Tuesday 23 rd February 2016 at 9am. Board Room, Ystwyth Corporate Building, Hafan Derwen

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1 COFNODION Y CYFARFOD PWYLLGOR CYNLLUNIO BUSNES A SICRHAU PERFFORMIAD CYMERADWYO / APPROVED MINUTES OF THE BUSINESS PLANNING & PERFORMANCE ASSURANCE COMMITTEE MEETING Date and Time of Meeting: Venue: Tuesday 23 rd February 2016 at 9am Board Room, Ystwyth Corporate Building, Hafan Derwen Present: In Attendance: Mike Ponton, Independent Member & BP&PAC Chair (MP) David Powell, Independent Member & Vice-Chair (DP) Margaret Rees-Hughes, Independent Member (MRH) Simon Hancock, Independent Member (SH) (PART) Bernardine Rees, HDdUHB Chair (BR) (PART) Sian-Marie James, HDdUHB Vice Chairman (SMJ) Karen Miles, Director of Finance, Planning & Performance & Executive Lead (KM) Philip Kloer, Medical Director & Director of Clinical Strategy (PK) Lisa Gostling, Director of Workforce & OD (LG) Caroline Oakley, Director of Nursing, Quality & Patient Experience (CO) Jill Paterson, Deputy Director of Primary Care, Community, Mental Health & Long Term Care (JP) (Representing Kathryn Davies) Dr Michael Thomas, Consultant in Public Health (Representing Teresa Owen) Libby Ryan-Davies, Director of Mental Health & Learning Disabilities (LRD) (Representing Joe Teape) Alison Gittins, Head of Corporate Governance Support (AG) (Representing Sarah Jennings) Laurence Williams, Local Medical Committee Representative (LW) Helen Williams, Community Health Council Representative (HW) Pamela Parsons, Community Health Council Representative (PP) Julie James, Independent Member (JJ) (PART as an observer) Michelle Campbell, Head of Performance Management (MC) Anthony Tracey, Assistant Director of IM&T (AT) (PART) Keith Jones, General Manager (KJ) (Item 5) Sue Lewis, County Director & Commissioner for Pembrokeshire (SL) (PART) Sarah Perry, General Manager Unscheduled Care (SP) (PART) Caroline Lewis, Service Delivery Manager (CL) (Item 5) Sharon Daniel, Assistant Director of Nursing Infection Prevention & Control (SD) (Item 5) Sue Watkins, Finance Project Manager, Committee Support (SW) Jeanette Mitchell (Observer) Agenda Item BPPAC(15)84 INTRODUCTIONS AND APOLOGIES FOR ABSENCE Mike Ponton introduced everyone and enquired if there were any objections to the meeting being recorded to aid minute taking and no objections were raised. Apologies for absence were received from: Eifion Griffiths, Independent Member John Gammon, Independent Member Steve Moore, Chief Executive Officer Joe Teape, Deputy Chief Executive/Director of Operations Kathryn Davies, Director of Commissioning, Therapies & Health Action Page 1 of 24

2 Science Teresa Owen, Director of Public Health Sarah Jennings, Director of Governance, Communications & Engagement Wendy Evans, Local Partnership Forum Representative Ken Jones, Stakeholder Reference Group Representative Joanne Wilson, Interim Board Secretary Alyson Thomas, Community Health Council Representative Kevin Davies, Welsh Ambulance Services Trust Phil Parry, Health Professionals Forum Representative Paula Martyn, Chair of Stakeholder Reference Group BPPAC(15)85 DECLARATIONS OF INTERESTS No interests were declared. BPPAC(15)86 MINUTES OF THE BUSINESS PLANNING & PERFORMANCE ASSURANCE COMMITTEE MEETING HELD ON 26 th JANUARY 2016 Page 1- correction required to Caroline Oakley s title to Director of Nursing, Quality & Patient Experience. Page 20 Final paragraph should state Charitable Funds Committee, not Audit & Risk Assurance Committee. SW SW BPPAC(15)87 MATTERS ARISING TABLE OF ACTIONS FROM BUSINESS PLANNING & PERFORMANCE ASSURANCE COMMITTEE MEETING HELD ON 26 th JANUARY 2016 BP&PAC(15)17 - POTENTIAL OPTIONS FOR THE PROCUREMENT OF AN AUTOMATED INFECTION SURVEILLANCE SYSTEM Caroline Oakley reported that a national system is to be procured, therefore there will be no need to find a local solution. BP&PAC(15)78 - WITHYBUSH HOSPITAL CHEMOTHERAPY DAY UNIT (CDU) DEVELOPMENT to reflect the change to the minute, the timescale should state Charitable Funds Committee on 10 th March, not ARAC on 8 th March. SW BPPAC(15)88 KEY PATIENT FLOW KPI s (WITH FULL BOARD PERFORMANCE ASSURANCE REPORT FOR INFORMATION) Bernardine Rees updated the Committee on her recent conversation with the Deputy Minister about the Health Board s performance, in which some frustration was expressed from a patient focus sense. Whilst Hywel Dda is the only Health Board at present, to show a continued improving trajectory, albeit smaller than anticipated, it is important that efforts remain focussed on delivery, in terms of the work it still has to undertake. Mrs Rees requested that in discussions with clinical teams, the opportunity is taken to: a) provide reassurance and thanks for the work that they are doing; b) recognise the difficulties they are experiencing; c) re-inforce the message that the Health Board not only has to deliver what it said it would, but that it needs to better it by year end. The purpose of bringing this to the Committee s attention at this point in today s meeting is: Page 2 of 24

3 1. That it has to remain foremost in the minds of members, that the Health Board has to deliver what it said it would deliver; 2. To demonstrate the level of interest that NHS Wales is taking in performance. Mike Ponton stated that the challenge for the Committee today was to keep its finger on the pulse coming up to the end of the year and to gauge how the Health Board is really doing in terms of its performance. Also, the April 2016 meeting would be of particular importance for the Committee in its review of 2015/16, of what has been learned and what it intends to take forward in the coming year. Sian-Marie James and Jill Paterson joined the meeting. Karen Miles drew attention to the list on page 1 of the SBAR, as being the items that the Deputy Minister focuses significantly upon and the operational team representatives at today s meeting were asked to update the Committee on the actions and issues that arose from that latest Internal Performance Assurance Review (IPAR) held on 17 th February A mixed position was noted in terms of performance as illustrated on pages 5-7 of the SBAR and there are some areas that are showing as red because they are absolute targets, however Hywel Dda is within an improving trajectory but now needs to get itself over the top. The key issues raised at the IPAR on 17 th February 2016 were: Cancer Target the trajectory for improvement will not be known until March 2016, so although a certain level of assurance can be provided today, it is not quite where the organisation would have hoped for February It is further complicated by the handover to other specialist services within the pathway, but assurance was provided that every effort is being made to deliver internal Hywel Dda timeline improvements to allow those external services the necessary time to achieve their element of the target. Unscheduled Care has seen significant activity over the last few weeks which has affected performance, in particular, the 95% delivery that had been assured for Bronglais General Hospital (BGH) and for Prince Philip Hospital (PPH). It is unlikely that PPH will achieve this due to the delay in the opening of beds and border realignment pressures, although these will need to be evidenced but Steve Moore had urged the team to try and get PPH to cross the line as much as it can. BGH is still uncertain but every effort is being made to achieve the 95% target. Given that it is an absolute target, Referral to Treatment (RTT) remains on red, but the Health Board is on target to reach the 4, week breaches and is hopeful that it can improve on that figure by year end. However, a significant number of elective operations were cancelled in the last week so those numbers are being closely monitored. There is no doubt that validation has helped significantly and the next step is to review the second cohort of between 26 and 36 week breaches to see where inroads can continue to be made through validation of waiting lists and to understand the capacity required to meet patient demand. This addresses the Health Board Chairman s question Page 3 of 24

4 around focus on the patient. There have been some good treatment inroads although the Health Board did not receive the level of outsourcing it anticipated in terms of cataracts but is delivering as much as it can internally. The Health Board Chairman s message that 4,595 is the minimal improvement position was also re-inforced. Diagnostics is holding its own although there are some issues around Colonoscopies which are being monitored closely. The finances are moving continuously at present due to the release of significant amounts of in-year slippage monies by Welsh Government (WG). Karen Miles advised that this is being managed with Martin Sollis and WG and assured the Committee that an improvement on the forecast 32.5m deficit is anticipated in the Month 11 position, moving the Health Board nearer to its potential planning forecast. Independent Members (IM s) were invited to comment on the SBAR: In response to a query around Cancer penalties from Helen Williams, Karen Miles advised that this is not straightforward and involves both a commissioning conversation and an operational conversation. Hywel Dda will be looking at what its own performance should look like in terms of handover, and at that point, how it might apply penalties and sanctions. In answer to a question on whether or not Morriston Hospital has had an impact on PPH performance, Sarah Perry advised that a post code analysis of patients arriving at PPH indicates there is no significant increase to the norm, however, Hywel Dda ambulance crews waiting at Morriston to hand over affects Category A performance and WAST is focussing on ways to improve the availability of Hywel Dda ambulances for Hywel Dda residents. In terms of the reduction in performance against the 4hr Stroke measure, Sarah Perry reported that nurse specialists are currently validating the Quality lmprovement Measures and have been in contact with WG around the issues with this particular measure. Whilst improvements have been made with stroke beds being ring-fenced, there is still a shortfall across the Health Board and a piece of work is underway to look at capacity, particularly within the GGH site and whether stroke rehabilitation could be better delivered in a community setting. Michelle Campbell added that in general, all Health Boards across Wales struggled in January 2016, with the All Wales reported position being worse than Hywel Dda s performance. IM s felt that the report is becoming more familiar as time passes and it contains the key elements, however as it matures, it would be helpful if a statement were included around the degree of confidence (high/medium/low) in the actions being taken to improve performance. Karen Miles agreed to include it in future reports. KM/MC Simon Hancock received an update from Dr Michael Thomas on the uptake of the Flu Vaccine across directorates, referred to at the bottom of page 3 of the SBAR. Page 4 of 24

5 In terms of outsourcing and the difficulty with cataracts, Mike Ponton acknowledged that although the ultimate aim is to become more self sufficient and minimise the need for outsourcing in the future, in the interim few years there would still be a role for it and asked what the Health Board is doing to avoid the end of year dash to secure extra capacity. Karen Miles outlined the strategic actions being taken to create inroads into waiting times for patients: Significant demand and capacity planning has revealed the recurrent weekly gaps, where they are in terms of outpatients or treatments, and by specialty and site and has highlighted issues around insufficient capacity and where there is a need to appoint more staff to those specialties. This is informing the IMTP specialty plans in particular and the expectation is that Hywel Dda consultants would carry out the work in this area. The 4,595 backlog position has to reduce by 1,500 per year and this is where some outpatient and treatment outsourcing will be considered. A commissioning plan for outsourcing the backlogs is currently being developed, focussing on Orthopaedics, General Surgery and Urology in the first instance, with the possibility of Ophthalmology. A significant Outpatient Modernisation Programme is underway, given that many of the issues stem from this stage of the pathway and this is also the reason for the outsourced validation work by Cymbio being extended to 26 weeks waits, to achieve further improvement in that area. At an All Wales level as Directors of Finance and Procurement, a national procurement framework is being created to help with the commissioning of outsourced services in future. Karen Miles assured the Committee that first and foremost the Health Board s focus is on getting the weekly and monthly demand and capacity in alignment, that requiring a local solution. Jill Paterson added that the outcomes of the delivery plans are expected over the next week which will determine the level of activity required, and from there, it will move into a more strategic conversation and consideration of financing, by which time the national framework should be in place to enable the commissioning process to progress more easily. The aim is to adopt a more strategic approach in taking decisions around outsourcing at the outset rather than waiting until the final months of the year, therefore, over the coming year, internal delivery and capacity issues will be defined, putting the Health Board in a stronger place in terms of being able to deliver the required capacity through its own provider services. Ms Paterson advised that this was a new phase for the Health Board in commissioning and there was much work to develop, but the priority would be to create a Quality Framework, setting out specific thresholds for different areas and the Health Board would be seeking assurance from providers around their compliance with that criteria and deciding how and when to intervene if necessary. Given the significant investment across Wales in Ophthalmology outsourcing for instance, Bernardine Rees felt that strategically, the Health Board should be looking at collaboration across Wales to deliver Page 5 of 24

6 services differently and locally, albeit in a different way to how it is currently undertaken, which is not putting the patient at the heart of what it is trying to do. Longer term, on an All Wales basis, there is an opportunity to look at planned care and how low risk/high volume services are delivered across the region to achieve a sustainable NHS in Wales. It is for the Chief Executive Officers and the Planned Care Committee to start to think differently about outsourcing for the NHS in Wales as a collective and this will not happen if organisations continue to approach outsourcing as a mechanism to deliver. In response to a specific question around the inclusion of Dermatology in outsourcing plans, Jill Paterson confirmed that it was included in the capacity review, but reinforced the Health Board Chairman s view that it is the whole model of care that needs to be considered going forward. Bernardine Rees clarified that rather than advocating the abolishment of outsourcing altogether, the recommendation is that it be utilised as a bridge to take the organisation towards a more sustainable model. Mike Ponton concluded that this is an important issue for the BP&PAC and identified three mains themes from the discussion: Planning - members need to be clear about how outsourcing is being planned; Performance assurance is required that the plans are effective and delivering; Quality care should be taken to ensure that the responsibilities of Quality, Safety & Experience Assurance Committee (QSEAC) and BP&PAC overlap appropriately. It is not BP&PAC s place to drill down into the quality issues, but to take assurance from QSEAC that this is being addressed as part of its work. In response to a query about the actions recorded on the SBAR following IPAR meetings, Karen Miles described the format of the monthly IPAR s, explaining that it is a similar process to that which is followed at this Committee, but with far more granularity, with Steve Moore holding the Executive Leads and their officers directly to account by working through the entire performance report in detail with them. The actions outlined in the SBAR are those further actions requested by Mr Moore as a result of this review and they in turn are reported in the main Integrated Performance Assurance Report brought before the Committee. Karen Miles undertook to ensure that these are cross referenced in future reports. Mike Ponton agreed that if it can be made clear that this has been factored into the report, then BP&PAC can take assurance from the work of the IPAR. KM/MC The Committee was guided through the performance report domains by the Lead Executive or their representative, highlighting key points by exception. Staying Healthy Pages a brief update on Childhood Vaccinations, Smoking Cessation and Uptake of Flu Vaccination was presented by Dr Michael Thomas on behalf of Teresa Owen. There were no further questions. Page 14 Basket of 8 Chronic Conditions was presented by Sue Lewis on behalf of Joe Teape. Mrs Lewis noted some frustration in the ability Page 6 of 24

7 to use the data at the top of page 14 in any meaningful way from a delivery perspective given the 3 month delay. Caution was advised in relation to the boundary changes, as there is no indication of whether or not a proportion of the increase in emergency admissions reported in GGH was due to the intake of Withybush General Hospital (WGH) patients, however the correlation of an increase in GGH and a decrease in WGH admissions would suggest that changes in the boundary should be considered and reflected in this discussion. The IMTP investment will also be taking effect from quarter 3, so an improving trajectory should be observed when those posts are embedded. Sue Lewis undertook to drill down further into the re-admissions data to understand their impact. In-depth discussion took place around the various aspects of the Atrial Fibrillation and Cardiovascular figures on page 15 and the complexities of managing it in the community. The Committee was advised of issues with the quality and consistency of some patient s notes which may be preventing conclusions from being drawn and the need to include the so what factor in the reporting by providing explanations behind the raw data. Bernardine Rees was interested to know how the Health Board will get behind that data and how that will support the individual patients to manage their chronic conditions at home. Karen Miles advised that in terms of the quality of clinical coding, the aim is to undertake improvement work around the Health Board s Standard Operating Procedures and Policies in the new financial year together with the operational teams, especially around the coding of episodes of care. That should reveal where there is demand and where investment is targeting that demand and work is to be tendered which will allow improvements to be made in the quality and timeliness of informatics. Philip Kloer felt that a snapshot survey was required, of a small proportion of notes focussing on: validation of the condition/diagnosis; ascertaining whether more could have been done for those patients or whether things could have been done differently; identification of the factors that are affecting patients. Laurence Williams supported this approach and felt that it was important that the primary reason for patient admission was reported in this paper. Michelle Campbell also reported that patient level data by practice and by cluster is now available to be shared with County Directors to support this domain going forward and Karen Miles added that in terms of the strategic objectives in the IMTP, the plans which support the cardiovascular programme of care are being collated and this is the sort of information that the programme leads would be expected to be cognisant of, to make the connections that this Committee requires. SL PK Safe Care Page 26 DTOC Mental Health, Libby Ryan-Davies explained the key reasons for the Health Board not being where it had hoped to be in relation to its 12mths rolling DTOCs, in particular, two long standing complex cases which have been delayed by lack of suitable local provision for their care. The Local Authority and the Health Board have been working together to open up the market place for such cases which will aid commissioning. Lack of medium secure capacity nationally has led to major risks around the management of some patients, both in terms of their care and in the increased variable pay Page 7 of 24

8 cost of 1:1 care, however Hywel Dda is in negotiation with WHSSC to recoup these costs. Mrs Ryan-Davies assured the Committee that a robust mechanism is in place to manage DTOCs and the variable pay position and issues are being escalated locally and nationally. In terms of what is being done to increase capacity for medium secure, the Committee was advised that there is a national shortage in Wales and further afield which is being managed by WHSSC, however the Health Board is being proactive in tracking cases coming up for step down to low secure provision and considering whether they can be repatriated to alleviate the pressure on medium secure capacity. Sian-Marie James advised that from a WHSSC perspective, this has been identified as a significant issue and priority for them and TOR s have been agreed around how they will review the commissioning of medium secure provision. Margaret Rees-Hughes observed that safe discharge must always override the DTOC factor. Julie James joined the meeting as an observer. Page 29 - Hospital Acquired Infections, Sharon Daniel advised the Committee that sampling has improved which has reduced the incidence of false positive results and there has been a reduction in January 2016 compared to the same month last year. However, of the 7 HCAI s recorded, 4 were avoidable and detailed action plans have been put in place. Infections are still coming in from Primary Care and time out sessions have taken place around improvement methodologies to try and move towards achievement of this target. In summary, there is work in progress, some improvement is evident, but there are still incidences of infection in secondary care which need to be monitored closely. Page 34 Healthcare Acquired Pressure Sores in Hospital Setting, Caroline Oakley advised that although in the main, the trajectory is progressing on track, any form of hospital acquired pressure ulcer constitutes harm to the patient and every incidence is analysed in detail. There are difficulties in determining whether or not they are avoidable and this depends on the quality of the notes. The target for 2016/17 is: 1. to continue to improve the position to eradicate harm; 2. to start work in the community. Margaret Rees-Hughes confirmed that the deep dive analysis into this area is picked up by QSEAC. Effective Care Page 40 Clinical Coding - referring to the significant impact that long term sickness of two individuals has had on performance, Karen Miles reported on the recovery actions being taken to put clinical coding back on track, anticipating that performance will have improved by the end of the financial year. Dignified Care Page 48 Hand Hygiene, Caroline Oakley noted that as has been regularly pointed out this is a particularly flawed methodology but has to be measured. Page 43 Postponed Admitted Procedures, Caroline Lewis explained that although everything possible is being done to maintain elective Page 8 of 24

9 activity, emergency pressures on bed availability have led to cancellations. Patients are being forewarned that due to winter pressures, there may be unscheduled clashes and they may have their operations cancelled at short notice. Bernardine Rees observed that the elements missing from this report are: 14 procedures postponed, but on how many occasions? How is this communicated with the patients? How does the Health Board guarantee they will be a priority for re-booking? How many of those patients, if any, decline the offer? Due to the organisation of care between elective and unscheduled, it is inevitable, at present, that cancellations will occur, but the main concern is around the communication process. It is unclear whether the structure is in place which will allow such assurance. Mike Ponton noted that BP&PAC is concerned about the implications, but requested that QSEAC look into the process and share its findings with BP&PAC for assurance. QSEAC Timely Care Page Ambulance Handover, Sarah Perry reported that the deterioration in the month of January was unsurprising given that seasonal pressures are taking effect, however GGH and PPH have improved on their January 2015 performance. There is increased focus on ambulance handover and more proactive steps are being taken to ensure capacity is available in the emergency department to accept handovers. Hywel Dda is usually around 1 5% of the All Wales average in relation to time lost over the 15 minutes, so overall, handover performance is relatively good. Sharon Daniel left the meeting at 10.20am. There is also significant deterioration in January 2016 of the >1 hour handovers, due to bed capacity issues in BGH and lack of space in A&E to accept handovers which has had a significant impact on this performance target. The Committee was advised that discussion has taken place at Executive level in efforts to expedite repatriation of some of these patients to neighbouring Health Boards. Page Ambulance Waiting Times, Sarah Perry reported that performance fell short of the required profile for January 2016 and described the main issues around beds and staffing, especially in BGH which had been expected to achieve 95% by year end. It is hoped that the earlier transfer of patients to the discharge lounge prior to arrival of their transport and the support provided by the workforce team to improve recruitment will improve the situation. Reliance on locum staff in A&E has been a factor in WGH, which shows the lowest performance, however it has now fully recruited to its consultant vacancies. Increased activity at key times of the day has had an impact on GGH and the profile of attendances is being reviewed and discussed with WAST on 26 th February Each of the sites have reviewed their performance and the actions put in place for improvement and a newly appointed Unscheduled Care Improvement Director has been focussing on the performance data and metrics at each site and working with the Delivery Page 9 of 24

10 Unit to define a robust plan to deliver significant improvement in performance. Ms Perry explained that diverts from WGH to GGH and from GGH to PPH were still in place because of the capacity issues across all of the hospitals and essentially, WGH has had to reopen the beds that were closed, and more. IM s observed some confusion around the surge beds/divert issue and were advised that Joe Teape has also commissioned a paper which will describe the plan to deal with these difficulties, and this will come to BP&PAC in due course. Sarah Perry addressed queries around the plans to deal with the increase in 12hr waits in A&E, the majority of which are due to lack of beds or staff to man them. Following a Delivery Unit review of discharge procedures, there is scope for improvement in the internal discharge pathway, particularly around the increasing number of frail, elderly patients presenting with a number of medical problems. Ms Perry outlined a number of areas for improvement, including earlier assessment and training and the synchronisation of the patient care pathway and advised that the model in PPH should be shared across other sites. Bernardine Rees expressed concern that despite the Board s investment over the last year, non-mental Health DTOCs continue to rise and questioned how proactive the Health Board is being in managing this plan, given that the Committee has heard today that there are still recruitment issues and there is still requirement for further investment in the community. The Committee agreed that it would like to focus on this area at the next performance meeting. The challenge for the Health Board in doing the best for its patients means that it has to be realistic about the progress achieved with its plans and their delivery. Karen Miles advised that many of the plans in train for safe capacity opening were due to come to fruition in quarter 4 and reminded the Committee of the conscious decision taken to not denude the acutebased establishment further by bringing community recruitment online earlier which has resulted in a significant lead in time for communitybased solutions. Mrs Miles felt that the Executive will be able to demonstrate a positive change in trajectory at the next meeting and as an Executive collective, provide the Committee with an assessment of when it will be considered safe to remove the diverts. Mike Ponton suggested that for the coming year, the Committee should consider tracking of such issues, in order to be asking the right questions at the right time. In response to a question on whether or not Social Services representation on the bullet rounds impacted DTOC performance, Karen Miles confirmed that at the last Board meeting, the Director of Social Services asked that DTOC be looked at from both a Social Service and Health perspective in order to be able to place assurance on the reporting and Rhian Dawson and the County Directors are undertaking this work. Sue Lewis confirmed that the ICF investment has allowed work to be undertaken to assess the pre-medically fit, whose indicators suggest a complex discharge, where considerable time is currently lost, but it was important to note that 30% of the DTOCs were awaiting transfer to other Health Boards. Mike Ponton concluded that the Committee needs to see tangible results of the investment in this area and also be assured that plans for the future are robust and will deliver improvement so the offer from the Social Services Associate member of the Board is an important one. Page 10 of 24 JT JT/SP

11 Page 68 Stroke Quality Improvement Measures, Sarah Perry explained the reasons for the key issues around the 72hr pathway care and the Thrombolysis Care targets. An excellent care pathway is in place in BGH where significant improvement has been made and the aim now is to replicate it across the Health Board. One of the key areas where Hywel Dda fails to deliver is in the 24hr target, due to the unavailability, particularly on bank holidays, of the Stroke consultant. This is a new area of measurement for the Health Board and an action plan has been discussed with the Stroke Steering Group, which recommends that the plan be strengthened, include clearer actions and be linked to Therapies which play an important role in the pathway. Weekly performance review meetings are taking place with Therapies representatives to understand where things have gone wrong and to put in place improvement action plans. Following a query on why this area isn t RAG rated, it was explained that this is the scoring mechanism in use by the rest of Wales, however, Karen Miles undertook to provide an addendum note that explains this. Page 72 Urgent Suspected Cancer, Keith Jones explained that since this report was issued, further data has been received from ABUHB showing an over 62 day waiting time position just shy of 91%, which is based on 7 breaches, rather than the 8 projected. Four of these breaches are shared breaches and without them, Hywel Dda would have achieved its 95% target. However, a dip in performance is expected in February 2016 due to work being undertaken to reduce the backlog. There is a slight drop in performance of the Non-Urgent Suspected Cancer waiting time, but this contains another shared breach, without which the 98% planned profile would have been achieved. Unusually, there were 2 local breaches, one reflecting the ongoing challenges around a single consultant in Dermatology and the GI breach was an exceptional incidence. Mr Jones described the challenges facing the Health Board in assessing and diagnosing patients in the early stages of the pathway, reporting that significant effort has gone into sourcing additional outpatient capacity which has led to improvements being seen in first outpatient waits. Inroads are being made into the backlog, with the aim being to go into March 2016 with the minimum backlog possible. There is cautious optimism at present, although nothing further from a performance or management perspective can be done to reduce the waits of the 13 patients listed in the table on pages due to the reasons provided in the paper. Partly as a result of Hywel Dda s escalation of the capacity issues experienced in the Lung pathway and Thoracic Surgery, WHSSC as the commissioner, has recognised that insufficient capacity is being commissioned and has taken steps to improve this situation for 2016/17. In response to a query on whether Bristol could be considered as an alternative provider, Mr Jones explained that due to patient relationships already having being established with Swansea clinicians, it was preferable to commission services as locally as possible. The second Gynaecology Cancer surgeon is not due to start until late summer but Hywel Dda does not have any current patients at risk in a tertiary centre. Limited success in recruiting Radiotherapy consultants to Singleton means that it continues to impact on access to radiotherapy treatment, however the nursing issues around chemotherapy provision have been resolved and a number of Hywel Dda patients have been identified for Page 11 of 24 MC

12 repatriation back to the Health Board to secure their treatment more quickly. Work is ongoing with Swansea to allow patients to receive their chemotherapy locally, regardless of where they are treated by their Oncologist. Keith Jones concluded that although some of the big risk areas are not out of the woods by any means, there is an improving picture overall. Specific questions from Members on the rules around clinical suspension and the ongoing support for patients were addressed. Philip Kloer feels strongly that if WHSSC are unable to provide an urgent solution to the Thoracic Surgery capacity issue, in the interim, the Health Board will need to source services elsewhere until WHSSC can find a more local solution. Jill Paterson undertook to pick this issue up with David Eve, to seek assurance from WHSSC in terms of how they will equalise capacity with demand quickly or if that is not possible, an urgent conversation is needed to find alternatives for those patients. Page RTT, Caroline Lewis reported that the current position is 5,210, which is still 615 patients above the 4,595 target for year end, but as an operational team, they are doing everything they can to get below that figure and a number of key actions being taken were outlined. The consensus is that the Health Board will improve on the 4,595 breaches it is projecting and having already benefitted from the validation exercise, this will be achieved mainly through targeted management activity between now and the end of March Sian-Marie James raised a point of accuracy on page 78 that 140 of the 200 outstanding Ophthalmology patients have been treated and ENT are recruiting one consultant, not two. Page 82 Diagnostic Waits, Sarah Perry explained the significance of hitting the year-end target of zero breaches in this area given the 3.5m conditional investment by WG and the impact on the patient, and assured the Committee that each individual is being followed closely throughout the pathway to ensure this is achieved. There has been significant improvement since the end of January and at present, there are no Cardiology breaches. Philip Kloer advised that this was having a positive effect on patients and clinicians, having previously had long waiting lists in this area and it is how one would wish to run a hospital. Karen Miles added that the aim for next year is to achieve zero 6 week waits. Page 84 Delayed Follow Up Appointments, Caroline Lewis reported that a Task & Finish Group led by Joe Teape monitors the actual number of patients waiting over their target dates and the figure has reduced in January The process of validation and the resulting options for patient management was described in detail to the Committee and although Ophthalmology has been the main focus of this exercise, it has also been rolled out to other specialties. Karen Miles added that although it may seem that there is small scale progress, the list is being added to all the time and concerted effort has gone into analysing the top four specialities, of which Ophthalmology has been the main focus. This will be the subject of a presentation that Joe Teape intends bringing to the next Performance BP&PAC. JP MC JT Members were invited to raise any concerns in relation to pages outside of the meeting. Page 12 of 24

13 Our Staff and Resources Page 107 Workforce: Recruitment - Lisa Gostling maintains the view that by this coming autumn, nursing establishment vacancies will be vastly reduced. A recent visit to the Philippines resulted in 208 nursing job offers being made in addition to 42 interviews and job offers made previously. The Student Nurse Open Day on 20 th February resulted in 20 Mental Health nurses, 5 Paediatric and 51 general nursing job offers being made to newly qualified nurses who will start in September Preparation to receive and support the new staff will involve a lot of work for the Workforce & OD team over the coming months, but the outcome will mean a significant improvement in nurse recruitment. The Health Board is using the same agency it has employed for its nurse recruitment, to source Paediatric and Radiology Consultants from overseas, initial efforts focussing on India, given that is where many of the call centre clinicians are based who already undertake work for Hywel Dda and if successful, it will be rolled out for other specialties. As part of the procurement contract with the same company, a piece of work is underway looking at sourcing Mental Health & LD practitioners from England, New Zealand and Australia. Caroline Oakley acknowledged the phenomenal amount of work being undertaken by the recruitment team, but cautioned that the impact of the Safe Staffing Bill that has recently gone through Parliament has yet to be ascertained. It is anticipated that once this has gained royal ascent, guidance will be developed over the first 6 months of the new financial year and whilst much of the work has already been undertaken on Medical and Surgical wards, the impact is unknown in terms of Mental Health and Paediatrics. Given the high level of recruitment at present, the Committee was updated on the day-to-day issues experienced around induction backlogs and the solutions being explored with other providers and Caroline Oakley and Mrs Gostling addressed specific queries from Members around how news of the new nursing recruitments is communicated to staff and the successful recruitment to middle grade A&E doctors in WGH being rolled out elsewhere in the Health Board. Lisa Gostling also confirmed that delays are still being encountered in NMC registration checks of European nurses, but the Philippino recruits undergo checks in the Philippines prior to application, then take an examination on arrival in the UK, so are not subject to such delays. PADR - Mrs Gostling outlined the ongoing work to increase the PADR performance, explaining that a number of 1:1 meetings have been set up to support individual managers, given that as from April 2016 anybody over Band 7 who has not had a PADR will not receive their progression increment. Sickness Absence Mrs Gostling reported that this has reduced slightly but with the caveat that the report was run quite early. It is anticipated that once establishment levels have been recruited to, it should allow more time for PADRs and staff should not be under so much pressure so sickness levels should reduce. Disciplinary the amount of detail provided on page 98 should reduce in Page 13 of 24

14 future, but the trajectory is heading in the right direction and all cases are being actively managed by the team. Bank and Agency groups have been established to look at how bank and agency, recruitment, medical workforce and e-rostering systems are used more efficiently to help reduce the variable pay bill and create a more sustainable workforce and the Committee will be sighted on the outcomes as work progresses. Margaret Rees-Hughes informed the Committee that QSEAC had identified some major risks in mandatory training performance which it was escalating to Board as compliance is not at the required level. Karen Miles explained that given the Service and Workforce positions are exceptionally dynamic, this is also reflected in the finances. The Health Board is expecting to hold and to improve upon its 32.5m deficit, the improvements being mainly due to clarification from WG around policy lead issues, of the entitlement to the full allocation of funding for items which had previously only matched actual expenditure in year. RTT activity and Unscheduled Care remains an issue and there is a watching brief in months 11 and 12 because of the variable pay consequences on the 32.5m forecast deficit. It is important to note that the efforts of the recruitment team will not filter through into the current year s financial position. Mrs Miles reported that the Health Board is cash poor at present, but WG have given an undertaking that they are taking a fixed point on the 32.5m (or below) deficit and will look to extend a cash accommodation to allow the organisation to pay its bills. There will be no further significant resource available to reduce the position beyond Hywel Dda s planning figure and the expectation is that the final deficit will be in the region of 27-28m which will be repayable in future years. Notification has just been received of 700k discretionary capital and plans are in place to deal with mainly backlog issues and particular equipment which is giving cause for concern. Mrs Miles anticipates that the Month 11 position will look very different once discussions around the final allocations are concluded with WG. Mike Ponton concluded that today s discussion on performance has been the most thorough to date and should form the template for future meetings. Not only should sufficient time be reserved in the next performance meeting, but the agenda also needs to be planned to accommodate this. Bernardine Rees, Caroline Lewis and Keith Jones left the meeting. BPPAC(15)89 HYWEL DDA INTERMEDIATE CARE FUND INVESTMENT IN COMMUNITY SERVICES Sue Lewis presented an overview of the investment received as part of the Intermediate Care Funding and advised that not all of the schemes that were funded initially came to fruition. The significant reduction in the revenue allocation for 2015/16 meant that efforts needed to be refocused on : a) Schemes that would provide value for money; b) Schemes that could prove they were meeting the criteria; Page 14 of 24

15 c) Schemes that were sustainable and would build on existing capacity. Together with Local Authority partners, an assessment was made of what was and was not working and there was a lot of commonality in terms of where people wanted to invest the additional resource. The aim was to build upon existing services and look at opportunities to move forward in an integrated way, therefore the two regional themes were: Investing to go further; Investing to join up. All of the proposals submitted were benchmarked and challenged by the Health Board and the Regional Collaborative in terms of how additionality could be demonstrated. Mrs Lewis explained that the performance indicators being proposed by WG were not considered to be stringent enough in evidencing this so the Health Board has looked at how it can build in more tangible indicators, linking back to DTOCs and how people can be kept out of hospitals and there is a piece of work in progress to provide that for next year. Each of the three counties have invested in slightly different schemes, but generally, the thrust of the investment was about: Admission avoidance; Early discharge; Safe discharge; Repatriation to community services but building on existing services. Mrs Lewis reported that notification has been received indicating that investment levels for 2016/17 will return to the year 1 value, therefore there will be a re-allocation and reprioritisation against the investment. It is Mrs Lewis understanding that there will not be a capital element for next year, but where capital investment has been made in year 1, some schemes have yet to come to fruition due to lead in times for building and revamping estates. Detailed reports are available for each of the schemes should anybody wish to see them. Anthony Tracey joined the meeting. Simon Hancock described the PIVOT scheme in Pembrokeshire which, with an investment of 90k has successfully avoided 960 bed days costing nearly 0.245m. The report was commended for its quality and detail and it was felt that it was a good example of partnership and coproduction and demonstrated what could be achieved with investment across Health and Social Care. The Committee: RECEIVED the report for information and assurance. ENDORSED the approach taken at regional and Health Board level to considerably strengthen intermediate care services. BPPAC(15)90 NHS EXTERNAL PROVIDERS DIRECT PATIENT CARE Karen Miles advised that this report was provided as a watching brief on Hywel Dda s external contract provision with other Health Boards whilst the commissioning framework for this area is being developed. This is Page 15 of 24

16 how the external providers are being tracked and it is quite fluid, given that they have also received RTT funding to achieve the 36 week target for all patients in the cohort, regardless of residency. It is in a holding position, but will provide flavours of how services will be commissioned and improved upon going forward. Laurence Williams queried progress against the action arising from the December meeting in which plans were required from ABMUHB and C&V to address the outstanding waits by the end of the year and was advised that there are two things ongoing during this reporting cycle: 1. There have been improvements to some of the longest waits by some of those providers but Hywel Dda has yet to be sighted on them given the data is only up to month 9; and 2. The monies received came in around month 8 so in many instances, the plans to improve trajectories for Hywel Dda residents are not yet firm enough. The paper has been brought to this Committee as the external contracting position but the next steps for improvement will need to centre on the commissioning trajectory. It was suggested that for the next performance meeting, this report is a dovetail between what can be seen contractually during the year and what we would want to commission going forward, with some headline indicators of what that will mean for patients and also quality. That will be in keeping with the fact that the Board has to be sighted on commissioning intentions going forward as part of the IMTP and it will also describe the process. Jill Paterson confirmed that a paper is going to Executive Team on commissioning intentions and will then come to this Committee. JP/DE The Committee NOTED the contents of the report. BPPAC(15)91 HEALTH BOARD REVENUE ALLOCATIONS 2016/17 Karen Miles advised that as part of the IMTP, the Health Board needs to be assured of its income assumptions from WG. An allocation letter has been issued for 2016/17 and a supplementary allocation is due for the additional items listed in this report. It is important to note that the organisation is looking at m, added to which, there will be 44.31m of other resource allocations released throughout the year. Therefore m will be the sum which will be included in the IMTP. Mrs Miles highlighted some of the issues/assumptions detailed in the assessment: GMS, Community Pharmacy and Dental contracts are as yet unknown. Anticipate 200m general allocation growth, of which Hywel Dda s share will be 24.2m. An increase in the Intermediate Care fund from 30 50m across Wales. 30m increased funding for older people and Mental Health Services. Sue Lewis left the meeting. There is not such welcome news in terms of: Page 16 of 24

17 Continuing Healthcare Retrospective claims a change in accounting treatment means that they will remain the Health Board s liability, but will be accounted for in AME. i.e. the organisation does not incur the cost until they are paid out, but it will bear the brunt of the cash and resource outlay in the year the payment is made. This is estimated to be in the region of 4-5m within the next 2-3 years. In contrast to 2015/16 when it received additional funding, the Health Board will be expected to pick up the estimated cost of 1.5m for Hepatitis C and Eculizumab from the additional 24.2m growth investment mentioned above. Assurance has been sought from pharmacy leads as to whether this is the upper estimate or whether growth is expected in this area of high cost drugs. There are no changes to existing arrangements for Junior Doctors rotational costs this is to provide clarity. Apprenticeship Levy the requirement for the organisation to take on apprentices - could potentially result in a 1.6m hit. The Pay Award assumption reflects the National Finance Agreement. It is important to note that whilst the 200m growth investment is based on resource mapped shares, the Intermediate Care Fund and the Mental Health funding is not. Therefore, it is incumbent on Community and Mental Health colleagues to pull out all the stops to secure as much as they can as Hywel Dda s cannot expect to automatically be awarded its usual 12.2% share. Karen Miles undertook to make sure County Directors were aware of this. The Nuffield model is included for planning purposes only, given that there is no mandate until such time as a Welsh Government is formed. Primary Care ring fencing remains in place albeit that specific issues are sue to be reviewed around the Dental contract. Early indicators show that the Directed Enhanced Services for Warfarin is likely to result in a 0.7m hit to the Health Board s position. The Inter Health Board and Trusts LTA and SLA Uplift changes forms part of the negotiation around the IMTPs. In summary, these items are flavours of where the Health Board is in terms of the confirmed allocation letter and a supplementary is expected, which will change its financial strategy for the next three years. KM Apart from Tier 1 Target information for Mental Health and the paper on ICF funding, Sian-Marie James observed a lack of Primary Care, Community and Mental Health Services performance content in the papers, especially NHS Dental waiting list performance given that underperformance has been discussed at Primary Care Applications Committee. Libby Ryan-Davies felt that there would be an opportunity with the new Mental Health money, given that there are clear indications from WG around the outcome measures that will need to be reported on. Mrs Ryan-Davies agreed that the Tier 1 Targets currently offer a Page 17 of 24