APPENDIX 1. Our Three Year Plan. Our purpose is to always: Put the patient first. And. 5 Key Change Programmes. Continuously improve services

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1 APPENDIX 1 Our Three Year Plan Our purpose is to always: Put the patient first And Continuously improve services 5 Key Change Programmes

2 Our 3 Year Plan Background Gwent and South Powys residents tell us that they want a healthcare system that: Is there for them when they need it; Supports individuals, families and communities to be healthy; Provides safe, high quality care; and Addresses the specific needs of patients and families. To meet this need, Aneurin Bevan University Health Board was established in 2010 as the single health authority to co-ordinate and deliver health services to the populations of Blaenau Gwent, Caerphilly, Monmouthshire, Newport and Torfaen County Boroughs and South Powys. Our aim is to improve the health and wellbeing of the population within these areas by continually improving the quality, accessibility and sustainability of services. Our surveys of patients on the quality of care they receive, tell us that most of our population is satisfied with the care they receive, but we all recognise that things can be further improved. Specifically patients and carers would like it to be easier to access services more locally and have shorter waiting times. Many people have also expressed concern about the long-term future of healthcare services and whether the services they will need when they are older will be there when they need them. We are working together to knit NHS health care more tightly with social care services, consistently, for older and vulnerable people in all parts of Gwent and South Powys Working In Partnership It is clear that the needs of some of the most vulnerable people in the communities we serve cannot be met by one organisation alone. This is especially true for patients who require more than one service to maximise their health, wellbeing and independence. Working together with local statutory and voluntary sector organisations is critical to ensuring that people receive the care that they need. Working together also means closer collaboration with patients and their carers, supporting people to be active partners in decisions about the healthcare they receive and the actions they need to take to get better (we call this co-production). Challenging Times Our Integrated (service model, workforce and financial) Medium Term Plan sets out the key challenges that we face over the next three years including: People in Gwent and South Powys are getting older, there are more of them and many have chronic and complex health problems People want the best treatment when they are ill, they want to be involved in their care and have a positive experience Funding is limited, costs are rising. Our system must find better ways of doing things by focusing on treatments that benefit patients and deliver them efficiently Our workforce needs to continue to change and adapt to new ways of working. Our Clinical Futures Service Strategy describes our vision shifting more care into primary and community settings and consolidating specialist hospital services. It describes the progress we have already made and the improvements we need to make in the next three years. We have organised these key changes into five Strategic Change Programmes. 1. Reduce Health Inequalities - to ensure that everyone has access to the same high standard of health and wellbeing. 2. Value Based Clinical Services - to deliver high quality clinical services that are known to work well. 3. Maximise Capacity - to ensure everyone who needs to can access services quickly and as close to home as possible. 4. Redesign Services - to ensure they deliver the best care possible and in response to the changing needs of the population. 5. Workforce - to ensure we have the right staff with the right skills to meet the needs of patients. In order to improve the quality of our services we will Prioritise Patient Safety to ensure that everything we do adds to people s health and wellbeing Improve the experience of patients and carers when they need to use our services

3 Our 3 Year Plan our approach to improving quality, accessibility and sustainability Improving Quality, Safety and Patient Experience means getting the right care to the right patient at the right time every time. We believe that every patient should: Receive the best possible care available when they need it Have a positive experience when using our services so that they feel involved in their care, well informed of what is wrong; understand what treatments are available and what choices can be made. Be treated with respect and dignity at all times. Living Our Values Quality and Patient Safety must be at the centre of our work if we are to achieve excellence Every member of staff needs to be able to answer yes to these five simple questions Delivering high quality services is the essential part of everything we do. We can check that we are delivering high quality services by meeting relevant standards and by aspiring to continual improvement. This applies to all staff and how they do their job, 24 hours a day, 7 days a week. A good patient experience is at the heart of delivering high quality in healthcare in Aneurin Bevan University Health Board. To achieve this, we need to be able to see the patient experience through the patient s eyes, while recognising that every patient is an individual. We rely on patients and carers to tell us what it is like to use our services and whether their experience of using our services could be better. We recognise that there are some parts of our service that need to improve more than others. In recent years we have made good progress in improving end of life care (palliative) and reducing the number of people who die when they might not have expected to, we continually measure, report and track improvements through RAMI (Risk Adjusted Mortality Index). We have also made good progress in reducing the number of patient infections and pressure sores acquired whilst in hospital. On both of these issues we now compare well with other hospitals across Wales but are determined to improve further and measure ourselves against the best in the United Kingdom. Following the Francis Review (Mid Staffordshire Inquiry) and the Andrews Report (Bridgend and Neath Hospitals Review), there are quite rightly high expectations on us to consistently deliver high quality care to patients. We will work with our local communities and our staff to assess and where necessary redesign services, whilst seeing patients as equal partners in treatment decisions. The challenge is to develop an improved relationship with the public so that they feel more closely involved in their own care and empower them to help us make more informed decisions about the appropriate use of healthcare. Over the next three years The views of patients, carers and the public will directly inform and impact on the way we deliver care Patient stories and experiences will be integrated into our decision making All wards will have the right staffing levels to deliver good quality care We will be transparent about our successes and our shortfalls and will be open and honest as to how we respond Patients will experience optimal clinical outcomes comparable with Best in Class We will operate within an organisational culture that challenges poor care, attitudes and behaviours We will reduce waiting times for outpatient follow ups and cancelled operations We will have zero tolerance for healthcare acquired infections and pressure sores We will continue to improve patient safety and care, adding years to life and life to years where we can

4 Strategic Change Programme 1 reduce health inequalities Aneurin Bevan University Health Board is committed to improving the health of our local population as well as treating sickness. The health of an individual and the population of Gwent and South Powys as a whole are affected by many factors including what we eat, how we exercise, our genetic makeup, individual lifestyle choices and access to health services and support. A healthier future for our population is also dependent on the effect of our education, employment and the environment on how we live, work and play. Taken together these factors determine how healthy we are as individuals. We know that different people and communities across Gwent and South Powys have different health needs and sizeable inequalities in health and access to healthcare. People living in some areas are healthier and live around 10 years longer than those living in our most deprived areas. The gap for how long people live in good health can be up to 20 years. This difference is often referred to as health inequality. Unfortunately, some people with the greatest needs, often living in our most deprived areas, find it more difficult to access good medical and healthcare services than people living in other areas. This is sometimes referred to as the inverse care law. Keeping healthy is essential to achieving a good quality life. Many people in Gwent and South Powys make choices about their life which make them more likely to be unhealthy. Our aim is to help people stay healthy and avoid unnecessary ill-health. 43% adults drink above recommended limits 24% of adult population are smokers 70% of the factors affecting people s health are within an individual s own control The foundation of a healthy lifestyle is laid down in childhood. Children and young people who live in poor or socially deprived communities often have poorer health. In four of the five Local Authority areas between 24 30% of children are living in poverty. Our aim is to give every child the best start in life through actions to make sure that:- Babies are born healthy Pre-school children are safe, health and develop their potential Children and young people are safe, healthy and equipped for adulthood Working more closely with local people and communities we can postpone deaths for people with or at high risk of heart disease, cancer and diabetes. General Practice has a pivotal role to play in supporting people to live healthy and independent lives. Through Making Every Contact Count we are also equipping more and more of our workforce (working in hospitals, clinics, communities and primary care) with the tools to offer appropriate advice on staying healthy to every patient they meet. We are concentrating on: Smoking Cessation Living Well, Living Longer Reducing Obesity Smoking cessation service for pregnant women Expansion of the Community Pharmacy smoking cessation service Expanding the Hospital Smoking cessation service Lessening the impact of the Inverse Care Law in our most deprived communities Reducing the number of risk factors for Heart Disease in our most deprived populations, increasing the proportion of people who are receiving and complying with all aspects of their care plan (Optimal Management) Continuing to immunise our children against childhood diseases Expanding adult weight management service Putting our Child obesity action plan in to practice Implementing staff food and fitness policies 71% adults do not undertake recommended physical activity 25% of adults are obese (bmi 30) 67% of adults report unhealthy eating We are working with Local Authorities, voluntary organisations and others to build a healthier future for our population. Substance Misuse Implementing a new Gwent Alcohol harm reduction pathway

5 Strategic Change Programme 2 value based clinical services (doing the right thing) We are concentrating on The number of available tests, drugs, treatments and procedures in modern medicine is large and growing. But just because something is available does not mean that we should use it. Interventions with little if any benefit to patients Why we do, what we do - identify and stop treatments of limited value NICE (National Institute for Health and Care Excellence) evidence based advice on areas of clinical practice that are not clinically (or cost) effective INNU (interventions not normally undertaken by NHS, for example face lifts) Unnecessary tests, drugs, treatments and procedures do not add value to care and may potentially be hazardous to the health of patients. For example, X-rays and CT scans expose patients to radiation and over prescribing of antibiotics which in many cases makes little difference to the patient and has contributed to a build up of resistance to drugs. Commissioning (Internal and External) Applying principles of Prudent Health Care to specialist services commissioned on behalf of our residents Clear agreed plans of care for patients, agreeing what we will and will not do (sometimes called "Ceilings of Care") Transparent, fair and clinically sound decisions about the treatments we offer Reducing waste, variation and harm (linked to 1,000 Lives + programme) NHS in Wales must move towards a culture of 'prudent health care' not providing treatment where it is unlikely to benefit the patient, or could do harm if it is to carry on providing an equitable service. Diagnostic Investigations Understanding the extent to which junior doctors/clinical teams are making requests on a routine basis, rather than a reflection of individual patient need Only doing tests where it makes a difference Ensure our clinicians talk to each other about whether investigations are necessary and in the best interest of the patient, so that they use the resources available to them wisely Mark Drakeford, Minister for Health and Social Care (2014) Our aim is to deliver health care that fits the needs and circumstances of patients and that actively avoids wasteful care that is not to the patient's benefit. Medicine Effectiveness and Management Making sure patients have the right combinations of medicines to meet their clinical needs Making sure patients understand why it is important to use medicines as directed by their doctor or pharmacist - and use their medicines properly This means that some treatments that were used previously will be stopped and where appropriate replaced by new technologies or medicines that will improve the treatment of our patients. There are number of areas that we will focus on over the next three years, ensuring that the latest evidence is shared with clinical staff and put into practice. Let s think again (everyone should ask these basic questions) Do I really need this test, treatment or procedure? What are the downsides? Are there simpler, safer options? What happens if I do nothing?

6 Strategic Change Programme 3 maximising capacity (doing things the right way first time, every time) Timely access to the right service supports good outcomes for patients. It reduces the risk of complications due to further deterioration of health, unnecessary investigations and admissions. Moreover it lessens the burden on families and other support services. Welsh Government sets national targets for the length of time it takes to see a GP, hospital doctor or therapist, have an investigation or procedure and be seen within an Emergency Department, for example. We are striving to meet all these targets as a means of improving patient experience, safety and improving quality of services. We have made good progress in ensuring that all patients are seen as quickly as possible. However, we know that we still have a lot of work to do, including:- Improving access to urgent (same-day) primary care appointments Eliminating long waiting times in our Emergency Departments Minimising waiting times for specialist follow-up Reducing number of cancelled operations Improve timely access to investigations, particularly in radiology, cardiac and endoscopy, so that no patients wait longer than 8 weeks. Our healthcare system is not as efficient as it should be. We need to eliminate waste from healthcare to make sure that it is more affordable and to improve access to services for those that need them. referral to a hospital consultant than in other areas across Wales. We know we have further work to do to ensure maximum value for every pound of tax payers money spent on healthcare. Our aim is to optimise the way we organise and deliver services, ensuring that we are as efficient and effective as the best. We will develop alternatives services which are more community based and new technologies for example mobile apps, Skype and other on line tools together with improving access to advice only services will play a critical role. In parallel we are establishing a bigger role for services outside of hospital, so more care can be delivered in the community. We are concentrating on: Improve Efficiency and Delivery Transforming Care Benchmarking (comparing ourselves to the best hospitials in the UK) Using technology wisely (electronic health records helping to move information not paper note; Telemedicine/telehealth - including telephone consultations) Managing demand (making sure patients access the right care, in the right place at the right time) Improving the flow of very ill patients through our system, including timely transfer of patients from ambulances to clinical services Assessing the needs of frail older people as soon as they come into contact with our services Sustainable Clinical Models (right staff, right location, right quality, right time) Simplifying and modernising Outpatient services Reducing waiting times for planned care to a maximum of 36 weeks, with at least 95% seen within 26 weeks Everyone owns a piece of the inefficiency problem and therefore of its solution We overuse our hospitals for example a 999 call is 30% more likely to lead to a hospital admission and the length of time a patient spends in hospital, particularly for older people, is longer than in the best regions of England. Other resources are also used less efficiently than they could be. Our patients in Gwent are twice more likely to miss their outpatient appointment than their fellow citizens in Wales. A visit to a General Practitioner is 16% more likely to lead to a External Commissioning Applying the principles of "prudent healthcare" to those services we commission from other healthcare organisations on behalf of our population including Very specialist services for example complex surgery like heart transplants Routine services provided by neighbouring Health Boards or Trusts

7 Strategic Change Programme 4 service redesign (sustainable healthcare) Patients are at the heart of everything the health service does and should not fall through gaps in the system. We were told that many patients find themselves being shunted around, and that it would be better if more services were designed and organised around their needs. Healthcare in the United Kingdom tends to send patients into hospital, whereas people need access to the right treatment in the appropriate setting for their condition. Our Clinical Futures Strategy set out our plans to develop services that could both treat the healthcare problems of the people we serve and be affordable. We planned to deliver most services as close to home as possible by:- Developing more community and primary care services to meet the majority of healthcare needs Creating a small network of Local General Hospitals for those patients who still need to go to hospital for treatment Building a new Specialist Critical Care Centre to ensure that those patients who are most ill have all of the services they need in one place. (Planning is well advanced for this new facility which is due to open in 2019) NHS Wales cannot continue to try to provide the same services in every hospital. Instead we need to pool our resources and expertise and deliver better outcomes for the small number of patients who need life-saving and/or very specialist care when they need it. In 2013, the South Wales Programme, consulted on the best way to configure some specialist services that provide care for the sickest patients. When people have life and/or limb threatening conditions they need to be seen by senior clinicians as soon as they arrive, whatever the time of day or night. This kind of treatment can only be delivered by teams of doctors, nurses and therapists who have specialist skills, which they use day in and day out so they remain expert in what they do. This means that obstetric, neonatal and paediatric inpatient services, together with services for people with life or limb threatening conditions, will be provided in fewer hospitals, which the programme calls Regional Centres. The majority of patients will not need to go to Regional Centres and will continue to get consistently great care from their local NHS Services at home, in the community or in hospital. Gwent will have one Regional Centre by 2019 which will be the purpose built Specialist and Critical Care Centre near Cwmbran. In the meantime we will continue to provide services intended for the SCCC across our existing acute hospitals. Our top priority is to deliver safe care, where we cannot be sure that services are safe we consolidate them in fewer hospitals in advance of the new SCCC opening. This means the patient gets the right diagnosis and starts the right treatment quicker. We are concentrating on: Service Sustainability Bed reconfiguration Strengthening Primary and Community Care Complex Healthcare Improving acute stroke services and outcomes (faster treatment) Strengthening Emergency General Surgery services Consolidating inpatient care for sick children, doctor assisted births and care for very ill new born babies on one site Expanding dialysis services across Gwent Getting the right number of beds in the right place to meet the pjysical and mental health needs of our population as close to their community as possible Changing the number and location of beds in our community and acute hospitals as part of our Clinical Futures plan We have clustered our communities into 12 Neighbourhood Care Networks (NCNs) of between 30-50,000 people. We will organise and deliver all primary and community care services through these NCNs Increasing the number of patients that get all of their care outside of hospitals Better use of medicines Expanding specialist Mental Health services, bringing people closer to home for their care Reducing the length of time old and vulnerable people spend in hospital by improving services that can be provided at home "In One Place" (Housing Associations, Social Care and NHS - working together to provide the right house, with the right care package for vulnerable people We cannot continue to provide these services in more than one hospital indefinitely

8 Strategic Change Programme 5 our workforce The success of our services is directly related to our staff. It is vital that we use the excellent skills, talents and experience of our workforce whilst ensuring that we plan and configure our most valuable resource to better meet the needs of patients. One of the biggest challenges for today s professional workforce is the growing demand on services, both now and in the future, from older people with multipleillnesses (both mental and physical), who need integrated long-term health and social care. There is a mismatch between the location of the current workforce and where the care is needed. There is a pressing need for more specialist skills in primary and community care and for more generalist skills in hospital care in order to meet the needs of patients and deliver our Clinical Futures Strategy (overview shown below). Many of the skills of our workforce are transferrable from hospital to community services. We want and support our staff to develop the skills and confidence to work in a variety of care settings. To do this we will: Make the best use of the skills of staff we already have, and those that will work for us in the future Have safe staffing levels across our services Train and support staff to work in new ways Plan for, and recruit, the workforce we require to meet patient need We are concentrating on: Service redesign Workforce Efficiency Aligning our workforce with new service models Developing new roles for staff for example Advanced Practitioners Job Planning for Consultants (using this scarce clinical resource to best effect) 7 day services Using E rostering (electronic rostering tool) to ensure safe staffing levels Reducing the level of sickness in our staff to below 4% Making our workforce more responsive with staff able to work in different ways and different locations (sometimes call Agile Working) Supporting the wider community through alternative recruitment (for examplejob experience opportunities, volunteering) Workforce Reduction Reducing the cost of managing the service Making sure we have the right staff with the right skills in place VERS (Voluntary Early Release) Benchmarking the way we use our workforce with other NHS organisations Giving staff the opportunity to purchase additional Annual Leave Workforce redesign is needed because the nature of health work is changing and the skills of the current workforce are not well matched for future needs Organisational Development Annual review for all staff (PADR) Working more closely with staff to modernise services and working practices Developing aspiring leaders for now and the future Supporting the development of team working in every part of our organisation Getting the right number of staff with the right skills in the right place at the right time is sometimes referred to as rightsizing the workforce. Getting the workforce right is important to make sure that we can afford all of the staff we need to provide all of the services we need to deliver.

9 Conclusion accelerating change We continue to build on our reputation through the hard work of our staff and the high quality services we deliver to patients. But in order to meet our future challenges our five strategic change programmes in our plan are designed to create a stronger, more integrated health system. It puts people first and will help them to be well and stay well and help us to deliver quality care when they need it. It will shift the focus from over-dependence on hospital care to care that is in most circumstances closer to home. It also brings forward our Clinical Futures plans particularly those for specialist and critical care services between now and the opening of the SCCC in We are committed to providing services as close to the communities we serve as possible, where it is clinically safe to do so. If we are not able to maintain the safety of specialist services provided on more than one site, we will move to single site working for that service. All five strategic change programmes work together and require us to work in partnership with other public sector and voluntary organisations. The success of our three year integrated medium term plan depends on one common element; the active participation of both healthcare providers and users of the system. The commitment of our population is needed. It will be their effort to stay healthy and active, making wise decisions about their health, and being open to change that will enable us to build a strong healthcare system and ensure that it is sustainable for generations to come. If you would like more information you can download a copy of our Three Year Integrated Medium Term Plan at We are also developing fact sheets on each of the key programmes which will be available on the Health Board s internet. Your Views tell us what you think of our plans If you are a patient or carer. Please tell us what it is like to use our services and whether your experience of using our services could be better. You can share your experiences and suggestions with us by writing to: - Aneurin Bevan University Health Board, Our Three Year Plan, Headquarters, St Cadoc s Hospital, Lodge Road, Caerleon Newport, NP18 3XO If you are, or work for, one of our partners. Please tell us what it is like to work with our services, where we can work even more closely and how we can improve public sector services and ultimately create a healthier future for our citizens by writing to: - Or ABUHB3yrplanfeedback@wales.nhs.uk If you are a member of our staff. Please tell us what it is like to work in our services and what we can do together to make our services better by: - Visiting the Staff Forum, Talking about Health Board Issues Or ABUHB3yrplanfeedback@wales.nhs.uk