to provide the necessary specialist advice and programme infrastructure to Directorates and Localities with the support of a Programme Management Office; also enabling clinical engagement and encouraging clinical leadership is a key tenet of this approach.

The principles of this are outlined in more detail below:-

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• Prime business partner support is provided to Directorates and Localities via nominated leads for planning, information, patient care & safety (PC&S), workforce and financial support.

• Where additional support or local expertise is required, this will be provided from temporary backfill or redeployment e.g. certain numbers of clinical sessions for specific purpose/project

• Internal support made available from a small programme management office/central delivery support unit (PMO/DSU) provides the opportunity to build up and develop specialist local expertise on improvement and change management

• External support by exception e.g. where specific expertise is required and not available internally or if there are capacity problems.

The following diagram summarises the totality of our delivery model:- Delivery Model

11.3 Corporate Governance The Health Board has in place maturing governance and assurance arrangements, which has received support from the Wales Audit Office, following their initial structured assessment process. Indeed these arrangements have been developed and strengthened further during the last year and been further recognised within their 2014 assessment. Our delivery, governance and assurance arrangements are built on an organisational culture that is based on listening and learning which directs

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its role in determining policy and setting strategic direction and also ensures that there are effective internal control mechanisms for the Health Board that demonstrate high standards of governance and behaviour. This is of course, set against a back drop of the Health Board ensuring that it remains responsive to the needs of its communities. The system of internal control is informed by the work of Internal Auditors, Clinical Audit and the Directors within the organisation who have responsibility for the development and maintenance of risk assurance and internal control frameworks comments on this are made by External Auditors in their Annual Audit Report and other reports. In addition the work of Healthcare Inspectorate Wales (HIW) in both their planned and unplanned work and other regulators is utilised. We also have a very active Community Health Council who undertake a comprehensive visiting programme and their feedback and engagement with the Health Board is a key assurance tool utilised by the organisation. During 2014/15 the Board has held a workshop on the development of a new Board Assurance Framework (BAF) aligned fully to its 3-year Plan. The Board approved a new framework at its Board meeting in March 2015. The BAF is predicated on the UHBs 3 Year Plan and also maps the business of the Board and its Sub-Committees against its 5 key organisational objectives. The Board also reviewed and approved its annual plan of business for 2015-2016 at this meeting, ensuring monitoring and scrutiny of the delivery of plan featured prominently within it. The BAF is designed to support the Board to deliver its Strategy as outlined within its 3 Year IMTP 2015-2018. The framework also serves to inform the Board on principal risks threatening the delivery of the UHB’s objectives. The BAF aligns principal risks, key controls, its risk appetite and assurances on controls alongside each objective. Gaps are identified where key controls and assurances are insufficient to mitigate the risk of non-delivery of objectives. This enables the Board to develop and monitor action plans intended to close the gaps. Board responsibility for the Board Assurance Framework

It is the responsibility of the Board to:

• Determine its Strategic direction and related objectives; • Identify the principal risks that threaten the achievement of these

objectives; • Agree its “risk appetite” recognising the interdependencies of

objectives and the impact of mitigating risks on one may adversely impact on others;

• Agree the key strategic and operational plans that will deliver those objectives and which encompass the controls and actions in place to

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manage the identified risks; • Monitor delivery through robust performance and assurance

arrangements; • Ensure that plans are in place to take corrective action where there

is minimal assurance that agreed objectives will be fully delivered; • Sustain and uphold dynamic risk management arrangements (in

particular an up to date and well maintained risk register) The Audit Committee has oversight on behalf of the Board on:

• the adequacy of the assurance processes • the effectiveness of the management of principal risks

In line with current arrangements, each principal risk is designated to a Board Sub-Committee which has responsibility on behalf of the Board to seek assurance that those risks are being managed in accordance with the agreed risk appetite and approved plans.

THE ASSURANCE FRAMEWORK IN ITS OPERATIONAL CONTEXT

At a high level, the following schematic represents the Board Assurance System.

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To ensure appropriate assurance arrangements are in place the Board is supported by a number of sub committees, namely, the Integrated Governance Committee; the Audit Committee; the Quality and Safety Committee; the Corporate Risk Committee; Remuneration and Terms of Service Committee; Mental Health Act Monitoring Committee, the Finance & Performance Committee and the Primary Care Committee. These key Committees of the Board scrutinise Executive Director delivery of the Board’s strategic priorities and will closely monitor and scrutinise the delivery of the integrated 3 year plan, along with the Board who are actively engaged in its ongoing development. Patients and the public have an important role to play in proactively participating in their care and it is important that the organisation addresses this requirement in its governance arrangements. The University Heath Board has recognised that work is needed to introduce a more co-ordinated approach to ensure the patient voice is proactively informing service delivery and more importantly to ensure that information captured is readily available for reporting to Board on ‘lessons learned’ and implementing changes to working practices.

GOALS AND OBJECTIVES Strategic goals, objectives

agreed through 3 year Integrated Business Plan

CONTROL ARRANGEMENTS - Operational plans - Performance Framework - Scheme of delegation - Policies and procedures - Action plans - Clinical / Corporate

Business meetings

ASSURANCES - Performance measures - External, internal and

clinical audit - Regulatory and inspection

agencies - Delivery and action plans - Board & Committee

reports - Stakeholders

RISKS - Principal risks identified

from IMTP & Risk Registers

- Board determines its risk appetite

- Ongoing review and monitoring through risk register

ASSURANCE

SYSTEM

REPORTING - Reports to Board,

Committee & Welsh Government

- Annual Report, Governance, Quality and Financial Statements

ASSESSMENT - Internal & External

reports and recommendations

- Performance indicators and analyses

- Review of assurance framework

- Observational findings

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A Quality Delivery Strategy (aligned with the Board’s ‘Cwm Taf Cares’ philosophy) has been developed and in place from 2014, which clearly articulates the key actions that will ensure this happens in a more coordinated and structured way. Indeed Wales Audit Office recognised the strength of the Board’s patient, public and engagement work in its structured assessment process. This work will be further informed by the important lessons that the Board has learnt from Francis and the joint review that was undertaken by Healthcare Inspectorate Wales and the Wales Audit Office into the governance arrangements at Betsi Cadwaladr University Health Board (BCUHB). The joint report issued in June 2013, made many recommendations for the BCUHB and the wider NHS with regards to governance arrangements, including a recommendation that the wider NHS in Wales “should reflect and learn from the issues raised in the report”. The report had recommendations for individual Health Boards and NHS Wales. It is acknowledged that many of the issues could occur in the Health Board. Indeed during 2014, the Health Minister received and published ‘Trusted to Care’ a report into aspects of care at Abertawe Bro Morgannwg UHB and which identified learning not just for that organisation but for NHS Wales. A detailed review and Board workshop was held to inform our existing internal quality delivery plan and related priorities and this work was also informed by our review of Dignified Care? the report of the Older Peoples Commissioner. A number of ‘unannounced’ Executive led ‘walkrounds’ were undertaken to support internal assurance mechanisms and these are continuing. Over the last year we have made good progress in completing a review of our clinical governance arrangements and making changes to those arrangements which have been captured within our new Strategy for Quality. This not only articulates the important lessons learnt from Francis and Keogh along with other relevant Inquiries, but importantly reflecting on feedback received from our patients and communities. Our own HIW review into governance arrangements published in spring 2012 resulted in us developing a comprehensive action plan in response. During this year we have also reviewed the significant progress we have made against the agreed actions and ensured the few outstanding actions were captured in our action plan in response to the main recommendations from the BCUHB review. The Health Board’s Integrated Governance Committee has reviewed and endorsed the revised action plan and routinely monitors related progress.

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Over the last 2 and a half years there has been a significant amount of work undertaken to strengthen the governance and accountability arrangements supporting the delivery of the quality, performance and financial targets within the organisation and this progress has also been recognised by Wales Audit Office within its Structured assessments undertaken over the last three years. The organisation through its established clinical business meeting model has strengthened its arrangements for reviewing delivery and holding directorates to account to reflect the move to integrated planning and delivery. The Wales Audit Office Structured Assessment in 2012 concluded that the Health Board had substantially strengthened its governance arrangements by clarifying and maturing the roles of the Board’s sub committees. The governance and internal control environment has been substantially changed and is maturing to support more effective Board assurance. This coupled with significant development of management information has assisted greatly. Encouragingly progress has been maintained and developed further during 2013 and 2014. As outlined above we are also developing the current arrangements for reviewing delivery and holding Directorates to account to reflect the move to integrated planning and delivery

The significant progress made on the Health Board’s governance and assurance mechanisms as reflected in the 2012, 2013 and 2014 Wales Audit Office Structured Assessment reports will continue to be built on as we move forward on our journey of improvement from being an organisation that has matured its governance and assurance arrangements from ‘developing’ to consistently ‘practicing’. The Health Board’s governance and assurance arrangements also have a strong focus on performance and delivery. Whilst challenges remain going forward, good progress is being made in this area of our work and notable improvements in performance have featured during 2014/15. Robust scrutiny through the Board’s Finance & Performance Committee will remain the focus going forward. The Health Board will ultimately approve and oversee implementation and delivery of the 3 year Plan. Central to implementation and delivery of the Plan is robust local scrutiny and assurance arrangements endorsed by the Health Board that provide assurance in relation to contractor services, directly provided services and commissioned services. In support of this, the Board will rely on its existing Governance and Assurance arrangements with Executive Board; Executive Programme Board and Clinical/Corporate Business meetings being utilised to monitor operational delivery of key elements of the plan.

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The key sub-committees of the Board involved in monitoring and scrutinising delivery of the plan will include, but not be limited to; the Finance & Performance Committee and the Quality and Safety Committee, but with regular updates provided to the Board on progress.

11.4 Principal Risks to Delivery & Mitigating Actions

The Health Board has an approved strategy for risk management and a related action plan that clearly outlines the organisation’s risk appetite and process for ensuring the Board’s plans are built on a foundation of risk assessment that informs mitigating actions. Chapter 9, sub-section

9.10 also outlines a number of specific risks to a number of current financial assumptions in the plan which are key.

To support this and as part of our risk management approach to the implementation of the Plan, the Health Board has an organisational Risk Register, which is published quarterly and considered by the Integrated Governance Committee, the Audit Committee and the Corporate Risk Committee. Further supported with the direction of the Executive, it ensures key risks aligned to delivery are considered and scrutinised by the relevant Sub-Committee of the Board e.g. statutory and Tier 1 finance and performance targets are scrutinised routinely at the Finance & Performance Committee.

The Health Board approach to risk management ensures that risks are identified, assessed and prioritised; ensuring appropriate mitigating actions are taken. Progress against these actions is reported to the appropriate business meetings in place across the organisation and as

Cwm Taf’s Integrated Assurance & Monitoring System

Other Board Sub Committees also scrutinise delivery as

appropriate.

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outlined above organisational risks are considered at Executive Board and scrutinised by the appropriate Sub-Committee of the Board.

Arrangements at a Directorate level have been strengthened to ensure that health and safety issues are properly considered and managed in line with the Board’s Strategy and related policy. Regular audits are undertaken on prioritised areas and this information is then used to ensure necessary improvements are introduced and implemented. A training programme is in place and related resource issues are being addressed to ensure improved compliance and uptake of training. Staff awareness of the need to manage risks is encouraged through regular communication and the incident reporting system and the ‘datix’ risk module is being rolled out across the Health Board to better capture assessed risks and the actions being taken to mitigate them. Case studies and patient stories are presented to the Board’s Sub-Committees and scrutiny panels, in order that lessons can be disseminated and shared. The Wales Audit Office has recognised as part of its structured assessment programme that the organisation has a positive open and listening culture focused on learning and improvement. The organisation’s commitment to risk management, bedrock of its governance and assurance processes, means that work will continue to ensure that:

• Risks related to the delivery of the organisations plans will be subject to regular assessment, review and scrutiny via the appropriate sub-committee of the Board.

• There is compliance with legislative requirements where non compliance would pose a serious risk.

• Evidence based guidance and best practice is utilised in order to support the highest standard of clinical practice.

• All sources and consequences of risk are identified and these risks are assessed and either eliminated or minimised.

• Information concerning organisational risk is shared with staff across the Health Board and where appropriate partner organisations.

• Damage and injuries are minimised and people’s health and well being is optimised.

• Resources diverted away from patient care to fund risk reduction are minimised.

• Lessons are learnt from a variety of Board processes including; compliments, incidents and claims in order to share best practice and reduce the likelihood of recurrence.

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The Health Board manages risk through its Directorate structures. Annex

A6 sets out a summary of key risks that will be monitored routinely through Board processes that are considered to impact on some elements of the Plan. Going forward, the organisational risk register is being reviewed and where appropriate updated on a bi-monthly basis by the Executive Board. Work continues to ensure the Board’s governance arrangements and the processes and the structure of the Risk Register are robust and aligned with the Board Assurance Framework, which was updated and approved as a Framework in the March 2015 Board meeting

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