Bundle Health Board - public 1 March 2018

Transcription

1 Bundle Health Board - public 1 March OPENING BUSINESS AND EFFECTIVE GOVERNANCE : Chairman's Introductory Remarks - Dr Peter Higson : Special Measures Update - Mr Gary Doherty : Apologies for Absence : Declarations of Interest : Draft Minutes of the Health Board Meeting held on for accuracy and review of Summary Action Log 18.71a Minutes Health Board Public v0.03.doc 18.71b Summary Action Log Public_v doc 2 ITEMS FOR CONSENT : Committee and Advisory Group Chair's Assurance Reports Audit Committee (Mr C Stradling) Quality, Safety & Experience Committee (Mrs M Hanson) Finance & Performance Committee (Mrs M W Jones) Financial Recovery Group (Dr P Higson) Remuneration & Terms of Service Committee (Dr P Higson) Strategy, Partnerships & Population Health (Mrs L Meadows) Mental Health Act Committee (Mrs M Hanson) Healthcare Professionals Forum (Prof M Rees) Stakeholder Reference Group (Mr Ff Williams) Chair's Assurance Report AC V3.0 at doc Chair's Assurance Report QSE V1.0.docx Chair's Assurance Report FPC V1.0.doc Chair's Assurance Report FRG V1.0.doc Chair's Assurance Report R&TS V1.0.doc Chair's Assurance Report SPPH v1.0.doc Chair's Assurance Report MHAC V1.0.doc Chair's Report HPF V1.0.doc Chair's Report SRG V1.0.doc : Mental Health Act 1983 as amended by the Mental Health Act Mental Health Act 1983 Approved Clinician (Wales) Directions Update of Register of Section 12(2) Approved Doctors for Wales and Update of Register of Approved Clinicians (All Wales) - Mr Gary Doherty Recommendation: The Board is asked to ratify the attached list of additions and removals to the All Wales Register of Section 12(2) Approved Doctors for Wales and the All Wales Register of Approved Clinicians AC & s12 Report.docx : Board Annual Cycle of Business - Mrs Grace Lewis-Parry Recommendation: The Board is asked to approve the Annual Cycle of Business 18.74a Cycle of Business coversheet.docx 18.74b Cycle of business.docx 3 FOR DISCUSSION : Finance Report - Mr Russ Favager Recommendation: It is asked that the report is noted Finance Board Report - Month 10.docx : Wales Audit Office Annual Letter - Mrs Grace Lewis-Parry Recommendation: The Board is asked to receive the report 18.76a Annual audit report WAO coversheet.docx 18.76b Annual Audit Report WAO 2017.pdf : Wales Audit Office Structured Assessment Mrs Grace Lewis-Parry

2 Recommendations: The Board is asked to 1)receive the report 2)accept the recommendations in the Structured Assessment 3) note the initial management response to the Structured Assessment 18.77a Structured Assessment coversheet.docx 18.77b Structured Assessment 2017_final.pdf :06 - Lunch / Comfort Break : Integrated Quality & Performance Report - Ms Morag Olsen Recommendation: The Board is asked to note the report a IQPR coversheet.docx 18.78b IQPR Board Version at 1025.pdf : Living Healthier Staying Well : Our Strategy for the Future - Mr Geoff Lang Recommendation: The Board is asked to 1) Receive the report 2) Approve the strategy paper for formal publication 18.79a LHSW coversheet v1.docx 18.79b LHSW Strategy Doc Final Draft - v9 SB pdf 4 14:06 - FOR INFORMATION Medicines Management Annual Report - Ms Morag Olsen Recommendation: The Board is asked to note the annual report Pharmacy Medicines Management Annual report.doc Vascular Services Update - Dr Evan Moore Recommendation: The Board is requested to note and approve the work which has been undertaken to date a Vascular report.docx 18.81b Vascular appendix.pdf Welsh Health Specialised Services Committee Joint Committee Approved Core Briefing WHSCC Joint Committee Core Briefing APPROVED.pdf Information circulated since the last Board meeting White Paper Bevan Commission Special Measures Improvement Framework Action & Progress Log Self assess RAG rating BCU Response to Options Paper on NHS Wales Performers List Summary of In Committee Board business to be reported in public Recommendation: The Board is asked to note this paper In committee items reported in public.docx 5 CLOSING BUSINESS Date of Next Meeting am at Neuadd Reichel, Bangor Committee Meetings to be held in public before the next Board Meeting Charitable Funds Committee ; Quality, Safety & Experience Committee ; Finance & Performance Committee

3 Draft Minutes of the Health Board Meeting held on for accuracy and review of Summary Action Log a Minutes Health Board Public v0.03.doc Minutes Health Board Public v Betsi Cadwaladr University Health Board (BCUHB) Minutes of the Health Board Meeting held in public on in Neuadd Reichel, Bangor Present: Dr P Higson Cllr C Carlisle Mr J Cunliffe Mr G Doherty Mr R Favager Cllr B Feeley Mrs M Hanson Mrs G Harris Mr G Lang Mrs G Lewis-Parry Dr E Moore Ms M Olsen Miss T Owen Mr C Stradling Mr Ff Williams In Attendance: Mrs K Dunn Mr D Jenkins (via Skype) Chairman Independent Member Independent Member Chief Executive Executive Director of Finance Independent Member Independent Member Executive Director of Nursing & Midwifery Executive Director of Strategy Board Secretary Executive Medical Director Chief Operating Officer Executive Director of Public Health Independent Member Associate Board Member, Chair of Stakeholder Reference Group Head of Corporate Affairs Independent Adviser Translator, staff, observers and members of the public Agenda Item Chairman's Introductory Remarks Action The Chairman was pleased to announce that the Health Board had scored highly in the Stonewall Workplace Equality Index this year, securing a ranking of 51 st place in the index compared to 95 th last year. In addition it was reported that Jack Jackson, the Health Board s team leader for mental wellbeing & counselling, had been awarded the Trans Role Model of the Year Award for the whole of the UK The Chairman also informed the Board of the need to make a retrospective correction to the previously approved minutes from the December meeting to clarify that the Ty Doctor practice in Nefyn was not a managed practice. The Chairman welcomed a group of visitors from Lesotho who were in North Wales for a range of events as part of the International Health Group initiative. In addition, a warm welcome back was extended to Mr Andy Roach after a period of absence, and representatives of Wales Audit Office guests were also welcomed Special Measures The Chief Executive referred to a statement that had been released on the day of the meeting by the Cabinet Secretary and which had been circulated to board members.

4 Minutes Health Board Public v The statement highlighted progress made by the Board and also areas for further improvement, It provided confirmation that there will be further improvements and milestones to be achieved over the next months as part of continuing special measures Apologies for Absence Apologies for absence were received for Mrs Marian Wyn Jones, Mrs Nicola Stubbins, Prof Jo Rycroft-Malone, Mrs Bethan Russell-Williams, Mrs Lyn Meadows and Mr Adrian Thomas Declarations of Interest Mr J Cunliffe declared an interest in item in respect of his wife being a clinical psychologist in the employment of the Health Board Draft Minutes of the Health Board Meeting held on for accuracy and review of Summary Action Log The minutes were agreed as an accurate record, pending the amendment to to read a proportion of the 13m allocated. A matter arising was raised by the Chief Executive to inform the Board that it had been necessary to make an amendment to the Special Measures Phase 3 report which had been submitted to Welsh Government in terms of correcting the terminology relating to the Internal Tawel Fan Group. The summary action log was noted, and it was stated that the letter to the palliative care team had now been sent by the Chief Executive Committee and Advisory Group Chair's Assurance Reports Financial Recovery Group (FRG) The Director of Finance presented the report and drew members attention to the key risks and assurances as highlighted. He added that with the production of the Month 9 position the FRG was focused on the actions being taken and there was a particular improvement in mental health Local Partnership Forum (LPF) The Chief Executive presented the report and drew members attention to the key issues highlighted. He added that a key area for discussion at the next meeting would be staff engagement. The Executive Director of Public Health took the opportunity to update the Board on the latest situation with regards influenza in that it continued to circulate but at a reduced level. BCU was the best performing Health Board with regards to numbers of vaccinations delivered but was still below the target. The Chairman asked that planning for the next flu season be undertaken earlier, and it was confirmed that a debrief was already planned for reviewing the previous season Stakeholder Reference Group (SRG) The Chairman stated that he had agreed with the SRG Chair that he could raise an issue ahead of the assurance report being available from the meeting held on The SRG Chair stated that the meeting had been made aware of a consultation relating to the NHS Wales Performers List with a closing date of and that the SRG had expressed strong concerns over the current arrangements in that they did not help improve recruitment challenges. The SRG had favoured Option 1 from the consultation

5 Minutes Health Board Public v which suggested a UK-wide performers list, but were aware that Option 3 may be more feasible. The Executive Director of Strategy felt that the SRG s view was in line with the Health Board s experience of the matter. It was agreed that the Board s response to the consultation would be shared with members once finalised. GL Integrated Quality & Performance Report The Chief Operating Officer presented the report, confirming that the Finance & Performance Committee and the Quality, Safety & Experience Committee had scrutinized their respective domains. Overall she stated that it had been a very busy couple of months in terms of activity particularly in Emergency Departments, Minor Injury Units and within the GP out of hours service. There were also much higher levels of red 999 calls resulting in attendances at BCU sites. In terms of Referral to Treatment (RTT) performance had markedly dropped. With regards to the impact of influenza, it was noted that 222 flu cases had been admitted to acute sites of these being during January, and an increased number of patients requiring critical care The Executive Director of Nursing & Midwifery reminded members that influenza affected the workforce as well as patients which in turn affected the ability to staff wards. The Health Board was continuing to utilise temporary agency staff to maintain the quality and safety of services The Executive Medical Director referred to the section on patient safety notices and that these were now starting to move towards resolution, and that performance against research and development targets was also improving. With regards to mortality, the Executive Medical Director referred to recent press coverage regarding the figures at Ysbyty Glan Clwyd (YGC) and he went on to explain that crude mortality rates do not take into account any element of risk factor or expectations for different cohorts of patients and different circumstances. Whilst the use of crude rates for large populations was useful, there was a need to be more careful in their application to smaller groups. The Executive Medical Director confirmed that mortality rates within the Emergency Department (ED) at YGC had peaked above the Welsh average in January 2017 but had been falling since that time. In addition, mortality rates across all admissions to YGC had also been falling and now lay below the Welsh average. Members were assured that all deaths within the ED were reviewed and there was a high level of confidence that the triage system was working well, however, patients were unfortunately arriving at ED in poorer health and also spending more time there. The Executive Medical Director outlined a range of approaches that were being undertaken to address this, including - a mortality reduction strategy to focus on improving patient flow; improvements in ensuring patients were hydrated, reducing the risk of pressure ulcers, appropriate and accurate medication, falls prevention; targeted mortality reviews and ensuring a choice of palliative care for patients and families. The Vice Chair asked that given the complexity of the issue every opportunity should be taken to provide assurances to the population and patients of YGC in particular around the safety of services The Executive Director of Nursing & Midwifery went on to remind members of the infection prevention challenges facing the Board and that trajectories had not been achieved for clostridium difficile nor MRSA, despite the initial improvement following the external review undertaken in Members were also briefed on the Safe Clean Care campaign that had been launched across all sites and which had a good level of involvement from a range of staff groups.

6 Minutes Health Board Public v The Chief Operating Officer drew members attention to cancer performance and concerns around the 62 day target due to delays within endoscopy. She confirmed that the mobile units were now in place and additional sessions were being provided through the Robert Jones Agnes Hunt Hospital in Gobowen. Stroke performance had declined, predominantly due to unscheduled care pressures. It was confirmed that 13.2m had been allocated for RTT by Welsh Government to reduce over 36 week waits, and extra capacity to deliver this within BCUHB was now in place as well as with other external healthcare providers. The Chief Operating Officer indicated there associated risks were incorporated within CRR11 (access and delivery) A discussion ensued. It was suggested that the 13% increase in minor injury units should be read as a positive development in terms of encouraging their use for appropriate ailments and injuries rather than the acute Emergency Departments. The Chief Operating Officer reported that additional support to redesign unscheduled care had commenced with the provider s first focus to be on improving flow through EDs, using YGC as the basis for sharing learning, before moving onto whole system redesign. The importance of ensuring that cross-organisational issues were identified between the Health Board and North Wales Police was also highlighted in terms of understanding unscheduled care pressures. With regards to the deterioration in Child Adolescent Mental Health Services, the Chief Operating Officer would follow up specific questions with Cllr Carlisle. She was also asked to confirm the December position with regards to in-patient and out-patient cancellations for Mr Stradling. MO It was resolved that the Board note the report Finance Report The Executive Director of Finance reflected that as it had not been a full month since the last Board meeting there was no new financial information other than that verbally reported to the Board on , and as such he would concentrate on the key headlines and the actions being taken. He reminded the Board that the report had been discussed at the Finance & Performance Committee on the and the headlines also discussed at the last Financial Recovery Group meeting. He drew members attention to the cover sheet which confirmed that at Month 9 the Board had overspent by 32.8m, 19.5m of this relating to the planned budget deficit of 26m approved by the Board meaning the variance against plan was a 13.3m overspend after 9 months. The Executive Director of Finance pointed out that the monthly run rate had been on the trajectory set as part of our financial recovery plan to deliver against the 36m deficit control total with Welsh Government and that Month 9 saw a continuation of the improved run rate since September down from the 2.6m in December to 2.2m With regards to the main drivers for areas of overspend, the Executive Director of Finance highlighted improvements in Out of Area Placements, Medical and Nursing Agency and a slowing down of the overspending run rate in the Mental Health division from 900k per month to 400k per month. He also informed the Board that as of the previous week there were no Out of Area placements for Mental Health which was a significant achievement bearing in mind there were 56 in May It was reported that a range of focussed actions continued across several areas which included: Minimising the use of agency staff whilst ensuring continuity of care through the use

7 Minutes Health Board Public v of nursing bank staff as a preference. Work with the Workforce & Organisational Development department and universities on recruitment to ensure that training places in BCUHB were as attractive as possible. Continued focus on reducing medical agency spend which had now reduced by 1m per month. Maintaining a downward trajectory on continuing health care with introduction of pilot schemes with care homes for step down beds. Initiatives with GPs regarding over the counter drugs, drugs that shouldn t be prescribed, reducing clinical variation and increasing home care drug deliveries for those patients on long-term specialist therapy The Executive Director of Finance suggested that the focus for everyone in the organisation but specifically operational managers was what could be achieved over the next couple of months rather than continual analysis and diagnos. There was a need to concentrate on their entire budget and not on the current overspending areas, as a lack of focus can lead to unsighted emerging issues. He also wished to take the opportunity to highlight a training event in Wrexham delivered by Professor Sir Muir Gray and his team around Better Value Healthcare. The Executive Director of Finance went on to remind the Board that the current financial projections did not include the outcome of the Supreme Court Judgement in relation to Continuing Healthcare fees and that work was ongoing to estimate the potential impact with colleagues across Wales to ensure a consistent approach. Similarly the Health Resource Group (HRG4+) was also excluded from current projections as discussions continued with NHS England who had referred the matter up to the Department of Health. In summary the Executive Director of Finance concluded that the Board s financial position and performance against the financial targets had continued to improve at Month 9 but was still disappointing and the underlying financial position remained extremely challenging A discussion ensued. The Chair of the Stakeholder Reference Group raised a query regarding cash receivable performance and whether there were any issues with prompt payment via NHS England. The Executive Director of Finance would provide him with more detail outside of the meeting. He also assured the Board that whilst the Board s cash position may impact on the ability to pay creditors within 30 days, small and medium sized companies would be prioritised. A question was posed regarding the level of confidence in achieving the 36m position and the likelihood of needing to consider less popular savings plans, and the Executive Director of Finance indicated that the position would be clearer at Month 10 although the headline to note was that there was evidence that the Board had actually reduced its spend. The Board were also reminded that the draft budget for would be presented at a meeting before the end of March. RF It was resolved that the report be noted Financial Governance Review The Chief Executive presented the paper which provided the executive summary of the external review undertaken by Deloitte. He indicated that the areas covered did in fact go wider than purely financial governance, and he was confident that the Board had already being addressing a range of the issues that had been identified. The Chairman was of the view that the external scrutiny as part of the review had been a helpful piece of work which was welcomed by the Health Board. He indicated there had been a very useful feedback session with the consultants and that he would wish to see

8 Minutes Health Board Public v the action plan being cross-referenced with other areas of work such as Special Measures and the Structured Assessment by Wales Audit Office A discussion ensued. A concern was raised that the management response to R11 may potentially be destabilising when read in the context of the whole report, and that it would not be desirable to lose the focus of the existing strong financial reporting. With regards to R11 the Executive Director of Finance emphasised that whilst this appeared to focus on the finance department, the principles applied much more widely and that the transformation agenda needed to be addressed by the whole organisation. A general comment was made that the progress within the management action plan could be tighter as there were several references to ongoing or in progress. The Chief Executive suggested that some of the actions were quite likely to remain ongoing as they did need to continue on a long-term basis, however, he accepted that some of the recommendations could be split into separate elements with individual milestones. A typographical error was pointed out in that R9 should refer to The Chairman added that there would be a need to pause and reflect on the statement from the Cabinet Secretary regarding special measures and interventions relating to the Health Board, and the indication that the Board would remain in Special Measures for a further months. There would need to be continued pace and momentum for the current work relating to the Special Measures Improvement Framework (SMIF) and the additional requirements that are subsequently confirmed by Welsh Government It was resolved that: (1) the report be received; (2) the action plan in response to the recommendations be endorsed; and specifically (3) the Board agree to the expansion of the top level organisational structure and sanction the appointments of a Director of Turnaround and Director of Transformation as outlined within the action plan. GLP In addition to the recommendations within the paper it was resolved that the action plan be aligned with the existing SMIF process and progress be monitored through the SMIF Task & Finish Group North Wales Population Assessment Regional Plan 2018/ The Executive Director of Strategy presented the paper which had been developed and overseen through the Regional Partnership Board to meet the requirement of the Social Services & Well-Being Act (Wales) 2014 for Health Boards and Local Authorities to publish a joint plan by April The Vice Chair of the Health Board indicated that she was the BCUHB representative on the Regional Partnership Board and was pleased to be able to provide the plan for endorsement by BCUHB and she was hopeful the plan would address some historical difficulties in aligning health and social care agendas A discussion ensued. The Executive Director of Public Health welcomed the approach to planning through needs assessment. The Local Authority Independent Member indicated she was very supportive of the partnership approach but noted her concern that the size of North Wales did present a challenge. The Chair of the Stakeholder Reference Group welcomed the plan and the references to Registered Social Landlords (RSLs), and was keen to ensure the links between the Regional Partnership Board and RSLs were stronger. The Vice Chair indicated this had been raised and there would be a need to ensure the RSLs added value to the work of the

9 Minutes Health Board Public v Regional Partnership Board. In response to a question regarding cross-referencing to the draft three year plan, the Executive Director of Strategy confirmed that the workstreams did read across It was resolved that the Board endorse the North Wales Population Assessment Regional Plan Living Healthier Staying Well : Our Strategy for the Future The Chairman proposed that following the recent statement from the Cabinet Secretary and the ongoing work to prepare a Three Year Plan for the Health Board as opposed to an Integrated Medium Term Plan, the Strategy be received and a formal launch be arranged for the Board meeting scheduled for the The Board were assured that the Strategy set out the organisation s strategic intentions and that a full and robust engagement process had been followed. The Executive Director of Strategy asked members to reflect on the wealth of information and rich data that supported the Strategy in terms of the engagement process and equality impact assessment. He also indicated that a more public-facing version of the Strategy would need to be developed which still captured the Board s priorities and direction of travel. GL It was resolved that the Board receive the report and endorse the strategy pending review in line with the Cabinet Secretary statement of Orthopaedic Plan Update : Musculoskeletal Services The Chief Operating Officer reminded the Board that papers had previously been received setting out the principles underpinning the development of a sustainable elective orthopaedic surgery service in North Wales, and that the aim of this latest report was to provide an update of progress against the orthopaedic plan A discussion ensued. In response to a question regarding the emphasis on a network approach to orthopaedics, the Chief Operating Officer confirmed this related to clinicians working together to share best practice and working differently particularly within clinical audit. The Chairman felt that any future updates to the Board would benefit from more cross-referencing of referral to treatment data, and it was suggested the next update report should be planned for April. MO It was resolved that the Board note the current progress against the orthopaedic plan particularly in respect of musculoskeletal services; as well as the further developments to support the delivery of a sustainable elective orthopaedic service for North Wales Mid Wales Healthcare Collaborative Update The Board Secretary reminded the Board that the Mid Wales Healthcare Collaborative had been established in 2015 made up of three Health Boards, 3 County Councils and the Welsh Ambulance Services NHS Trust. A new set of terms of reference had been developed and a summary paper was being submitted to all partner Boards for adoption A discussion ensued. It was felt the required financial commitment was modest when compared to the importance of this collaborative effort to focus health and social

10 Minutes Health Board Public v care for the Mid Wales area. The Executive Director of Public Health felt that the collaborative addressed a range of important issues for the residents of south Gwynedd and the priorities were linked to health and well-being and the work of the Public Service Boards It was resolved that the Board 1.Note the progress on the work undertaken by the MWHC and the areas of work that are being progressed and achievements that are being made. 2.Agree the final Terms of Reference and Operating Framework for the Mid Wales Joint Committee, Appendix 1, to replace the existing Terms of Reference for the MWHC. 3.Note that Collaborative Health Boards have discussed the contribution of 33% towards the actual financial costs incurred for the establishment of the MWJC team for 2018/19 onwards. 4.Agree to the development of the proposed Sub Group structure, as outlined in the operating framework, for which draft Terms of Reference will be presented to the shadow Mid Wales Joint Committee meeting on 12th March Agree the establishment of key leadership roles for the Mid Wales Joint Committee and nominations for these roles will be presented to the shadow Joint Committee meeting on 12th March Note the development of a handover statement for the taking forward by the new Joint Committee. 7.Note the work being undertaken to develop the proposed Mid Wales Joint Committee work programme for presenting to the shadow Joint Committee meeting on 12th March Note the work being undertaken to confirm the additional funding requirements for RHCW for the first 6 months of 2018/19 pending clarification of its future relationship with Health Education Improvement Wales (HEIW) Strategic Dementia Action Plan for Betsi Cadwaladr University Health Board The Executive Director of Nursing & Midwifery presented the Strategic Action Plan which she confirmed had been informed by a number of individuals, organisations and professionals including people living with dementia, their relatives and carers. She highlighted that the national plan had yet to be published and the BCU document would therefore need to be reviewed against it when available. It was noted that the next steps would be to develop implementation milestones to fulfil actions with partners that met the needs of the population. The Executive Director of Nursing & Midwifery suggested that the document was also a pledge to deliver recognisable improvements for patients and families living with dementia. She highlighted a range of approaches that were now iin place including open visiting, fast track access to other services for those with dementia, and John s Campaign A discussion ensued. A comment was made that the references to people being affected by dementia could be more appropriately phrased as living with dementia. In addition, concern was expressed that there were no timescales for delivery nor costings within the document, and that the references to specific types of therapy were too restrictive as there were other options available. In respect of resources, it was stated that the task and finish groups would be responsible for determining this against the required actions. The point was also made that the document didn t address the need for changing staff behaviours in terms of dealing with a dementia patient who had presented for other aspects of treatment. In response, it was noted that the Alzheimer s

11 Minutes Health Board Public v Society were one provider of training but it was important to reflect that different levels of training would be required depending on the area of work, and that patients and service users should be involved in designing and/or delivering training. The Vice Chair felt personally that the implementation of the Plan was the key stage, although she very much welcomed that the document placed dementia care firmly across all aspects of services and not just within mental health. The Chairman asked that section 8 be strengthened and that the title of the document should be amended to A Strategic Dementia Plan He asked that the Executive Director of Nursing & Midwifery take on board the comments made, and circulate a briefing note to members on the next steps and the role of the task and finish groups in implementing the Plan It was resolved that the Board: 1.Approve the paper 2. Note that the Strategic Plan will be reviewed when the National Plan is published Parliamentary Review "Different System of Care Needed to Deliver for the People of Wales" It was resolved that this national report was noted Emergency Ambulance Services Committee Confirmed Minutes It was resolved that the minutes be noted Emergency Ambulance Services Committee Summary of Key Matters It was resolved that the minutes be noted Welsh Health Specialised Services Joint Committee Approved Minutes It was resolved that the minutes be noted Welsh Health Specialised Services Joint Committee Approved Briefing It was resolved that the briefing be noted Information circulated since the last Board meeting It was resolved that the Board note the detail of information circulated as follows: Public Health Wales " Health and its determinants in Wales" Healthcare Inspectorate Wales "Tell us what you think about new strategic priorities" Summary of In Committee Board business to be reported in public It was resolved that the information be noted Date of next meeting

12 Minutes Health Board Public v It was resolved that the Board note the next meeting would be held on Thursday am in Venue Cymru, Llandudno Committee Meetings to be held in public before the next Board Meeting It was resolved that the Board note the following Committee meetings would be held: Strategy, Partnerships & Population Health Committee ; Audit Committee ; Quality, Safety & Experience Committee ; Finance & Performance Committee Exclusion of Press and Public It was resolved that members of the press and public be excluded from the remainder of the meeting which would be conducted in-committee.

13 b Summary Action Log Public_v doc Lead Minute Reference and Action Agreed Executive / Member G Doherty 18/11.1 Write to the Six Steps palliative care team to acknowledge the winning of the Kings Fund award G Lewis-Parry 18/ Share an appropriate summary of the SMIF Group s self assessment D Sharp 18/22.2 Arrange for consideration of risk & risk appetite at a board development session M Olsen 18/20.1 Ensure the Director of Performance considered whether data was available for North Wales patients who received unscheduled care outside of BCU G Lang 18/37.3 Share copy of BCU response to consultation on NHS Wales Performer s List when completed M Olsen 18/38.6 Discuss Cllr Carlisle s concerns HEALTH BOARD SUMMARY ACTION LOG ARISING FROM MEETINGS HELD IN PUBLIC Original Timescale Set March March March March Summary Action Plan Health Board arising from meetings held in public Update Letter being drafted for CEO signature Letter sent RAG rated self-assessment with SMIF Chair for approval before circulating to Board Circulated. Tentative date of 5 th April being investigated Session will be built into future board development programme This data is not readily available as patients access unscheduled care services across the UK as emergencies arise, however, the volume of patients accessing services where BCU holds contracts are included in the data reported to F&P Committee, and through the Contract Review Group review the quality indicators for sites with contracts where our patients tends to access such as COCH. Action to be closed Closed Closed Closed Closed March Circulated via Closed March Concerns will be picked up as part of the KPI presentation to F&P Committee on Closed 1

14 regarding CAMHS performance outside of the meeting R Favager 18/39.5 Share more detail on cash receivable performance with SRG Chair G Lewis-Parry 18/40.3 Work to incorporate recommendations of Deloitte financial governance review within the SMIF process G Lang 18/42 Arrange formal launch of LHSW Strategy at Board on M Olsen 18/43.2 Provide further update paper on orthopaedic musculoskeletal services in April March Information sent to SRG Chair Closed April Recommendations from the financial governance review now incorporated within the consolidated action plan and will be reviewed by SMIF Closed March Achieved Closed April Paper in hand. Cycle of business updated. Closed V Summary Action Plan Health Board arising from meetings held in public 2

15 Committee and Advisory Group Chair's Assurance Reports Chair's Assurance Report AC V3.0 at doc Health Board To improve health and provide excellent care Committee Chair s Report Name of Committee: Audit Committee Meeting date: 9/2/18 Name of Chair: Responsible Director: Summary of key risks and other items discussed: Mr Ceri Stradling Mrs Grace Lewis-Parry 1. Summary of discussion of each relevant risk on the Corporate Risk Register: - Not Applicable 2. Summary of main business conducted in public session: The Committee considered the Internal Audit progress report that reflected one reasonable assurance report relating to the Medic online project dealing with Medical Rotas and four limited assurance assessments on the National Standards for Cleaning, Occupational Health Service, staff Safehaven and compliance with Job Evaluation policy. The Committee was assured that the recommendations of the Cleaning Standards audit were being addressed as part of the 90 day plan launched in January Internal audit will follow this up in due course. The Head of Occupational Health attended to discuss a response to the internal audit report. It had that found that the service was cost effective and was highly regarded but questioned whether the service was sufficient and sustainable given it had failed to deliver on a number of its current objectives and there were significant risks to losing staff and skills over the next four years. All the recommendations were accepted and a full management response had been provided. 1

16 The Senior Associate Medical Director attended to present management s response to the Safehaven report that had found that there were deficiencies in approved procedures, high level reporting and scrutiny of concerns raised and keeping individuals updated with progress. All recommendations had been accepted and have already been implemented. The Interim Director of Workforce attended to discuss the report dealing with compliance with Job Evaluation policy. The report had drawn attention to the large number of panels that had been cancelled delaying the job application process and that it is not always clear that jobs advertised have been vetted by job evaluation. The Interim Director discussed the unwieldly nature of the current process and agreed to discuss the scope for streamlining matters with the Partnership Forum. Due to particular circumstances the Committee agreed to defer two planned audits until later in the audit cycle. These relate to the audit of the Programme Office and Clinical Coding. Members also discussed the urgency and importance of Clinical Coding. Considered the WAO update report and agreed that the Audit Plan for would be circulated for member consideration and Chair s action outside of a meeting to avoid delaying it until May The Committee discussed and approved the WAO Structured Assessment report and the Annual Audit Report that had already been presented to the Health Board. It was agreed that the delivery of the agreed actions would be monitored as part of the Special Measures Improvement Task & Finish Group. The Committee reviewed the updated management responses to the WAO review of Estates and Discharge Planning and were assured that the WAO were satisfied with the responses and timescales. These actions will be tracked by the Committee via the Team Central tracking arrangements. The WAO also submitted their national review of the Informatics service. As both a national and local response are being developed it was agreed to defer going through the report in detail until the May meeting and to invite the Head of IT to attend to discuss local factors. Received and noted an update on the Board s Assurance Framework and the planned next steps. 2

17 Considered and endorsed changes to Standing Orders relating to updates to terms of reference for the Quality, Safety and Experience Committee, Local Partnership Forum and Charitable Funds Committee. With regards to the latter the change related to a membership change with the Chief Executive being replaced by another nominated Executive. The Committee recommended that further discussion take place outside the meeting with regard to who was best placed from the Executive Team to serve on the Committee but agreed to the principle of the change. The Committee also formally endorsed the change in reporting lines for the Financial Recovery Task and Finish Group which would now report directly to the Finance and Performance Committee and noted that its terms of reference would be updated to reflect this. Reported the matters discussed in committee on Matters considered in Committee: The Head of Finance and Head of Safety and Learning from the NHS Shared Service Partnership attended to present the Welsh Risk Pool Annual Report for From next year an individual report will also be prepared for each Health Board. Attention was drawn to the national growth in the number and value of negligence cases settled over the last 7 years but that these had now somewhat plateaued. The number of annual payment orders as opposed to one-off settlements had also increased significantly and these have first call on the annual national budget available. Another main development has been the reduction in the discount rate and this has been a major factor in driving up the value of settlements. The Head of Safety & Learning was able to point to the positive steps that the Board was taking to deal with matters through redress and learning the lessons from claims and that this needs to continue to reduce the potential size of any risk sharing supplement levied in the future. In the percentage of claims arising in the Health Board reflected our proportionate size but ultimately the value of likely settlements was only 14% of the Welsh total indicating a generally positive claims handling process. Reviewed the Financial Conformance Report covering procurement, payroll, amounts payable and receivable. The Committee also approved the losses and special payments for the period. Received and considered the Activity Report of the Post 3

18 Payment service which again demonstrated good coverage and outcomes for the year to date. Considered update report of the Local Counter Fraud service including an update of actions taken to improve procedures at Managed Practices and follow up work to investigate potential irregularities. Reviewed the Audit Tracker tool for both Internal and External Audit recommendations and considered the front end report. It was noted the total number of high priority recommendations outstanding for each review was not excessive but requested that the relevant managers for Radiology Services and Medicines Management attend the May meeting to discuss progress. The Committee agreed to clear all items highlighted as completed. The Committee noted the following: - Progress with the WAO review of Public Health - A District Nursing checklist for Independent Members - Committee annual reporting arrangements - A WAO client satisfaction survey. Key assurances provided at this meeting: The Health Board s Occupational Health Service is viewed positively by users. Deficiencies identified in the Safehaven service have already been addressed. The Board is taking positive steps to limit both the financial impact of negligence claims and also to promulgate learning to reduce the incidence of future claims. The Health Board has received positive feedback from a HMRC inspection on how it has responded to fully implement the changes to the off-payroll tax regulations introduced in April Key risks and concerns: Issues to be referred to another Committee Matters requiring escalation to the Board: The sufficiency and sustainability of the Occupational Health Service need to be kept under review. The Board is asked to approve the following changes to Standing Orders:- The Terms of Reference of the Quality, Safety and Experience 4

19 Committee and Local Partnership Forum as detailed in the report presented to Audit Committee, which can be accessed from the link provided at the end of this paper. The Committee also considered a membership change in respect of the Charitable Funds Committee with the Chief Executive being replaced by another nominated Executive. The Committee recommended that further discussion take place but agreed to the principle of the change. The Executive Director of Nursing and Midwifery has subsequently agreed to serve on the Committee. The Committee also formally endorsed the change in reporting lines for the Financial Recovery Task and Finish Group which will now report directly to the Finance and Performance Committee and noted that its terms of reference would be updated to reflect this, the Board is asked to formally endorse this which is in accordance with the position as reported within the Deloitte s Financial Recovery Action Plan. Planned business for the next meeting: Range of Standing Items plus consideration of Annual Governance Statement, Annual Quality Statement, Annual Report and Accounts, and WAO NWIS audit report. Date of next meeting: 31 st May v3.0 5

20 Chair's Assurance Report QSE V1.0.docx 1 Health Board To improve health and provide excellent care Committee Chair s Report Name of Committee: Quality, Safety & Experience Committee Meeting date: Name of Chair: Responsible Director: Summary of key risks and other items discussed: Mrs Margaret Hanson Mrs Gill Harris, Executive Director of Nursing & Midwifery Summary of discussions focused on Committee owned risks on the Corporate Risk Register: CRR02 Infection Prevention & Control Whilst noting an improvement in flu immunisation uptake within the Mental Health & Learning Disabilities and Estates & Facilities Divisions, the Committee would wish the respective Directors to respond via a briefing note setting out the reasons for low uptake and how they intended to address this. The Committee was advised that the organisation would not be able to reach the target for reducing the prevalence of C- Difficile infections and unlikely to deliver on reductions in E-Coli infection rates. Details of the 90-day plan to reduce HAI rates were shared. It was noted that the official launch would be and would be overseen through the Executive Management Group. Reports on the progress with delivery of the action plan would be reported via QSG to QSE each month. CRR04 Maternity The quarterly assurance report was received, which highlighted close working with Public Health Wales around smoking cessation and other health promotion activity aimed at pregnant women. The governance framework documents relating to the organisational development work at the maternity unit at Ysbyty Glan Clwyd would be shared with the Committee. The Committee was assured that progress, which had been made over the past two years, was being sustained. CRR05 Learning from Patient Experiences The Director of Quality, Safety, Patient Experience & Nursing for the Welsh Ambulance Services NHS Trust attended the

21 2 meeting, as part of planned discussions between the two organisations on patient experience. The Committee was briefed on a number of initiatives being delivered by this key partner agency. An update on the Implementation of the Patient Advice and Support Service (PASS) was considered. This highlighted that cancelled appointments remained a regular theme in concerns and complaints and impacted adversely on patient experience. The formal evaluation of the PASS would be shared with the Committee, as soon as it was available. The Committee was keen that the initial work be evaluated so that a PASS service could be rolled out to all appropriate BCU sites asap. CRR13 Mental Health A copy of the latest draft Strategic Dementia Action Plan for BCUHB was tabled. It was confirmed that families of patients on the Tawel Fan Ward had been involved in its development. The plan had been scrutinised prior to the meeting at QSG. The Committee was supportive of keeping nationally agreed dementia-friendly terminology within the plan. Following incorporation of other points raised by members, the plan was approved and would now be presented to the Health Board at its meeting on the The Committee received the latest external assurance review of mental health services, together with the initial response from the division to its findings. The Committee was assured that the outcomes of this work would be fed into and cross checked against the thematic action plan that the division had developed as part of its quality improvement action plan. The Committee received the review report. Summary of other business discussed: A paper on was received on in patient falls management, updating the committee on progress with rolling out the Board s falls reduction strategy. The Committee expressed concern around the slow pace of this work and poor progress made to date, bearing in mind that falls was one of the top 3 harms to patients within BCUHB. Officers were asked to consider how this was going to be improved and bring a further paper back to the Committee to provide the assurance required in this respect. The Committee reviewed the domains of the IQPR allocated to it. Concern was expressed about on-going challenges with nurse staffing ratios. Key assurances provided at this meeting: The inaugural Pharmacy & Medicines Management Annual Report was presented to the Committee. This would be presented subsequently to the Health Board in March. The Committee welcomed the report, which provided a broadly

22 3 Key risks and concerns: Special Measures Improvement Framework Theme/Expectation addressed Issues to be referred to another Committee Matters requiring escalation to the Board: Planned business for the next meeting: Date of next meeting: v1.0 positive summary of the progress made in this important area of the Board s activity, with risks clearly articulated. The Committee was concerned about the impact on the quality of care provided by ongoing challenges related to ward staffing levels. It requested further assurance about the management of current vacancy levels and the use of escalation beds, as part of winter pressures, which impacted further on staffing levels. Independent Members asked for further assurance on how matters reaching the Quality Safety Group (QSG) were resolved. It was agreed that the Executive Director of Nursing & Midwifery and the Director of Performance would consider how actions delegated to the QSG were followed up and reported back to QSE in an appropriate, timely way. Additionally, the Executive Director of Nursing and Midwifery, as Chair of the QSG, would ensure that the QSG agendas and minutes were circulated to QSE members each month. The Committee Chair, concerned at the delay in the Committee receiving a management response to a Welsh Risk Pool Themed Review of Emergency Departments undertaken in October 2016, asked that the governance processes underpinning the response to and management of external reports be reviewed as a matter of urgency. Leadership and Governance Strategic & Service Planning Engagement Mental Health Maternity Services None None Range of regular reports plus Compliance with WHC (2017)045 regarding health clearance of healthcare workers and management of healthcare workers infected with bloodborne viruses Safeguarding annual report Stroke care CHC assurance report Mortality report Primary care quality assurance report Nurse staffing update Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board

23 Chair's Assurance Report FPC V1.0.doc 1 Health Board To improve health and provide excellent care Committee Chair s Report Name of Committee: Finance & Performance Committee Meeting date: Name of Chair: Mrs Marian Wyn Jones Committee Chair Responsible Director: Mr Russell Favager Executive Director of Finance Summary of key risks and other items discussed: Informatics updates on performance against the Informatics operational plan objectives and draft priorities for the next 3 years were discussed. The Committee received an update on the financial position. The deficit at Month 9 was 32.8m, with concerns raised in particular on the financial position in the East Area Team and Ysbyty Glan Clwyd. There has been a notable improvement in performance within the MHLD division. The forecast position of 36m remains a challenging requirement, with a number of significant risks; mainly around continuing healthcare and prescribing. The Committee were briefed on the financial plan for the coming three years. This demonstrated a financial challenge over three years of 157m; but opportunities exceeding 181m based on benchmarking with others. The challenge for the organisation will be to translate those opportunities into change programmes which deliver the necessary savings. The Committee considered the capital programme for the year. The Health Board has approved capital funding of 72.8m for the year from WG; and 74.3m if all other sources of funding are included. Expenditure of 39.9m has been incurred to Month 9, which places a significant requirement on expenditure in the final quarter. The Committee were assured that the CRL would be fully utilised. The Committee considered the key performance indicators of the health board in particular recognising the challenged performance on USC and actions being taken to mitigate risk for our population and noting the appointment following formal tender of PWC to support immediate improvement. The Committee reviewed the challenges of year end delivery for RTT, diagnostics and cancer. It was noted that cohort management and treat in turn were key to the delivery of the year end RTT position and that was the Executive Medical Director s advice to consultants. The commencement of work within the mobile theatres in Wrexham was noted as providing additional capacity to improve

24 2 Key assurances provided at this meeting: Key risks and concerns: Special Measures Improvement Framework Theme/Expectation addressed Issues to be referred to another Committee Matters requiring escalation to the Board: Planned business for the next meeting: Date of next meeting: RTT, endoscopy and cancer waits but that the backlog developed would take time to clear. Other performance indicators raised as a concern included: CAMHs, GPOOH and staff appraisal. These will be followed up at the next meeting. The Committee approved the revised Special Leave Policy WP14b (All Wales policy) An NHS Wales Shared Service Partnership Committee assurance report dated was received. An Information Governance update report was received Actions taken to address the financial position Progress against Capital schemes Actions taken to address improvements required in unscheduled care and RTT performance The Committee noted that finance and performance are both the subject of targeted intervention by WG. Financial position and forecast outturn. Performance on unscheduled care and RTT trajectory. Progress on capital schemes requires escalation in the final quarter Ysbyty Glan Clwyd capital scheme. Delivery of improvement and year end performance for USC, RTT and diagnostics. Governance and Leadership themes None WCCIS issues Financial position Unscheduled care and RTT Range of regular reports plus External Contracts update Workforce Intelligence report Workforce policies Registration and Revalidation updates Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board V1.0

25 Chair's Assurance Report FRG V1.0.doc 1 Health Board To improve health and provide excellent care Committee Chair s Report Name of Committee: Finance Recovery Group (FRG) Meeting date: Name of Chair: Responsible Director: Summary of key risks and other items discussed: Key assurances provided at this meeting: Key risks and concerns: Issues to be referred to another Committee Matters requiring escalation to the Board: Planned business for the next meeting: Dr Peter Higson Mr Russell Favager, Executive Director of Finance The Group focused on updates from each Director on progress on increasing savings and reducing costs. Actions have included work on agency/locum costs, escalation beds, medicines/device management, flow/capacity, interventions not normally used (INNUs), staffing reviews, continuing healthcare and delayed transfers of care. Action has been taken across a wide range of areas in order to reduce the deficit financial position. The measures employed to date have had a positive effect and will continue until the 36m or less planned deficit target is delivered. The focus on referral to treatment time (RTT) targets and unscheduled care performance is continuing alongside efforts to achieve savings. Month 10 (M10) financial data will be crucial in providing assurance on the Health Board s ability to meet the 36m target by year end. Should M10 figures not demonstrate the required improvement trajectory, it will become necessary to introduce further measures and control. None (the Finance & Performance Committee will continue to be updated on progress routinely) None (the Board will received its own financial update covering the issues discussed). Month 10 position.

26 2 Date of next meeting: Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board V1.0

27 Chair's Assurance Report R&TS V1.0.doc 1 Health Board To improve health and provide excellent care Committee Chair s Report Name of Committee: Remuneration & Terms of Service (R&TS) Committee Meeting date: Name of Chair: Responsible Director: Summary of key risks and other items discussed: Key assurances provided at this meeting: Key risks and concerns: Special Measures Improvement Framework Theme/Expectation addressed Issues to be referred to another Committee Matters requiring escalation to the Board: Planned business for the next meeting: Dr P Higson, Chairman Mr R Jones, Interim Executive Director of Workforce & Organisational Development Medical job planning Director remuneration Development of new roles. Significant efforts made in relation to the training & education of doctors and use of the Allocate electronic system are demonstrating positive impacts. Dr E Moore believes that progress is on track to achieve 100% complete job planning by April The R&TS Committee believes that the work done to date provides an encouraging platform for medical job planning in the future. It was noted that should new roles be developed, the implications for existing roles require consideration. Leadership Governance - None. Remuneration report

28 2 Date of next meeting: Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board V1.0

29 Chair's Assurance Report SPPH v1.0.doc 1 Health Board To improve health and provide excellent care Committee Chair s Report Name of Committee: Strategy, Partnerships & Population Health Committee Meeting date: Name of Chair: Mrs Lyn Meadows Independent Member Responsible Director: Mr Geoff Lang Executive Director of Strategy Summary of key risks and other items discussed: The Committee discussed and provided comments on the draft three year plan 2018/21. Further discussion will take place at the next Committee Meeting on 5 th March and the Committee will meet informally to review progress and support the development of the Plan in advance of the meeting. Considered the Regional Growth Bid which has been submitted by the six Local Authorities after development in partnership with input from the Health Board s Chairman and Chief Executive through the Regional Leadership arrangements. The Committee were keen to ensure that the Health Board becomes more involved within the developing multi-agency governance arrangements for the Growth Bid in order to contribute to and benefit from improved partnership working and skilled employment opportunities. received an update on work in delivery of the Armed Forces Covenant alongside a range of partners across North Wales. The needs of veterans were discussed which highlighted work needed to ensure linkage with various BCU strategies. It was pleasing to note that the Health Board had achieved a silver award through the Armed Forces employer recognition scheme. The National Armed Forces Day to be held in Llandudno on was noted. The potential effect of this event on the provision and access to a variety of health services was discussed. It was noted that preparations are underway to ensure that the Board contributes positively to this major event and is able to respond to any service demands arising from it.

30 2 was provided with an update on progress in relation to system wide developments to support implementation of the North Wales Mental Health Strategy including detail on year one priority work being progressed in partnership through the Local Implementation Teams. endorsed the Board s 2017/18 annual report against the National Oral Health Plan for submission to Welsh Government. The workshop held on provided the opportunity for Committee Members to discuss the draft 3 year plan along with other Health Board members who were also invited to attend. Key assurances provided at this meeting: Key risks and concerns: Special Measures Improvement Framework Theme/Expectation addressed Issues to be referred to another Committee Matters requiring escalation to the Board: Planned business for the next meeting: The following assurances were gained in the meeting : Positive developments were noted through the work of the Armed Forces Forum. Preparations for Armed Forces Day are underway. Progress noted in partnership working to progress implementation of the Mental Health Strategy through the Local Implementation Teams. Significant work noted within dental services in response to the National Oral health Plan The Committee noted concerns regarding significant work remaining to develop the Board s 3 year plan 2018/21 risks associated with the potential service impact of Armed Forces Day due to the very high number of visitors expected were noted concerns over ongoing difficulties with access to dentistry in parts of North Wales Strategic & Service Planning Engagement None identified None identified in this meeting Annual Operational plan monitoring report Progress update on development of 3 year plan 2018/21 Draft Learning Disability Strategy Well-being Plans Area Planning Board for Substance Misuse

31 3 Date of next meeting: V1.0 Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board

32 Chair's Assurance Report MHAC V1.0.doc 1 Health Board To improve health and provide excellent care Committee Chair s Report Name of Committee: Mental Health Act Committee Meeting date: Name of Chair: Responsible Director: Summary of key risks and other items discussed: Mrs Margaret Hanson Mr Andy Roach 1. As part of the review of the Board s Standing Orders, as reported to the Audit Committee and ratified by the Board on 21st September 2017, the Mental Health Act Committee received its amended TORs. The changes included the confirmation of the maximum reappointment period for Associate Hospital Managers and the standardised paragraph in relation to the Wellbeing of Future Generations Act. The Committee was pleased to note that the recruitment of Associate Hospital Managers is being progressed on a rolling basis and two new additions to the team have begun to shadow hearings following their induction. 2. The Committee noted that Health Inspectorate Wales had visited a number of Mental Health Division units in the period since its last meeting and feedback in relation to the application of the Mental Health Act within those visits was positive. An unannounced visit to the Heddfan Unit found that it provided safe and effective care, with the recording of legal documentation under the MH Act and Deprivation of Liberty Safeguards compliant. 3. The Committee considered the work undertaken to improve Care & Treatment Plans within the Health Board s services. The Committee was told that improvements to this important aspect of the Mental Health Measure were being driven by Service Managers, via local action plans with clearly articulated targets. As a result, the Division was performing on target for the percentage of residents with a valid CTP completed in both its Older Peoples and Learning Disability Services. Work in adult services remained on-going to achieve their targets. The

33 2 Committee noted that the quality of CTPs also needed to be addressed. A report would come to a future meeting, updating members on the outcomes of the recent work undertaken across Wales around this issue by the Welsh Government s Delivery Unit. Key assurances provided at this meeting: 1. The good work of the Welsh Language team in the East was recognised by the committee, following reports from members of the Power of Discharge Committee about the assistance given to a Welsh speaking patient with dementia. The team provided support to the unit so that the gentleman could live his life through the medium of Welsh whilst on the Heddfan unit. 2. The Committee was pleased to receive an update on Deprivation of Liberty Safeguards (DoLs) performance data, which had improved as a result of the recruitment and training of additional Best Interest Assessors [BIA]. The Committee noted that the Corporate Safeguarding Team have successfully appointed to a BIA post, with the candidate receiving his BIA award from Manchester University in September The revised proposal in the Safeguarding Service structure realignment confirms that there will be 6 BIAs across the Health Board, with two in each area. Arrangements have also been put in place to recruit sessional bank BIAs to provide additional capacity until a full complement of staff is obtained. The Committee was assured that training on DoLs has been made available at Level 2 and Level 3 and was now mandatory. This training has been revised and improved to ensure staff have a better understanding of mental capacity issues and completion of DoLS applications. Bespoke training has also been undertaken across various sites. There are plans to provide training on mental capacity and DoLS to Paediatrics, F1 and F2 doctors, Senior Medical Staff in the East Division and Mental Health Act Associate Hospital Directors. The Committee was informed that all responsible bodies across Wales are struggling to meet the demand created by DoLs. 3. The Committee considered an update on the arrangements and service developments for the approval and re-approval of Approved Clinicians and section 12[2] Doctors in Wales. It noted that Health Board representatives were regularly meeting with Welsh Government and the issues of concern to the Committee, around better training for and recruitment of both Approved Clinicians and S12 (2) Doctors, have been discussed. The Committee was assured that an improvement plan was being developed nationally to

34 3 respond to the challenges described in the paper, to be rolled out by September Key risks and concerns: 1. The Committee received an update on CAMHS services within the Health Board and their performance against the Mental Health Act and Mental Health Measure targets. It was of concern to the Committee that the good performance in relation to this from earlier in the year had tailed off. The reasons behind this were discussed, centring on staffing issues. Both recruitment to new posts and sickness levels in parts of the service were driving down performance. 2. The Committee received an Independent Mental Health Advocacy [IMHA] Performance Report. This provided an update on performance reported to Welsh Government for 1 st January 2017 to 31 st March The Committee was concerned by the substantial increase in referrals for IMHA services in this quarter, with demand being driven up by requests from both detained and informal patients. Special Measures Improvement Framework Theme/Expectation addressed Issues to be referred to another Committee Matters requiring escalation to the Board: Planned business for the next meeting: Mental Health None None Department of Health's Independent Review of the Mental Health Act 1983 Committee Cycle of Business Healthcare Inspectorate Wales monitoring report Analytical Review of S136 in North Wales Deprivation of Liberty Safeguards - Update Report Independent Mental Health Advocacy Performance Report Update on the approval functions for Approved Clinicians & Section 12(2) Doctors in Wales Child and Adolescent Mental Health Services (CAMHs) Update Defining a Health Based Place of Safety for young people under age 18 years Mental Health Act/Mental Health Measure Monitoring Data

35 4 Date of next meeting: Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board Committee Chair s Assurance Report Template V4.0 June.16

36 Chair's Report HPF V1.0.doc 1 Health Board To improve health and provide excellent care Advisory Group Chair s Report Name of Advisory Group: Healthcare Professionals Forum (HPF) Meeting date: Name of Chair: Responsible Director: Summary of key items discussed: Key advice / feedback for the Board: Professor Michael Rees Mr Adrian Thomas, Executive Director of Therapies & Health Science 1. The Forum received an update and presentation on Betsi Cadwaladr University Health Board (BCUHB) Strategic Dementia Action Plan from the Consultant Nurse for Dementia. 2. The Executive Director for Public Health delivered an overarching presentation on Public Health to HPF Members. 3. A verbal update on the Patient and Visitor Violence (PVV) Report was received by members from the Consultant Psychiatrist & Honorary Professor (BCUHB, Bangor University and Mysore Medical College & Research Institute). HPF members received a presentation on the Strategic Dementia Action Plan and are fully supportive of the strategy. Members would like the Board to consider the opportunity to influence our role as commissioners as well as our role as a provider. HPF members received the overarching presentation on Public Health and are supportive of the team. HPF members ask the Board to consider how it can raise raising Public Health campaigns with contracting Healthcare Professionals not in the Health Board e.g. Flu Vaccination. HPF members received a presentation on the Patient and Visitor Violence (PVV) Report. Members would like the Board to note that they have read the recommendations of the report and support them being prioritised and taken forwards across the Health Board. HPF members also asked if the organisation has established a working group to implement this. HPF members noted the change in the level of police intervention and the potential impact on this for patients and staff.

37 2 Planned business for the next meeting: Date of next meeting: Range of standing items plus: Performance Update Clinical Academic Careers presentation Primary Care Update Healthy Prestatyn Project Draft Cycle of Business Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board v1.0

38 Chair's Report SRG V1.0.doc 1 Health Board To improve health and provide excellent care Advisory Group Chair s Report Name of Advisory Group: Stakeholder Reference Group Meeting date: 22 nd January 2018 Name of Chair: Mr Ffrancon Williams Responsible Director: Summary of key items discussed: Mr Geoff Lang Well North Wales Programme update Glynne Roberts, Well North Wales Programme Manager provided an update on the development of the programme. Glynne referred to the annual report which was included within the papers that provided details of first year of the programme and gave a presentation covering the following areas The aims of the programme and its focus on supporting those in the most deprived areas The focus within the programme on multi-agency working to develop new solutions to challenges The examples of work which are ongoing in each Local Authority area, ensuring a spread of work across North wales The development of health and wellbeing centres with different models emerging to meet local needs The proposed focus on homelessness and the programme of work planned for 2018/19 The work ongoing to support and develop the roll-out of social prescribing across North Wales The Chair summarised the discussion; that the programme was positive, noted the challenges and reiterated the importance of ensuring local needs are addressed and that these may vary between Local Authorities. Emphasis was also placed on the need for wider thinking at all levels within communities to do things differently and recognition of the importance of wide engagement.

39 2 Executive Director Public Health Annual Report 2017 Teresa Owen, Executive Director of Public Health presented the annual report for 2017 improving public health through primary care and highlighted the 9 main chapters listed, noting that whilst alcohol and substance misuse was not included within the report this remains a priority. The presentation highlighted the following key issues The four key domains in which Public Health Wales operates, these being health protection, health intelligence, health service quality and health improvement The critical role that primary care has to play in improving health Key issues such as smoking, obesity and child health where primary care can offer a significant improvement in preventing ill health The critical role of vaccination in protecting health The importance of the 5 ways to wellbeing and their impact upon community resilience The increasing awareness of the need for collective action to reduce Adverse Childhood Experiences in order to reduce their negative impact upon health and wellbeing throughout life The Chair summarised discussions; the importance of immunisations for Carers given the importance of Carers (generally) and the requirement for continued partnership working between Local Authorities and Health particularly around designing health services around leisure centres to support this agenda. It was noted that the health and wellbeing hub in Colwyn Bay is situated within the leisure centre and is a positive example which is working well. Corporate Plan Update 3 year priorities Geoff Lang provided a brief update on the corporate plan, referring to a number of presentations that had been received previously by the SRG which have helped to shape the content of the Board s developing strategy and plan. It was noted that the formal engagement phase regarding the strategy was completed in December 2017 and the outcome will be presented for ratification at the Health Board meeting on 1 st February The Chair reflected the number of positive opportunities the group has had to contribute to this work and their support for the identified strategic direction.

40 3 The NHS Wales Performers List Under Any Other Business, a letter received by the North Wales CHC Chief officer, Geoff Ryall-Harvey dated 8 th January 2018 regarding an options appraisal being carried out by Welsh Government of the NHS Wales performers list was discussed. It identified concerns regarding current arrangements which prevent GPs from England working in Wales without being registered on the Wales performers list, despite being on a similar list within England or Scotland for example. There was strong feeling of frustration amongst the Group that this process was bureaucratic and impractical and was a barrier in supporting GPs to work cross border particularly in light of the difficulties in GP recruitment. It was acknowledged that the performers list process did provide a level of assurance that all GPs are subject to revalidation and that there was a system ensuring intelligence around GP validation and checks which was in place in other regions across the UK and that these arrangements had arisen as a result of the Harold Shipman Inquiry. The Chair acknowledged the discussions and strong concerns expressed at the meeting. He noted the recommendation from the group to provide advice to the Health Board that the regulations are amended for GPs to ensure optimal flexibility for them to work across the borders and for them to be automatically included if already on a performers list elsewhere in the UK. The Group requested that this be included in considering the Health Board s own response to the options appraisal. Key advice / feedback for the Board: That the importance of continued wide engagement with communities in the development of Well North Wales be noted, along with the need for solutions which reflect differing local needs. Consideration should be given to widening access to flu vaccinations, particularly for Carers and those working in the care sector That the work to bring Leisure Services and Health closer together be progressed further to deliver more benefits That the Living Healthy Staying Well strategy development work has afforded good opportunity for input from the Group which should continue as detailed plans are developed. That the Health Board reflect strong views of the SRG of the need for maximum flexibility in the ability of GPs to work across borders under the Performer s List regulations in considering its response to the Welsh Government s consultation.

41 4 Special Measures Improvement Framework Theme/Expectation addressed Planned business for the next meeting: Strategic planning Engagement and listening to stakeholders views Business for the next meeting was agreed as follows Annual Quality Statement. Audiology presentation to be rescheduled following cancellation at today s meeting Corporate Plan update Lessons learnt from patient liaison service Date of next meeting: V1.0 Monday 19 th March 2018 Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board

42 Mental Health Act 1983 as amended by the Mental Health Act Mental Health Act 1983 Approved Clinician (Wales) Directions Update of Register of Section 12(2) Approved Doctors for Wales and Update of Register of Approved Clinicians (All Wales) - Mr Gary Doherty AC & s12 Report.docx Board Paper Item 1 st March 2018 To improve health and provide excellent care Title: Mental Health Act 1983 as amended by the Mental Health Act Mental Health Act 1983 Approved Clinician (Wales) Directions Update of Register of Section 12(2) Approved Doctors for Wales and Update of Register of Approved Clinicians (All Wales) Author: Responsible Director: Public or In Committee Strategic Goals Mrs Heulwen Hughes All Wales Project Support Manager for Approved Clinicians and section 12(2) Doctors Dr Evan Moore, Executive Medical Director Public (Indicate how the subject matter of this paper supports the achievement of BCUHB s strategic goals tick all that apply) 1. Improve health and wellbeing for all and reduce health inequalities 2. Work in partnership to design and deliver more care closer to home 3. Improve the safety and outcomes of care to match the NHS best 4. Respect individuals and maintain dignity in care 5. Listen to and learn from the experiences of individuals 6. Use resources wisely, transforming services through innovation and research 7. Support, train and develop our staff to excel. Approval / Scrutiny Route Purpose: Significant issues and risks Equality Impact Assessment The information is collated by the All Wales Project Support Team and register updates are submitted directly to the Board. Betsi Cadwaladr University Health Board is the Approval Board for Approved Clinicians and Section 12(2) Doctors in Wales and as such, receives regular register updates. Register updates are presented for Section 12(2) Doctors and Approved Clinicians for and for No equality impact assessment is considered necessary for this update paper. Approval Process is part of Legislative process.

43 Recommendation/ Action required by the Board The Board is asked to ratify the attached list of additions and removals to the All Wales Register of Section 12(2) Approved Doctors for Wales and the All Wales Register of Approved Clinicians. Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board

44 Update of Register of Approved Clinicians and Section 12 (2) Approved Doctors for Wales 9 th December nd February 2018 AC S12 (2) Approvals and Reapprovals Removed Expired 0 2 Approvals suspended 7 NA yearly evidence not submitted as no longer working in Wales Approvals re-instated 1 NA yearly evidence submitted late Approval Ended 2 0 Removed AC approved NA 8 No longer registered 0 0 Transferred from AC NA 0 register Approval Ended as no 0 0 longer working in Wales Registered without a licence to practice 0 0

45 Mental Health Act 1983 as amended by the Mental Health Act Mental Health Act 1983 Approved Clinician (Wales) Directions Update of Register of Approved Clinicians for Wales Approvals and re-approvals 11 9 th December nd February 2018 Surname First Name Workplace Expiry Date Burden Thomas St Cadocs Hospital, Lodge Road, Caerleon, Newport, NP18 3XQ 26 December 2022 Jebadurai Jeshoor Kumar Llandough Hospital, Penlan Road, Penarth, Cardiff CF64 2XX 26 December 2022 Noblett Joanne Dept of Liason Psychiatry, Morriston Hospital, Swansea, SA6 6NL 27 December 2022 Dunsby Ann-marie Llandough Hospital, Penlan Road, Llandough, CF64 2XX 01 January 2023 Bigham Lucy Llandough Hospital, Penlan Road, Llandough, Cardiff, CF64 2XX 01 January 2023 Sargeant Matthew Hafan Hedd Resource Centre, Lloyds Terrace, Newcastle Emlyn, SA38 9NS 04 January 2023 Edwards Ruth Gorwelion Resource Centre, Llanbadarn Rd, Aberystwyth, Dyfed SY23 1HB 16 January 2023 Fitzpatrick Helen Conwy CAMHS, Argyll Road, Llandudno, Conwy LL30 1DF 16 January 2023 Megeri Deepak Gelligron CMHT,Gelligron Road, Pontardawe, Swansea, SA8 4LU 18 January 2023 Kumar Sugandha Hafan y Coed, University Hospital Llandough, Penarth, CF64 2XX 24 January 2023 Alexa Ariana Simina Links Centre CMHT, CRI Buildings, Longcross Street, Cardiff CF24 0SZ 01 February 2023 Approvals expired 0

46 Approvals suspended yearly evidence not submitted as no longer working in Wales 7 Surname First Name Workplace Expiry Date Machiwenyika Eric LDHQ, 2nd Floor, 1 Penlan, Penlan Road, Carmarthen SA31 1DN 9 December 2019 Hussain Shahid Substance Misuse Service, 7 Brighton Road, Rhyl, Denbighshire, LL18 26 October EY Rauf Obaid Ur New Hall Independent Hospital, New Hall Road, Ruabon, Wrexham 23 December 2020 LL14 6HB Lowe Arvind Kumar Priory Hospital, Church Village, Church Road, Tonteg, Pontypridd, 30 November 2021 CF38 1HE Palia Satnam Singh Heatherwood Court Hospital, Llantrisant Road, Pontypridd, CF37 1PL 2 January 2022 Rajagopal Manoj Bryn Hesketh Unit, Hesketh Road, Colwyn Bay, Conwy LL29 8AT 23 December 2020 Stanly Thushara Ablett Unit, Glan Clwyd Hospital, Bodelwyddan LL18 5UJ 01 February 2022 Approval re-instated yearly evidence submitted late 1 Surname First Name Workplace Expiry Date Mellor Richard Ablett Unit, Ysbyty Glan Clwyd, Sarn Road, Boddelwyddan. LL18 5UJ 21 December 2021 Approvals Ended 2 Surname First Name Workplace Expiry Date Albuquerque Selwyn Romeo Jude Cefn Coed Hospital, Waunarlwydd, Cockett, Swansea, SA2 0GH 19 January 2022 Gray Marion St Davids Hospital, Cowbridge Road East, Canton, Cardiff, CF11 9XB 18 April 2022

47 Approvals and Re-approvals 10 Mental Health Act 1983 Update of Register of Section 12(2) Approved Doctors for Wales 9 th December nd February 2018 Surname First Name Workplace Date Application Received Hazem Abdul Ali Area 2 CMHT Central Clinic, 21 Orchard Street, Swansea SA1 5AT 18 December 2022 Yeates Caroline Yr Hen Laethdu, St Davids Hospital, Carmarthen, SA31 3HB 10 January 2023 Hardt Helmut Hafan Hedd, Adpar, Newcastle Emlyn, SA38 9NS 25 January 2023 Pyves Catherine Anne Cefn Coed Hospital, Cockett, Swansea, SA2 0GH 10 January 2023 Memon Muhammad Ismail Prince Phillip Hospital, Bryngwyn Mawr, Llanelli, SA14 8QF 02 January 2023 Williams Susan Elizabeth Llandrindod Wells Medical Practice, Spa Road East, Llandrindod Wells, 10 January 2023 Bartlett Robert Owen Tim Dyffryn Clwyd Mental Health Team, Middle Lane, Denbigh, LL16 15 January UR Thilakan Murugesh MHSOP, Llandough Houspital, Penarth, CF64 2XX 17 January 2023 Jeal Susan Margaret Neath Port Talbot Hospital, Port Talbot, SA12 7BX 15 January 2023 Payyazhi Girija Hywel Dda Centre Regent Way Chepstow Monmouthshire NP16 5BS 24 January 2023 Removed Expired 2 Surname First Name Workplace Date Approval Expires Broadhurst Caroline Private (Home address) 21 January 2018 Grant Lloyd Central Surgery, North Street, Newport NP20 1HX 19 January 2018

48 Removed Ended 0 Removed AC approved 8 Surname First Name Workplace Date Approval Expires Kumar Sugandha MHSOP, St David s Hospital, Cowbridge Rd East, Cardiff, CF11 9XB 22 July 2020 Dunsby Ann-Marie Keir Hardie Health Park, Aberdare Road, Merthyr Tydfil, CF48 1BZ 29 December 2019 Bigham Lucy Whitchurch Hospital, Park Road, Whitchurch, Cardiff CF14 7XB 22 December 2019 Roberts Owen Whitchurch Hospital, Park Road, Whitchurch, Cardiff CF14 7XB 16 September 2019 La Cock Chris Private (Home Address) 13 January 2018 Pasunuru Kavitha Ty Bryn Unit, St Cadocs Hospital, Lodge Road, Caerleon, Newport. 16 December 2017 NP18 3XQ Dyer Timothy Catherine Gladstone House, Hawarden Way, Mancot, Flintshire CH5 17 December EP Fernando Sudantha Marque ABMU LHB, Forge Centre, Port Talbot 08 January 2018 No longer registered 0 Transferred from AC Register 0 No longer working in Wales 0 Registered without a licence to practice 0

49 Board Annual Cycle of Business - Mrs Grace Lewis-Parry a Cycle of Business coversheet.docx 1 Health Board To improve health and provide excellent care Title: Author: Responsible Director: Public or In Committee Strategic Goals Health Board Annual Cycle of Business Mrs Kate Dunn, Head of Corporate Affairs Mrs Grace Lewis-Parry, Board Secretary Public (Indicate how the subject matter of this paper supports the achievement of BCUHB s strategic goals tick all that apply) 1. Improve health and wellbeing for all and reduce health inequalities 2. Work in partnership to design and deliver more care closer to home 3. Improve the safety and outcomes of care to match the NHS best 4. Respect individuals and maintain dignity in care 5. Listen to and learn from the experiences of individuals 6. Use resources wisely, transforming services through innovation and research 7. Support, train and develop our staff to excel. Approval / Scrutiny Route Purpose: Significant issues and risks Special Measures Improvement Framework Theme/ Expectation addressed by this paper Equality Impact Committee Business Management Group The Health Board has previously agreed a range of business standards and governance process to ensure that it conducts its business in line with Standing Orders. The Annual Cycle of Business is a key component of these processes and is presented to the Board annually for consideration. The Annual Cycle of Business needs to remain sufficiently flexible to allow for realignment of items following any amendments to reporting or submission deadlines. Governance Not required for a governance paper of this nature

50 2 Assessment Recommendation/ Action required by the Board The Board is asked to approve the Annual Cycle of Business Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board Board Coversheet v8.0 June 2016

51 b Cycle of business.docx 1 Part 1 Annual Recurring Business BOARD CYCLE OF ANNUAL BUSINESS AND FORWARD PLANNER Agenda Items Notes Cttee Apr May (L) Jun Jul (L) AGM Aug Sep (L) Oct Nov (L) Dec Jan (L) Feb Mar (L) Annual Accounts Agency & Locum Deployment in Wales * see note at end Annual Consultations Summary Annual Cycle of Business Annual General Meeting minutes Annual Governance Statement Annual Quality Statement WG requirement WHC2017/042 Procedural WG requirement (contained in SOs) WG requirement (detailed within MFA) A A QSE/A to delegate authority to AC to delegate authority to AC to delegate authority

52 2 Agenda Items Annual Report of the Health Board Annual Reports of Board Committees Approved Clinicians and Section 12(2) Doctors Business Cases/Capital Developments(as appropriate) Chair s Assurance Reports from Committees Charitable funds audited accounts and annual report Civil contingency and business Notes Cttee Apr May (L) WG requirement has to be presented by end Sept each year WG requirement as detailed within Standing Orders WG requirement *every other meeting Compliance with SFIs and WG requirements Good practice Requirement under Charities Act WG requirement A Relevant Cttee MHAC F&P Relevant Cttee CFC SPPH to AC Jun Jul (L) AGM Aug Sep (L) Inc AGS and AQS Oct Nov (L) Dec Jan (L) Via Ch Ass Rep Feb Mar (L)

53 3 Agenda Items continuity update (via SPPH Chair s report) Corporate Risk & Assurance Framework Director of Public Health Annual Report Documents signed under seal Engagement Strategy (via SPPH Chair s Report) Equality & HR Annual report inc Strategic Equality Plan progress Finance report Finance Strategy/budget and financial framework Notes Cttee Apr May (L) WG requirement WG requirement A SPPH WG requirement as set out in SOs - WG requirement WG requirement Monthly report in view of deficit WG requirement SPPH QSE / SPPH F&P F&P Jun Jul (L) IoS from SPPH AGM Aug Sep (L) Oct Nov (L) Dec Jan (L) Feb Mar (L) Health & Care WG requirement QSE

54 4 Agenda Items Standards scrutiny Health and Safety Annual Report Health Care Inspectorate Wales reports (as appropriate) Infection Prevention and Control reports IQPR Joint Committees (EASC and WHSCC) Key Matters and Minutes Medicines Management Mental Health Assurance Reports Notes Cttee Apr May (L) Statutory requirement (HSE regulations) WG requirement WG requirement QSE QSE QSE Jun Jul (L) AGM Aug Sep (L) WG QSE/ requirements F&P As required Requirement of national WAO Audit into medicines management WG requirement and linked to Special QSE QSE Oct Nov (L) Dec Jan (L) Feb Mar (L)

55 5 Agenda Items Mental Health Strategy Mental Health Tawel Fan Updates Primary Care Contracts (new awards) Primary Care Updates (at least quarterly) Prison Health Putting Things Right Annual Report (incorporating link to Ombudsman Annual Report) Research & Development Risk Management Strategy Measures Notes Cttee Apr May (L) WG requirement Compliance with Sos (as required) Advice from All Wales Board Secretaries and WG WG/Ombudsman requirement WG requirement SPPH QSE SPPH QSE QSE SPPH A Jun Jul (L) AGM Aug Sep (L) Oct Nov (L) Dec Review of WG requirement A Jan (L) Feb Mar (L)

56 6 Agenda Items SOs/SFIs and Scheme of Delegation Service Change (vascular) Strategy Development Notes Cttee Apr May (L) WG requirement To include primary / community care WG requirement SPPH (monitoring of AOP) Jun Jul (L) AGM Aug Sep (L) Safeguarding Updates (as and when via QSE Chair s Report plus QSE annual report also via QSE Chair s report in March) Seasonal Plan WG requirement SPPH Social Services and Well-being Act/Partnership Governance Special Measures Progress Reports *themed focus reports WG requirement WG requirements SPPH Oct Nov (L) Dec Jan (L) Feb Draft IMTP * * * * * * Staff Engagement F&P Mar (L) Final IMTP ann rep

57 7 Agenda Items Notes Cttee Apr May (L) Jun Jul (L) AGM Aug Sep (L) Oct Nov (L) Dec Jan (L) Feb Mar (L) Tripartite Group Tissue and Organ Donation annual report University status of the Health Board Wales Audit Office Annual Audit Report Wales Audit Office Structured Assessment Well-being of Future Generations Act Welsh Language strategic/annual report(s) WG requirement every 3 years WG/WAO requirement WG/WAO requirement WG requirement WL Commissioner requirements QSE A A SPPH SPPH Via Chair Rnep 2019

58 8 Key: A CFC F&P MHAC PoD R&TS SPPH QSE Audit Committee Charitable Funds Committee Finance and Performance Committee Mental Health Act Committee Power of Discharge Sub-Committee Remuneration and Terms of Service Committee Strategy, Partnerships and Population Health Committee Quality, Safety and Experience Committee

59 Finance Report - Mr Russ Favager Finance Board Report - Month 10.docx Health Board To improve health and provide excellent care Title: Finance Report Month 10 Author: Responsible Director: Public or In Committee Strategic Goals Mrs Helen MacArthur, Head of Financial Services Mr Russell Favager, Executive Director of Finance Public 1. Improve health and wellbeing for all and reduce health inequalities 2. Work in partnership to design and deliver more care closer to home 3. Improve the safety and outcomes of care to match the NHS best 4. Respect individuals and maintain dignity in care 5. Listen to and learn from the experiences of individuals 6. Use resources wisely, transforming services through innovation and research 7. Support, train and develop our staff to excel. Approval / Scrutiny Route Purpose: Significant issues and risks This report is subject to scrutiny by the Finance and Performance Committee prior to submission to the Board. The purpose of this report is to provide a briefing on the financial performance and position of the Health Board for the year to date and the forecast for the year. The Health Board approved an Interim Financial Plan on 16 March which approved a deficit budget as a planning assumption of 26m; following a need to deliver savings of 35.4m. As at Month 10, there is an adverse variance against plan of 13.0m ( 34.7m deficit). The variance relates to under-delivery of savings and continued overspending within Secondary Care and Mental Health & Learning Disability Division (MHLD) due to unscheduled care pressures, out of area placements, nurse agency costs and packages of care. It is pleasing to note an improvement in the Health Board s underlying run rate in line with the Financial Recovery Plan was approved by the Board in September Despite all the additional controls and actions put in place achievement 1

60 of the deficit of 36m will still be very challenging, and are dependent on the Financial Recovery Plans signed off by the divisions being delivered and still requires action across the Health Board to maintain the reduction in the underlying run rate. Delivery is being overseen by the Finance and Performance Committee and supported by the Financial Recovery Group. Special Measures Improvement Framework Theme/ Expectation addressed by this paper Equality Impact Assessment Recommendation/ Action required by the Board The Health Board is forecasting a cash shortfall because of the deficit, and has sought repayable Strategic Cash Support of 36m from the Welsh Government to meet cash commitments in March Support of 26m has been confirmed leaving a shortfall of 10m. There is ongoing discussion with the Welsh Government on managing the remaining cash shortfall. Costs associated with implementing improvements arising from Special Measures are included within departmental budgets. Not applicable It is asked that the report is noted. 2

61 Executive Director of Finance Report Month /18 Russell Favager Executive Director of Finance Betsi Cadwaladr University Health Board 3

62 1. Executive Summary 1.1 Purpose The purpose of this report is to outline the financial position and performance for the year to date, confirm performance against financial savings targets and highlight the financial risks and outlook for the remainder of the year. 1.2 Context The table below sets out the Health Board s revenue performance against the breakeven duty for the first and second rolling three year period. On the 16 March, the Board approved the 2017/18 budget of a deficit of 26m and this has subsequently been revised to 36m. 17/18 Year 14/15 15/16 16/17 17/18 (budget) (revised forecast) m First rolling three year period 75.9 Second rolling three year period The Minister for Health and Social Services placed the Health Board in Special Measures in June The implementation of the Special Measures Improvement Framework has resulted in additional costs for the Health Board, necessitated to address longstanding areas of concern. The Health Board received a specific allocation in 2015/16 and 2016/17 to support the additional costs incurred as part of Special Measures. Many of these costs still remain and are currently funded through the Health Board s general revenue allocation. 4

63 1.3 Summary of key financial targets Key Target Achievement against Revenue Resource Limit (Performance against 26m budget deficit) Performance against savings and recovery plans (Internal target against ledger profile) Achievement against Capital Resource Limit Compliance with the requirement to pay Non-NHS invoices within 30 days of receipt of a valid invoice Annual target Year to date target Year to date actual 000 (36,000) (21,700) (34,700) ,500 32,000 30, ,818 50,278 46,148 % Cash balance at month-end 000 7,300 7,300 5,123 Forecast Risk 1.4 Revenue position At Month 10, the Health Board has overspent by 34.7m ( 1.9m in month 10). Of this, 21.7m relates to the Health Board s planned budget deficit and 13.0m represents an adverse variance against the financial plan. The adverse variance reflects under delivery of savings across the Health Board and activity and cost pressures predominantly within the divisions of Mental Health and Learning Disabilities and unscheduled secondary care. Month 10 again saw an improvement in the monthly run rate down from 2.2m to 1.9m. This is a significant achievement from the high position of 4.8m overspend in June However more needs to be done across the organisation to ensure that the run rate continues to improve, Ysbyty Glan Clwyd, Wrexham Maelor and the East Area Team are of particular concern. The improvement in the run rate is required to offset the overspending in the first half of the year and deliver the 36m forecast. In month 10 there were continued improvements in Out of Area Placements and Medical Agency costs. Despite these improvements pressures remain within nurse agency costs and care packages for MHLD patients. 1.5 Cash releasing efficiency savings The Health Board set itself an initial ambitious target of 35.4m (3.5%). Due to year to date overspends it has been necessary to identify further recovery actions. As at Month 10 savings and recovery plans of 45.0m have been identified. 31.3m relate to cash releasing schemes. As at Month 10 a total of 30.1m of savings have been delivered and considerable further action is required across the Health Board to increase delivery to achieve the forecast outturn of a deficit of 36m. 5

64 1.6 Forecast revenue position and risk assessment Action has been taken across the Health Board to improve the expenditure run rate. Improvements in the run rate are not sufficient to deliver the 26m budget and the full year forecast remains at 36m. Action continues to be taken to address known areas of pressure which include care packages, out of area placements and the cost of agency staff. The forecast reflects pressures in a number of key areas including unscheduled care pressures, care packages, non achievement of recovery actions around escalation beds, out of area cost pressures, managed practices and Estates costs. These are being partially mitigated through additional opportunities including the implementation of the rate cap for medical agency staff, further savings from procurement and medicines management and tighter controls and enhanced focus on discretionary expenditure including care packages. 1.7 Balance sheet The Health Board is required to pay at least 95% of non-nhs invoices within 30 days of receipt of a valid invoice. As at Month 10, the Health Board has paid 94.0% of its non-nhs invoices within 30 days and action continues to be taken to address areas of known non-compliance. The closing cash balance as at 31 January was 5.1 m which is within the internal target set by the Health Board. As the Health Board is forecasting a deficit of 36m the full year cash requirement will exceed its cash allocation and Strategic Cash Support has been requested from the Welsh Government. The Welsh Government has confirmed cash support of 26m leaving a cash shortfall of 10m. Work is ongoing to identify options for the management of the cash shortfall but it is likely the managing of this cash shortfall will impact on the Public Sector Payment Policy target. 1.8 Key actions being taken The Financial Recovery Group (FRG) meets regularly to oversee and monitor delivery the actions from the Financial Recovery Plan approved by the Board. Further financial improvement opportunities are being identified; and opportunities to reduce, avoid or defer expenditure are being explored and implemented where appropriate. Maintaining the momentum on the reduction of agency staff remains a key financial risks although the Health Board has seen a reduction in the monthly Medical Agency costs of a further 0.4m during the month. Expenditure on Nurse Agency remains a concern, particularly given unscheduled care pressures and the high level of vacancies and targeted local work is being undertaken in areas of high usage. Health Board wide actions include improved use of the Bank Office, e- rostering and recruitment actions. Stringent financial controls have been implemented to ensure that there is an escalation process for high cost care placements and approval mechanisms are 6

65 robust, and work is ongoing to ensure that these are being followed consistently in all instances. A strategic review of care packages is ongoing and this includes work with two English CCGs and NHS Collaborative to ascertain good practice and identify opportunities for improvement. Focussed action is being taken on the East Area Team, Ysbyty Glan Clwyd and Wrexham Maelor to ensure that learning is applied across the organisation. The underlying deficit position being assessed as part of planning cycle for 2018/19 and development of the IMTP. 7

66 2. Revenue position 2.1 Financial performance by division The table below provides an analysis of the Month 10 budget to actual position for the Health Board s operating divisions. North Variances West Centre East Wales Total m m m m m Area Teams (1.1) (1.2) 0.2 Contracts (1.3) (1.3) Provider Income Secondary Care Mental Health Corporate (0.6) (0.6) Reserves (2.6) (2.6) Variance from Plan Planned Deficit 21.7 Total 34.7 Red: represents adverse variances in excess of 0.5% Amber: represents adverse variances equal to, or less than, 0.5% Green: represents favourable variances Commentary by division Area Teams are currently reporting an adverse variance of 0.2m due to pressures in the East Area Team in particular, which has deteriorated further in month. These arise from undelivered savings, increased drugs costs for Health Board delivered services, GP prescribing costs and growth in both the number and cost of care packages. These are partially offset by underspends within the dental service, therapies and palliative care. Contracts are reporting a favourable variance due to activity with local providers, however, there are pressures within the WHSSC contract. The year to date position does not include costs associated with the new English treatment tariff known as HRG4+. These costs are being managed by WHSSC the risk is estimated to be circa 3.6m for the year. Secondary Care Division continues to overspend in month 10 and has a total overspend of 8.6m to date due to undelivered savings and other cost pressures within pay related expenditure. The use of medical and nurse agency remains a significant factor, some of which is being incurred to address costs associated with pressures within unscheduled care and deliver waiting time targets. Ysbyty Glan Clwyd remains a significant concern and the financial position deteriorated by 0.7m in January. The year to date overspend within YGC of 4.4m compares to 1.2m 8

67 the same time last year with unscheduled care representing 3.3m of the overspend. Mental Health and Learning Disabilities (MHLD) has a year to date overspend of 8.5m which is due to out of area placements, pressures with individual packages of care, agency costs and undelivered savings. Whilst the division still had an unacceptable overspent of 0.6m in month this is below the year to date overspend average run rate of 0.9m per month. 9

68 2. Revenue position 2.2 Cumulative revenue position by expenditure category Subjective trend analysis Spend YTD 'm Variance YTD 'm In month variance 'm 13 Month Trend Narrative Primary Care (7.5) (1.2) Primary Care Drugs Pay (Health Board provided services excluding out of hours) Clinical Supplies (excluding drugs) Clinical Supplies - drugs (1.6) (0.4) Other non pay Underspends within dental, therapies and area management are offsetting overspends in other areas. Prescribing costs remain a key cost pressure with a year to date overspend of 4.4m The year to date variance reflects significant use of agency staff due to vacancies which is most notable within Medical and Dental and Nursing staff groups. The year to date variance also includes non delivery of savings schemes. Further analysis is provided within section Action continues to be taken across the Health Board to manage non pay expenditure. This includes work on consistently to enable cost savings to be achieved. The Health Board has experienced significant cost pressures within this area of expenditure including high cost cancer drugs, rheumatology, care of the elderly and sexual health drugs. This continues to be a key area of focus to ensure that costs are managed whilst maintaining clinical value. This includes a range of expenditure headings including premises costs, utilities, travel costs and losses. Significant management action is taken to identify opportunities to manage costs. The year to date includes 5.0m of unidentified and unachieved savings. 10

69 Subjective trend analysis Spend YTD 'm Variance YTD 'm In month variance 'm 13 Month Trend Narrative Commisioned Services (0.3) Care Packages This area of expenditure includes services with other NHS bodies including WHSSC as well as out of area placements for Mental Health and Learning Disability patients. Expenditure has continued to grow over the last financial year, mainly reflecting out of area placements. This is expected to grow further over the remainder of the financial year due to expenditure to deliver waiting list targets. This is a key area of expenditure for the Health Board and is subject to significant activity and cost pressures. The variance mainly relates to Mental Health and Learning Disabilities schemes. Action is being taken to manage costs although this remains a key risk area. Other Income (104.0) (3.2) (0.6) The level of income received by the Health Board includes additional income from other public sector bodies including HMP Berwyn. Cost of Capital WG Allocation (1,160.2) Total This includes the annual depreciation and impairment charges. Depreciation is charged in equal installments over the financial year whilst impairments are recorded as a single annual exercise. Welsh Government allocations are generally reflected in 1/12ths apart from impairment funding which is recorded as impairments arise. The Health Board has a year to date adverse variance of 34.7m against a planned variance of 21.7m. 11

70 2. Revenue position Pay Payroll expenditure year to date is 586.8m including Health Board delivered primary care functions including managed practices and the Out of Hours Service. The year to date payroll expenditure excluding Managed Practices and Out of Hours is 573m which is an adverse variance against plan of 5m. 62M 60M 58M 56M 54M 52M 50M 48M 46M 44M Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Substantive Bank Overtime Agency Average Substantive Average Bank Average Overtime Average Agency The year to date expenditure on agency staff is 30.0m which is an average of 3.0m per month, representing 5.2% of total pay. This is a reduction against the monthly average of 3.8m for 2016/17, reflecting the significant reduction in Medical Agency costs. The table overleaf provides the trend on agency costs for the previous thirteen months and demonstrates the variability in this area of expenditure. Excluding Managed Practices and Out of Hours, Medical and Dental Pay is 3.0m overspend (Month 9: 3.3m) year to date which includes the cost pressures arising from agency doctors. The Health Board has implemented the All Wales cap on medical agency costs. This is being led by the Executive Medical Director and will continue to be closely monitored in forthcoming months. Nurse agency costs increased in month due ongoing pressures arising from unscheduled care and significant recruitment difficulties. Targeted action in areas of high usage is continuing and is being overseen by the Executive Director of Nursing to focus on a reduction whilst maintaining quality and safety of patients. 12

71 000s 3,000 Agency Costs 2,500 2,000 1,500 1, Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Agency Medical Agency Nursing Agency Other 13

72 3. Cash Releasing Efficiency Savings & Recovery Plans 3.1 Savings/Recovery Plan Requirement The Health Board set a challenging savings target of 35.4m for 2017/18 to achieve a deficit of 26m. This included 30.4m (3%) for cash releasing savings and a further 5.0m (0.5%) for cost avoidance schemes. The Board has approved a Financial Recovery Plan which includes additional recovery actions for implementation in this financial year. The recovery plan of 14.5m, included further savings of 11.1m plus additional funding assumptions in relation to the All Wales Treatment Fund. During Month 7 further opportunities were identified which included a reduction in discretionary spend of 1m across the Health Board and additional savings schemes of 3m. All schemes have a service lead and are required to have a project initiation document (PID) which includes the need to undertake a quality impact assessment to ensure that quality and safety are appropriately considered. Delivery of both the savings and recovery plans is managed using the PMO methodology. 3.2 Identified Savings/Plans The total value of identified schemes is 45.0m. The original savings requirement was 35.4m, of which 32.4m have been identified. Further recovery actions of 12.6m have been identified and these will be supplemented with a further 1m of reduced expenditure arising from discretionary expenditure controls. The forecast delivery of savings for 2017/18 is 40.6m. Savings schemes are subject to scrutiny to ensure that there is a robust approach supported by a project brief and appropriate quality and equality impact assessments. This work is being overseen by the PMO Steering Group which is chaired by the Chief Executive. Further opportunities continue to be explored to mitigate against slippage and, further cost pressures which arise and also to prepare for the 2018/19 financial year. 3.4 Performance The risk profile and anticipated delivery of schemes will continue to be critically reviewed over the forthcoming months to further strengthen the arrangements. The impact of unidentified savings is 6.4m year to date. It is essential that assurance is gained through the PMO Steering Group and the Financial Recovery Plan that planned savings will be delivered in accordance with the delivery profiled. 14

73 4. Revenue Forecast Position 4.1 Financial year forecast revenue position The current full year forecast of 36m reflects additional cost pressures and slippage in the performance of saving plans. Action is being taken to improve financial performance in a number of areas including care packages, out of area placements and agency costs. The table below outlines the key risks to achieving the revised forecast. 15

74 Risks Risk level Explanation The outcome of the Supreme Court Judgment in relation to Continuing Healthcare fees Unidentified/under delivery of savings Continuing Healthcare Packages (CHC) Primary Care Prescribing Change in tariff methodology in England (HRG4+) and risks to the WHSSC contract The provisional figure for 2017/18 in respect of the recent judgment for Continuing Healthcare fees is 1.8m. If this is applied retrospectively to 2015/16 it is estimated that the provision required could be in the range 5.5m - 8m. To achieve the revised deficit the Health Board will be required to continue to deliver the challenging savings and recovery target. The Health Board is experiencing significant ongoing pressures in relation to both the underlying number and cost of care packages. The forecast deficit of 36m includes a deterioration of 3.1m and it is considered that a residual risk of 0.5m remains. The year to date pressure on primary care prescribing is 3.6m. Significant action is being taken by the Medicines Management team to reduce costs and drive efficiency. However, growth in usage remains alongside NCOS pressures. The current working assumption is that the HRG4+ risks will be resolved through negotiation between WHSSC and NHS England. The WSSC contain is subject to detailed scrutiny and is being actively managed. The outcome of the Supreme Court Judgment in relation to Continuing Healthcare fees has not been factored into the Health Board s financial projections. Work is ongoing to estimate the potential impact with colleagues across Wales to ensure a consistent approach. A verbal update will be given at the Board meeting. 16

75 5. Balance Sheet 5.1 Cash The closing cash balance as at 31 January was 5.1m which is within the internal target set by the Health Board. The cumulative cash support received against the reported deficit position is outlined below. The difference between the outturn position and the cash support received reflects management of working capital balances. The management of cash remains a key priority and repayable strategic cash support of 36m is required to enable the Health Board to fully meet year end liabilities. The Welsh Government has confirmed cash support of 26m leaving a shortfall of 10m. There are ongoing discussions with Welsh Government colleagues in relation to the management of this cash shortfall. Year 14/15 15/16 16/17 17/18 (forecast) Total Deficit 'm Confirmed Repayable Strategic Cash Support 'm Cash Shortfall Accounts Payable The Health Board is required to pay at least 95% of non-nhs invoices within 30 days of receipt of a valid invoice. As at Month 10, the Health Board has paid 94.0% of its non-nhs invoices within 30 days. This is below target due to the ongoing delays in the processing and authorising of nurse agency invoices, following the introduction of the All Wales Framework. Focussed work is continuing to address weaknesses and to improve performance whilst ensuring that all necessary checks are completed. 17

76 '000 '000 14,000 Trade Aged Payables 12,000 10,000 8,000 6,000 4,000 2,000 0 < 30 days days days > 90 days >60 days Accounts Receivable The management of amounts due to the Health Board is a key focus of the cash management arrangements. The increase in Monthly monitoring of amounts outstanding is undertaken to ensure that recovery is in place with a quarterly report to the Audit Committee. Debts over 90 days are a particular focus and include staff salary overpayments for which instalments are agreed. The increase in recent months relates to bills raised against English NHS bodies for work undertaken by the Health Board. 14,000 Trade Aged Receivables 12,000 10,000 8,000 6,000 4,000 2,000 0 < 30 days days days > 90 days Total >60 days 5.2 Capital expenditure The Capital Resource Limit at Month 10 is 72.8m. There is significant investment in a number of key projects including the YGC redevelopment, the SURNICC, the 18

77 redevelopment of the Emergency Department in YG and primary care health centre developments. In addition, the Health Board has received a number of allocations for upgrades across the Health Board estate and IT. Year to date expenditure is 46.1m against the plan of 50.3m. The year to date slippage of 4.2m will be recovered over the remainder of the financial year and the Health Board is forecasting to achieve its capital resource limit, subject to risks associated with any funding adjustments. 19

78 6. Conclusion 6.1 Conclusions The Health Board full year forecast at Month 10 remains a deficit of 36m, which has been notified to the Welsh Government. The Health Board will continue to seek every opportunity to reduce this forecast deficit closer to the original planned 26m deficit. Achievement of the forecast is dependent on Financial Recovery and Savings Plans being delivered and requires action across the Health Board to reduce the underlying run rate. Achievement of the financial forecast will require further substantial improvement in the underlying run rate and there are a number of known risks to achieving this as outlined in Section 4. The risks include non delivery of savings and recovery plans, further deterioration in known cost pressures such as care packages and unscheduled care and additional pressures including Primary Care Prescribing and lost theatre capacity in Wrexham Maelor due to building issues. The issue of the potential significant financial impact of HRG4+ on WHSSC commissioned services has not yet been concluded and remains a key risk. This relates to the new HRG tariff in England which has seen material increases in some specialised service tariffs. The Health Board is currently working with other Health Boards and Welsh Government colleagues to assess the implications and impact. The impact for the Health Board could be 3.6m and this has not been factored into the current deficit forecast of 36m. Similarly the outcome of the Supreme Court Judgment in relation to Continuing Healthcare fees has not been factored into the Health Board s financial projections. Work is ongoing with Welsh Government and colleagues across Wales to ensure a consistent approach. Achieving the financial plan, while not compromising the quality and safety of its services, is an important element in developing trust with Welsh Government, the Wales Audit Office, Health Inspectorate Wales and the public. In order to deliver the required improvements in the financial position to achieve the original financial plan set, the Health Board needs to ensure that the series of controls and processes that flow through the organisation are complied with. Similarly there is a clear scheme of financial delegation through Standing Financial Instructions (SFIs) that need to robustly adhered to. Management focus needs to be on continued implementation and compliance of the grip and control actions put in place; exercising control on their entire budget and not only the current overspending areas to avoid the risk of unsighted emerging issues. The Health Board is facing a cash shortfall during March The Welsh Government has confirmed strategic cash support of 26m, leaving a shortfall of 10m. There is ongoing discussions with Welsh Government colleagues on the management of the remaining cash shortfall. 20

79 6.2 Recommendation It is asked that the report is noted, including that the forecast outturn remains at 36m and recognising the significant risks to the financial position which are outlined in Section 4. The management of cash remains a key priority including the management of the shortfall in requested strategic cash support. 21

80 Wales Audit Office Annual Letter - Mrs Grace Lewis-Parry a Annual audit report WAO coversheet.docx 1 Health Board To improve health and provide excellent care Title: Wales Audit Office Annual Audit Report 2017 Author: Responsible Director: Public or In Committee Strategic Goals Wales Audit Office Ms Dawn Sharp, Acting Board Secretary Public (Indicate how the subject matter of this paper supports the achievement of BCUHB s strategic goals tick all that apply) 1. Improve health and wellbeing for all and reduce health inequalities 2. Work in partnership to design and deliver more care closer to home 3. Improve the safety and outcomes of care to match the NHS best 4. Respect individuals and maintain dignity in care 5. Listen to and learn from the experiences of individuals 6. Use resources wisely, transforming services through innovation and research 7. Support, train and develop our staff to excel. Approval / Scrutiny Route Purpose: Significant issues and risks The report has been reviewed by the Executive Team. It was also presented in committee to the Board on the ahead of submission to the Audit Committee on the The Board is required to consider the Annual Audit Report. The Annual Audit Report states that an unqualified true and fair opinion has been issued on the financial statements together with a qualified regularity opinion and a substantive report alongside the audit opinion. In terms of arrangements for securing efficiency, effectiveness and economy in the use of resources, auditors reviewed the Health Board s financial planning and management arrangements and undertook Performance Audit reviews on specific areas of service delivery. The findings of this work demonstrate that the Health Board continues to experience significant financial challenges and needs to develop a more transformational approach to savings schemes if it is to reduce its growing cumulative deficit. The report goes on to state that some

81 2 Equality Impact Assessment Recommendation/ Action required by the Board governance processes are strengthening, but the Board urgently need to demonstrate a positive impact on the organisation s performance and finances; and that the Health Board is making efforts to improve services, but its current arrangements are increasingly stretched. EqIA is not considered necessary for this paper The Board is asked to receive the report Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board

82 b Annual Audit Report WAO 2017.pdf Annual Audit Report 2017 Betsi Cadwaladr University Health Board Audit year: 2017 Date issued: January 2018 Document reference: 328A

83 This document has been prepared as part of work performed in accordance with statutory functions. In the event of receiving a request for information to which this document may be relevant, attention is drawn to the Code of Practice issued under section 45 of the Freedom of Information Act The section 45 code sets out the practice in the handling of requests that is expected of public authorities, including consultation with relevant third parties. In relation to this document, the Auditor General for Wales and the Wales Audit Office are relevant third parties. Any enquiries regarding disclosure or re-use of this document should be sent to the Wales Audit Office at infoofficer@audit.wales. I welcome correspondence and telephone calls in Welsh and English. Corresponding in Welsh will not lead to delay. Rydym yn croesawu gohebiaeth a galwadau ffôn yn Gymraeg a Saesneg. Ni fydd gohebu yn Gymraeg yn arwain at oedi. Mae r ddogfen hon hefyd ar gael yn Gymraeg. This document is also available in Welsh. The team who prepared this report on my behalf comprised Amanda Hughes, Andrew Doughton, Dave Thomas and Mike Usher.

84 Contents Summary report 4 Detailed report About this report 9 Section 1: audit of accounts 10 I have issued an unqualified true and fair opinion on the financial statements of the Health Board together with a qualified regularity opinion and I placed a substantive report alongside my audit opinion 10 Section 2: arrangements for securing efficiency, effectiveness and economy in the use of resources 12 Appendices The Health Board continues to experience significant financial challenges and needs to develop a more transformational approach to savings schemes if it is to reduce its growing cumulative deficit 12 Some governance processes are strengthening, but the Board urgently needs to demonstrate a positive impact on the organisation s performance and finances 14 The Health Board is making efforts to improve services, but its current arrangements are increasingly stretched 18 Appendix 1 reports issued since my last annual audit report 26 Appendix 2 audit fee 28 Appendix 3 significant audit risks 29 Page 3 of 32 - Annual Audit Report 2017 Betsi Cadwaladr University Health Board

85 Summary report Summary 1 This report summarises my findings from the audit work I have undertaken at Betsi Cadwaladr University Health Board (the Health Board) during I did that work to discharge my responsibilities under the Public Audit (Wales) Act 2004 (the 2004 Act) in respect of the audit of accounts and the Health Board s arrangements to secure efficiency, effectiveness and economy in its use of resources. 2 My audit work focused on strategic priorities and the significant financial and operational risks facing the Health Board, and which are relevant to my audit responsibilities. The separate reports I have produced during the year have more detail on the specific aspects of my audit. My team discuss these reports and agree their factual accuracy with officers before presenting it to the Audit Committee. My reports are shown in Appendix 1. 3 The Chief Executive and the Executive Team have agreed the factual accuracy of this report, which my team presented to the Board on 1 February. The Audit Committee will receive the report at its meeting on the 9 February. I strongly encourage the Health Board to arrange wider publication of this report. Following Board consideration, I will make the report available to the public on the Wales Audit Office website. 4 My audit work can be summarised under the following headings. Section 1: audit of accounts 5 I have issued an unqualified true and fair opinion on the financial statements of the Health Board together with a qualified regularity opinion, although in doing so I brought one issue to the attention of officers and the Audit Committee as set out in Exhibit 1 of this report. 6 I have also concluded that the Health Board s accounts were properly prepared and materially accurate. 7 My work did not identify any material weaknesses in the Health Board s internal controls relevant to my audit of the accounts. 8 Alongside my audit opinion, I placed a substantive report on the Health Board s financial statements to highlight its failure to meet its two financial duties. 9 The Health Board did not achieve financial balance for the three-year period ending , nor had it prepared an approved integrated three-year medium term plan for the period to , therefore it failed to meet both the first and the second statutory financial duties under the NHS (Wales) Finance Act Section 2 of this report has more detail about the financial position and financial management arrangements. Page 4 of 32 - Annual Audit Report 2017 Betsi Cadwaladr University Health Board

86 Section 2: arrangements for securing efficiency, effectiveness and economy in the use of resources 10 I have examined the Health Board s financial planning and management arrangements, its governance and assurance arrangements, and its progress on the improvement issues identified in last year s Structured Assessment. I did this to satisfy myself that the Health Board has made proper arrangements for securing efficiency, effectiveness and economy in the use of its resources. I have also undertaken Performance Audit reviews on specific areas of service delivery including reviews of estates, GP out-of-hours (OOH) services, discharge planning arrangements, emergency ambulance service commissioning arrangements, and follow-up outpatients services. My conclusions based on this work are set out below. The Health Board continues to experience significant financial challenges and needs to develop a more transformational approach to savings schemes if it is to reduce its growing cumulative deficit 11 While the Health Board has a reasonable savings delivery track record, its savings approach is not sufficiently improving the overall financial sustainability and financial standing of the organisation. Over the period between 2012 and 2017, the Health Board has set savings plans targets of 193 million, and has achieved 192 million. For 2017/18, the plan at the beginning of the year included a 35.4 million savings target. However, as the year has progressed, a growth in unanticipated costs became apparent. In response, the Health Board has developed additional savings schemes, but had also revised its forecast in-year deficit from 26 million to 36 million. The forecast deficit for the three-year period ending 31 March 2018 now stands at 85.3 million. 12 The Health Board s arrangements for savings planning and delivery are strengthening, but its approach is predominantly based on an annual cycle and has been too focused on in-year cost control, placing too great a reliance on short-term and non-recurrent savings. Revised accountability arrangements for the Programme Management Office team are now broadening its focus, and there is also a good track record of finance department support for services. However while available if specifically requested, change management, workforce planning, procurement and informatics support for saving schemes, was not systematically provided to saving scheme owners. At present, the Health Board s savings approach is also impacted by growth of in-year costs, which is increasing the focus on short-term solutions. There is opportunity to increase the focus on service transformation, improving value and productivity, efficiency and reducing waste. The Health Board is developing arrangements to help secure more sustainable financial improvements and needs to progress these with increased urgency. Page 5 of 32 - Annual Audit Report 2017 Betsi Cadwaladr University Health Board

87 13 Financial savings monitoring and scrutiny arrangements are strengthening as a result of lessons learnt from previous years and significant financial risks faced in the current year. The Health Board s approach for monitoring savings delivery at a management level is well established. The PMO monitoring group oversees progress of financial savings plans and receives increasingly clear information on saving schemes. Board and committee savings monitoring has been sufficient to discharge a general duty to oversee the impact of financial savings, and the level of detailed information to enable effective support and scrutiny is improving. Some governance processes are strengthening, but the Board urgently needs to demonstrate a positive impact on the organisation s performance and finances 14 Governance structures are well administered, but there are opportunities for further improvement and re-shaping of the terms of reference of the Finance and Performance Committee and strengthening Board decision making, with a greater focus on affordability. My work has identified good administration, process and management of Board and committee meetings. However, the demands on the Health Board and its governance arrangements are changing. In particular, I noted the demanding agenda of the Finance and Performance Committee. Whilst I acknowledge the establishment of the Financial Recovery Group in September, the Finance and Performance Committee s terms of reference may need to be reviewed. This should ensure the Committee can provide the oversight and stimulus for recovery of its finance and performance positions, once the Financial Recovery Group has had sufficient time to embed into the overall governance arrangements of the Board. I also considered performance monitoring arrangements are in place within the Health Board and noted a deterioration in performance in a number of key areas within the national delivery framework. 15 I also found: that board assurance framework arrangements are progressing well and continuing to develop, with the aim of introducing them early in 2018; the Health Board is supported by high-level key internal controls which are continuing to strengthen, although there is opportunity to strengthen clinical audit; the Health Board has made effective use of the national fraud initiative to detect fraud and overpayments; good information governance foundations are in place, and the Health Board has recognised and is investing resources to meet new General Data Protection Regulation requirements; recent minor changes to the organisational structure have proceeded as planned; the Health Board is addressing the issues identified in last year s structured assessment, although more work is needed; and Page 6 of 32 - Annual Audit Report 2017 Betsi Cadwaladr University Health Board

88 in general, the arrangements for monitoring recommendations made by internal and external audit are improving. The Health Board is making efforts to improve services, but its current arrangements are increasingly stretched 16 My work programme has included a review of medical equipment management and a follow-up of my previous consultant contract reviews. My conclusions are as follows: further work is needed to continue to develop important areas which enable the efficient, effective and economical use of resources: the Health Board continues to have a clear programme of public engagement and a track record of gaining a wide representation of community groups. This may need to become specifically focussed on key service changes, and may need to include formal consultation, as plans start to progress. the Health Board has continued with its living healthier staying well strategy development. The Health Board indicates it is on track to produce its integrated medium-term plan for change management capacity and capability is an area that has been an issue for the Health Board for some time, and I have commented on the need to strengthen its arrangements since workforce performance measures show that the Health Board performs well in some areas such as sickness absence. However, there also remain a number of significant workforce challenges faced across the organisation including recruitment and the reliance on temporary workforce. the Health Board is improving its approach to estates management, but is struggling to allocate sufficient resources to estates and lacks an overall strategy to tackle high-risk areas. the day-to-day operation of the radiology service is well managed, but increasing demand, workforce challenges, poor IT systems, aging equipment and weak strategic planning present risks to future delivery. the Health Board is planning more strategically and clearly to improve GP OOH services, but in a challenging environment is not yet achieving a modern, consistent, well-resourced and staffed service that meets national performance targets. the Health Board can demonstrate its intention to improve patient flow and discharge planning, but staff confidence and training remain challenging and performance remains poor. Page 7 of 32 - Annual Audit Report 2017 Betsi Cadwaladr University Health Board

89 the Health Board has made progress in addressing recommendations from previous audit work although important actions remain outstanding in a few key areas. the Health Board has made progress responding to recommendations made in my 2015 follow-up outpatients report, but it still needs to improve the way it identifies clinical risks and incidents, quicken the pace of service improvement and reduce the backlog of delays. 17 I would like to thank the Health Board s staff and members for their assistance and co-operation during the audit. Page 8 of 32 - Annual Audit Report 2017 Betsi Cadwaladr University Health Board

90 Detailed report About this report 18 This Annual Audit Report 2017 to the board members of the Health Board sets out the findings from the audit work that I have undertaken between December 2016 and November I undertake my work at the Health Board in response to the requirements set out in the 2004 Act 1. That act requires me to: a) examine and certify the accounts submitted to me by the Health Board, and to lay them before the National Assembly; b) satisfy myself that the expenditure and income to which the accounts relate have been applied to the purposes intended and in accordance with the authorities which govern it; and c) satisfy myself that the Health Board has made proper arrangements for securing economy, efficiency and effectiveness in its use of resources. 20 In relation to (c), I have drawn assurances or otherwise from the following sources of evidence: the results of audit work on the Health Board s financial statements; work undertaken as part of my latest structured assessment of the Health Board, which examined the arrangements for financial management, governance and assurance; performance audit examinations undertaken at the Health Board; the results of the work of other external review bodies, where they are relevant to my responsibilities; and other work, such as data-matching exercises as part of the National Fraud Initiative (NFI) and certification of claims and returns. 21 I have issued a number of reports to the Health Board this year. The messages contained in this annual audit report represent a summary of the issues presented in these more detailed reports, a list of which is included in Appendix The findings from my work are considered under the following headings: Section 1: audit of accounts Section 2: arrangements for securing economy, efficiency and effectiveness in the use of resources 23 Appendix 2 presents the latest estimate on the audit fee that I will need to charge to cover the actual costs of undertaking my work at the Health Board, alongside the original fee that was set out in the 2017 Audit Plan. 24 Finally, Appendix 3 sets out the significant financial audit risks highlighted in my 2017 Audit Plan and how they were addressed through the audit. 1 Public Audit (Wales) Act 2004 Page 9 of 32 - Annual Audit Report 2017 Betsi Cadwaladr University Health Board

91 Section 1: audit of accounts 25 This section of the report summarises the findings from my audit of the Health Board s financial statements for These statements are the means by which the organisation demonstrates its financial performance and sets out its net operating costs, recognised gains and losses, and cash flows. Preparation of an organisation s financial statements is an essential element in demonstrating appropriate stewardship of public money. 26 In examining the Health Board s financial statements, I am required to give an opinion on: whether they give a true and fair view of the financial position of the Health Board and of its income and expenditure for the period in question; whether they are prepared in accordance with statutory and other requirements, and comply with relevant requirements for accounting presentation and disclosure; whether that part of the remuneration report to be audited is properly prepared; whether the other information provided with the financial statements (the annual report) is consistent with them; and the regularity of the expenditure and income in the financial statements. 27 In giving this opinion, I have complied with my Code of Audit Practice and the International Standards on Auditing (ISAs). I have issued an unqualified true and fair opinion on the financial statements of the Health Board together with a qualified regularity opinion and I placed a substantive report alongside my audit opinion The Health Board s accounts were properly prepared and materially accurate 28 The draft financial statements were produced for audit by the agreed deadline of 28 April 2017 and were of a good quality. Despite the challenging deadline, I found the information provided in the accounts to be relevant, reliable and materially complete. 29 My substantive report explains the two statutory financial duties applicable from and the cumulative performance of the Health Board against the duties Page 10 of 32 - Annual Audit Report 2017 Betsi Cadwaladr University Health Board

92 over the three years to The Health Board failed to meet both the first 2 and the second 3 financial duty. 30 I am required by ISA 260 to report issues arising from my work to those charged with governance before I issue my audit opinion on the accounts. My Financial Audit Engagement Lead reported these issues to the Health Board s Audit Committee on 30 May Exhibit 1 summarises the key issues set out in that report. Exhibit 1: issues identified in the Audit of Financial Statements Report The following table summarises and provides comments on the key issues identified. Issue The process to identify related party transactions could be strengthened Auditors comments Board Member declarations were incomplete as there was a lack of clarity over which positions should be declared by members on their annual return. As a result, the finance team had to carry out additional work in order to prepare the Related Party Disclosures contained in Note 24. Whilst I was satisfied that the disclosures were complete, I recommended that the process is enhanced to capture all relevant information in one place. 31 As part of my financial audit, I also undertook a review of the Whole of Government Accounts return. I concluded that the counterparty consolidation information was consistent with the financial position of the Health Board at 31 March 2017 and the return was prepared in accordance with the Treasury s instructions. 32 The Health Board s draft charitable funds financial statements were prepared in accordance with agreed timetables. I issued an unqualified opinion on the charitable financial statements on 6 December My work did not identify any material weaknesses in the Health Board s internal controls 33 I reviewed the Health Board s internal controls that I considered to be relevant to the audit to help me identify, assess and respond to the risks of material misstatement in the accounts. I did not, however, consider them for the purposes of expressing an opinion on the operating effectiveness of internal control. My review did not identify any significant deficiencies in the Health Board s internal controls. 2 The first financial duty is to break even over the three-year period to The second financial duty is to have in place an Integrated Medium Term Plan (IMTP), approved by the Welsh Ministers, for the period to Page 11 of 32 - Annual Audit Report 2017 Betsi Cadwaladr University Health Board

93 Section 2: arrangements for securing efficiency, effectiveness and economy in the use of resources 34 I have a statutory requirement to satisfy myself that NHS bodies have proper arrangements in place to secure efficiency, effectiveness and economy in the use of their resources. I have undertaken a range of performance audit work at the Health Board over the last 12 months to help me discharge that responsibility. This work has involved: reviewing the Health Board s planning and delivery of financial savings and their contribution to achieving financial balance; assessing the effectiveness of the Health Board s governance and assurance arrangements through my structured assessment work, including a review of the progress made in addressing structured assessment recommendations made last year; assessing the application of data-matching as part of the National Fraud Initiative (NFI); specific use of resources work on radiology services, GP OOH services, discharge planning and a local audit review of estates; and assessing the progress the Health Board has made in addressing the recommendations raised by previous audit work on the management of follow-up outpatients, and reviewing the Health Board s arrangements for tracking progress against external audit recommendations. 35 I have also undertaken performance audit work that has examined the governance arrangements within the Emergency Ambulance Services Committee, and also the collaborative working arrangements between local public health teams and Public Health Wales NHS Trust. 36 In addition to my programme of audit work, my team also undertook a joint review with Healthcare Inspectorate Wales. This work assessed areas that were identified in my previous joint reviews of governance arrangements. The report was published in June The main findings from my programme of work are summarised under the following headings. The Health Board continues to experience significant financial challenges and needs to develop a more transformational approach to savings schemes if it is to reduce its growing cumulative deficit 38 In addition to commenting on the Health Board s overall financial position, my structured assessment work in 2017 has considered the actions that the Health Board is taking to achieve financial balance and create longer-term financial Page 12 of 32 - Annual Audit Report 2017 Betsi Cadwaladr University Health Board

94 sustainability. I have assessed the corporate arrangements for planning and delivering financial savings in the context of the overall financial position of the organisation. I have also reviewed progress the made in addressing previous structured assessment recommendations relating to financial. I summarise my findings below. While the Health Board has a reasonable savings delivery track record, its savings approach is not sufficiently improving the overall financial sustainability and financial standing of the organisation 39 Over the last five years, the Health Board has set relatively ambitious but achievable savings targets. Over the period between 2012 and 2017, the Health Board has set savings plans targets of 193 million, and has achieved 192 million. For in particular, the plan at the beginning of the year included a 35.4 million savings target and a predicted year-end deficit of 26 million. However as the year has progressed, a growth in costs became apparent which has resulted in the Health Board developing additional savings schemes and also revising its forecast deficit from 26 million to 36 million. The expected three-year deficit for now stands at 85.3 million. As such, the Health Board will not meet its requirement to spend within allocation as set out in the NHS Finance Act (Wales) 2014 for the period The rolling nature of the requirements set out in this Act mean also that the Health Board is highly unlikely to recover its three-year cumulative position for at least another two years. The Health Board s arrangements for savings planning and delivery are strengthening, but its approach has been too focused on in-year cost control. There is an opportunity to increase the focus on service transformation, improving value and productivity, efficiency and reducing waste 40 Corporate leadership and management of savings have been subject to numerous changes in recent years. Over the last three years, there has been reliance on an external consultancy, appointment of an interim Director of Turnaround and support of a minimally staffed Programme Management Office (PMO). Revised accountability arrangements for the PMO team are now broadening the focus of the team and there is a good track record of finance department support for services. However, support from other enabling functions, could be strengthened. I understand that Health Board is starting to address these issues as part of savings planning approaches. 41 There is a clear desire in the Health Board to embrace prudent healthcare 4 and value-based healthcare 5 principles but they currently are not well embedded into service planning. At present, the Health Board s savings approach is predominantly 4 Achieving prudent healthcare in Wales 5 NHS Confederation Value Based Healthcare Page 13 of 32 - Annual Audit Report 2017 Betsi Cadwaladr University Health Board

95 based on an annual cycle, placing too great a reliance on short-term and nonrecurrent savings. It is also impacted by growth of in-year costs, which is increasing the focus on short-term solutions. Financial savings monitoring and scrutiny arrangements are strengthening as a result of lessons learnt from previous years and significant financial risks faced in the current year 42 The Health Board s approach for monitoring savings delivery at a management level is well established. The PMO monitoring group oversees progress of financial savings plans and receives increasingly clear information on saving schemes. Board and committee performance monitoring of savings has been sufficient to discharge a general duty to oversee the impact of financial savings. However, until recently, the level of detail provided did not sufficiently enable effective challenge, support, escalation and remedial action at Board or committee level. The Health Board has addressed the recommendation made relating to the timeliness of financial reporting to the Board 43 In my 2016 structured assessment, I made a recommendation to improve the timeliness of financial information that is being reported to the Board. Over the last year, the Health Board has improved the timeliness of reporting through verbal financial updates at in-committee sessions of the Board and also run additional board briefing sessions. It is also bringing forward the Board meeting dates so they are earlier in the month. Some governance processes are strengthening, but the Board urgently needs to demonstrate a positive impact on the organisation s performance and finances 44 My structured assessment work has assessed the Health Board s governance and assurance arrangements. This included the effectiveness of the board and its governance structures and the progress made in addressing previous structured assessment recommendations and improvement issues. My findings are set out below. Governance structures are well administered, but there are opportunities for further improvement and re-shaping of terms of reference and strengthening Board decision making, with a greater focus on affordability 45 My audit work reviewing the Board and its committees during 2017 shows that they are well administered and conduct their business properly. This includes a planned cycle of business, varied agenda and transparency in public reporting. I continue to note good inter-relationship and co-ordination between the Board s committees as well as improvement in the function of the Strategy, Partnerships and Population Health Committee and Audit Committee. However, while there is a notable Page 14 of 32 - Annual Audit Report 2017 Betsi Cadwaladr University Health Board

96 commitment to improve, the Board needs to strengthen decision making with a greater focus on affordability. This needs to ensure that the decisions it makes at the Board are affordable now and also help to put the organisation on a stronger financial footing in future. 46 My team found that the Finance and Performance Committee has a clear agenda with a positive contribution of the independent membership. They also note recent strengthening in the style of scrutiny, which needs to continue. However, there is a significant demand on the committee, given the increased scrutiny and focus that is needed on finance and performance within the Health Board. Whilst I acknowledge the establishment of the Financial Recovery Group in September, evidence indicates that the committee s current remit is too broad to allow it to adequately focus on some of the key finance and performance challenges that the Health Board is facing. The Finance and Performance Committee s terms of reference may need to be reviewed to ensure the Committee can provide the oversight and stimulus for recovery of its finance and performance positions, once the Financial Recovery Group has had sufficient time to embed into the overall governance arrangements of the Board. 47 I have also highlighted some areas where the Health Board will need to either strengthen its governance process or determine the impact of its arrangements. This relates to strengthening the flow of assurance between the officer-led Quality and Safety Group and the Quality, Safety and Experience Committee and building on existing clinical audit planning and reporting approaches. Board assurance framework arrangements are developing well, supported by key internal controls which are continuing to strengthen 48 Over the past year, there has been a clear focus on strengthening Board assurance framework arrangements. This includes setting the requirements for the board assurance framework approach, which comprises: a board assurance framework narrative document which defines the shape of the overall governance arrangements; an assurance map which is used to determine assurance requirements and how these assurances will be obtained; and corporate risk management arrangements. 49 My work has also considered high-level internal control arrangements. As part of this I have identified that the Health Board has a regular and comprehensive programme of internal audit work with sufficient resources to deliver it. This work last year was summarised in a Head of Internal Audit report that gave reasonable assurance overall for As part of the internal audit programme, I have also considered the work of the capital audit team. Their recent work on a major capital project at the Health Board has identified a range of issues that the Health Board needs to address and apply lessons learnt. 50 There is a clear local counter fraud services work plan. This team is sufficiently resourced and includes a balance of work spread across the domains of strategic Page 15 of 32 - Annual Audit Report 2017 Betsi Cadwaladr University Health Board

97 governance, inform and involve, prevent and deter and hold to account as required in the NHS protect standards. 51 The audit committee receives a quarterly conformance report which provides a good perspective and provides assurance on the level of conformance with procedures on procurement, payroll, accounts receivable and loses and special payments. The Health Board also has a range of policies and procedures in place, and is currently working to strengthen its policy control arrangements and supporting systems. Good information governance foundations are in place, and the Health Board has recognised and is investing resources to meet new General Data Protection Regulation requirements 52 Caldicott is a key element of the Information Governance and Confidentiality agenda. This helps to ensure that personally identifiable information is adequately protected 6. The Health Board has completed a Caldicott Information Confidentiality self-assessment in April 2017 and currently assess themselves at 88% compliant. The introduction of the General Data Protection Regulation (GDPR) comes into force on 25 May 2018 and introduces some significant changes to data protection requirements and principles. The Health Board has recognised the legislative changes early and has a transition programme underway to assess readiness and implement the new requirements under the GDPR. Although some progress has been made, a number of activities remain in progress. Whilst performance monitoring arrangements are in place within the Health Board, these have not prevented a deterioration in performance in a number of key areas within the national delivery framework 53 Health bodies in Wales are set and held to account on a range of national measures and targets that are set out in the NHS Wales Delivery Framework I have considered overall progress against the national delivery framework measures that the Health Board reports on monthly and have highlighted key areas of concern. My work has indicated that the Health Board has made some improvements in performance on measures notably in the national performance domains of staying healthy, safe care, effective care and individual care. Irrespective of the like-for-like performance improvement over the last 12 months, the Health Board is not achieving many national targets, and performance has deteriorated in important areas. The most significant area of concern relates to timely care where the Health Board is only achieving 5 out of 18 national standards. I understand that the Health Board will be targeting some additional monies to improve elective waiting times. 6 Information Governance and Caldicott 7 NHS Wales Delivery Framework Page 16 of 32 - Annual Audit Report 2017 Betsi Cadwaladr University Health Board

98 Recent changes to the organisational structure have proceeded as planned 54 The Health Board has made minor changes to its organisation structure during the year. Those changes are starting to have positive affect. The changes included moving the communications function to the Chief Executive s office, and information governance and risk management teams have moved within the remit of the Board Secretary. In addition, I understand that over the past three months, the responsibility for complaints, concerns and incidents has now transferred to the Executive Director of Nursing. My work has found that the transfer of the team has been successful and the backlog of responses to concerns is reducing, but more work is now needed to strengthen the lessons learnt processes. The Health Board has made effective use of the NFI to detect fraud and overpayments 55 The NFI is a biennial data-matching exercise that helps detect fraud and overpayments by matching data across organisations and systems to help public bodies identify potentially fraudulent or erroneous claims and transactions. It is a highly effective tool in detecting and preventing fraud and overpayments, and helping organisations to strengthen their anti-fraud and corruption arrangements. 56 Participating bodies submitted data to the current NFI data matching exercise in October The outcomes were released to participating bodies in January The Health Board is a mandatory participant in NFI. In January 2017, the Health Board received NFI data-matches through the NFI web application. The datamatches highlight anomalies which when reviewed can help to identify fraud and error. The Health Board has made good progress in reviewing the data-matches. No frauds have been identified as a consequence of the review undertaken providing assurance that the Health Board s counter-fraud arrangements are working effectively. The exercise has helped to identify 1,818 in VAT errors which has or is being recovered from suppliers. In , the NFI introduced a new module matching across payroll, creditor payment and Companies House records. These data-matches can help to identify undisclosed staff interests and procurement fraud. The NFI web application shows that the Health Board has commenced reviewing these matches but in some cases, the outcome of the reviews has not been recorded within the web application. The Health Board should ensure that the review of these matches has been completed and all outcomes have been recorded. The Health Board is addressing the issues identified in last year s structured assessment, although more work is needed. In general, the arrangements for monitoring recommendations made by internal and external audit are improving 58 I have considered the extent that the Health Board has progressed against recommendations made in last year s structured assessment. Overall, I found that the Health Board is making progress, although in some areas it has been slow. Page 17 of 32 - Annual Audit Report 2017 Betsi Cadwaladr University Health Board

99 59 In addition to reviewing the actions taken to address my 2016 structured assessment recommendations, I considered the effectiveness of the Health Board s wider arrangements to respond to my audit recommendations. I found that the Health Board is strengthening its process for tracking Internal Audit and External Audit recommendations. It has introduced a new system that monitors the progress against target deadlines and routinely reports progress on Internal Audit and External Audit recommendations to the Audit Committee. The approach is providing an improved understanding on progress against recommendations and where recommendations have not been completed within the indicated timeframe. The Health Board is making efforts to improve services, but its current arrangements are increasingly stretched Further work is needed to continue to develop important areas which enable the efficient, effective and economical use of resources 60 My Structured Assessment work has reviewed how a number of key enablers of efficient, effective and economical use of resources are managed. My key findings are summarised in Exhibit 2. Exhibit 2: summary of key use of resources findings The following table summarises the key findings on use of resource enablers from structured assessment. Issue Stakeholder engagement Strategy and planning Summary of findings The Health Board continues to have a clear programme of public engagement and a track record of gaining a wide representation of community groups. The Health Board is, however, not formally consulting on major service change as part of its preparation for publishing its of Living Healthier Staying Well strategy or IMTP. It may need to do so in coming years as plans develop further. The Health Board has continued with its living healthier staying well strategy development. It is engaged with the four North Wales Public Service Boards and development of wellbeing assessments, the North Wales population assessment and has developed its own local needs assessment. Overall, the Health Board has progressed its strategy and planning development. It will, however, need to ensure sufficient clarity in its plans to help provide an effective platform for change and a financially sustainable future. Page 18 of 32 - Annual Audit Report 2017 Betsi Cadwaladr University Health Board

100 Issue Change management capacity Workforce planning ICT and use of technology Estates and assets Summary of findings Change management capacity and capability is an area that has been an issue for the Health Board for some time, and I have commented on the need to strengthen its arrangements since I have seen a number of changes over this time including a Programme Management Office, Programme review groups and service transformation groups but as arrangements have developed, they also have become complex, with differing structures and areas of focus. Workforce performance measures show that the Health Board performs well in some areas such as sickness absence, and compares well to other bodies in Wales. Initiatives such as the Health Board s step into work and Project SEARCH programmes are offering access to work experience for people in the community facing disadvantage. The Board also supported and approved the staff engagement strategy in January However, there also remain a number of significant workforce challenges. Since 2011, reliance on agency staff has been worsening with agency staffing costs reaching 45 million in Recruitment also remains a significant challenge particularly for hard to fill specialist areas. I also considered overall management capacity. I noted: that the Executive Directors can be drawn into operational management issues, which is indicative of a wider need to strengthen the breadth and depth of senior management expertise below executive director level; clinical engagement and clinical leadership has also been a significant issue for the Health Board; and fragility of the senior management structure in the Mental Health division. The Health Board developed its Informatics Operational Plan that sets the objectives and priorities for the current year. The Health Board s informatics department has historically has funding constraints and is attempting to balance its resource across operational requirements, new initiatives, systems and developments. The funding constraints may limit the extent that the Health Board can use technology to support and enable savings and efficiencies in other areas. My team has undertaken a specific review of estates management. A summary of my findings is provided below. The Health Board is improving its approach to estates management, but is struggling to allocate sufficient resources to estates and lacks an overall strategy to tackle high-risk areas 61 My team found that the Health Board does not currently have an estates strategy. Its development is reliant on the approval of the Health Board s Living Healthier, Page 19 of 32 - Annual Audit Report 2017 Betsi Cadwaladr University Health Board

101 Staying Well strategy and will be prepared during At present though, the absence of a strategy makes it more difficult for the Health Board to make or prioritise decisions on capital. This includes decisions on estate disposal and approval of new capital projects. The Health Board currently has an estates portfolio valued at around 420 million and nearly 60% of the estate is over 30 years old. The Health Board s backlog maintenance on a risk-adjusted basis is valued at 41.5 million 8, as of Nearly 21 million of its backlog is categorised as high risk, which is the greatest proportion in Wales. Recent completed building work and re-developments in progress should help to reduce some of the backlog, but it remains a significant challenge given the age profile of its estate. The Health Board s capital programme sub-group considers each of the discretionary capital proposals based on a number of factors including risk, statutory compliance, financial balance and alignment to the operational plan. While this group allocated 14.4 million for schemes in , the bids submitted for the financial year amounted to over 30 million. 62 NHS Wales estate dashboard data shows that the Health Board s estate performance has declined, particularly in relation to physical condition and statutory and safety compliance, over the period to and did not meet any national estate targets in This may be the reason driving such a high proportion of work on reactive rather than planned work. Currently, the resources available are not enabling the Health Board to keep pace and effectively manage the risks associated with its aging estate portfolio. 63 During 2015, the Health Board re-structured some divisions, which included bringing together the functions of estates and facilities within one division. This has had a positive effect leading to better allocation of funding between the estates and facilities functions. Staff report the restructure has had a positive effect, leading to clearer lines of accountability. The day-to-day operation of the radiology service is well managed, but increasing demand, workforce challenges, poor IT systems, aging equipment and weak strategic planning present risks to future delivery 64 The Health Board should have a clear strategic plan that sets out how it will meet current and future demand for radiology services. The Health Board s previous plan is now out of date, and while there was some work to introduce a five-year plan, this was not completed. This constrains its ability to set out sound operational plans for the service. 65 The increasing role of radiology in clinical care has led to growing demand for radiological examinations, in particular for CT and MRI scans. However, demand for radiological services is generally beyond the local department s control, and other specialties do not always give notice of changes that impact on radiology 8 NHS Estates, A risk-based methodology for establishing and managing backlog Gateway reference 4102, TSO, Page 20 of 32 - Annual Audit Report 2017 Betsi Cadwaladr University Health Board

102 demand. In relation to its workforce, the proportion of the Health Board s radiologists over 60 is higher than for the rest of Wales. This may increase the rate of staff turnover over in future in an environment where vacancies are difficult to fill. 66 I found that for planned care, there are few patients waiting longer than eight weeks for radiology appointments. Radiological reporting times are generally good and outsourcing of OOH reporting has helped to reduce reporting pressures. While in general that there was good open access to radiology services in relation to unscheduled care, access of emergency radiology services outside of normal working times was more limited. 67 There are fewer magnetic resonance imaging scanners when compared to Wales, computerised tomography and ultrasound scanners have shorter operating hours, and scanning at weekends is limited. In addition, some equipment is reaching the end of life expectancy but there is no replacement budget. The Health Board is planning more strategically and clearly to improve GP out-of-hours services, but in a challenging environment is not yet achieving a modern, consistent, wellresourced and staffed service that meets national performance targets 68 My 2017 review aimed to establish whether the Health Board is ensuring that patients have access to effective and resilient GP OOH services. I found that the Health Board is working to improve how it plans services, but its strategy is undocumented. Since my fieldwork, the Health Board s GP out-of-hours Future Service Task and Finish Group has been charged with developing a strategic approach. While there is no specific strategy for GP OOH overall, there is an action plan which has evolved from the original 2015 report actions. 69 The way the Health Board s divisions are managed presents challenges. Staff my team spoke to during my review understood the Executive leadership structure and operational accountability. However, staff also indicated that the professional clinical reporting lines are not currently clear. Long-term workforce issues continue to affect the sustainability of the service. When compared with other health boards in Wales, the Health Board has the lowest size of GP pool per 1000 population. The service has taken some steps to address this issue. 70 Between and the Health Board s expenditure on GP OOH services reduced by 14% in real terms. In , the Health Board subsidised its GP OOH services to the sum of 0.05 million. This amounted to the smallest percentage of subsidy paid by a health board as a percentage of its notional allocation, equating to 0.7% and significantly lower than the national average of 16.9%. If the Health Board is to develop sustainable GP OOH services, it will need an appropriate budget setting approach aligned to unscheduled care strategy. 71 The Health Board needs to strengthen performance against national targets and its work to ensure demand is appropriate. My team identified: scope to do more to help patients access GP OOH services and signpost patients to the right service; opportunity to strengthen the call answering services; and Page 21 of 32 - Annual Audit Report 2017 Betsi Cadwaladr University Health Board

103 a need to improve how the service performs with see and treat and hear and treat services. The Health Board can demonstrate its intention to improve patient flow and discharge planning, but staff confidence and training remain challenging and performance remains poor 72 My work found that the Health Board is taking a number of steps to achieve its vision for improving discharge planning and patient flow. In particular, my team noted that plans, such as the Health Board s AOP and seasonal plan, articulate a clear intention to strengthen discharge planning as part of an approach to improve patient flow. The Health Board has recently developed pathways that draw on good practice, but a number of elements that could support discharge planning are absent, including development of standards for response times and quality, and processes for clinical information sharing. 73 The Health Board provides three discharge teams but these are available weekdays only and practice varies across hospitals. Although each district general hospital operates a discharge lounge, there is variation in their operating times, overall capacity and productivity. My team also found that staff training was historically poor, and staff awareness of, and confidence in, policies, pathways and community services is inconsistent. The Health Board is now taking steps to address poor access to, and compliance with, training for discharge planning. It is also taking action to increase its understanding of, and response to, a number of internal and external barriers to timely discharge, but some staff lack confidence to conduct difficult conversations with patients with regard to discharge. 74 Arrangements for monitoring, reporting and scrutinising discharge planning are generally effective. There are clear lines of accountability for monitoring and improving discharge planning and patient flow with regular scrutiny of performance. However, despite some recent improvement in the percentage of patients with long discharge delays, performance for discharge planning remains relatively poor. The Health Board has made progress in addressing recommendations from previous audit work although important actions remain outstanding in a few key areas 75 In addition to reviewing the effectiveness of the Health Board s arrangements to manage and respond to recommendations made as part of my audit work as discussed in paragraphs 60 to 61, my work has found that: the Health Board has responded to my 2016 structured assessment recommendation to maintain its focus on strategy development to ensure it meets its own challenging timescales. This recommendation will remain in progress until Board approval of its corporate strategy and plans. the Health Board continues to adapt its change management arrangements in response to my 2015 structured assessment recommendation, but at Page 22 of 32 - Annual Audit Report 2017 Betsi Cadwaladr University Health Board

104 present, these are still not sufficiently shaped to meet the organisation s change management arrangements. 76 During the last 12 months, I have also undertaken detailed follow-up audit work to assess the progress that the Health Board has made in addressing concerns and recommendations arising from previous audit work in specific areas of service delivery. The findings from this follow-up work are summarised in Exhibit 3. Exhibit 3: progress in implementing audit recommendations in specific service areas The following table summarises the key findings from my review of progress on follow-up outpatients Area of follow-up work Progress update of follow-up outpatients Conclusions and key audit findings The Health Board has made progress responding to recommendations made in my 2015 report, but it still needs to improve the way it identifies clinical risks and incidents, quicken the pace of service improvement and reduce the backlog of delays. The Health Board: is fulfilling its requirement to report follow-up outpatient data as per the Welsh Government requirement, although system issues did prevent submission for a short period. is continuing to expand the way it analyses and manages follow-up outpatient information and while this informs operational improvements, it is not yet consistently used to reduce inappropriate clinical variation in practice has a clearer understanding of clinical specialties that present the greatest risk of irreversible harm if delays occur in follow-up appointments, but this is not at clinical condition level. has focused on backlog delays but it still needs to modernise services to ensure they are fit for the future. This will be an ongoing requirement and is happening in a small number of specialties, but needs greater scale, pace and clinician/service driven involvement. Collaborative commissioning arrangements have helped drive some important changes for emergency ambulance services in Wales; however, the maturing arrangements require greater commitment from some partners 77 My review of the all-wales arrangements for commissioning emergency ambulance services found that the Emergency Ambulance Services Committee (EASC) has helped drive some important changes, such as the development of the CAREMORE 9 model. However, structures and roles to secure accountability for emergency ambulance services are unclear. I found that there is scope to clarify the roles of EASC, the Welsh Government and the Chief Ambulance Services 9 The CAREMORE model is a made in Wales commissioning method. Its registered trademark belongs to Cwm Taf University Health Board on behalf of NHS Wales. Page 23 of 32 - Annual Audit Report 2017 Betsi Cadwaladr University Health Board

105 Commissioner in relation to emergency ambulance service performance, finance and service modernisation. And although the formation of EASC has supported all-wales ownership of emergency ambulance services, my team identified that EASC needs to do more to drive through service transformation. In addition, the sub-group structure, which underpins EASC, lacks clarity and purpose, which is impacting on attendance by health board staff and the ability of the sub-groups to make a meaningful contribution. 78 Partners support the commissioning model but the pace with which health boards are driving the necessary changes to enable it to work as intended varies, and the model does not consider regional or cross-border activity. My work identified that there is a general willingness of WAST and health boards to work together to improve ambulance services, but the level of ownership of emergency ambulance performance and pathway modernisation by health boards is variable, with the predominant focus on the latter stages of the ambulance pathway, such as, ambulance handovers. I reported that WAST is properly responding to agreements set out by EASC, however, health boards compliance with and level of understanding of the requirements set out in CAREMORE vary. 79 My work found that commissioning arrangements are underpinning some improvements to emergency ambulance services. The introduction of the new clinical response model is supporting partners to achieve Welsh Government performance targets, with the potential for further performance improvements from other recently agreed initiatives. Planned service changes and performance monitoring of partners are now increasingly aligned with the Ambulance Patient Care Pathway (referred to as the five-step model). But, more consistency is needed across health boards and it is too soon to say if this is having an impact. There is a significantly improved and broader set of measures which focus on activity and performance through the Ambulance Quality Indicators. However, partners are not yet doing enough to fully understand patients outcomes and experience when receiving emergency ambulance care. Collaborative arrangements for managing local public health resources do not work as effectively as they should do 80 My review of Public Health Wales collaborative arrangements for managing local public health resources found that effective collaboration in relation to health improvement work is dependent upon consensual leadership, which is not always evident. In the overall public health system, a broad range of people and organisations contribute to protecting and improving health and wellbeing, and reducing health inequalities in Wales. No one organisation is wholly responsible for achieving improvements in population health and wellbeing but achievement is predicated on effective collaboration. 81 While it may not be desirable to identify a single system leader, there does need to be greater clarity over respective roles of the different stakeholders within the system. My work found that there is a lack of meaningful dialogue between the Page 24 of 32 - Annual Audit Report 2017 Betsi Cadwaladr University Health Board

106 Public Health Wales NHS Trust (the Trust), local public health teams and the Health Boards Directors of Public Health about respective roles, responsibilities and an agreed framework about what work is best done collectively. 82 Currently, there is an absence of effective arrangements to ensure that value for money is being secured from the resources allocated to local public health teams. Meetings do not take place between the Trust and Directors of Public Health to discuss how resources to improve health and wellbeing are used and whether they deliver the intended benefit. My work also found a lack of robust methods for allocating or changing resources of local public health teams. Instead, ad hoc discussions take place as vacancies arise. 83 My work found that arrangements are in place to support professional registration of staff deployed across local teams, but more clarity is needed on how this is used to demonstrate professional competence and career progression. New arrangements are also helping to strengthen appraisal processes and personal development planning, but more needs to be done to assess the collective development needs of local public health teams. 84 Mechanisms for communicating and sharing information between the Trust and local public health teams are underdeveloped. There is no standardised approach for sharing information about what works well and what different players were doing at both a national and local level. My work also found a lack of arrangements for co-ordinating work developed or delivered locally or nationally, and communicating information to the same shared partners. 85 I have noted the collective and collaborative management response that has been prepared by the Trust, Health Boards and Welsh Government to my findings. I intend to undertake further work in 2018 to assess the progress that has been made to address the concerns identified above. Page 25 of 32 - Annual Audit Report 2017 Betsi Cadwaladr University Health Board

107 Appendix 1 Reports issued since my last annual audit report Exhibit 4: reports issued since my last annual audit report The following table lists the reports issued to the Health Board in Report Financial audit reports Date Final Accounts Audit Deliverables February 2017 Audit of Financial Statements Report May 2017 Opinion on the Financial Statements June 2017 Audit of the Charity Financial Statements Report November 2017 Opinion on the Charity Financial Statements December 2017 Performance audit reports Emergency Ambulance Services Commissioning April 2017 Radiology Services June 2017 GP Out-of-Hours Services June 2017 Follow-up outpatients progress update August 2017 Collaborative Arrangements for Managing Local Public Health Resources October 2017 Review of Discharge Planning October 2017 Review of Estates November 2017 Structured Assessment 2017 December 2017 Other reports 2017 Audit Plan February 2017 In addition to the work above, my team undertook a follow-up review of governance arrangements jointly with Healthcare Inspectorate Wales. This work was reported in June An Overview of Governance Arrangements Page 26 of 32 - Annual Audit Report 2017 Betsi Cadwaladr University Health Board

108 Exhibit 5: performance audit work still underway There are also a number of performance audits that are still underway at the Health Board. These are shown in the following table, with the estimated dates for completion of the work. Report Cross-sector thematic: Review of the integrated care fund Estimated completion date July 2018 Review of Primary Care June 2018 Page 27 of 32 - Annual Audit Report 2017 Betsi Cadwaladr University Health Board

109 Appendix 2 Audit fee The 2017 Audit Plan set out the proposed audit fee of 462,953 (excluding VAT). My latest estimate of the actual fee, on the basis that some work remains in progress, is in accordance with the fee set out in the outline. Included within the fee set out above is the audit work undertaken in respect of the shared services provided to the Health Board by the Shared Services Partnership. Page 28 of 32 - Annual Audit Report 2017 Betsi Cadwaladr University Health Board

110 Appendix 3 Significant audit risks Exhibit 6: significant audit risks My 2017 Audit Plan set out the significant financial audit risks for The table below lists these risks and sets out how they were addressed as part of the audit. Significant audit risk Proposed audit response Work done and outcome The risk of management override of controls is present in all entities. Due to the unpredictable way in which such override could occur, it is viewed as a significant risk [ISA ]. There is an inherent risk of material misstatement due to fraud in revenue recognition and as such this is treated as a significant risk [ISA ]. My audit team will: test the appropriateness of journal entries and other adjustments made in preparing the financial statements; review accounting estimates for biases; and evaluate the rationale for any significant transactions outside the normal course of business. My audit team will consider the completeness of miscellaneous income. I completed focussed audit testing as planned on the relevant areas of the financial statements. No evidence found of biased judgements or estimates. I completed audit work as planned and no evidence was found of material misstatement due to fraud in revenue recognition. Page 29 of 32 - Annual Audit Report 2017 Betsi Cadwaladr University Health Board

111 Significant audit risk Proposed audit response Work done and outcome It is highly probable that the Health Board will fail to meet its statutory financial duties. The month-10 position showed a year-to-date deficit of 27.9 million and forecast a year-end deficit of 30 million. I am likely to place a substantive report on the financial statements, explaining the failure and the circumstances under which it arose. The current financial pressures on the Health Board increase the risk that management judgements and estimates could be biased in an effort to achieve any financial duties set. There is a significant risk that the Health Board will face severe pressures on its cash position at the year-end. A shortfall of cash is likely to increase creditor payment times and impact adversely on Public Sector Payment Policy (PSPP) performance. There is a risk that the Health Board will not have implemented my recommendations arising from my procurement follow-up reviews. My audit team will undertake testing of the Health Board s financial duties. My audit team will audit the PSPP performance bearing in mind the cash pressures on the Health Board. My audit team will assess progress in implementing the recommendations arising from my follow-up reviews to inform my regularity opinion. I reviewed the Health Board s financial management arrangements, significant financial standing issues and areas of the financial statements which could contain financial balance. The Health Board reported an overspend against resource allocation of 29.8 million and a cumulative overspend over the three year period to of 75.9 million. As a result, the Health Board failed to meet its first statutory financial duty. I completed focussed audit testing as planned and concluded that in all material respects, its performance was correctly stated. I completed focussed audit testing as planned and concluded that progress had been made and identified no issues that would impact on my regularity opinion. Page 30 of 32 - Annual Audit Report 2017 Betsi Cadwaladr University Health Board

112 Significant audit risk Proposed audit response Work done and outcome I have identified a number of disclosures as being material by nature. These include the disclosure of Related Parties and the Remuneration note. I will design detailed testing to obtain the required assurance that disclosures identified as material by nature are complete, accurate and in line with the requirements of the Manual for Accounts issued by the Welsh Government. I completed focussed audit testing as planned on the disclosures deemed material by nature. I concluded that the disclosures were complete, accurate and in line with the requirements of the Manual for Accounts issued by the Welsh Government. Page 31 of 32 - Annual Audit Report 2017 Betsi Cadwaladr University Health Board

113 Wales Audit Office 24 Cathedral Road Cardiff CF11 9LJ Tel: Fax: Text phone.: Website: Swyddfa Archwilio Cymru 24 Heol y Gadeirlan Caerdydd CF11 9LJ Ffôn: Ffacs: Ffôn testun: E-bost: post@archwilio.cymru Gwefan:

114 Wales Audit Office Structured Assessment Mrs Grace Lewis-Parry a Structured Assessment coversheet.docx 1 Health Board To improve health and provide excellent care Title: Wales Audit Office Structured Assessment 2017 Author: Responsible Director: Public or In Committee Strategic Goals Wales Audit Office Ms Dawn Sharp, Acting Board Secretary Public (Indicate how the subject matter of this paper supports the achievement of BCUHB s strategic goals tick all that apply) 1. Improve health and wellbeing for all and reduce health inequalities 2. Work in partnership to design and deliver more care closer to home 3. Improve the safety and outcomes of care to match the NHS best 4. Respect individuals and maintain dignity in care 5. Listen to and learn from the experiences of individuals 6. Use resources wisely, transforming services through innovation and research 7. Support, train and develop our staff to excel. Approval / Scrutiny Route Purpose: Significant issues and risks Equality Impact Assessment Recommendation/ Action required by The report has been reviewed by the Executive Team. It was also considered in-committee by the Board on ahead of submission to the Audit Committee on The Board is required to consider the Structured Assessment from the Wales Audit Office and the associated management response. The overall conclusion from Wales Audit Office for the 2017 Structured Assessment work is that the Health Board continues to find itself in an extremely challenging position, both in terms of its finances, and performance against a number of key national targets. The Health Board continues to evolve its corporate arrangements for governance, financial management, strategy development and workforce planning but these have not yet sufficiently enabled the Health Board to be where it needs to be with its finances and performance. EqIA is not considered necessary for this paper The Board is asked to receive the report

115 2 the Board accept the recommendations in the Structured Assessment note the initial management response to the Structured Assessment Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board

116 b Structured Assessment 2017_final.pdf Structured Assessment 2017 Betsi Cadwaladr University Health Board Audit year: 2017 Date issued: January 2017 Document reference: 285A

117 This document has been prepared as part of work performed in accordance with statutory functions. In the event of receiving a request for information to which this document may be relevant, attention is drawn to the Code of Practice issued under section 45 of the Freedom of Information Act The section 45 code sets out the practice in the handling of requests that is expected of public authorities, including consultation with relevant third parties. In relation to this document, the Auditor General for Wales and the Wales Audit Office are relevant third parties. Any enquiries regarding disclosure or re-use of this document should be sent to the Wales Audit Office at infoofficer@audit.wales. The team who delivered the work comprised Andrew Doughton, Nick Raynor, Alan Hughes, Dave Thomas and Mike Usher.

118 Contents Summary report Introduction and background 4 Key findings 5 Recommendations 12 Detailed report The Health Board continues to experience significant financial challenges and needs to develop a more transformational approach to savings schemes if it is to reduce its growing cumulative deficit 14 Some governance processes are strengthening, but the Board urgently needs to demonstrate a positive impact on the organisation s performance and finances 26 While the Health Board is making efforts to improve its use of resources, required changes are not yet keeping pace with the Health Board s increasing service pressures 37 Appendices Appendix 1 the Health Board s management response to the 2017 structured assessment recommendations 47 Page 3 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

119 Summary report Introduction and background 1 Our structured assessment work helps inform the Auditor General s views on Betsi Cadwaladr University Health Board s (the Health Board) arrangements to secure efficient, effective and economic use of its resources. 2 Our work in 2016 found the Health Board was laying some sound foundations to secure its future and the pace of change is increasing, although it remains in a challenging financial position and has considerable further work to do across a range of important areas. 3 As in previous years, our 2017 structured assessment work has reviewed aspects of the Health Board s corporate governance and financial management arrangements and, in particular, the progress made in addressing the previous year s recommendations. NHS bodies are facing growing financial pressures and challenging financial duties set out in the NHS Wales Finance Act (Wales) Therefore, we have also reviewed the Health Board s arrangements to plan and deliver financial savings. 4 We have also used this year s structured assessment work to gather evidence to support a pan-wales commentary. It will set out how relevant public sector bodies are working towards meeting the requirements of the Wellbeing of Future Generations Act (Wales) This commentary will be reported separately early in The findings set out in this report are based on interviews, observations at board, committee and management group meetings, together with reviews of relevant documents and performance and finance data. 6 The Health Board has been subject to substantial commentary on its governance arrangements, through our previous structured assessments and our joint work with Healthcare Inspectorate Wales (HIW), of which the latest follow up was published in June In 2015, the Welsh Government placed the Health Board in Special Measures 2. The Deputy Minister for Health issued a Special Measures Improvement Framework to the Health Board on 29 January 2016, setting out expected improvement milestones over the next two years. 7 Our structured assessment this year has not focused specifically on the steps included in the Health Board s special measures plan. However, we have commented in areas that are relevant to its special measures plan where those areas fall within the scope of the structured assessment review. 1 An Overview of Governance Arrangements Joint review undertaken by Healthcare Inspectorate Wales and the Wales Audit Office 2 Welsh Government statement in June 2015 Page 4 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

120 8 We are also aware that the Welsh Government has commissioned Deloitte LLP to undertake both a review of the Health Board s financial governance arrangements, and separately to examine capital planning arrangements at Ysbyty Glan Clwyd. On the latter, it is important to indicate that we have not undertaken any examination of these arrangements, either through structured assessment work, or otherwise. Key findings 9 The Health Board continues to find itself in an extremely challenging position, both in terms of its finances, and performance against a number of key national targets. The Health Board continues to evolve its corporate arrangements for governance, financial management, strategy development and workforce planning but these have not yet sufficiently enabled the Health Board to be where it needs to be with its finances and performance. The findings underpinning these conclusions are summarised below. Financial planning and management 10 We found that the Health Board continues to experience significant financial challenges and needs to develop a more transformational approach to savings schemes if it is to reduce its growing cumulative deficit. Financial performance 11 While the Health Board has a reasonable savings delivery track record, its savings approach is not sufficiently improving the overall financial sustainability and financial standing of the organisation. 12 Over the last five years, the Health Board has set relatively ambitious savings targets. In most years, the Health Board has been successful delivering against those expectations. Over the period between 2012 and 2017, the Health Board has set savings plans targets of 193 million and has achieved 192 million. However, there is: a high degree of variation in the success of individual savings plans, with notable over-delivery and non-delivery; and a trend of cost growth during both the and financial years which have to be countered by additional short-term saving schemes. 13 For in particular, the plan at the beginning of the year included a 35.4 million savings target and a predicted year-end deficit of 26 million. However as the year has progressed, a growth in costs became apparent which increased the year-end deficit forecast. In recognition of this significant issue, the Health Board has developed additional savings schemes but these do not go far enough to recover the financial position to meet the original plan. Moreover, there remain risks to the achievement of the revised savings schemes. This has resulted in a Page 5 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

121 challenging position where the forecast deficit has been formally revised from 26 million to 36 million. This increases the three-year deficit for from 75.5 million to 85.3 million. As such, the Health Board will not meet its requirement to spend within allocation as set out in the NHS Finance Act (Wales) 2014 for the period The rolling nature of requirements set out in this Act also means that the Health Board is highly unlikely to recover its three-year cumulative position for at least another two years. Financial savings planning and delivery arrangements 14 The Health Board s corporate arrangements for savings planning and delivery are becoming stronger, but they need to be more focused on longer-term sustainability. There is opportunity to increase the focus on service transformation, improving value and productivity, efficiency and reducing waste. 15 Corporate leadership and management of savings has been subject to numerous changes in recent years. Over the last three years, the Health Board has used an external consultancy, appointed an interim Director of turnaround and continued to be supported by a minimally staffed Programme Management Office (PMO). Revised accountability arrangements for the PMO team and a possible merging of this team with the improvement team are now broadening the focus and create the potential for extra capacity. We also found that finance department savings planning support has worked well over the last 12 months and the executive led programme review groups have helped provide structure and accountability in many instances. However, while available if specifically requested, change management, workforce planning, procurement and informatics support for saving schemes, was not systematically provided. We understand that Health Board is starting to address these issues as part of savings planning approaches. The Health Board also uses data and benchmarking which helps to identify scope for better efficiency and the potential for cost reduction in many areas, but this is not yet used systematically at an operational level to develop savings targets and plans. 16 While the Health Board is drawing on previous years experience to strengthen its approach to the management of savings schemes, these are not well integrated into the Health Board s annual operating plan. At present the Health Board s savings approach is predominantly based on an annual cycle, placing too great a reliance on short-term and non-recurrent savings. It is also impacted by growth of in-year costs, which is increasing the focus on short-term solutions. There is a clear desire in the Health Board to embrace prudent healthcare 3 and value based healthcare 4 principles but they currently are not well embedded into service planning. It is encouraging that the Health Board is recognising the areas identified 3 Achieving Prudent Healthcare in Wales 4 NHS Confederation Value Based Healthcare Page 6 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

122 above, and has recently created a value steering group, chaired by the Medical Director, to help take aspects of this agenda forward. Financial savings monitoring 17 Financial savings monitoring and scrutiny arrangements are strengthening as a result of lessons learnt from previous years and significant financial risks faced in the current year. 18 The Health Board s approach for monitoring savings delivery at a management level is well-established. The PMO monitoring group oversees progress of financial savings plans and receives clear information on savings schemes and this information continues to improve. While overall arrangements for monitoring are relatively sound, the impact of the arrangements on the overall financial position are more of a concern. 19 Board and committee performance monitoring of savings has been sufficient to discharge a general duty to oversee the impact of financial savings. However, until recently, there has not been sufficient detail provided to enable effective challenge, support, escalation and remedial action at Board or committee level. From August 2017, the Finance and Performance Committee has started to receive more indepth and specific reports on a division or thematic level. This has helped strengthen the focus and rigour of scrutiny. The Board has also set up a Financial Recovery Group. This is providing opportunities to strengthen oversight and scrutiny of savings plans, but this group needs to rapidly demonstrate strengthened scrutiny and a positive impact on the financial position. Progress in addressing previous structured assessment recommendations on financial planning and management 20 In 2016, we recommended that the timeliness of financial reporting to the board needed to improve. This has been achieved through verbal briefings and presentations to in-committee and other Board sessions. The recently established Financial Recovery Group is also helping to provide regular oversight on the organisations finances. From January 2018 onwards, the Board has also brought forward its meetings to accommodate improvements in the timeliness of finance and performance meetings. Page 7 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

123 Governance and assurance 21 In reviewing the Health Board s corporate governance arrangements, we found some governance processes are strengthening, but the Board urgently needs to demonstrate a positive impact on the organisation s performance and finances. The reasons for reaching this conclusion are summarised below. 22 Our observations of the Board and its committees during 2017 shows that they are well-administered and conduct their business properly. This includes a planned cycle of business, varied agenda and transparency in public reporting. While there is a notable commitment to improve, the Board needs to strengthen decision making with a greater focus on affordability, particularly when approving plans and proposals. 23 Governance structures are well administered, but there are opportunities for further improvement and re-shaping of terms of reference of the Finance and Performance Committee. We continue to note good inter-relationship and coordination between the Board s committees through the formal Committee Business Management Group, and more informal meetings of the committee chairs. We have identified improvement in the function of the Strategy, Partnerships and Population Health Committee and Audit Committee. We also recognise the progress that the Health Board is now making on its Board Assurance Framework and assurance mapping. 24 We have however highlighted some areas where the Health Board will need to either strengthen its governance process or determine the impact of its arrangements. This relates to strengthening the flow of assurance between the officer led Quality and Safety Group and the Quality, Safety and Experience Committee. We first identified this issue in We also identified as part of this year s work, the opportunity to strengthen the clinical audit approach to better target quality priorities and risks as well as provide assurance to the Quality, Safety and Experience Committee. 25 We found that the Finance and Performance committee has a clear agenda with a positive contribution of the independent membership. We also note recent strengthening in the style of scrutiny, which needs to continue. However, there is a significant demand on the committee given the increased scrutiny and focus that is needed on finance and performance within the Health Board. The committee is overseeing a deteriorating financial position, worsening of key aspects of performance and some key capital issues and risks. Given that it also has responsibilities in other key areas, notably workforce and informatics, there is a concern that the committee s current remit is too broad to allow it to adequately focus on some of the key challenges that the Health Board is facing. 26 Whilst performance management arrangements are in place within the Health Board, these have not prevented a deterioration in performance in a number of key areas within the national delivery framework. We have identified worsening performance relating to patients waiting on the referral to treatment pathway, the follow-up outpatient waiting list and those waiting for unscheduled care. We Page 8 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

124 understand that there has been additional targeted investment, made available from November 2017 onwards, and aimed at improving performance. 27 The Health Board has made minor changes to its organisation structure during the year. This included an area that we have been concerned about for some time relating to Executive leadership of the concerns/putting things right team. Those changes are starting to have positive affect. 28 The Health Board is demonstrating that it is taking a proactive approach in preparing for the new General Data Protection Regulation requirements. However, it also needs to ensure that it improves the timeliness of responses to statutory information access requests. Progress in addressing previous structured assessment recommendations on governance and assurance 29 The Health Board is in the process of addressing the recommendations made last year in relation to governance and assurance. Progress is summarised below relating to recommendations made last year the following areas: Board development programme The action is complete. The Health Board adopted a thematic focused board development agenda throughout Assurance mapping Original target date set as ongoing. Work to implement the assurance map will need to align to timeframes for strategy and planning to ensure it aligns to agreed objectives. Learning lessons and putting things right Original target dates March to June 2017 and action remains in progress. The new accountability arrangements for the central term are starting to take effect. New systems and processes are developing, but there remains more to do to ensure lessons are effectively learnt and consistently applied. Ward to board culture Original target dates December 2016 to May Action remains in progress. New systems and processes are developing, but there is a need for further improvement. Other enablers of the efficient, effective and economical use of resources 30 While the Health Board is making efforts to improve its use of resources, required changes are not yet keeping pace with the Health Board s increasing service pressures. In reaching this conclusion, we reviewed aspects relating to strategy and planning, change management, workforce arrangements, use of estates and informatics. 31 The Health Board continues to have a clear programme of public engagement and a track record of gaining a wide representation of community groups. Alongside the general engagement work, the Health Board plans targeted engagement activity Page 9 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

125 where it is considering making specific changes. The Health Board is not, however, formally consulting on major service change as part of its preparation for publishing its Living Healthier Staying Well strategy or IMTP. It may need to do so in coming years as plans develop further. 32 The Health Board has continued with its Living Healthier Staying Well strategy development. It is engaged with the four North Wales Public Service Boards and development of well-being assessments, the North Wales population assessment and has developed its own local needs assessment. The Health Board has identified the further actions required for development of its IMTP from October 2017 onwards. Overall, the Health Board has progressed its strategy and planning development. It will however, need to ensure sufficient clarity in its plans to help provide an effective platform for change and a financially sustainable future. 33 Change management capacity and capability is an area that has been an issue for the Health Board for some time, and we have commented on the need to strengthen its arrangements since The Health Board attempted to recruit a director of transformation. Unfortunately, this has not resulted in an appointment, and the Health Board has needed to utilise interim arrangements. We have also seen a number of changes over this time including a PMO, Programme review groups and service transformation groups but as arrangements have developed, they also have become complex, with differing structures and areas of focus. The Health Board needs to ensure that it puts in place arrangements that bring together in a cohesive and structured way, its corporate change management arrangements as well as creating effective change capacity and capability within the divisions. 34 While aspects of workforce management are reasonably effective and setting a positive tone, there remain some significant issues including reliance on a temporary workforce, recruitment challenges and low levels of clinical engagement. There are a number of positive attributes to the way the Health Board is managing its workforce. Workforce performance measures show that the Health Board performs well in some areas such as sickness absence, and compares well to other bodies in Wales. Initiatives such as the Health Board s step into work and Project SEARCH programmes are offering access to work experience for people in the community facing disadvantage. The Board supported and approved the staff engagement strategy in January The strategy has a broad focus and includes work on culture, building reflective learning improvement skillsets, ward leadership, wider leadership capability development and staff recognition and awards. 35 However, there also remain a number of significant workforce challenges. Since 2011, reliance on agency staff has been worsening with agency staffing costs reaching a peak of 45 million in although there is evidence to indicate that costs have started to reduce during Recruitment also remains a significant challenge particularly for hard to fill specialist areas. Given these challenges, the Health Board will need to adopt a more tactical approach to recruitment to improve the appeal to clinical staff. In addition, medical and allied health training has not sufficiently met the Health Board s staffing needs. This Page 10 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

126 specifically relates to converting initial training numbers requested at an all Wales level into permanently employed north-wales based staff over the medium to longterm. This is an issue that will require close working between the Health Board and a number of stakeholders including the Welsh Government, the deanery and other South Wales based training partners, WEDS, and local training partners in North Wales and North West region. 36 We also considered overall management capacity. We noted that the Executive Directors can be drawn into operational management issues, which is indicative of a wider need to strengthen the breadth and depth of senior management expertise below executive director level. Medical engagement and leadership has also been a significant issue for the Health Board. This area continues to require effort and we understand that the Medical Director is leading work to help strengthen arrangements. 37 We are increasingly concerned about the fragility of the senior management structure in the Mental Health division. Sickness absence has affected the continuity of senior leadership and is placing increasing pressure within that division and on senior management. The Health Board has put in place interim senior management arrangements to stabilise the existing leadership team. 38 Restructuring of the estates department resulted in some improvement, but the Health Board is struggling to allocate sufficient resources to estates and lacks an overall strategy to tackle high-risk areas. The Health Board currently has an estates portfolio valued at around 420 million. It also has the highest backlog maintenance in Wales on a risk-adjusted basis valued at 40.1 million 5. This should reduce with new and ongoing building work and redevelopment projects, but will remain a significant challenge for the Health Board because of the age profile of its estate. The Health Board does not currently have an estates strategy but anticipates that it will be published by autumn 2018 after publication of the Health Board s strategy and plans in April At present though, the absence of a strategy makes it more difficult for the Health Board to make decisions on capital, such as disposal of estate or prioritisation and approval of new capital projects and works. 39 The Health Board is improving its use of technology, but constrained resources may affect the extent that technology is used to support service efficiency. The Health Board developed its Informatics Operational Plan that sets the objectives and priorities for the current year. The Health Board s informatics department has historically seen a constraint in funding and is attempting to balance its resource and focus across operational requirements and support of new initiatives, systems and developments. This may limit the extent that the Health Board can use technology to support and enable savings and efficiencies in other areas. 5 NHS Estates, A risk-based methodology for establishing and managing backlog Gateway reference 4102, TSO, Page 11 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

127 Progress in addressing previous structured assessment recommendations on use of resources 40 The Health Board is in the process of addressing the recommendation made last year and in 2015 in relation to use of resources. Progress is summarised below relating to the following areas: Strategy and planning, delivery of plan within timescales Original target date November Action remains in progress as the determinant of success is the approval of corporate strategy and plans in March Change management capacity and capability The recommendation made in Action remains in progress because the Health Board continues to rely on consultancies and needs to build its overall capability for change. Recommendations 41 Recommendations arising from the 2017 structured assessment work are detailed in Exhibit 1. The Health Board will also need to maintain focus on implementing any previous recommendations that are not yet complete. The Health Board s management response detailing how it intends responding to these recommendations will be included in Appendix 1 once complete and considered by the relevant board committee. Exhibit 1: 2017 recommendations 2017 recommendations Financial savings R1 R2 R3 R4 R5 R6 Embed a savings approach based on targeting savings at areas where benchmarking demonstrates inefficiencies, to deliver longer-term sustainability. Identify where longer-term and sustainable efficiencies can be achieved through service modernisation and application of approaches such as value based healthcare, productivity improvements and invest to save. Ensure that budget holders receive the necessary specialist support from enablers such as the Programme Management Office, workforce, procurement and informatics teams when developing and delivering their savings plans. Ensure that financial savings assumptions are fully integrated into annual and medium-term plans so that savings efficiencies form part of service modernisation. Develop an approach for providing assurance to the relevant committee where delivery of saving schemes may affect service quality or performance. Further strengthen the corporate monitoring approach to ensure it supports and enables savings plans which are slipping, and encourages longer-term savings and efficiency programmes. Page 12 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

128 2017 recommendations Governance arrangements R7 R8 R9 Ensure that plans presented to the Board include costed options where applicable, and contain sufficient information to indicate to the Board that they are affordable in the short, medium and long-term. Review the remit of the Finance and Performance Committee with particular consideration to its breath of its current responsibilities. Build on the Health Board s programme of clinical audit to ensure it: a) aligns with quality strategy priorities and risks; b) sets out patient/quality outcomes or impact as a requirement of audit planning to help it understand the value that clinical audit is contributing; and c) informs the Quality, Safety and Experience committee with clear and focussed assurance reports. Change management R10 Consolidate, strengthen and sufficiently resource the change enabling capability of the organisation. Specifically the Health Board should: a) ensure financial savings are embedded into change programmes and plans; b) strengthen capacity and capability within centrally managed change programmes; c) strengthen change enabling capability and capacity in divisions; d) ensure workforce, informatics and other enabling resources are integral to change delivery arrangements; e) ensure clinical engagement and leadership are integral elements within change programmes; and f) strengthen accountability for progress against plans, including the annual operating plan and when developed, the Integrated Medium Term Plan (IMTP). Workforce management R11a Work with educational partners, research partners and internal stakeholders to shape new job roles to increase the attractiveness of the job offer as part of clinical staff recruitment. R11b Increase tactical recruitment capacity to support delivery of R11a. R12 Strengthen middle and senior management skills to provide sufficient breadth of business and financial capability and to support succession planning. Informatics R13 Increase investment in technology where this clearly will result in a greater level of returned cashable efficiencies or transformational economies. Page 13 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

129 Detailed report The Health Board continues to experience significant financial challenges and needs to develop a more transformational approach to savings schemes if it is to reduce its growing cumulative deficit 42 Our structured assessment work in 2017 considers the actions that the Health Board is taking to achieve financial balance and create longer-term financial sustainability. This year s work has had a specific focus on the Health Board s arrangements for planning and delivery of financial savings. 43 We have not considered detailed approaches for individual saving scheme planning and delivery, although we have looked explicitly at medicines management and informatics saving schemes to help inform our views on the overall the effectiveness savings planning and delivery arrangements in the Health Board. In addition, we have reviewed progress made in addressing previous recommendations relating to financial management. Our findings are set out below in the following structure: impact of approaches to savings on the overall financial standing of the organisation; arrangements in place to plan and deliver savings; monitoring and scrutiny of savings; and progress against recommendations made in last year s structured assessment. While the Health Board has a reasonable savings delivery track record, its savings approach is not sufficiently improving the overall financial sustainability and financial standing of the organisation 44 Each year, the Health Board is allocated revenue by the Welsh Government to provide the resources for the Health Board to pay for locally provided and contracted healthcare services for its resident population. This allocation is known as the Revenue Resource Limit (RRL). Each year there are increases in the RRL allocated at the beginning of the year by the Welsh Government. These increases in revenue help to address inflationary costs of healthcare 6. This includes growth in pay costs, medication costs, and increasing demand for services. 45 The Health Board forecasts its planned expenditure, which it sets against the financial allocation and other income streams. In each of the last three financial years, this has left a resource gap that the Health Board addressed in part through savings and cost control measures. However, these measures alone have not been sufficient to meet this overall resource gap with the consequence that the Health Board has operated to a planned financial deficit position at the end of the year. 46 As a result, the Health Board breached its resource limit by spending 75.9 million in excess of the 3,991 million that it was authorised to spend in the three-year period The following conclusions describe the effectiveness of past saving performance, and the overall impact on the financial standing of the organisation. 6 Economic assumptions 2016/17 to 2020/21 Page 14 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

130 The Health Board has a reasonable track record of delivering the savings targets it has identified 47 Over the last five years, the Health Board has set relatively ambitious but generally achievable savings targets. In most years, the Health Board has been successful delivering against those expectations (Exhibit 2). Over the period between 2012 and 2017, the Health Board has set savings plans targets of 193 million, and has achieved 192 million. The Health Board also increases the savings target during the year to help counter unplanned growth in service costs. This growth in costs can occur for a range of reasons including, for example, winter pressures and flu or greater need for specialist out of county placements. Exhibit 2: summary of saving scheme delivery The chart shows the trend of achievement of saving schemes over the last six financial years. The grey columns show savings planned at the beginning of the year (planned at month 1) versus savings reported (red columns) as delivered at the end of the year Savings, million Planned mth 1 Savings delivered Source: Savings reported by the Health Board in its monitoring returns to the Welsh Government There was a high degree of variation in the success of savings plans for In , the Health Board s total resource gap was 60.3 million. To help address the gap, it agreed a savings plan that totalled 26 million at the start of the year. The Health Board identified 301 saving schemes to help it meet its annual savings target. Exhibit 3 provides summary analysis prepared by the Health Board on over and under-delivery against its saving schemes. 49 By the end of the financial year, the Health Board revised its savings target from 26 million to 30.6 million. It over-delivered against its savings plans by achieving 33.5 million in savings. While it is positive to note the over-delivery against savings plans, there was a high degree of variation in the success of savings approaches. The overall position was helped by some significant overachievement in a small number of schemes and six unplanned schemes providing 1.2 million in Page 15 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

131 savings. The scale of over and under-delivery indicates that the Health Board could further improve its savings planning and delivery arrangements. Moreover, because of growth in service costs during the year, the net effect of over-delivery of savings and increase in costs meant that even though the Health Board over-achieved its savings, it only marginally reduced its planned deficit. Exhibit 3: summary of saving scheme delivery The table describes the performance against saving schemes at the end of the financial year. Category Number of identified schemes Sum of planned schemes ( ) Sum of actual scheme delivery ( ) Sum of differences between actual and planned savings ( ) Identified savings schemes overdelivering by 50,000 or more 33 6,629,474 18,213,684 11,584,210 Identified savings schemes overdelivering by 49,999 or less 35 1,912,351 2,494, ,285 Identified savings schemes achieved exactly the planned amount (+/- 10) 88 4,876,827 4,876, Identified savings schemes underdelivering by 9,999 or less , ,078-46,281 Identified savings schemes underdelivering by 10,000 to 49, ,340,042 1,886, ,724 Identified savings schemes underdelivering by 50,000 or more 30 9,244,532 4,436,856-4,807,676 Identified savings schemes delivering 0 (nil) savings 76 5,108, ,108,091 Unplanned savings schemes 1,152,839 1,152,889 Total ,638,677 32,389,377 1,750,701 Source: Betsi Cadwaladr University Health Board The Health Board s savings schemes do not bridge the entirety of its resource gap and the position for is looking very challenging 50 In , the Welsh Government s RRL allocation to the Health Board increased by 2% to 1,383 million. The Health Board has determined its other income streams and set this against its total forecasted expenditure. This created a total resource gap of 61.4 million. The Health Board originally identified a 30 million deficit, but following discussions with the Welsh Government reduced this to 26 million. This resulted in a savings requirement of 35.4 million. Page 16 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

132 51 By November 2017, the Health Board overspent against its budget trajectory. It therefore has introduced additional financial recovery measures. However, even with this increase stretch, the Health Board has revised its overall forecast annual deficit for the year upward from 26 million to 36 million. While the Health Board has allocated the new savings requirements across divisions, delivery of the savings schemes presents a risk, particularly as a high proportion are required at year end, over the winter pressures period (Exhibit 4). Exhibit 4: summary of saving scheme delivery performance and forecast The chart shows the trend of achievement of saving schemes at month 8 of the financial year alongside forecast thereafter. Million Savings Recovery Savings target Source: Betsi Cadwaladr University Health Board 52 The Health Board has implemented additional financial recovery measures, processes and controls. It is positive to note that the Health Board was already aware of and is strengthening all key areas of concern relating to central savings arrangements that we have identified during the course of our work. However, as a result of the recent deterioration in financial performance, the Health Board: faces a risk of not achieving its revised savings target; and will not achieve its agreed deficit plan, ie to achieve an agreed deficit of 26 million without effective remedial action or additional financial allocation. As of November 2017, the annual forecast deficit has been revised to 36 million. 53 As part of NHS Finance Act (Wales) requirements, the Health Board must spend within its financial allocations over a rolling three-year financial period. As identified previously, the Health Board 7 National Health Service Finance (Wales) Act 2014 Page 17 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

133 has developed savings approaches but these do not bridge the entirety of the resource gap. The Health Board s approach to savings planning is helping to contain the overall growth in its expenditure. However, it is not significantly reducing its planned deficit within a given year, or cumulative deficit over a rolling three-year period (Exhibit 5). For example, the Health Board s three-year deficit position for the period is expected to be 85.3 million. The Health Board will not meet its requirement to spend within allocation as set out in the Act for the period Exhibit 5: three-year cumulative financial positon (deficit) The chart shows growth in the forecast three-year cumulative deficit financial position of the Health Board, after income, costs and savings achieved are considered Total deficit million Source: Betsi Cadwaladr University Health Board The Health Board s arrangements for savings planning and delivery are strengthening, but its approach has been too focused on in-year cost control. There is opportunity to increase the focus on service transformation, value, improving value and productivity, efficiency and reducing waste 54 All Health Boards and Trusts in Wales have to identify savings to be able to aim to spend within their revenue allocation. For many bodies, growing cost pressures make it increasingly difficult to set a balanced budget, even with annual uplifts in funding. Traditional savings approaches across Wales have focused on cost control measures, procurement savings, recruitment freezes and changes in staff skill mix or grade mix, to name a few. Once these approaches have been exploited, health bodies will be required to think differently, because cost-cutting approaches will have diminishing returns. This section of the report considers the corporate arrangements for planning and delivering savings. We have not reviewed the design, accountability, risks or performance of individual saving schemes. Page 18 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

134 Corporate management of savings has been subject to numerous changes in recent years 55 In the Health Board, there has been a lack of continuity for the corporate management of saving schemes. This has affected the nature, scale and effectiveness of savings approaches adopted. Over the last three years, there has been reliance on an external consultancy to support programme management and a Programme Management Office (PMO) function, albeit one that was minimally staffed. The Health Board has also been unable to recruit substantively to the post of Turnaround Director, and has needed to fill this post on an interim basis. Collectively this contributed to a less than optimal and changing corporate approach to the corporate leadership and management of financial savings and one that historically focused more on reviewing savings, than enabling them. 56 In January 2016, the Finance and Performance Committee received a paper on options for the PMO, with a preferred option to create internal project management capacity in the Health Board. The pace of implementation of the new arrangements appears to have been an issue. However, new PMO accountability arrangements and changing the focus of the PMO are starting to create a positive reshaping of this important function. This includes a clearer remit for the team and proposal to consolidate the PMO and service improvement team as a coordinated resource to build team capability and development of policy, systems and process. The aim of these changes is to allow the team to better enable delivery of savings in the future, than it has been able to do in the past. 57 To help structure the change and savings approaches, the Health Board has set up a number of programme review groups. These groups have been in place for over a year and all have executive level ownership. The distribution of responsibilities for savings through these programme review groups is better spread across the Executive team than in the past. However, the Board need to keep the arrangements under review to ensure they too help enable and facilitate improvement in the management and delivery of savings. Arrangements to help budget holders achieve target savings have been strengthened but there is a need to make this support more proactive and systematic 58 The Health Board has recognised that senior management and service-level budget holders do not always have the necessary capacity and capability to plan, develop and deliver saving schemes and is providing additional support. 59 During , the Health Board set up arrangements to support budget holders through the alignment of finance directorate staff to divisions and services. We understand that this process of financial support has worked well over the last 12 months. However, there were concerns raised that past approaches adopted by the external consultancy and limited number of PMO staff did not sufficiently support the delivery of changes required to achieve savings. This is an area that the new PMO has sought to address when reshaping and refocusing its team. We also understand that the workforce planning and OD teams, informatics department and the procurement team are proactively engaged when specifically called upon to provide support. However, this support was not systematically provided during the savings planning stages, with the result that not all savings schemes benefited from the input of required expertise at the initial planning and design phase. The Health Board is seeking to address this as part of the planning cycle. Page 19 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

135 60 The Health Board has used Welsh Government s Invest to Save scheme 8 funding on two areas only in : electronic patient boards, and voluntary early release scheme (VERS). While we expect that use of VERS created a tangible cash benefit, the monitoring reports on the patient board implementation does not indicate whether a cashable efficiency was achieved. The concept of invest to save could be more widely used to help pump-prime required improvements, such as technology investments that result in cashable efficiency. Data on opportunities for cost improvements does not appear to be informing the identification and design of savings plans within the Health Board 61 As identified in the previous section, the savings planning approaches in resulted in a large number of saving schemes. The Health Board introduced measures to encourage transformation in with mixture of transformational and transactional savings. However, the transformational aspects of these did not deliver the required savings. Therefore, in the Health Board refocused its approach on in-year cost control and transactional savings. While the number of schemes has reduced from 301 in to 215 in , the number of schemes is likely to make local and central management of these schemes challenging. We also identified a number of low value schemes, and concerns were raised during interviews that the level of project administration required for these schemes was disproportionately high when considering the relatively low value of the savings likely to be achieved. This is now being addressed. 62 It is important that all health bodies across Wales understand the extent of inefficiency in the organisation. The Health Board has undertaken some analysis using Albatross benchmarking 9 to inform the finance team and budget holders on savings and efficiencies potential to help focus savings planning. This analysis provides reasonably detailed data on cost improvement opportunity. It is not clear, however, how this intelligence is used to inform identification of savings targets at an operational level, as we understand that the Health Board applied a uniform 3% savings target across the Health Board in The approach for allocation of savings in includes 0.5% cost avoidance but also provides a little more flexibility through 2% savings required from Area Teams and Hospital Teams with a further 1% as a shared target. This provides some limited option to protect services in the community that prevent growth in demand in the acute setting. The other service and corporate areas have a 3% target. 63 When constructing savings plans, it is important to consider the balance between, and effect of, recurring and non-recurring saving schemes. A greater focus on recurring and transformative schemes should make the budgetary pressure lower in following years. We found that of the total savings identified in , 43% of these were non-recurring. When looking at the specific savings category of pay costs, 53% were non-recurring (Exhibit 6). This raises concerns that savings are not sufficiently built into service re-design to make them financially sustainable in the future. 8 Welsh Government Invest to Save Invest to Save Patient Cost Benchmarking Page 20 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

136 64 The above findings indicate that transformational recurring savings are not a strong feature of savings planning. The Health Board needs to develop a more sophisticated approach to the identification and design of service plans, applying appropriate data and intelligence to identify where efficiency opportunities exist. 65 If the Health Board is going to demonstrate a continued trajectory of reduction in planned deficit over a number of years, there will need to be less reliance on non-recurring cost cutting measures and more focus on creation of a sustainable service models through: value based healthcare; tackling unwarranted variation in referrals and clinical pathways; challenging the fitness for purpose of existing models of care; significant and persistent attention on enhancing productivity; and prevention activity, but ensuring that this is delivering the required financial and quality outcomes. 66 It is encouraging that the Health Board is recognising the areas identified above, and has recently created a value steering group, chaired by the Medical Director, to help take the agenda forward. This has the potential to complement the on-going work in relation to transactional efficiency savings within the Health Board. Exhibit 6: split between recurring and non-recurring savings achieved in The chart shows high reliance on non-recurring savings, particularly in the area pay where non-recurring savings totalled almost 6.9 million Savings, million Pay CHC/FNC Medicines Mgt Non-pay Commissioned services Primary Care Recurring Non-recurring Source: Savings reported by the Health Board in its monitoring returns to the Welsh Government Page 21 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

137 67 There is a clear focus by the Health Board on development of annual approaches to development of saving schemes, but a lack of savings planning over the longer-term. Our evidence also indicates that the burden of savings delivery is weighted toward the last six months of the financial year. We believe these approaches are resulting in: lack of adoption of schemes that would otherwise deliver efficiencies in the longer term; lack of emphasis on sustainable efficiencies through service modernisation; financial and performance pressures coming together during the last six months of the year; schemes which are considered undeliverable within the year and then written-off; and lost opportunity for recurring savings. 68 The Health Board has indicated that it was already aware of these, using lessons from previous years and had already started to strengthen its arrangements, including: processes to reduce bureaucracy and the burden on budget holders for the management of low value schemes and transactional saving schemes under the value of 50,000; consolidating schemes into more meaningful programmes (albeit this will take some time as legacy schemes remain in place for the current year); strengthening project management on the higher risk schemes; increase focus on the proportion of recurring schemes; strengthening analytical capabilities in the PMO and service improvement team; planning savings on a rolling multi-year approach and spreading savings more equally within a financial year; implementation of an electronic system to streamline project management administration, analysis and progress reporting; and focusing on lead indicators that give an early warning of savings delivery risk. Whilst there is evidence that the Health Board is drawing on previous years experience to strengthen its approach to the management of savings schemes, such schemes are not well integrated into operational plans 69 All health bodies are required to develop a three-year integrated medium term plan (IMTP). Each year the Welsh Government sets out planning guidance to help inform the basic requirements of the plans. The Health Board has an approved Annual Operating Plan (AOP) in lieu of an IMTP, which it is currently developing. The AOP contains a short section on finances, including overall forecast cost pressures and inefficiencies for a 12-month period. 70 The AOP identifies the total savings requirements, the planned deficit in the current year, cumulative financial position and identifies that the plan is not fully funded. While this information is provided, it is appended to, rather than integrated into, the wider elements of the AOP. This makes it difficult to understand whether achievement of the deliverables that are identified in the plan will have a positive, neutral or negative affect on finances. Irrespective of this lack of clarity, and the fact that the plan was not fully funded, the Board received and adopted it. Page 22 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

138 Financial savings monitoring and scrutiny arrangements are strengthening as a result of lessons learnt from previous years and significant financial risks faced in the current year As a rule, the Board and its Finance and Performance Committee have not received sufficiently detailed information to support effective scrutiny and challenge of financial savings 71 Board and committee performance monitoring of savings has been sufficient to discharge a general duty to oversee the impact of financial savings. However, until recently, there has not been sufficient detail provided to enable focused challenge, support, escalation and remedial action at Board or committee level. The report provided to the Board on finances includes a section on efficiency savings. This contains a high-level report on performance against target, risks, savings trend against target, planned and actual savings with a forecast broken down by risk profile. This report provides enough information to satisfy a general duty to oversee financial performance, but it does not provide sufficient detail to be able to challenge in any depth. 72 Oversight of financial performance is delegated from the Board to its Finance and Performance Committee. This committee receives the same report that the Board receives, but ahead of the Board receiving it. Given the scope of this committee, it should have more time to focus on these financial issues but again does not receive sufficient detail as part of regular reports to allow it to challenge in greater depth. In August, however, the committee did receive a more in-depth report on financial performance and recovery of the Mental Health and Learning disability division. This enabled it to discuss key areas of concern, risks, service pressures and appropriateness of recovery action. This deep dive was a helpful and challenging process and was recently repeated with a focus on continuing healthcare. These approaches are enabling a stronger style of scrutiny and challenge which now needs to be replicated across other areas of service delivery. 73 It is also important that the Health Board understands any risks that savings schemes may have on the quality and delivery of services. We have seen very little evidence of the consequence of saving schemes on performance or quality being effectively reported to the committee or Board. However, we are aware that quality impact analysis forms part of the savings planning approach. A new Financial Recovery Group along with improved management information provide opportunities to strengthen oversight and scrutiny of savings plans, but this group needs to rapidly demonstrate an impact on the financial position 74 In our 2016 Structured Assessment report 10, we highlighted an issue relating to the timeliness of financial information going to the Board. While the Health Board has taken time to respond to this recommendation, recent rapid deterioration in the financial position has resulted in an increasing attention on finances. We are aware that the Board has met in-committee a number of times since the beginning of August. It has discussed the overall worsening of the financial position, additional savings and cost control requirements and measures to target scrutiny. In addition, the Board has formed a new Financial Recovery Group (FRG), which meets every two weeks. The group will operate on behalf 10 Structured Assessment 2016 Page 23 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

139 of the Board to maintain focus and oversight of the Health Board s financial position by monitoring the financial recovery plan. The group is chaired by the Chair of the Board, and includes independent members and executive membership. The group is not a permanent feature of the Board, but has in the short-term created an improved focus on savings and financial recovery. 75 Positively, the FRG: has more timely access to financial information, including lead indicators on high-cost activity which provide an earlier warning of cost growth and more timely; are considering how cost cutting measures might impact on service quality or might lead to changes that do not align with strategic direction; and are focusing on areas where financial recovery plan risk is the greatest. 76 However, our observations of the FRG during October 2017 indicated that it was still at the forming stage and while taking an oversight on the financial position was also reflecting on its function. The overall tone of the discussion was one that was intended to focus on support and enabling rather than challenge and scrutiny. However, our view is that a scrutiny and challenge role would better help communicate the seriousness of the financial position, allow the group to take grip of the finances and strengthen accountability for remedial action. We were also concerned that for two of the greatest cost drivers, workforce and clinical decision making, there was no evidence of senior leader representation at this Group. 77 Our observation at the FRG also indicated a short-term focus on cost cutting and variability in financial and business capabilities of service management. This is inevitable given the circumstances that have led to the creation of the Group. Whilst the Health Board will clearly need to ensure that the FRG is effective in applying a clear focus on the immediate opportunities for financial recovery, it is also important that it takes the opportunity to look beyond the current year and towards a more transformational approach to financial efficiency. Approaches for management oversight of savings through the PMO montioring group are well-established although the variable performance of savings schemes raises questions about the effectiveness of these arrangements 78 The Health Board s approach for monitoring savings delivery at a management level is wellestablished. The PMO monitoring group oversees progress of financial savings plans. The group includes a mix of executive, finance and programme management and it is supported by good information and analysis from the PMO team. The Health Board has recently improved the approach for reporting to enhance emphasis on project deliverables, cost growth indicators and financial outcomes. This should help the Health Board gain an earlier warning where performance is going off track. Each of the programme review groups meets monthly and reviews progress of the schemes within that programme and to determine if any further actioned is required. The programme review groups have in-depth information on individual saving schemes. We understand that the programme review groups escalate issues to the PMO monitoring group for resolution, although we are unclear how effective this is, given some recent slippage in the savings schemes. The Health Board therefore should consider how it builds enabling and support into its management and oversight arrangements. Page 24 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

140 79 In the previous section, we highlighted that the profile of actual savings delivery was weighted toward the year-end, and we thought this placed unnecessary pressure on the organisation. Savings targets reported by Finance as part of reporting to committee and the Board, however, are derived by splitting the total savings target into equal twelfths and spreading these across the year. This has a benefit of highlighting gaps against targets at an early stage but it does not represent the actual timeline that budget holders agreed to. This makes it difficult to understand the extent and impact of slippage on likely year-end savings achievement. 80 We have also considered the risk assessment approaches used by the Health Board to determine the degree of risk for savings schemes and likelihood of delivery. Until recently, the Health Board s approach has been quite variable, with risk assessments not providing a robust view on where the risks lie on saving schemes. We are aware that from the beginning of this year, the Health Board has developed a stronger approach for risk assessment, which is in the process of being adopted. This should help give greater assurance on the specific risks to saving schemes as a means to improve reporting. As a result of these approaches and progress on a number of saving schemes, there is a positive trend in the number of schemes categorised as green/low risk. Progress in addressing previous financial planning and management recommendations 81 In 2016, we made a recommendation relating to timeliness of financial reporting to the Board. Exhibit 7 describes the progress made. Exhibit 7: progress on the 2016 financial management recommendation 2016 recommendation Description of progress Financial reporting R1 Review the timing of Board meetings, with a view to improve the timeline for financial reporting to the Board. This has been achieved through more regular and detailed verbal briefings and presentations to in-committee and other Board sessions on the financial position. The recently established Financial Recovery Group is also helping to provide regular oversight on the organisation s finances. From January 2018 onwards, the Board has also brought forward its meetings to accommodate improvements in the timeliness of finance and performance meetings. Action complete Page 25 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

141 Some governance processes are strengthening, but the Board urgently needs to demonstrate a positive impact on the organisation s performance and finances 82 Our structured assessment work in 2017 has examined the effectiveness of the Health Board s governance structures, board assurance and internal controls, performance management and information governance arrangements. We have also assessed progress against recommendations made in Our findings are set out below. While there is a notable commitment to improve, the Board needs to strengthen decision making with a greater focus on affordability 83 The findings underpinning this conclusion are based on our review of the effectiveness of the Board, consideration of the growing contribution by and demand on independent members as well as board level decision making. Our findings are set out below. 84 Our observations of the Board during 2017 shows that it is generally well administered and conducts its business properly. The Board has a varied agenda, routinely publishes its papers in advance, and continues to be transparent in its business and public reporting. 85 The Board met its requirements for annual reporting for the financial year within the required timeframe. This included the annual quality statement, annual report and governance statement as well as a number of other documents including the health and safety, welsh language and putting things right annual reports. As part of this year s work, we have also considered its cycle of business ie its planned agenda and key requirements throughout the year. This continues to provide a good mechanism, which helps the Board and secretariat effectively schedule key aspects of its work while allowing sufficient flexibility to focus on specific risks, issues and emerging developments. 86 The Board has also recently reviewed its Standing Orders and Standing Financial Instructions, albeit the latter may change more significantly pending all Wales development work. The review of Standing Orders included some minor changes in the scheme of delegation and lines of accountability. Promisingly, the Board has explicitly delegated responsibility to meet the duties defined in the Wellbeing of Future Generations Act (2015) at Board and through all committees. 87 When considering the frequency of Board and committee meetings, formal board development and incommittee sessions, and other groups they are involved in, it is clear that there is a significant demand on independent members. There is no sign that this demand will reduce in the near future and it is likely that independent members will need to continue to contribute significantly more time than set out in their formal contractual commitment. 88 While there have been a number of positive attributes of the functioning of the Board, we are concerned about the extent of scrutiny in some specific and important instances. We have already identified earlier in this report that the Board had received and approved its annual operating plan, and that it was clear that the plan was not fully funded. We also reviewed the Orthopaedic plan proposal, which the Board has approved. The orthopaedic plan was presented to the Board as a single option with other possible service options already discounted. While we do not provide a view on the Page 26 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

142 decision, there was no evidence that the other service options were costed or which options were the most affordable for the medium to long-term. 89 Given the current and worsening financial position of the Health Board, it is of concern that we have identified examples of plans being approved without sufficient consideration of affordability. This is clearly an aspect of board effectiveness that needs strengthening as part of the wider approach to securing deficit reductions and a more sustainable financial position. 90 In 2016, we made the following recommendation relating to board effectiveness and the need to strengthen its board development activities. Exhibit 8 describes the progress made. Exhibit 8: progress on 2016 board and committee effectiveness recommendations 2016 recommendation Description of progress Board effectiveness R3 The Health Board should review its Board development programme and consider how it can be used to improve the balance and quality of support and challenge provided by independent members to drive improvement. Board development sessions have been more consistent than in the past and driven around a small number of important themes. This programme includes a number of themes including board effectiveness and developing an ambition for improvement, strategy and transformation, and developing approaches for scrutiny. Action complete Governance structures are well-administered, but there are opportunities for further improvement and re-shaping of terms of reference 91 The findings underpinning this conclusion are based on our review of the governance structures and the associated assurance arrangements. Our key findings are set out below. 92 In general, the committees that we have observed were well-administered, with clear agenda that reflected the terms of reference of that committee. The Health Board continues to prepare and publish its committee papers sufficiently in advance. The committees of the Board operate in public and in a transparent way, but there is potential to use the in-committee sessions more effectively to enable scrutiny in more sensitive and confidential areas. 93 We continue to note good inter-relationship and coordination between the committees through the formal Committee Business Management Group, and informal meetings of the committee chairs. In general terms, there also continues to be good assurance reporting from committees to the Board. We have provided some specific commentary on the operation of the committees, as well as identifying areas for development and improvement, below. 94 Strategy, Partnerships and Population Health Committee Over the last 12 months, we have noted an improvement in oversight of the ongoing development of strategy and plans by the Strategy, Partnerships and Population Health Committee. It is clear that the committee has an increasing understanding and is informed on key stages of the strategy and planning process as well as emerging strategic themes. Page 27 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

143 95 As part of this year s work, we considered the relationship between the Strategy, Partnerships and Population Health Committee and the Finance and Performance Committee in the context of capital estates decisions. We noted that the Strategy, Partnerships and Population Health Committee is responsible for oversight of strategy and plan development and delivery, and the Finance and Performance Committee is responsible for major capital and related estate approvals. We observed an item on estate disposal that the Finance and Performance Committee approved, but it was not clear if some of the aspects of disposal would align to emerging plans and strategy currently in development. This highlights a need to ensure strategic fit of capital and estate changes, whether, investing or disinvesting, particularly once the IMTP and estates strategy are developed. 96 An additional challenge for the Strategy, Partnerships and Population Health Committee is its role in oversight of the partnership agenda. Currently the committee receives update reports from Public Service Boards and other significant partnerships. The partnership arrangements in particular for this Health Board have the potential to be highly complex and challenging. The Board will need to keep its approach for scrutiny and oversight of partnerships under review to ensure arrangements are proportionate and effective. 97 Quality, Safety and Experience Committee As part of the overview of governance arrangements conducted jointly by the Healthcare Inspectorate Wales and Wales Audit Office we have recently commented on the quality and safety assurance arrangements. We have not reviewed these arrangements further as part of this year s Structured Assessment. During our interviews we did not identify specific concerns relating to the function of the committee. However, we were told of concerns relating to the formal flow of assurance between the executive led Quality and Safety Group into the Quality Safety and Experience Committee. This is an area that we have identified as an issue since The Committee has itself identified that this needs resolving and is seeking improvement. 98 Finance and Performance Committee We have considered the operation of the Finance and Performance Committee as part of our focus on financial savings. We have observed good administration of the committee as well as a clear agenda and a positive contribution of the independent membership. We have also seen some strengthening in the style of scrutiny. The committee adopted a stronger scrutiny style recently in relation to Mental Health Division and Continuing Healthcare finances, and helped the committee to gain a fuller understanding of the extent of issues. Most recently this resulted in the committee not endorsing proposed continuing healthcare plans until the Committee could gain assurance that the team developed sufficient actions to deliver financial recovery. This type of scrutiny and gatekeeping will be required in future to ensure high standards of management proposal and action. 99 Whilst the committee has shown some strengthening in its scrutiny style it is overseeing a deteriorating financial position, worsening of key aspects of performance and some key capital issues and risks. A concern therefore emerges about the Committee s capacity to adequately scrutinise this growing list of challenges, noting the breadth of its functions, which also include the oversight of Informatics services and aspects of workforce and OD. Given the deterioration in the financial position, it is perhaps unsurprising that a new Financial Recovery Group has been established. Noting that the group has been set up as a temporary measure, it would still be helpful to have greater clarity on the respective roles of the FRG and the finance and performance committee in relation to the scrutiny of financial performance and reporting to the Board. Page 28 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

144 100 Audit Committee The Audit Committee is actively engaged in the Board Assurance Framework development and considers the governance and control arrangements of the Health Board s other committees. This year has seen the Audit Committee adopt formal processes for reviewing the annual reports of the other committees. This has helped improve the rigour of the committee annual report approval process and has helped provide moderation and consistency of reporting. The agenda is effectively planned around key business dates, such as the review of annual reports and statements, Head of Internal Audit Opinion, Accounts and the External Audit of the Accounts. The committee has clear terms of reference, undertakes self-assessment reviews and regularly reviews its cycle of business. Board assurance framework arrangements are developing well, supported by key internal controls which are continuing to strengthen 101 As part of last year s structured assessment approach, we considered arrangements that health bodies have in place to assess, plan and provide assurances as part of a board assurance framework approach. Our commentary in last year s report identified that the Health Board has been developing its system of assurance and developed an interim Corporate Risk Assurance Framework (CRAF). We have reviewed the progress made since last year as well as key aspects of internal control. Our findings are outlined below. 102 Board assurance arrangements Over the past year, there has been a clear focus on strengthening Board assurance framework arrangements. The Audit Committee held a development session in May 2017 to progress board assurance arrangements. This helped to shape thinking around board assurance processes, needs and format while also helping to identify gaps in assurance. Since this session, the Health Board has also been working with peer support from Cwm Taf University Health Board. This has helped to share approaches, lessons and receive challenge and support. The Health Board has continued its board assurance development approach over the summer and is in the process of developing a three-strand approach for its board assurance framework. This includes: a board assurance framework narrative document which defines the shape of the overall governance arrangements; an assurance map which is used to determine assurance requirements and how these assurances will be obtained; and corporate risk management arrangements. 103 The Health Board now needs to implement and embed these arrangements, aligning the introduction to the timeline for IMTP approval. This should help the Board structure to its assurances around objectives set out in the plan. 104 Key internal controls As part of this year s structured assessment, we have considered the operation of key controls. This included internal audit and capital audit, local counter fraud services, clinical audit plans, and post-payment verification work as well as processes to help ensure compliance with policy and procedures. 105 Our work has identified a regular and comprehensive programme of internal audit work with sufficient resources to deliver it. The Internal Audit team complete the audit programme within the required timeframe, although delivery can be pressured towards the end of the calendar year. This work last year was summarised in a Head of Internal Audit report that gave reasonable assurance overall for Page 29 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

145 Interviews indicate that so far this year, there is an increasing trend of limited assurance reports. The Health Board has indicated that this is a result of focus by internal audit on key areas of risk. 106 As part of the internal audit programme, we have also considered the work of the capital audit team. Their recent work on a major capital project at the Health Board has identified a range of issues that the Health Board needs to address and apply lessons learnt. As a result of this work, the Health Board needs to ensure sufficient strengthening of internal controls, assurance flows and improved responsiveness to risks and issues, on its other ongoing and planned capital projects. 107 The Health Board is strengthening its process for tracking Internal Audit and External Audit recommendations. It has introduced a new system that monitors the progress against target deadlines. Where progress is not sufficient, it issues automated reminders to officers. The Health Board routinely report progress on Internal Audit and External Audit recommendations to the Audit Committee. The approach is providing an improved understanding on progress against recommendations. However, the reports indicate that a number of recommendations have not been completed within the indicated timeframe. There may need to be a stronger management focus on this in future if this trend continues. 108 There is a clear local counter fraud services work plan. This team is sufficiently resourced and includes a balance of work spread across the domains of strategic governance, inform and involve, prevent and deter and hold to account as required in the NHS protect standards. The counter fraud annual report provides an honest view on areas that are progressing well and those requiring further improvement. We also understand that the local counter fraud services responds positively to views of key stakeholders to help strengthen its programme of work. 109 Post Payment Verification team visits are completed as planned for General Medical Services (GMS), Ophthalmology and Pharmacy contractor payments. In addition, they have now started to include GMS visits for their managed practices. The team has successfully identified recoveries totalling around 38,000 and their work acts as a tool to deter fraudulent behaviour and provide assurance on compliance with policy and process. 110 The Health Board has a clinical audit plan for the period , which the joint Audit and Quality, Safety and Experience committee approved, in November The Health Board has developed a clinical audit framework to help distinguish the differing oversight roles of the two committees. A significant focus of the plan is on national clinical audit initiatives and some rolling corporate clinical audits. The Health Board will benefit in future by strengthening how it: shapes the nature of local clinical audit to align with quality strategy priorities and quality risks; sets out patient/quality outcomes or impact as a requirement of audit planning to help it understand the value that clinical audit is contributing; and reports clinical audit assurances into the Quality, Safety and Experience committee. 111 The audit committee receives a quarterly conformance report which provides a good perspective on the level of conformance with procedures on procurement, payroll, accounts receivable and loses, and special payments. This shows that controls are in place, there are processes to monitor conformance with the controls, and that the Health Board is taking improvement action where necessary. 112 The Health Board has a formal policy for Declarations of Interest that requires all Board members and all staff on pay band 8c and above to complete. There are 753 staff that meet these criteria, but from a Page 30 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

146 low baseline in September when only 132 employees had submitted their response, the Health Board has significantly improved this to 667 declarations submitted in November This movement is positive and reflects improved processes, systems and focussed effort. The Health Board will need to build on this momentum by ensuring the declarations of interest are routinely included in line management discussion with employees, or through the appraisal process. 113 The Health Board has a range of policies and procedures in place, and is currently working to strengthen its policy control arrangements and supporting systems because: some policies are out of date, some significantly so; there is no single point of access for policies; version control needs strengthening; and there needs to be a process to ensure policies are reviewed at appropriate intervals. 114 In 2016, we made the following recommendation relating to board assurance. Exhibit 9 describes the progress made. Exhibit 9: progress on 2016 recommendations 2016 recommendation Description of progress Board assurance R2 The Health Board should build upon its assurance mapping work and work towards a board assurance map to complement the corporate risk register, and ultimately the IMTP. As identified in the commentary above, the Health Board has now shaped its overarching approach for its board assurance arrangements and now needs to implement these. The Health Board should now look to align the timing of the assurance mapping process to the corporate planning timeline to ensure that it links assurances to organisational objectives and priorities. Target date set as ongoing. Action in progress Whilst performance monitoring arrangements are in place within the Health Board, these have not prevented a deterioration in performance in a number of key areas within the national delivery framework 115 Health bodies in Wales are set and held to account on a range of national measures and targets that are set out in the NHS Wales Delivery Framework In addition to these national targets, health bodies can set local measures and targets to focus on areas particularly pertinent to them. We have reviewed corporate performance monitoring and reporting arrangements as well as the trend in performance against key targets. Our key findings are set out below. 11 NHS Wales Delivery Framework Page 31 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

147 116 As part of this year s structured assessment, we have considered overall progress against the national delivery framework measures that the Health Board reports on monthly and have highlighted key areas of concern. Given our review took place halfway through the financial year, we have considered overall progress over the 12-month period from September 2016 to September Our work has indicated that the Health Board has made some improvements in performance on measures notably in the national performance domains of staying healthy, safe care, effective care and individual care. Irrespective of the like for performance improvement over the last 12 months, the Health Board is failing to meet over 70% of the national targets and performance has deteriorated in important areas. 117 The most significant area of concern relates to timely care where the Health Board is only achieving 5 out of 18 national standards. The areas where the Health Board is meeting or near to the national standards include red 1 ambulance response times, 31 day cancer targets and 24 and 72 hour stroke assessments. However, there is a significant and deteriorating position relating to patients: waiting less than 26 weeks from referral to treatment (83.1% against a target of 95%); waiting less than 36 weeks from referral to treatment (8,781 patients against a target of 0 patients); spending less than 4 hours in A&E (80.2% against a target of 95%); spending 12 hours or more in A&E (859 against a target of 0); and overdue their target date on the follow up waiting list (70,530 against a plan of 55,000). We have, in particular identified the long-term growth in referral to treatment delays (Exhibit 10). Exhibit 10: referral to treatment, September 2015 to September 2017 Change in the numbers of patients waiting on the referral to treatment target waiting beyond the 26-week and 36-week target to 36 weeks Over 36 weeks Linear (26 to 36 weeks ) Linear (Over 36 weeks ) 0 Source: Stats Wales Page 32 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

148 118 We understand that the Health Board will be targeting some additional monies to improve elective waiting times, particularly focussing on patients most delayed. Depending on the approach adopted, the Health Board may find it challenging to increase elective activity at the same time as the Health Board is responding to unscheduled care demand over the winter period. At present, the Health Board is struggling to balance the demand across different parts of the Health system and at different times of the year including unscheduled care pressures that affect elective care productivity. 119 As part of this year s work, we considered how performance is reported to the Board and its committees. In general, the content of performance reporting presents a clear dialogue that indicates actual performance data, trend, positioning in Wales, accountability, and improvement/recovery actions. The Board s Integrated Quality and Performance Report (IQPR) provides a summary of performance, and follows the delivery framework domains as well as containing detail where performance is off track. 120 The performance reports presented to the committees follow the same style and content as the report presented to the Board. The IQPR split into two parts that are clearly allocated to either the Finance and Performance Committee and the Quality, Safety and Experience Committee. While this allows scrutiny on the content prior to the Board meeting, there is opportunity to provide: targeted information to help committee members understand patterns of variation; and stronger focus on patient, population and well-being outcomes. 121 Performance reporting on the progress of delivery of the Annual Operating Plan is through the Strategy Partnerships and Population Health Committee. The Health Board s reports indicate progress against the plan is off track at quarter two. The Health Board should review its approach for performance monitoring against delivery of plans, and how the Health Board responds to slow or nondelivery. This is particularly important in light of the Integrated Medium Term Plan that is currently in development. Recent changes to the organisational structure have proceeded as planned 122 As part of the recent overview of governance arrangements, conducted jointly by the Healthcare Inspectorate Wales and the Wales Audit Office, we commented on the changes to structure from the old clinical programme group structure to the new secondary care, area and mental health divisional structure. We published this work in June 2017, and therefore we did not seek to review the effectiveness of the current organisational structure as part of this year s structured assessment. We have however considered recent changes to the structure at an executive portfolio level, and identified specific factors during interviews and observations. 123 Since our 2016 structured assessment work, the Director of Corporate Services post has been removed and those responsibilities for the teams within that function have been redistributed to other executive directors. Those changes have now taken place. The communications function has now moved to the Chief Executive s office, and information governance and risk management teams have moved within the remit of the Board Secretary. 124 The changes also included an area that we had been concerned about since This related to the executive responsibility for complaints, concerns and incidents. From May 2017, the responsibility for that team transferred to the Executive Director of Nursing and Midwifery. The reasoning behind this Page 33 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

149 change is to help join up the complaints and incident management process to care-based quality improvement initiatives. Interviews indicate that: the transfer of the team into the nursing directorate has been successful; the concerns response backlog is reducing; but more work is now needed to strengthen the lessons learnt processes. 125 In 2016, we made the following recommendation relating to embedding continuous quality improvement throughout the organisation s structures. Exhibit 11 describes the progress made. Exhibit 11: progress on 2016 recommendations 2016 recommendation Description of progress Learning lessons R4a The Health Board should look at further steps to improve clinical leadership and ownership of Putting Things Right processes, to support the improvement needed in response times and learning from complaints, incidents and claims. R4b The Health Board should strengthen its processes for systematically reporting, cascading and implementing lessons learnt. Culture R5 Work to support a positive and open culture from ward to board needs to expand beyond the most challenged teams to help the wider organisation understand and apply positive values and behaviours. The Health Board has realigned the clinical leadership and ownership of putting things right processes to the portfolio of the Executive Director of Nursing and Midwifery. We understand that more work is required still to ensure lessons are effectively identified, shared and applied. It is positive however that the Health Board is making good in-roads into its concerns backlog. A new graphical system for analysing, interpreting and reporting near real-time analysis on patterns of complaints, concerns and incidents as well as a range of other factors is being rolled out. This new ward safety dashboard system allows users, whether ward based nursing teams, middle and senior management, to assess patterns of quality or harm and identify remedial action sooner. Original target dates March to June Action remains in progress. The Executive Director of Nursing and Midwifery and Medical Director are leading on quality improvement initiatives. This includes improving work on harms, mortality, leadership walkabouts, concerns data and the new ward safety dashboard as mentioned above. While these are positive, there clearly remains more to do. The Health Board is focusing on patient experience and is setting up systems in the hospital and primary care settings to Page 34 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

150 2016 recommendation Description of progress listen to patient feedback, and analyse and respond to complaints and incidents. We are also aware that the Health Board is looking to introduce values-based recruitment, although recruitment remains a significant challenge for the Health Board. A recent peer review relating to Healthcare Associated infection indicated that there remain some significant pockets in the organisation where the Health Board needs to address cultural issues. Original target dates December 2016 to May Action remains in progress. Good information governance foundations are in place, and the Health Board has recognised and is investing resources to meet new General Data Protection Regulation requirements 126 All Health Bodies need to ensure that they maintain the security, confidentiality and accessibility of patient records and other sensitive information. This requirement is enforced through the Freedom of Information Act (2000), NHS Caldicott requirements, and present Data Protection Act 1998 legislation that is soon to be replaced by the new General Data Protection regulation The introduction of the General Data Protection Regulation (GDPR) comes into force on 25 May 2018 and introduces some significant changes to data protection requirements and principles. GDPR introduces changes to the rights and freedoms of the data subject and these include the following changes: mandatory reporting to the Information Commissioner s Office within 72 hours of all data breaches where there is a risk to the rights of the data subject; scope of the act now extends beyond the boundary of Europe, for data processing of European data subjects. This might affect Health Bodies that participate in global research studies; penalties for breach of policy can extend to an upper limit of 4% of turnover, or 20 million (whichever is the greater); changes in rights including right to access, right to be forgotten, erasure and improving clarity of consent; and reduction in the timescales allowed for responding to subject access requests to 30 days. 128 The Health Board, led by the Senior Information Risk Officer, which is incorporated within the role of the Board Secretary, has recognised the legislative changes early and has a transition programme underway to assess readiness and implement the new requirements under the GDPR. Although some progress has been made, a number of activities remain in progress. These include developing and 12 The EU General Data Protection Regulation Page 35 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

151 completing an Information Asset Register, Privacy Impact Assessments for information flows and processing and further developing the network of information asset owners. Aligned to GDPR, Caldicott is a key element of the Information Governance and Confidentiality agenda in Wales. It provides organisations working in Health and Social Care with a set of recommendations and principles to help ensure that personally identifiable information is adequately protected 13. Our work this year has identified that the Health Board has completed a Caldicott Information Confidentiality self-assessment in April 2017 and currently assess themselves at 88% compliant. We also identified that the Health Board has a number of Caldicott and information governance improvement actions underway in These include: developing and implementing guidance and training for staff on the use of data protection impact assessments and increasing compliance to staff information governance training; developing an information asset register to meet GDPR requirements; mapping information flows and information sharing arrangements with third parties; reviewing the information governance strategy and records management policy; and rolling out the information governance toolkit to primary care GP practices. 129 In addition to this compliance activity, the Health Board needs to ensure that it responds to information access requests relating to the Freedom of Information and Data Protection Acts. The Health Board s performance in for responding to information requests within the required timeframe reported in the April 2017 Annual Information Governance report was: 70% in respect of Freedom of Information Act requests, against a requirement of 100%; and 75% in relation to Data Protection subject access requests, against a requirement of 100%. 130 Overall, the Health Board is demonstrating that it is taking a proactive approach in preparations for the new data protection legislation. However, it also needs to ensure that it improves the timeliness of responses to statutory information access requests. The Health Board may need to keep its information governance team resources under review over the next 6 to 12 months to ensure that it balances these requirements. 13 Information Governance and Caldicott Page 36 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

152 While the Health Board is making efforts to improve its use of resources, required changes are not yet keeping pace with the Health Board s increasing service pressures There is a clear programme of engagement on the strategic direction, but the Health Board is yet to consider how it will engage the public on service change as plans start to form 131 The findings underpinning this conclusion are based on our review of arrangements in place to effectively engage with stakeholders and work with partners. Our key findings are set out below. 132 As part of recent work, we identified that the Health Board s public engagement approach is now more comprehensive than we have seen in the past. The Health Board has developed a clear programme of engagement with the aim of gaining a wide representation of community groups. The Health Board has adopted national guidance and developed a systematic approach for determining the forms of engagement required. This includes a comprehensive and continuous programme of engagement activities either arranged by the Health Board or attending other partners and community events. These are focused on the emerging strategic direction as part of Living Healthier Staying Well, as well as gaining general feedback on the Health Board s services. To date, the Health Board has attended over 80 events, including: open sessions for staff in the acute and some community sites to help take views and discuss strategic direction of the Board; engagement with partnership forums such as the Stakeholder Reference Group and Public Service Boards to help align strategic fit with other organisation s corporate plans and partnership plans; discussion with a range of community groups on the strategic direction; and targeting groups who represent people sharing protected characteristics as defined in the Equality Act Alongside the general engagement work, the Health Board plans targeted engagement where it is considering making specific changes. The Health Board is, not formally consulting on major service change as part of its preparation for publishing its Living Healthier Staying Well strategy or IMTP. Whilst there is no requirement to consult on strategy or IMTP, the Health Board will need to ensure that it has the appropriate arrangements in place to engage, and if necessary consult with the public and other key stakeholders on any plans to re-shape health services in North Wales. While the strategic planning process has progressed well, the Health Board will need to develop strategy and plans which both are financially balanced and provide sufficient clarity on changes to its services 134 The findings underpinning this conclusion are based on our review of the Health Board s approach to strategic planning. We have also considered the progress made in addressing the recommendation in Our key findings are set out below. Page 37 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

153 135 All Health Bodies are required to develop an integrated medium term plan. The Welsh Government however, informed the Health Board that it did not expect it to prepare integrated medium term plan for the period Instead, the Welsh Government required the Health Board to develop an approvable plan early in 2018 for the period. 136 Since our 2016 Structured Assessment, the Health Board has developed an overall approach to planning which included a requirement to develop: the Living Healthier Staying Well strategy; an annual operating plan for the period ; and an integrated medium term plan for the period As part of the recent overview of governance arrangements 14 conducted jointly by the Healthcare Inspectorate Wales and the Wales Audit Office, we raised a concern about the lack of clarity relating to strategy and plan development in April relating to the latter part of The Health Board has since developed a range of clear actions for the remainder of the 2017 calendar year, and has reported their progress to the Strategy, Partnerships and Population Health Committee. 138 The Health Board has continued with its Living Healthier Staying Well strategy development. The Health Board engages with the four North Wales Public Service Boards and it contributed to development of well-being assessments, the North Wales population assessment and the Health Board s own local needs assessment. In addition to this work, the Health Board is continuing with the three strands of the living healthier staying well strategic approach; those being improving health and reducing inequalities, care closer to home and acute care. Our interviews have indicated that the Health Board is starting to pursue an outcomes oriented approach. The Health Board is also now working with the International Consortium for Health Outcomes Measurement (ICHOM) 15 with a particular focus on Respiratory and Ophthalmology. The focus on outcomes is an increasingly positive direction of travel. This work should help the Health Board align patient centred outcomes, population outcomes and potentially wider outcomes and objectives as part of the Wellbeing of Future Generation (Wales) Act The Health Board has identified the further actions required for development of its IMTP from October 2017 onwards. This includes finalising commissioning intentions, development of service transformation group plans and key deliverables for The Health Board commissioned a consultancy earlier in the year to undertake service and demand modelling. The consultancies completed its work in October The outputs of this work are being used to inform the Health Board and help to shape the work of its service transformation groups. These groups are focusing on the following areas: improving health primary care planned care unscheduled care 14 An Overview of Governance Arrangements 15 International Consortium for Health Outcomes Measurement 16 Well-being of Future Generations (Wales) Act 2015 Page 38 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

154 children s services community services mental health 140 While this gives assurance on progress to date, it appears there is little time for the service transformation groups to form their plans by the end of December 2017 as part of the wider IMTP development. We also heard during interviews that the service transformation groups are at a mixed state of maturity. Some, such as the planned and unscheduled care groups, may struggle, given immediate service pressures that they are facing. 141 The Board received and adopted its annual operating plan on 18 May The plan contains reasonable assessment of the population health challenges; including those that are most life threatening or create greatest risk of ill health. Those major conditions help to shape and focus much of the content of the annual operating plan. While it is positive that there is clear analysis of population need, the plan contains a vast number of actions; over 309 were required to be completed by the end of quarter 2 alone. Moreover, many of these are basic management tasks, performance measures rather than actions, lack specificity, not well-grouped into programmes and are not easily measurable from a health outcome or impact perspective. In contrast to this, however, we are aware that there are a number of service-led initiatives and projects at differing stages including vascular, ophthalmology, orthopaedic, stroke and SuRNICC that are more coordinated around programmes of work. 142 Overall, there has been progress with both strategy and integrated medium term planning. However, it is clear from the current annual operating plan approach that in the context of the IMTP, the Health Board will need to: better integrate financial savings and costs into the plan (as identified earlier in this report); and set out programmes of work and provide sufficient clarity to enable a change and transformation at the required pace. 143 In 2016, we made the following recommendation relating to strategic planning. Exhibit 12 describes the progress made. As noted, this recommendation is still in progress, and given that it still encapsulates the fundament issues around strategic planning, we do not propose making further recommendations at this stage. Exhibit 12: progress on the 2016 strategic planning recommendation 2016 recommendation Description of progress Strategy and Planning R6 The Health Board must maintain focus on developing its strategy and plans to ensure it meets its own challenging timescales. As identified above, the Health Board has continued to focus on progressing its planning and strategy development in line with its timetable. The challenge now is to ensure that there is sufficient clarity within the plan and strategy to provide a platform for effective and expedient change. Original target date November Action remains in progress, in accordance with the Health Board s plan development timetable Page 39 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

155 Change management arrangements are developing, but the Health Board will need to keep these under review to ensure the pace and effectiveness of programme delivery 144 Change management capacity and capability is an area that has been an issue for the Health Board for some time, and we have commented on the need to strengthen its arrangements since We have seen some changes since 2014, and while the overall change resource has grown, it has also become more complex, with differing areas of focus. 145 While the Health Board is struggling to balance its finances and aspects of performance now, the future is likely to present even greater challenge. The Health Board s own data indicates over the longterm that there is likely to be growth in the older population. It has also identified potential growth in prevalence of Cancer, Diabetes, heart conditions, Stroke and visual impairment. At the same time the Health Board s medium-term financial forecasts do not indicate proportionately increasing financial income. This provides a compelling argument for service transformation and a sufficient pace of change. To this end, we have considered the change management capacity and focus of the existing groups, although we recognise that change structures may also be embedded at a divisional level. This function and capacity is described in Exhibit 13. Exhibit 13: corporate programme and change capacity Group Role General area of focus PMO monitoring group PMO team Service improvement team This group comprises of Executive, finance and project management office representatives. The group oversees the work of the Programme Review Groups, the overall financial savings positions and the greatest significant risks to achievement of savings schemes. This resource has been limited to three members of staff over the past months. This has resulted in it developing and concentrating on monitoring and gatekeeping the large number of saving schemes. While this activity has taken much of the capacity of the team in the past, new systems that help to administer and report progress processes are now in place. As a result, the team intends to better support adoption of professional project and programme management practices going forward. This team has around 15 staff. This team has been operationally distributed and have been supporting incremental improvement although we understand that in some instances they have been drawn into supporting operational issues. Current proposals indicate that the group will merge with the PMO team, but it is unclear whether this will create additional transformational change capacity. Financial savings Financial savings Continuous improvement Page 40 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

156 Group Role General area of focus Programme Review Groups Service Transformation Groups Consultancies The groups were set up in 2016 up to oversee planning and delivery of a collection of savings schemes. These groups are executive led and include Programme Management Office, finance and operational management. The Programme Review Groups report into the Programme Management Office monitoring group. These groups have been set up since They are focused on developing a divisional plans and shaping service design as part of the IMTP development. We are unclear the extent of change management capacity within these groups. The Health Board has stopped using consultants to oversee and drive the corporate change management arrangements. A consultancy was employed to support capacity and demand modelling. This work completed in Autumn The Health Board is currently seeking to appoint further consultancy capacity to drive focused unscheduled care service changes. This demonstrates a continuing shortfall in expertise and change management capacity. Financial savings Service change Financial savings Strategy development Service change and improvement 146 It remains unclear how the PMO and the Programme Review Groups, which focus on financial turnaround, are working with or alongside the Health Board s service transformation groups. We understand currently that the service transformation groups do not report into the PMO or the PMO monitoring group. It is also not clear whether the groups duplicate functions, overlap or ensure that the activity of one group does not compromise the effectiveness of others. The Health Board needs to ensure that its approach to drive change does not become fragmented. It would therefore benefit by clearly setting out the shape and design of the entirety of change structures. 147 The Health Board has recognised that it needs to strengthen its leadership capability and capacity to coordinate turnaround and transformation. Over the last 12 months, the Health Board has sought to recruit at different times a director of turnaround and a director of transformation but was unsuccessful at appointing both times. The Health Board needs to ensure that there is sufficient change leadership capacity; this will be even more important once the IMTP and Living Well Staying Healthy strategies are developed. 148 In 2015, we made the following recommendation relating to change management capacity. When we reported progress in 2016, the Health Board had not fully addressed this recommendation. Exhibit 14 describes the progress made. Page 41 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

157 Exhibit 14: progress on 2015 change management recommendation 2015 recommendation Description of progress Change management capacity and capability R6 The Health Board should move away from over-reliance on external consultants by creating/identifying dedicated in-house capacity and capability to support: change management; and service transformation. As identified in the commentary above, the Health Board continues to experience change management capacity and capability challenges, which are requiring additional external support. While work is continuing to strengthen inhouse resources, progress is not sufficient to provide assurance that complex wholesystem organisation-wide change will be successfully managed. Recommendation made in 2015, no target date set. Action remains in progress While aspects of workforce management are reasonably effective and setting a positive tone, there remain some significant issues including reliance on a temporary workforce, recruitment challenges and low levels of clinical engagement 149 As part of this year s work, we have considered workforce arrangements including aspects of workforce performance, specific initiatives underway or planed and risks and challenges. 150 Workforce performance measures reported to the Board show that areas such as sickness absence, although not hitting the national target is regularly in the top two performing health boards in Wales. The Health Board has developed arrangements to help analyse patterns of sickness absence and help to adapt its approach to sickness absence management. 151 Medical staff appraisals are above target at 98.5% completion and we understand that medical revalidation arrangements are working well. However, appraisal and Personal Development Review for non-medical staff is low and there appears to be a greater issue in estates and secondary care. 152 The Health Board is adopting workforce approaches to support the wider community in a way that aligns with several aspects of well-being of future generations by targeting factors affecting deprivation, economic mobility and equality: The Health Board has initiated a step into work programme that supports individuals in the community who have been unemployed for extended periods and are finding it difficult to obtain employment. While this initiative is about creating work experience opportunities, we understand that placements are unpaid. The Health Board may wish to consider an approach to remuneration upon reviewing the lessons learnt from this promising pilot. The Health Board has also initiated the Project SEARCH programme. This is a nine-month long school-to-work internship for disabled students that will take place entirely at the Health Board. This includes a combination of classroom instruction, career exploration, and on-the-job training and support. Page 42 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

158 153 The Board supported and approved the staff engagement strategy in January The strategy focuses on culture, building improvement skillsets, ward leadership, staff recognition and wider leadership capability development. The approach includes but is not limited to: organisational development using 3D (discover, debate and deliver) methodology and ward leadership development; a successful awards ceremony in 2016 which is being repeated in November 2017; the introduction of the Seren Betsi award to recognise staff who go the extra mile. The Health Board has evaluated the award approach after an initial pilot, and is continuing on a regular basis; and development of leadership capability. This involved the procurement of external consultancy services and was resourced using charitable funds. The Health Board should consider the sustainability of this approach in future for this important area of work. 154 The Health Board recognises in the Annual Operating Plan that it will be required to build a strong workforce through engagement, development and workforce transformation. Key deliverables in that plan though only focus on short-term actions and are not strategic. The Health Board has developed a new workforce modelling tool to enable it to analyse and scenario plan. It now needs to consider how it uses these tools to support transformation initiatives. This may require the further development of systems and tools, or a reshaping of the workforce function, particularly in relation to organisation design. 155 Medical engagement has been a significant issue for the Health Board, and it was identified during our interviews as an issue that still needs to be addressed. The 2016 Patterns of Medical Engagement in the Welsh Health Boards report indicates the level of medical engagement is low in the Health Board, and is particularly the case for consultant grade. A particular concern for the Health Board was identified in the survey relating to medical staff not having information to help them understand the financial implications of decisions they made. This aligns to our observation in a number of meetings that indicated limited medical representation when discussing finances of the Health Board. Medical engagement is core to safe, effective and efficient services in terms of both efficient operational practice and shaping future services. It is also key to productive and good value based healthcare. This area continues to require effort and we understand that the Medical Director is leading work to help strengthen engagement activity. 156 A significant and longstanding challenge is the Health Board s reliance on agency staff. This has been an issue since the formation of the Health Board and has become worse with agency staffing costs reaching a peak of 45 million in , but is now reducing in Changes including IR35 taxation requirements, Welsh Government agency rate cap and increased internal controls may help to contain or partially reduce costs in the short-term. Ultimately though, the most significant challenge the Health Board is facing in relation to its workforce, is recruitment. The recruitment challenges have gone back many years, and the reliance on agency staff to fill substantive gaps has grown over time. Our findings show: A new recruitment group is adopting different approaches including focusing the timing of recruitment exercises around graduation times. The Health Board has also started to recruit graduates conditionally before registration to prevent it losing potential candidates. Page 43 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

159 There is a new website and promotional video to communicate the benefits of working and living in North Wales. Feedback from staff indicates that even though there is no recruitment freeze, it is difficult to get timely sign off to recruit. The Health Board needs to guard against short-term vacancy control measures aimed at saving money actually resulting in greater costs if it then has to fall back to costly agency use or outsourcing to improve performance. Recruitment remains a challenge but appears to be more successful in particularly hard-torecruit areas when there is clarity on the design of services. This has been noted particularly with tertiary models such as vascular and the trauma offer in the Emergency Department in Ysbyty Gwynedd. More could be done however to design an offer for new staff whether lifestyle, educational, research, or innovative practice opportunities. We understand that there are frequently over 500 vacancies in the Health Board. While operational systems help facilitate recruitment, a more tactical approach is needed. This should ensure that the offer to potential candidates positively differentiates the Health Board. This could include further developing research and development opportunities, enhancing opportunities and links to universities or creation of specific roles and development opportunities. Medical and allied health training coordinated by key NHS and university partners has not sufficiently met the Health Board s staffing needs particularly relating to converting initial training placements into permanently employed north-wales based staff. 158 As part of our work we considered overall executive level capacity. It was frequently mentioned to us during interviews that the Executive team are drawn into operational management issues which other senior management should be dealing with. As identified earlier in the report, we also have highlighted concerns relating to variable business and financial capability at a middle to senior management level. This particularly related to delivery of savings and spending within budgetary allocation. Both these issues are indicative of an organisation that needs to strengthen the breadth and depth of management expertise. The Health Board should re-assess how it addresses this issue both to strengthen the organisation s overall management capability and to support succession planning. 159 We are also increasingly concerned about the fragility of the senior management structure in the Mental Health division. Our observation at committees and the Board as well as a number of interviews indicated that sickness absence has denuded the leadership within this division at a crucial time when it is attempting to take forward work to address significant concerns about mental health services in North Wales. We are aware that these factors may have contributed to overspending against budget and we heard of delays in finalising and recruiting to the division s management structure. Restructuring of the estates department resulted in some improvement, but the Health Board is struggling to allocate sufficient resources to estates and lacks an overall strategy to tackle high-risk areas 160 During 2015, the Health Board re-structured some divisions, which included bringing together the functions of estates and facilities within one division. This had a positive effect leading to better allocation of funding between the estates and facilities functions. Page 44 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

160 161 The Health Board currently has an estates portfolio valued at around 420 million. Nearly 60% of the estate is over 30 years old. The Health Board has the highest backlog maintenance in Wales on a riskadjusted basis valued at 40.1 million 17, as of Around 20 million of its backlog is categorised as high risk. In contrast, the next largest high risk backlog maintenance for a health body in Wales is 4 million. The Health Board s own backlog maintenance should reduce with new and ongoing building work and redevelopment projects, but will remain a significant challenge because of the age profile of its estate. 162 The Health Board uses a scoring mechanism across a number of criterion to allocate its limited funding for capital works. There is a capital programme sub-group, which considers each of the schemes put forward to receive discretionary capital. The capital programme sub-group prioritises schemes based on a number of factors including risk, statutory compliance, financial balance and alignment to the operational plan. While this group allocated 14.4 million for schemes in , the bids submitted for the financial year amounted to over 30 million. 163 NHS Wales estate dashboard data shows that the Health Board s estate performance has declined. This is particularly in relation to physical condition and statutory and safety compliance, over the period to It also did not meet any national estate targets in This may be the reason driving such a high proportion of work on reactive rather than planned work. Currently, reactive work accounts for 59% of activity. The Health Board s capital resources are not enabling it to keep pace and effectively manage the risks associated with its aging estate portfolio. 164 The Health Board does not currently have an estates strategy. Its development is reliant on the approval of the Health Board s Living Healthier, Staying Well strategy. The division anticipates that it will publish an estates strategy by autumn At present though, the absence of a strategy makes it more difficult for the Health Board to make or prioritise decisions on capital, such as disposal of estate and approval of new capital projects. The Health Board is improving its use of technology, but constrained resources may affect the extent that technology is used to support service efficiency 165 The Health Board developed its Informatics Strategic Outline Programme (SOP) for and submitted this to the Welsh Government. It has also developed a Informatics Operational Plan that sets the objectives and priorities for the current year. The Health Board s informatics department has historically seen funding constraints and within this environment is attempting to balance its resource and focus across: the day-to-day operational aspects of maintaining and supporting the current technology infrastructure throughout the Health Board; taking on new requirements such as technology support for the Health Board managed GP practices and IT aspects of new capital projects; and 17 NHS Estates, A risk-based methodology for establishing and managing backlog Gateway reference 4102, TSO, Page 45 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

161 supporting new initiatives and developments that enable clinical service transformation, major system implementation and efficiencies. 166 Our work on savings indicated that the informatics department, while needing to make savings in its own department, is supporting technology projects in other parts of the organisation to create efficient ways of working. We understand that the informatics department s own financial constraints are limiting the extent to which it can enable savings in other areas. The Health Board needs to revisit how it is funding functions which themselves have the potential to generate wider efficiency savings for the Health Board. 167 The Health Board continues to have a legacy from its predecessor organisations that includes ageing IT systems infrastructure and separate instances of the same system or different systems supporting similar functions across its sites. This makes support of the systems challenging and can inhibit standardisation of clinical practice, efficient workflow across sites, and consistency and timeliness of information reporting. This issue is not easy to resolve, and will need a strategic approach that aligns both with national strategy and the Health Board s own corporate strategy and plans. 168 The Health Board implemented the Welsh Patient Administration System (WPAS) in November 2016 in Ysbyty Glan Clwyd. However, there are a number of issues that are not fully resolved. This is affecting the quality and timeliness of information reported and is requiring additional remedial work. The Health Board has put the rollout of the WPAS to its other acute sites on hold until the issues in Ysbyty Glan Clwyd have been fully resolved. 169 The Health Board has formed a digital transformation board to set the direction for digital working across the Health Board, improve user and service engagement and agree IT priorities and initiatives. The Health Board is also setting up a clinical informatics network to provide an improved link between clinicians and the informatics department. 170 Processes are in place to identify and track informatics issues and risks the Health Board faces. This includes: the risk of potential threats arising from cyber-attacks. The Health Board recently updated and approved its Information and IT security policy in This may help mitigate some of these risks if the policy is effectively adopted; A backlog of clinical coding. The Health Board has provided both additional permanent and temporary resources for coding activity and plan to clear the backlog by June 2018; IT Business Continuity and Disaster Recovery plans are not consistently developed, approved and tested in all divisions; pace and effectiveness of ongoing national plans for deployment of the remaining Laboratory Information Management System modules, the new Welsh Emergency Department system and the new Welsh Community Care Information System; effectiveness of support and delivery provided from NHS Wales Informatics Service and monitoring service levels; and concerns over the safe and secure storage of paper medical records. Page 46 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

162 Appendix 1 The Health Board s management response to 2017 structured assessment recommendations Exhibit 15: management response The following table sets out the 2017 recommendations and the management response. Recommendation Intended outcome/ benefit High priority (yes/no) Accepted (yes/no) Management response Completion date Responsible officer Financial savings R1 Embed a savings approach based on targeting savings at areas where benchmarking demonstrates inefficiencies, to deliver longer-term sustainability. To ensure that plans are financially sustainable in the long-term, and targeted and shaped around areas of inefficiency. Yes Yes The Health Board s savings approach is based upon a transformation path; from a focus on stabilisation, to improvement and toward longer-term sustainability. Benchmarking is actively used as a tool to identify areas for improvement, and this approach has been refined for planning purposes. This approach has identified opportunities which, if fully implemented, would allow the Health Board to return to financial balance by year 3 of the forthcoming three-year planning period. As part of the approach to delivering change, the Health Board has developed a consistent approach through the BeTTER resource (Betsi Transformation & Efficiency Resource). This will be used consistently across improvement projects in the future. 31 March 2018 Executive Director of Finance Page 47 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

163 Recommendation Intended outcome/ benefit High priority (yes/no) Accepted (yes/no) Management response Each saving scheme is managed through a Programme Review Group, each led by an Executive Director. Completion date Responsible officer Financial savings R2 Identify where longer-term and sustainable efficiencies can be achieved through service modernisation, and application of approaches such as valuebased healthcare, productivity improvements and invest to save. To ensure savings approaches link to longer-term financial sustainability within services, through service modernisation. Yes Yes A Value Steering Group under the leadership of the Medical Director has been established to oversee the development of a value based framework, which will support the identification and delivery of opportunities around transformation, variation and standardization. Building on the Deloitte work in 2013, the Health Board has identified opportunities for savings and productivity improvements across the organization. Please see response to R1 for further details. 31 March March 2018 Executive Medical Director Executive Director of Finance Financial savings R3 Ensure that budget holders receive the necessary specialist support from enablers such as the Programme Management Office, workforce, procurement and informatics teams when developing and delivering their savings plans. To ensure those most challenged are enabled to develop and deliver against plans. Yes priority (yes/no) Yes The planning approach for next year will result in a number of Transformation Groups, which will be responsible for delivering transformational change across the Health Board; along with Enabling Groups which will focus on cross-cutting corporate themes (such as workforce change). 31 March 2018 Executive Director of Finance Page 48 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

164 Recommendation Intended outcome/ benefit High priority (yes/no) Accepted (yes/no) Management response A review of Corporate Services will also be undertaken with a view to ensuring that the support provided to the organisation is appropriate. Completion date Responsible officer 30 June 2018 Chief Executive Financial savings R4 Ensure that financial savings assumptions are fully integrated into annual and medium-term plans so that savings efficiencies form part of service modernisation. To ensure that efficiencies are an integral part of, rather than an addition to service planning. Yes Yes The Development of the IMTP for incorporate savings proposals to ensure that securing efficiencies is an integral component of Planning. 31 March 2018 Executive Director of Finance Financial savings R5 Develop an approach for providing assurance to the relevant committee where delivery of saving schemes may affect service quality or performance. To ensure that there is full awareness of any detriment to performance or quality of service as a consequence of delivery of plans. Yes Yes The relationship between the PMO Monitoring Group, chaired by the CEO and which monitors the impact on performance or quality, and the relevant committees will be reviewed as part of our plans for next year. 31 March 2018 Executive Director of Finance Page 49 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

165 Recommendation Intended outcome/ benefit High priority (yes/no) Accepted (yes/no) Management response Completion date Responsible officer Financial savings R6 Further strengthen the corporate monitoring approach to ensure it supports and enables savings plans, which are slipping, and encourages longer-term savings and efficiency programmes. To ensure: management s oversight of savings is effective at keeping savings plans on track and intervening when there is evidence of slippage; the FRG is clear about the focus of its work and approach, and can demonstrate that it is achieving the purpose for which it was created; and Yes Yes This will be reviewed by the new Turnaround Director. 31 March 2018 Executive Director of Finance pending the appointment of the Turnaround Director. Page 50 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

166 Recommendation Intended outcome/ benefit there is effective on-going scrutiny and challenge on savings as part of the routine work of the Finance and Performance Committee, supported by the necessary management information. High priority (yes/no) Accepted (yes/no) Management response Completion date Responsible officer Governance arrangements R7 Ensure that plans presented to the Board include costed options where applicable, and contain sufficient information to indicate to the Board that they are affordable in the short, medium and long-term. To ensure that the Board makes good choices that balance cost, quality and outcome and that it does not overcommit its resources. Yes Yes Plans will identify costs and affordability where this can be achieved within known resource assumptions. Where proposals have clear and expected additional costs, such as orthopaedic waiting times, reduction of the need for dialogue with Welsh Government regarding resource availability will be made explicit. Ongoing Executive Director of Finance Page 51 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

167 Recommendation Intended outcome/ benefit High priority (yes/no) Accepted (yes/no) Management response Completion date Responsible officer Governance arrangements R8 Review the remit of the Finance and Performance Committee with particular consideration to its breath of its current responsibilities. To ensure that the committee can continue to provide effective scrutiny within the context of an increasingly challenging environment. Yes Yes Whilst recognising that the Finance and Performance Committee s Terms of Reference are fairly broad, this reflects the deliberate decision of the Health Board to embed integrated governance arrangements so that the financial and operational performance are seen together. Given the deteriorating financial position, the Health Board has created a Financial Recovery Group to provide additional scrutiny and challenge on the detail of the financial position and improvement trajectory. These arrangements are evolving, and are not seen as a permanent feature of the Health Board s governance arrangements. Therefore, it would be potentially destabilizing to significantly revise the terms of reference of the F&P Committee that are changed at this stage. The Committee s terms of reference will be reviewed as part of the regular annual review and committee annual reporting process in the Spring. At that point, the Committee can consider them in the light of six months operation of the FRG. May 2018 Acting Board Secretary Page 52 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

168 Recommendation Intended outcome/ benefit High priority (yes/no) Accepted (yes/no) Management response Completion date Responsible officer Governance arrangements R9 Build on the Health Board s programme of clinical audit to ensure it: aligns with quality strategy priorities and risks; sets out patient/quality outcomes or impact as a requirement of audit planning to help it understand the value that clinical audit is contributing; and informs the Quality, Safety and Experience committee with clear and focussed assurance reports. To maximise the value of and assurance from the clinical audit resources. Yes Yes a) The Health Board s Clinical Audit Programme for includes Consent, Record Keeping, Discharge Planning and Informing GPs of Discharge within 48 hours. Additional BCUHB wide projects are Hospital Acquired Thrombosis, Rapid Response to Acute Illness, Ward Quality & Safety Audit, HARM Dashboard, Antimicrobial Audit, Prescription Chart Audit (including antibiotic, O2, medication errors, VTE), Infection Control and Reducing Mortality. A number of these areas are specifically mentioned within the Health Board s Quality Improvement Strategy, eg Hospital Acquired Thrombosis, Healthcare Associated Infections, Rapid Response to Acute Illness, Reducing Pressure Ulcers, Medication Errors and Reducing Mortality or contribute to the overarching priorities of our strategy to be Safe, Effective and Caring. Ongoing Executive Director of Therapies and Health Sciences. Page 53 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

169 Recommendation Intended outcome/ benefit High priority (yes/no) Accepted (yes/no) Management response b) The clinical audit areas, noted in a) above, have patient quality outcomes; and/or impacts on patients; and/or ensure the organisation is legally/ethically compliant, eg Consent Audit ensures legal/ethical compliance. Compliance with record keeping standards contributes to maximising patient safety and quality of care, supports professional best practice and assists information governance compliance. The form used to register local audits does contain a section in which the clinical team are required to document the improvements to patient care that will be delivered through the audit. The form also asks why the audit is being completed, eg DATIX, concern, risk, NICE or AWMSG. A number of areas also contribute to the Health Care Standards eg HAPU (HCS Standard 2.2), Falls (HCS Standard 2.3), Medication (HCS Standard 2.6) and Infection Prevention (HCS Standard 2.4). All new Clinical Audits will be reviewed to make sure they comply with the recommendation and propose outcomes and impacts. Completion date Ongoing Responsible officer Executive Director of Therapies and Health Sciences Page 54 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

170 Recommendation Intended outcome/ benefit High priority (yes/no) Accepted (yes/no) Management response c) Clinical Audit reports to QSE via the QSG and provides an Annual Report to the Joint Audit and Quality, Safety and Experience Committee. The QSG has started to escalate selected areas of concern to the QSE according to risk eg Stroke (December 2017), Mortality Report (November 2017) and Falls (August 2017). The QSG is planning to invite leads for selected National Audits to present at meetings in the coming year. In addition, HQIP and the National Clinical Audit and Patient Outcomes Programme are developing a National Clinical Audit Benchmarking report for some audits highlighting the top five indicators for each report. This is not yet available in Wales. The Corporate Annual Audit Plan will be agreed by QSG prior to being presented to QSE Committee. Completion date Ongoing June 2018 Responsible officer Executive Director of Therapies and Health Sciences/ Executive Director of Nursing and Midwifery and Executive Medical Director Executive Director of Therapies and Health Sciences Page 55 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

171 Recommendation Intended outcome/ benefit High priority (yes/no) Accepted (yes/no) Management response Completion date Responsible officer R10 Consolidate, strengthen and sufficiently resource the change enabling capability of the organisation. Specifically the Health Board should: ensure financial savings are embedded into change programmes and plans; To ensure that overall change capacity is sufficient and aligned to deliver required pace and effectiveness of changes required in the strategy and IMTP. Yes Yes The change management capacity and capability is being reviewed. A plan will be put in place by 31 March 2018, with supporting structures and processes being established by 30 June 18 for delivery of results by 31 March March June March 2019 Chief Executive strengthen capacity and capability within centrally managed change programmes; strengthen change enabling capability and capacity in divisions; ensure workforce, informatics and other enabling resources are integral to change delivery arrangements; Page 56 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

172 Recommendation Intended outcome/ benefit High priority (yes/no) Accepted (yes/no) Management response Completion date Responsible officer ensure clinical engagement and leadership are integral elements within change programmes; and strengthen accountability for progress against plans, including the annual operating plan and when developed, the Integrated Medium Term Plan. Workforce management R11a Work with educational partners, research partners and internal stakeholders to shape new job roles to increase the attractiveness of the job offer as part of clinical staff recruitment. R11b Increase tactical recruitment capacity to support delivery of R11a. To ensure that the Health Board maximises its recruitment potential to avoid leaving services short staffed or costly agency placements. Yes Yes The Workforce and Organisational Development (WOD) has good links with educational partners and continues to engage with them in respect of our commissioning needs, working closely with nursing and other clinical colleagues. WOD is also an active member of the North Wales regional workforce board and embraces multi-agency working, which looks to define future working requirements across all sectors. Ongoing. Position to be reviewed October Director of Workforce and OD Page 57 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

173 Recommendation Intended outcome/ benefit High priority (yes/no) Accepted (yes/no) Yes Management response A discussion paper will be presented to the Executive Team in January, which aims to launch a new attraction, recruitment and retention strategy. This must be seen however within the context of our on-going relationship with our shared services colleagues and the need to be more flexible with existing resources within WOD. Completion date June 2018 Responsible officer Director of Workforce and OD Workforce management R12 Strengthen middle and senior management skills to provide sufficient breadth of business and financial capability and to support succession planning. To ensure sufficient depth of management capability, delegated authority and to support succession planning. Yes Yes The Head of Organisational Development is aware of the requirement to enhance middle and senior management skills and initiatives that were started in 2017 will continue into 2018 with a further commitment to a training needs analysis approach. June 2018 Director of Workforce and OD Informatics R13 Increase investment in technology where this clearly will result in a greater level of returned cashable efficiencies or transformational economies. To maximise the value of informatics to support wider service efficiencies. Yes Yes Increased investment has occurred during in Informatics in fundamental areas such as clinical coding and the development of key post namely Chief Medical Information Officer and three Area based Medical Information Officers who will support the Chief Information Officer in prioritising schemes of work. Complete Page 58 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

174 Recommendation Intended outcome/ benefit High priority (yes/no) Accepted (yes/no) Management response The Digital Transformation Group has now been established and has had its inaugural meeting in November This will be the forum for agreeing priority investments and ensuring the annual plan, the IMTP and the Strategic Outline Plans (SOP) have been prioritised by the service and clinical leads. Completion date Complete Responsible officer Further business cases are under development of efficiency projects such as telemedicine, mobility and digital records including resource for business analysis, technical support to cope with expanding business as usual services which are becoming more complex due to evolution of technology and legislation such as mobile, GDPR, cyber security mitigation. A balance will need to be achieved between ensuring core services and change projects. These business cases will be submitted to appropriate local and national forums for consideration and will be an ongoing process as part of annual planning. June 2018 and annually as part of the organisational budget setting and planning process. Executive Medical Director - Evan Moore - (Dylan Williams) Page 59 of 60 - Structured Assessment 2017 Betsi Cadwaladr University Health Board

175 Wales Audit Office 24 Cathedral Road Cardiff CF11 9LJ Tel: Fax: Textphone.: Website: Swyddfa Archwilio Cymru 24 Heol y Gadeirlan Caerdydd CF11 9LJ Ffôn: Ffacs: Ffôn testun: E-bost: post@archwilio.cymru Gwefan:

176 Integrated Quality & Performance Report - Ms Morag Olsen a IQPR coversheet.docx 1 Health Board To improve health and provide excellent care Title: Author: Responsible Director: Public or In Committee Strategic Goals Approval / Scrutiny Route Purpose: Significant issues and risks Integrated Quality & Performance Report Dr Jill Newman, Director of Performance Ms Morag Olsen, Chief Operating Officer Public 1. Improve health and wellbeing for all and reduce health inequalities 2. Work in partnership to design and deliver more care closer to home 3. Improve the safety and outcomes of care to match the NHS best 4. Respect individuals and maintain dignity in care 5. Listen to and learn from the experiences of individuals 6. Use resources wisely, transforming services through innovation and research 7. Support, train and develop our staff to excel Four sections of the report have had prior scrutiny with the Finance & Performance committee and three sections have had prior scrutiny by the Quality Safety and Experience committee. This report provides the Board with a summary of key quality, performance, financial and workforce indicators. The integrated quality and performance report for June 2016 includes: National Indicators aligned to the seven national performance domains Locally agreed indicators aligned to the performance domains Many of our information sources are reliant upon good, accurate and reliable information systems. In the month of November, our acute site at Ysbyty Glan Clwyd transferred to a new computerised Patient Administration System. We have highlighted this within the report and in some cases we advise caution whilst work continues to validate the

177 2 information. Refreshed and updated information will be published in future reports. National Targets Domain Improved Performance Sustained Performance Decline in Performance RAG Staying Healthy G Safe Care A Effective Care G Dignified Care G Individual Care A Timely Care G Staffing and Resources R Total G Local Targets Domain Improved Performance Sustained Performance Decline in Performance RAG Staying Healthy G Safe Care R Effective Care G Dignified Care A Individual Care R Timely Care R Staffing and Resources A Total R

178 3 Key Performance Indicators: Financial Balance, Unscheduled Care (USC) and Referral to Treatment (RTT) performance was moved to Welsh Government targeted intervention in August Subsequently the Cabinet Secretary has in January 2018 confirmed that both Finance and Performance will be included within the Special Measures areas of the Health Board. Unscheduled Care performance declined further in January Pressure across the system lead to decisions being taken on a daily basis as to whether or not elective admissions could continue. Unfortunately a number of elective cases were cancelled. The Health Board worked closely with partners to support patients to be managed via alternative routes to ED, increased the number of escalation beds and aimed to discharge patients safely at the earliest opportunity. Staff shortages make staffing rotas fully challenging and limit the number of additional beds that can be opened. Despite the actions taken the 4 hour target declined to 72.43%, handover delays increased and number of patients waiting over 12 hours in ED increased. Ambulance response times to 8 minute calls remains well above the target and improved on the December performance. The volume of DTOCs increased slightly in January reflecting the use of capacity arising over the Christmas period. RTT performance is in line with plan for cohort reduction and is being monitored on a daily basis. The end of January over 36 week performance saw a reduction in the volume of patients waiting for the first time this year. The risks to end of year delivery remain high given the limited in-patient and day case capacity and the short time available to treat patients converting from outpatients. Diagnostic waiting lists increased to 1400 patients waiting over 8 weeks at the end of January due to increased waits for endoscopy. This is being addressed through additional insourcing and use of the mobile theatres. Cancer performance showed continued improvement in December 2017, delivering the 31 day NUSC target for the sixth consecutive month. In line with policy, this measure has been stood down from exception reporting requirements until such a time as performance deteriorates. Performance against the Cancer 62 day target improved to 88.0% (from 87.5%. It is a concern that the backlog of patients waiting over 62 days continues to rise. This increase relates directly to the constraints within Endoscopy and Urology at the present time. The challenges in Endoscopy affect the Health Board as a whole, and particularly in East due to loss of capacity on site, however, the use of mobile units on site is ensuring capacity is being addressed. In East and West, weekend Endoscopy lists have been agreed and arranged until the end of the financial year. Additional urology capacity in North West England has now been secured and funded and this will help to reduce delays to

179 4 urology surgery. The key messages from this month s report are: Staying Healthy The Annual Flu vaccination programmes were launched in September Covering the at risk groups, and the Health Board s Staff Flu campaign, sessions are now underway to ensure the uptake targets set are reached, and performance is higher than last year so as to protect our population and our staff. There is a strong communication strategy which aims to increase take-up and the campaign increases accessibility through the use of local vaccinators. So far this year, BCU has achieved the 70% target set for Over 65 s and is now focussing upon achieving the national 75% rate. BCU has also vaccinated more people against flu than any other HB in Wales and up to date information on how this year s campaign is progressing can be seen on pages 21, 22 & 23. Safe Care This month sees the introduction of the Harms Dashboard Slide. This slide will provide a high level overview of Harm Free Care across the organisation using the information gathered through the Harms Dashboard, launched in October The measures included in this dashboard are:- Hospital Acquired Pressure Ulcers (HAPU) Grade 3 and above) Falls resulting in harm Number of confirmed cases of C.Diff, MRSA/MSSA or E.Coli Number of catastrophic medication errors The monthly high level summary slide will be complemented with a full thematic review of harms which will be presented at QSE on a quarterly basis. The first thematic review will be presented in the March QSE Committee. The Introductory Harms Dashboard Slide can be seen on page 38. The data source for reporting the number of Hospital Acquired Pressure Ulcers (HAPU) was changed in January 2018, and data is now being taken from Datix, the Risk Management system. It is planned that all of the Health Boards in Wales will be using Datix to report, monitor and manage HAPU. The reason for the change is that Datix is a more accurate and comprehensive source of information. In line with National Reporting Requirements, the figures reported are HAPU of Grade 3, 4 or Unstageable only. For January 2018, 37 cases of HAPU (Grades 3 or above) were recorded on Datix. Actions are being taken to understand the reasons for this and ensure the performance returns to a downward trend. Further information can be seen on page cases of C.Difficile were reported across the Health Board in January 2018, the highest number since October The number of confirmed

180 5 cases of MSSA is at its highest so far this year at 21 cases. However, the number of confirmed cases of MRSA remains low at 2 cases. Further details of what the Health Board is doing to tackle infections can be seen on pages 28 to 30. Effective Care Risk Adjusted Mortality (RAMI) a newly revised indicator has been provided by CHKS from December The previous indicator has been withdrawn. The new indicator reflects that age and length of stay are key factors in predicting outcomes for patients and uses these more strongly in calculating the index. All previous data has now been run through RAMI 2017 and the results demonstrate that the Health Board s RAMI rate has been between 97 and 100 since December 2016 (The target rate is less than or equals 100). The latest available figure, August 2017 is 97. Further details on page 28. As performance against this measure has achieved the target rate of 100 for more than 3 consecutive months, it is recommended that it be removed from exception reporting until such time as performance deteriorates. Further detail is on page 43. In September 2017, 46.4% of episodes were clinically coded within 1 month of the episode end date and increase from 44.9% in August The additional resources and actions put in place in the last few months are beginning to demonstrate improvement which is expected to be sustained month on month in line with the recovery trajectory provided. The backlog continues to affect accurate and timely reporting of other measures such as admissions for chronic disease, mortality and daycase rates. Despite additional resources being put in place, due to the oldest episodes being cleared first, we do not expect to achieve the target rate until Quarter 2 or 3, 2018/19. Further details can be found on page 44. Individual Care In January 2018, the number of patients experiencing delays in their Transfers of Care (DToC) increased to 88 compared to 76 in December Although the actions and processes being put in place over the last few months are working, difficulties in securing places with 3 rd party providers continues to compound patient flow. As stated with last month s improved position, improvements should be noted with caution, as sustainability is proving challenging, given the increasing difficulty being reporting in recruiting staff to provide care packages. Details of what the services are doing to reduce DToCs can be found on page 48. In November 2017, the Committee agreed that the Mental Health measures would be reported one month in arrears as this is the validated position as opposed to reporting on an un-validated position. Adult Mental Health reported sustained performance across almost all areas of the Mental Health Measures. Details around the measure for users having a valid Care Treatment Plan in place at the end of each

181 6 month can be found on page 9. Performance in Child & Adolescent Services (CAMHS) has improved to 65.4% for Assessments but deteriorated to 65.5% for Interventions within 28 days. Further details can be seen on pages 49. Dignified Care There is continued concern that the number of patients having their procedures cancelled more than once, and undergoing that procedure within 14 days increased to 3.8%. Details of what is being done to improve performance can be seen on page 53. Timely Care As at the end of January 2018, 10,092 patients were waiting over 36 weeks for treatment (all specialties). Increased scrutiny is being applied through daily RTT control totals Further information can be found on page 58. Our Staff & Resources Sickness Rates rose for the 4th consecutive month at 5.26% in December Details of what is being done to reduce sickness rates can be seen on page 71. The financial position of the Health Board has required the development of a detailed recovery plan with targeted support being provided from Welsh Government. Full details are provided in the Director of Finance reports. Internal BCU Activity Report is not presented this month whilst data quality issues in relation to this are being explored. Special Measures Improvement Framework Theme/ Expectation addressed by this paper Equality Impact Assessment This paper supports the revised governance arrangements at the Health Board and supports the Board Assurance Framework by presenting clear information on the quality and performance of the care the Health Board provides. It also addresses key indicators for mental health and primary care. The Health Board s Performance Team are establishing a rolling programme to evaluate the impact of targets across the Equality & Diversity agenda. Recommendation/ Action required by the Board The Board is asked to note the report. Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board

182 b IQPR Board Version at 1025.pdf 1 Integrated Quality & Performance Report 2017/18 Performance to the end of January 2018 Health Board To improve health and provide excellent care

183 Table of Contents 2 Title 1 Flu Vaccinations (Health Care Workers) 23 Community Average Length of Stay 45 Out Of Hours 67 Table of Contents 2 Achievements Safe Care 24 Achievements Individual Care 46 Achievements Staff Resources 68 Foreword 3 Safe Care National Summary 25 Individual Care National Summary 47 Staff & Resources National Summary 69 Status Guide 4 Safe Care Local Summary 26 Monthly Comparison Table (Board) 5 Healthcare Acquired Pressure Ulcers 27 Delayed Transfers of Care Non-Mental Health Mental Health Assessment and Therapy Child & Adolescent 48 Staff & Resources Local Summary Sickness 71 Summary: Unscheduled Care: Activity 6 C.difficile infections 28 MHM Care & Treatment Plans (Part 2) 50 Financial Balance 72 Summary: Unscheduled Care: ED KPI 7 Staph Aureus infections 29 Achievements Dignified Care 51 Appraisals (Non Medical) PADR 73 Summary: Unscheduled Care: ED Actions Summary: Unscheduled Care: ED Pathways 8 MRSA and MSSA infections 30 Dignified Care Summary 52 Mandatory Training 74 9 Welsh Government Reportable Incidents 31 Inpatient Cancellations 53 Agency and Locum Spend 75 Summary: Unscheduled Care: DToC 10 Incidents 32 Outpatient Cancellations 54 Hospital Activity - Year to Date 76 Summary: Unscheduled Care: DToC 11 Patient Safety Alerts 33 Achievements Timely Care 55 Appendix A Further Information 77 Summary: Referral to Treatment (RTT) 12 Patient Safety Notices 34 Timely Care National Summary 56 Summary: Referral to Treatment (RTT) 13 Complaint Acknowledgement 35 Timely Care Local Summary 57 Summary: Referral to Treatment (RTT) Cohort Management Summary: 8W Diagnostic and Therapy Waits 14 Complaint Response 36 Referral To Treatment Caesarean Section 37 Diagnostic Waiting Times 59 Summary: Cancer Care 16 Harms Dashboard 38 Emergency Department Waits 60 Summary: Stroke Services 17 Safe Staffing 39 ED Waits over 12 Hours 61 Achievements Staying Healthy 18 Achievements Effective Care 40 Ambulance Handover Times 62 Staying Healthy National Summary 19 Effective Care National Summary 41 Urgent Suspected Cancer 63 Staying Healthy Local Summary 20 Effective Care Local Summary 42 NHS Dental Access 64 Flu Vaccinations (A Risk Patients) 21 Mortality Measures 43 Stroke Pathway 65 Flu Vaccinations (A Risk Patients2) 22 Data Quality 44 Follow Up Waiting List 66 Performance Report - January 2018 Page 2

184 3 Foreword Seven Domains We present performance to the Board using the frameworks against which NHS Wales is measured. This report includes the indicators from the seven domains of; Staying Healthy, Safe Care, Effective Care, Dignified Care, Individual Care, Timely Care and Our Staff and Resources. The first three domains of Staying Healthy, Safe Care, Effective Care are scrutinised at the Quality, Safety & Experience committee. The Individual Care domain has shared scrutiny, with some indicators being scrutinised by the Quality, Safety & Experience committee and the remaining indicators being scrutinised by the Finance & Performance committee. The final three domains of Dignified Care, Timely Care and Staffing & Resources are scrutinised by the Finance and Performance Committee. Computerised Patient Administration System at Glan Clwyd Hospital A significant number of data related issues have been identified with the Central Area patient Administration System (WPAS). These can be categorised as user error or system configuration issues. They are now being addressed as a matter of urgency via the Programme Board. Any significant trends in activity or waiting lists since November 2016 should be scrutinized. Introductory Reports & Exception reports Each new local indicator has an introductory report that gives the context of the indicator. We include exception reports where performance is either worse than the required standard or the Board require sight of the actions we are taking to maintain or improve performance. After we have achieved an indicator for three consecutive months, it will be stood down from exception reporting. We have moved to the use of bar charts in the exception slides to show month-on-month performance. Performance Report - January 2018 Page 3

185 Status Guide Performance Against Plan & Escalation Status Update 4 The Health Board received the National Delivery Framework for 2017/18 during April This framework will be used by Welsh Government as part of its performance framework and aligned to the escalation framework of Welsh Government. The indicators within this framework take precedent over previous indicators and those submitted to WG as part of the 2017/18 Operational plan. A separate paper is included in this month s report that addresses the mechanism being used to incorporate new or revised indicators in future IQPR reporting. The current measures, used in this report for assessing performance are shown below. Green Performance is better than the target level 90% - Red Crosshatch No Target Performance is worse than the target level Cross-hatch background. Where the background is cross-hatched this figure is the provisional, unvalidated position. No target level or the trajectory has not been set. This is used for new indicators which we are introducing into the report. The relevant executive director has been asked to set the target level. Arrow and Performance against Plan This report uses arrows to show if the position has become better or worse than the previous month. Where the arrow is coloured, green signifies that performance is better than where we planned to be this month, whereas red signals that we are worse than where we planned to be this month. Black indicates no profile plan has been set. The way we measure performance against plan is also being revised by the group noted above. The value is better than the previous month The value is the same as the previous month The value is worse than the previous month Performance Report - January 2018 Page 4

186 Comparison with Last Report Comparison 5 The two tables below show the levels of performance compared to the last reported period in the report, usually this is last month s position, but in some cases it is the previous quarter or year. Within this summary table, only the indicators for the Board are shown. National Indicator Summary Local Indicator Summary Domain Improved Performance Sustained Performance Decline in Performance RAG Domain Improved Performance Sustained Performance Decline in Performance RAG Staying Healthy G Staying Healthy A Safe Care A Safe Care G Effective Care G Effective Care A Dignified Care G Dignified Care R Individual Care A Individual Care A Timely Care G Timely Care G Staffing and Resources R Staffing and Resources A Total G Total G Performance Report - January 2018 Page 5

187 Summary Report: Unscheduled Care Activity (January 2018 ) 6 Performance Report - January 2018 Page 6

188 Summary Report: Emergency Departments 7 Indicator Sept 2016 Sept 2017 Oct 2016 Oct 2017 Nov 2016 Nov Dec Dec 2017 Jan 2017 Jan th Feb 2018 mtd 4 hour combined ED/MIU % % 78.8% % % 76.8% % % % % 12 hour ED waits 913 1, , , ,461 1,132 1, hour ambulance handover , , min Cat A response 79.2% 70.1% 81.4% 78.9% 82.2% 77.6% 77.2% 73.3% 72.5% 86.7% 71.9% Performance Report - January 2018 Page 7

189 Summary Report: Triage Category of Patients Attending ED Major Minor Priority One - Im m ediate Priority Tw o - Very Urgent Priority Three - Urgent Priority Four - Standard Priority Five - Non Urgent See and Treat Jan-17 Jan-18 1ST -9TH Feb 131 1% 71 1% % % % % % % % % % % 199 2% 92 1% 7 2% 60 0% 39 0% 20 4% Unknow n Unknow n 971 7% 812 6% 461 Total Increase of 555 amber category plus increase of 207 yellow category (not reduction in unknown is only 159 across all triage categories and so doesn t account for this shift). Shift continuing in early February figures. While ED triage category doesn t measure acuity directly, the increase in amber category patients and the maintained high level of yellow category patients does represent the increasing pressure on the Major work stream and the subsequently admitted pathways Nursing acuity tool being adopted which will more accurately reflect patient need in future. 8 Performance Report - January 2018 Page 8

190 Summary Report: Flu incidences per site Sept 2017 Jan Performance Report - January 2018 Page 9

191 Summary Report: Delayed Transfers of Care (DToC) 10 January 2018 Census Patients delayed Days delayed Total numbers Non Mental Health Mental Health Performance Report - January 2018 Page 10

192 Summary Report: USC - Actions to date 11 Daily Safety huddles implemented on all 3 sites evaluation work underway by DU Older peoples assessment areas open on all sites, comprising multi-disciplinary workforce led by senior clinician; data being reviewed for expected outcomes including: reduced average length of stay; reduced re-admission rates; improved patient experience; increased discharge to usual place of residence - YG COPA unit established led by COTE consultant currently comprises 12 beds with plans to extend to 24 beds although COPA patients are also seen on AMU and in ED currently in addition to those patients on the unit on Glaslyn Ward - Wrexham Comprehensive Assessment Unit established - - EMU due to commence at Llandudno Community Hospital - SAFER roll out ongoing Schemes identified for the additional allocation of Winter plan monies Price Waterhouse Coopers (PWC) appointed following formal tender process to provide additional support for unscheduled care, commenced 22 nd January Performance Report - January 2018 Page 11

193 Summary Report: Referral to Treatment (RTT) 12 Mean monthly pathway closures April 2017-Jan ,848 per month Rate of monthly closure pre WG investment 15,831, post WG investment 17,865 Jan 2018 highest volume of closures at 19,459 and 2,893 more than Jan ,918 pathways to close by to deliver 4237 (currently 15,155 open pathways within 36 week end of March cohort of patients) Performance Report - January 2018 Page 12

194 Summary Report: RTT Performance v Plan 13 Jan 2018 position All Patients Welsh Residents Over 36 weeks 10,089 (improved by 380) 9,979 Over 52 weeks 2,793 (improved 264) 2,767 Orthopaedics over 36 wks 3,979 3,947 Orthopaedics over 52 wks 1,567 1,553 Performance Report - January 2018 Page 13

195 Summary Report: Progress to date to achieve year end position of 4237 patients over 36 weeks As at 8 th Feb. 2018: 2,403 better than plan 14 Mean daily reduction currently c350 patients Performance Report - January 2018 Page 14

196 Patients Summary Report: Cohort Management 15 RTT over 36 March 2018 cohort reduction total plan total actual Daily monitoring of cohort reduction plan by site and specialty. Currently cohort to treat by end of March 2018 is 15,155 ( 2,403 ahead of plan however risk associated with need to treat patients through admitted route during the forthcoming weeks). Actions include: Internal Additional Activity, External additional activity, validation, cohort scheduling and cohort management. Twice weekly progress meetings. Performance Report - January 2018 Page 15

197 Summary Report: Diagnostics 16 Service heading Jan-18 Cardiology Total 0 Diagnostic Endoscopy Total 764 Imaging Total 0 Physiological Measurement Total 2 Radiology - Consultant referral Total 342 Radiology - GP referral Total 259 Neurophysiology Total 33 Grand Total 1400 Actions to address include: additional insourcing for endoscopy, mobile theatre commenced work in Wrexham , additional lists and transfer of patients to YGC US framework agreement for additional capacity Performance Report - January 2018 Page 16

198 Summary Report: Cancer performance December 2017 Target Delivered Issues & Actions 31 Days 98% 62 Days 95% 99.3% NUSC continues to deliver within 31 day target USC improved slightly in December to 88% with 13 breaches. This volume of breaches would normally deliver higher 88% performance, however with the Christmas period the overall activity level was lower than normal. 2 of the 13 breaches reflected the complexity of the patient pathway. Backlog USC increased reflecting delays in endoscopy and urological surgery. 209 over 62 days Tumour sites with largest volumes over 62 days Colorectal (81, of whom 57 in West and 16 in Central); upper GI (57, of whom 52 in West); urology (44, of whom 31 in Central); Additional urological surgery being undertaken in Liverpool, Manchester and Wirral Additional insourcing and new mobile theatre started to address challenges in endoscopy Performance Report - January 2018 Page 17

199 Our Achievements - Staying Healthy I am well informed & supported to manage my own physical and mental health 18 Phase one of new neonatal unit at Glan Clwyd Hospital complete Premature and very poorly infants being cared for at Glan Clwyd Hospital are now receiving care in the hospital s newly developed Neonatal unit. The new 18m SuRNICC (Sub-Regional Neonatal Intensive Care Centre) will care for newborn babies from across North Wales with significant care needs. The first phase of the project includes the construction of the new unit, which will feature five intensive care cots, five high-dependency cots, and nine special care cots. The new unit also features a dedicated isolation unit, a transitional care service to keep mums and newborn babies together, and on-site parent accommodation, helping patients with premature and sick babies spend as much time with their child as possible. The SuRNICC meets the latest modern neonatal healthcare standards and provides significantly improved facilities for both families of babies on the unit and neonatal staff. Mandy Cooke, Neonatal Service Manager, said: We re delighted to have moved in to the new unit, which will help us provide the best care possible to families from across North Wales. It means that all the babies within North Wales who are born premature or sick will receive the highest standard of care possible. Our staff take great pride in their work, and the new unit and equipment will help us provide even better care. The opening of the new-build phase of the development is a huge milestone in this project, and will help our staff to provide sick and premature babies from across North Wales with the best possible start in life. Gary Doherty Chief Executive of Betsi Cadwaladr University Health Board Performance Report - January 2018 Page 18

200 Staying Healthy Overview National Standards 19 Staying Healthy Number of emergency admissions for 8 chronic conditions per 100,000 population (rolling 12 months) Number of emergency readmissions for 8 chronic conditions per 100,000 population (rolling 12 months) % uptake of the influenza vaccine in Over 65's % uptake of the influenza vaccine in Under 65s in at risk groups % uptake of the childhood vaccines 5 in 1 age 1 Men C age 1 MMR1 age 2 PCV age 2 Hib MenC Booster age 2 % estimated smoking population treated by smoking cessation services; year to date % smokers treated by NHS smoking cessation COvalidated as successful; year to date % of reception class children (aged 4/5) classified as overweight or obese Of those practices set up to use MHOL, % who are offering appointment bookings Of those practices set up to use MHOL, % who are offering repeat prescriptions Executive Lead Morag Olsen Morag Olsen Teresa Owen Teresa Owen Teresa Owen Teresa Owen Teresa Owen Teresa Owen Teresa Owen Teresa Owen Teresa Owen Teresa Owen Morag Olsen Morag Olsen Exception Report? National Target March 18 Plan Current Plan Previous Current Month Arrow Welsh Benchmark No Oct-17 1st No Oct-17 2nd Yes 75.0% 70.0% 70.0% 69.0% 70.3% Jan-18 2nd Yes 75.0% 55.0% 55.0% 48.9% 50.8% Jan-18 2nd No 95.0% 95.0% 95.0% 96.8% 96.80% Q2-17/18 o - No 95.0% 95.0% 95.0% % Q2-17/18 - No 95.0% 95.0% 95.0% 96.1% 96.10% Q2-17/18 o - No 95.0% 95.0% 95.0% 96.7% 96.70% Q2-17/18 o - No 95.0% 95.0% 95.0% 96.2% 96.20% Q2-17/18 o - No 5.0% 4.7% 3.5% 3.9% 3.5% Q2-17/18 - No 5.0% 40.0% 33.0% 34.4% 29.8% Q2-17/18 - No % 25.4% 27.4% Pending Data 2015/16 o - No % 47.0% No Data No Data Dec-17 4th No % 88.0% No Data No Data Dec-17 1st Performance Report - January 2018 Page 19

201 Staying Healthy Overview Local Standards 20 Staying Healthy Percentage of children who received 3 doses of the 5 in 1 vaccine by age 1 Percentage of children who received 2 doses of the MMR vaccine by age 5 Executive Lead Teresa Owen Teresa Owen Exception Report? National Target March 18 Plan Current Plan Previous Current Month Arrow Welsh Benchmark No 95.0% 95% Q2-17/18 - No 95.0% 95% % 92.40% Q2-17/18 o - Performance Report - January 2018 Page 20

202 Exception Report: Flu Vaccination - Pregnancy Staying Healthy % uptake of the influenza vaccine in Pregnant women Executive Lead Teresa Owen Exception Report? National Target March 18 Plan Current Plan Previous Current Month Arrow Welsh Benchmark Yes 75.0% 75.0% 75.0% 40.70% - Apr-18 - Where we are The vaccination uptake on pregnant women will be available in April 2018 via a Point of Delivery audit that was conducted on 21 st January 2018 on women attending labour ward. Verbal reports from midwives and GPs says the campaign is going well. To date 3,444 pregnant women have been vaccinated, 277 more than at the same point last year. What are we doing about it Communications to the public will promote vaccination to ladies with new pregnancies and remind them it is not too late for vaccination Communications to GP practices have reminded them to keep inviting pregnant ladies Midwives and obstetricians are reminded to keep promoting vaccination to all pregnant women until the end of March 2018 Collaboration between midwife and GP practice continues to ensure we identify ladies with new pregnancies and those who are unvaccinated When do we expect to be back on track: Until the figures are published in April 2018, we are not able to state how well this year s campaign has gone, but early indications are that we are performing better than last year. Performance Report - January 2018 Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Page 21

203 Exception Report: Flu Vaccination Over 65s and Under 65s at risk Staying Healthy % uptake of the influenza vaccine in Over 65's % uptake of the influenza vaccine in Under 65s in at risk groups Intelligence Triangulated Executive Lead Teresa Owen Teresa Owen Root Cause Understood Exception Report? National Target Action Plan Set March 18 Plan Current Plan Where we are: 65 years and older: 70.3% (112,445 vaccinated out of 160,000) An additional 1,677 people have been vaccinated since the last submission. This means the health board has achieved the end of year performance expected in the Operational Plan.To reach 75% we need to vaccinate another 7,555 patients. At risk patients 6m-64y: 50.8% ( vaccinated out of 81,215). An additional 1,794 have been vaccinated since the last submission. To reach 55% we need to vaccinate another 3,394 patients. Steady increase in uptake across the BCUHB area since last report which is the highest in Wales. The trend compared to this time last year has improved slightly as we are 2% higher than at the same point last year in both groups. What are we doing about it: The focus of our work over the next 4 weeks is to: Ensure GP practices are aware of the current vaccine companies that have flu vaccine stock if they need more vaccine Remind GP practices about vaccinating patients that have just become eligible because of a new diagnosis or new pregnancy Implement the BCUHB Seasonal Flu Plan which includes further communications to the public, dovetailing the national plan Encourage robust recall for unvaccinated patients via text, letter or phone call and for practices to continue their campaign with vigour. Support lower uptake practices, including those with data issues. Communicate with cluster coordinators and the Flu lead in the Areas to raise awareness of cluster uptake. Check the accuracy of practice specific data When we expect to be back on track Operational Plan target delivered for over 65s, it will be challenging to deliver under 65s and national targets but the goal is still to achieve these. Actions Underway Previous Current Month Arrow Actions Complete Welsh Benchmark Yes 75.0% 70.0% 70.0% 69.0% 70.3% Jan-18 2nd Yes 75.0% 55.0% 55.0% 48.9% 50.8% Jan-18 2nd Performance Report - January 2018 Page 22

204 Exception Report: Flu Vaccinations Health Workers Staying Healthy % uptake of the influenza vaccine in Healthcare workers Executive Lead Teresa Owen Exception Report? National Target March 18 Plan Current Plan Where we are End of January 2018, 53.66% (n 9364) of staff have been vaccinated. 1,175 more than the 8,189 total for last year s whole campaign. BCUHB have administered the highest number of vaccines across Wales. There were significant increases in up-take within Mental Health & LD and Estates and Facilities teams, both showing improvements of % (n239) and +7.34% (n127) respectively. There is an increase in up-take across all Area teams, West 7.77% (n164), Central +9.59% (n295) and East +7.99% (n357). Secondary care is up +5.48% (n742) on the last year. What we are doing Weekly targeted messages are being sent out to the organisation on the impact of flu circulation and the importance of flu protection during flu peak weeks. Our key actions going forward are: Targeted work with local vaccinators to encourage continued support during the flu peak weeks, and to help support and protect the organisation from flu outbreaks Staff beliefs survey has been sent out to all staff who haven t had their flu vaccination to identify potential barriers to being vaccinated across the organisation Continued engagement with local managers and flu co-ordinators on priority areas, low up-take departments and dissemination of weekly reports to take forward actions Personal invites are being drafted and sent to all staff who haven t had their flu vaccination to date, encouraging up-take, highlighting the current impact of flu across North Wales and re-emphasising the importance of protection Communication work continues across the organisation addressing key messages on flu circulation, weekly flu drop in clinics and flu protection measures. Previous Current Month Arrow Welsh Benchmark Yes 62.5% 62.5% 62.5% 51.4% 53.7% Jan-18 - When we expect to be back on track A further 1,544 doses are required to achieve the 62.5% target (n 10,908) and based on current up-take trajectory it is unlikely that we will meet this target, however, we have already exceeded last year s target by 3.45% and we will continue to increase up-take going forward. Performance Report - January 2018 Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Page 23

205 Our Achievements - Safe Care I am protected from harm & protect myself from known harm 24 Safe Clean Care campaign launched Betsi Cadwaladr University Health Board has launched the Safe Clean Care Campaign in all three acute Hospitals. The campaign is focused on setting out essential Infection Prevention and Control actions which are required from all staff, patients and visitors. The Health Board is committed to providing Safe, Clean, Care. Staff, visitors and patients will soon see new signage and activities in our hospitals designed to raise awareness of the key elements of Safe Clean Care. By ensuring these actions are adopted by staff and patients we will see improvements in the quality of care we deliver. We plan to roll out activities to our community and other services later this year. Gill Harris, Executive Director for Nursing and Midwifery said: Our Safe Clean Care call to action is designed to provide support, training and resources for our staff. The campaigns aim is to reduce our patient infection rates and improve the quality of care for our patients. Safe, clean care is everyone s responsibility and we will be encouraging our staff to commit to six key elements: Cleaning hands before and after each patient contact Staff working in clinical areas being bare below the elbows Renewed focus on decluttering clinical areas. Isolating patients who need it effectively within two hours Safe care of devices such as catheters will be a priority and there will be a renewed focus on the correct prescribing of antibiotics. Prudent antibiotic prescribing Myself and my executive colleagues our making our commitment to challenge in a supportive and positive way any practice that doesn t allow us to provide Safe, Clean Care, and I hope staff, visitors and patients will join me Gill Harris, Executive Director Nursing and Midwifery Performance Report - January 2018 Page 24

206 Safe Care Overview National Standards Safe Care Number of healthcare acquired pressure ulcers in a hospital setting The rate of laboratory confirmed C.difficile cases per 100,000 of the population The rate of laboratory confirmed S. Aureus Bacteraemia (MRSA and MSSA) cases per 100,000 of the population Combined (co-amoxiclav, Cephalosporin & Quinolone items as percentage of total antibacterial items % compliance with Welsh Patient Safety - Safety Solutions Wales Alerts (post Apr-14) % compliance with Welsh Patient Safety - Safer Patients Notices (post Apr-14) Executive Lead Exception Report? National Target March 18 Plan Current Plan Previous Current Month Arrow Welsh Benchmark Gill Harris Yes Jan-18 - Gill Harris Yes Jan-18 3rd Gill Harris Yes Jan-18 1st Evan Moore Evan Moore Evan Moore No 5% 5.00% 9.40% 9.61% Q2-17/18 - Yes 100.0% 100% 100% 80.0% 80.0% Jan-18 - Yes 100.0% 100% 100% 95.0% 95.0% Jan Number of new never events Gill Harris No Jan-18 1st The Quality, Safety & Experience committee scrutinises the performance for the indicators above. Where performance has not reached the required standard, we have included an exception report. Performance Report - January 2018 Page 25

207 Safe Care Overview Local Standards Safe Care % of complaints acknowledged within 2 working days Executive Lead Exception Report? National Target March 18 Plan Current Plan Previous Current Month Arrow Welsh Benchmark Gill Harris Yes - 98% 98% 85% 96% Jan % of complaints closed within 30 working days % of complaints closed within 6 months Gill Harris Yes % 50.0% 42.9% 43.0% Dec-17 - Gill Harris No % 80.0% 97.0% 97.0% Aug-17 - The number of C.difficile reported cases in month The number of MRSA reported cases in month The number of MSSA reported cases in month Hand Hygiene Rates Ward Staffing Levels Fill Rate (Medical & Surgical Acute) Ward Staffing Skill Mix Ratio Registered : Unregistered (Medical & Surgical Acute) Maternity : Caesarean Section Rate % of incidents closed within 30 days % of incidents closed within 6 months Number of Regulation 28 responses overdue more than 56 days Of the serious incidents due for assurance within the month, % which are assured in the agreed timescale. % of hours lost due to Intensive Care Unit delayed transfers % of Intensive Care discharges within 4 hours of patient being ready Gill Harris Yes Jan-18 - Gill Harris Yes Jan-18 - Gill Harris Yes Jan-18 - Gill Harris No 95.0% 95.0% 95.0% 96.2% 97.1% Jan-18 - Gill Harris Yes 100% 95% 95% 83% 81% Jan-18 - Gill Harris Yes 60% 60% 60% 55% 56% Jan-18 - Gill Harris Yes % 24.9% 29.1% 24.4% Jan-18 - Gill Harris Yes % 65.0% 59.0% 59.0% Dec-17 - Gill Harris Yes % 80.0% 81.0% 81.0% Jul-17 - Gill Harris No Jan-18 - Gill Harris Yes 100% 50% 50% 37% 29% Jan-18 - Morag Olsen Morag Olsen Yes 5.0% Yes 95.0% Not submitted Not submitted Not submitted Not submitted 13.9% Pending Data 40.7% Pending Data Dec-17 o - Dec-17 o - Performance Report - January 2018 Page 26

208 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Exception Report: Pressure Ulcers (Reportable as SUI) Safe Care Number of healthcare acquired pressure ulcers in a hospital setting Executive Lead Exception Report? National Target March 18 Plan Current Plan Previous Current Month Arrow Welsh Benchmark Gill Harris Yes Jan-18 - Where we are: Due to issues with the accuracy of the data, the number of Healthcare Acquired Pressure Ulcers (HAPU) is no longer being taken from the WH&CMS portal and all Health Boards in Wales plan to use Datix Risk Management System to report, monitor and manage HAPU. The Welsh Government (WG) reportable figure concerns HAPUs of Grade 3, 4 or unstageable. In January, of the total 104 pressure ulcers recorded on Datix, 37 HAPU (Grade 3 and above) were reportable as serious untoward incidents to WG across the Health Board Number of healthcare acquired pressure ulcers in a hospital setting What are we doing about it: BCUHB continually seek to improve skin damage diagnosis and HAPU grading, encouraging and improving reporting arrangements. Adult Safeguarding Service oversight ensures focus is directed at patient centred risk assessment, care planning and care bundles. Clinical area improvement strategies progress towards lessons learnt and positive action plans, adopting initiatives pertinent to the clinical area involved. As part of the targeted work we are proposing to take forward: Making safe campaign: a time framed response to individual HAPU cases, investigations, lessons learnt and improvement strategies, to strengthen ward based responsibilities and accountabilities, as well as ensuring Tissue Viability Team support. STOP Pressure programme: Roll out of a HAPU prevention presentation, accessible to all staff via IT portal, enhancing knowledge to support all prevention strategies so driving a reduction in grade 1 & 2 HAPU s and eradicating the majority of grade 3 HAPU. When we expect to be back on track: We expect to be back on track by the end of Quarter 4, 2017/18. Actual Plan Target Performance Report - January 2018 Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Page 27

209 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Exception Report: C. difficile infections Safe Care The rate of laboratory confirmed C.difficile cases per 100,000 of the population Executive Lead Exception Report? National Target March 18 Plan Current Plan Previous Current Month Arrow Welsh Benchmark Gill Harris Yes Jan-18 3rd The number of C.difficile reported cases in month Gill Harris Yes Jan-18 - Where we are Based on current performance BCUHB cannot achieve the set reduction trajectory for C. Difficile, as the end of year target was to have no more than 180 cases, as at December 2017 we have had 203 cases. However, we are as an organisation working at pace to prevent further cases and critically, to minimise the impact of C.Difficile infection on our patients and their families. What are we doing about it Safe.Clean.Care.This campaign is focused on setting out essential Infection Prevention and Control actions which are required from all staff, patients and visitors, in order to significantly improve the safety and care of patients who visit and stay in our hospitals The rate of laboratory confirmed C.difficile cases per 100,000 of the population Actual Target Plan England Benchmark Benchmark Chart (Delayed Information) Number of cases of C.difficile per 100,000 of the population April Oct 2017 (Rolling) CWM TAF CARDIFF BCUHB ANEURIN BEVAN HYWEL DDA 0 ABMU Performance Report - January 2018 Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Page 28

210 Exception Report: S. aureus infections Safe Care The rate of laboratory confirmed S. Aureus Bacteraemia (MRSA and MSSA) cases per 100,000 of the population Executive Lead Exception Report? National Target March 18 Plan Current Plan Where we are Based on current performance BCUHB cannot achieve the set improvement/reduction trajectory for MSSA & MRSA combined, end of year target was to have no more than 138 cases, as at December 2017 we have had 145 cases. we are as an organisation working at pace to prevent further cases and critically, to minimise the impact of S.Aureus infection on our patients and their families. What are we doing about it Themes from reviews of MSSA Blood Stream Infections include skin and soft tissue infections in the community leading to bacteraemia, and in hospital poor cannula care and contaminated blood cultures. The programme of work to reduce these includes improving cannula care and blood culture technique through the use of aseptic nontouch technique (ANTT) by medical and nursing staff. The programme will be strengthened via additional actions in the 90-day plan Previous Current Month Arrow Welsh Benchmark Gill Harris Yes Jan-18 1st Performance Report - January 2018 Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Page 29

211 Exception Report: MRSA & MSSA infections Safe Care Executive Lead Exception Report? National Target March 18 Plan Current Plan Previous Current Month Arrow Welsh Benchmark The number of MRSA reported cases in month The number of MSSA reported cases in month Gill Harris Yes Jan-18 - Gill Harris Yes Jan-18 - Where we are Based on current performance BCUHB cannot achieve the set improvement/reduction trajectory for MSSA & MRSA combined, end of year target was to have no more than 138 cases, as at December 2017 we have had 145 cases. we are as an organisation working at pace to prevent further cases and critically, to minimise the impact of S.Aureus infection on our patients and their families. What are we doing about it Themes from reviews of MSSA Blood Stream Infections include skin and soft tissue infections in the community leading to bacteraemia, and in hospital poor cannula care and contaminated blood cultures. The programme of work to reduce these includes improving cannula care and blood culture technique through the use of aseptic nontouch technique (ANTT) by medical and nursing staff. The programme will be strengthened via additional actions in the 90-day plan Performance Report - January 2018 Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Page 30

212 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Exception Report: Reportable Incidents Safe Care Of the serious incidents due for assurance within the month, % which are assured in the agreed timescale. Executive Lead Exception Report? National Target March 18 Plan Current Plan Where we are There were 91 new cases reported in January 2018, of which the top 3 incident types reported to Welsh Government were; unexpected death whilst under the direct care of a health professional, grade 3 or above healthcare associated pressure ulcer develops and Patient fall resulting in harm/death to patient. Work streams are established within the Health Board to address the incident types/themes reported. 76 cases were due a closure form in January, of those 29% (22) were submitted within timeframe. 752 serious incidents (not including No Surprises) have been reported to WG for the period April 2017 to January Of these 34% (257) closure forms have been approved and closed by WG. Previous Current Month Arrow Welsh Benchmark Gill Harris Yes 100% 50% 50% 37% 29% Jan % 80% 60% 40% 20% 0% Of the serious incidents due for assurance within the month, % which are assured in the agreed timescale. What are we doing about it A process of an initial 72 hour review has been implemented led by the senior operational nurse managers for all WG reportable incidents. A comprehensive investigation will be undertaken for each and plans to deliver improvement are developed. Performance against the closure within 60 working days is being monitored by the local site/area weekly concerns meetings in each geographic area and weekly information is provided by the Corporate Team to support this. All serious incidents graded as major/catastrophic are reported to clinical executives on a weekly basis and to the relevant lead Nurse. The Quality dashboard has been launched within clinical areas and improvement trajectories for reduction of harm set. Work has commenced with Tissue Viability Team to strengthen early intervention and education. Actual Plan Target When we expect to be back on track The performance is above trajectory to address historic cases. Performance Report - January 2018 Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Page 31

213 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Exception Report: Incidents Closed Safe Care Executive Lead Exception Report? National Target March 18 Plan Current Plan Previous Current Month Arrow Welsh Benchmark % of incidents closed within 30 days % of incidents closed within 6 months Gill Harris Yes % 65.0% 59.0% 59.0% Dec-17 - Gill Harris Yes % 80.0% 81.0% 81.0% Jul-17 - Where we are In January 2018 a total of 2,860 incidents were reported via Datix. Of the incidents reported 49% (1402) related in no injury, 24% (700) resulted in personal injury and less than1% (20) resulted in death. The top 3 incidents reported are slips, trips, falls and collisions; pressure sore/decubitus ulcer and abuse etc of staff by patients. These themes are a consistent trend. The number of incidents closed within 30 days remains slightly below trajectory, of the 2,778 incidents reported in November 59% (1,649 incidents) were closed in 30 days. Incidents closed within 6 months, the performance continues to exceed target with 81% of incidents closed within the timeframe. The organisation has reported 27,082 incidents in total between April 2017 and January 2018, of the incidents reported 72% (19,389 incidents) have been finally approved. Incidents graded as 1-3 are the responsibility of the divisional management structures. Those graded 4 are coordinated by the investigation team and those at grade 5 are investigated by the Corporate Area. What are we doing about it Incident data is included as part of the dashboards lead by the Informatics teams. A process of an initial 72 hour review is being led by the senior operational nurse managers. Performance against both 30 day and 6 month response trajectories are being monitored by local daily and weekly meetings. The learning from incidents is reported to the divisional Quality & Safety Committees which are responsible for the delivery of improvement and sharing of lessons learnt. Reports are submitted to both the Quality and Safety Group and the Quality Safety and Experience meetings which detail themes and trends emerging. A revised reporting schedule is being implemented which requires the divisions to report on actions taken to learn from Concerns When we expect to be back on track Trajectories have been agreed for 2017/18 as part of the operational plan. 80% 60% 40% 20% 0% 100% 80% 60% 40% 20% 0% % of incidents closed within 30 days Actual Plan Target % of incidents closed within 6 months Actual Plan Target Performance Report - January 2018 Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Page 32

214 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Exception Report: Patient Safety Alerts Safe Care % compliance with Welsh Patient Safety - Safety Solutions Wales Alerts (post Apr-14) Executive Lead Evan Moore Exception Report? National Target March 18 Plan Where we are: To date the Welsh Government (WG) have issued 8 Patient Safety Alerts where compliance was due during the period of this report. 2 alerts remain open: Current Plan Previous Current Month Arrow Welsh Benchmark Yes 100.0% 100% 100% 80.0% 80.0% Jan % % compliance with Welsh Patient Safety - Safety Solutions Wales Alerts (post Apr-14) PSA003 The update to National Patient Safety Agency (NPSA) alert for safer spinal (intrathecal), epidural and regional devices was due for completion 01/07/2016. this aims to reduce the risk of intravenous medicines being administered by the intrathecal route, and epidural medicines being administered by the intravenous route. Action is also required to reduce the potential for medicines intended for regional anaesthesia to be administered by the intravenous route. 75% 50% 25% 0% PSA008 Nasogastric tube (NGT) misplacement: continuing risk of death and severe harm. Introduced to provide increased awareness of the risks with the initial placement of NGT and the steps required to prevent harm. Due completion 30/11/17 Actual Plan Target What are we doing about it: PSA003 The majority of elements now signed off, confirmation risk assessments have been completed and sign off from secondary care is awaited. This has been escalated to the Executive Medical Director and Highlighted at QSG. PSA008 With the exception of Secondary Care, all operational divisions have declared compliance. There has been extensive work to improve safety of NGT use, but Secondary Care need to confirm training of clinical staff (both Nursing & Medical). When we expect to be back on track: Secondary Care is required to confirm when we will be compliant against these two Patient Safety Alerts. Performance Report - January 2018 Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Page 33

215 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Exception Report: Patient Safety Notices Safe Care % compliance with Welsh Patient Safety - Safer Patients Notices (post Apr-14) Executive Lead Evan Moore Exception Report? National Target March 18 Plan Where we are: Welsh Government (WG) issued 38 Patient Safety Notices (PSN) where the compliance due by date is within the period of this report. The Health Board are compliant with 36 Notices, 2 remain open: Current Plan Previous Current Month Arrow Welsh Benchmark Yes 100.0% 100% 100% 95.0% 95.0% Jan % % compliance with Welsh Patient Safety - Safer Patients Notices (post Apr-14) PSN030 The safe storage of medicines: PSN034 Supporting the introduction of the National Safety Standards for Invasive Procedures What are we doing about it: PSN030 Escalated to the Quality & Safety Group. An audit across BCUHB against these standards has now been completed. PSN034 While there is good evidence theatres in BCUHB are compliant statements for similar areas with high numbers of interventional procedures is awaited. These include labour wards, catheter labs and endoscopy suites. Staff training in human factors and team training, is also specified in the Notice. While this too being progressed, secondary care have yet to declare compliance. 95% 90% Actual Plan Target When we expect to be back on track: PSN030 A report was presented at QSG in January 2018 PSN034 Was due for closure in January 2018 Performance Report - January 2018 Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Page 34

216 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Exception Report: Complaint Acknowledgement Safe Care Executive Lead Exception Report? National Target March 18 Plan Current Plan Previous Current Month Arrow Welsh Benchmark % of complaints acknowledged within 2 working days Gill Harris Yes - 98% 98% 85% 96% Jan-18 - Where we are In the month of January the Concerns Team received 108 new complaints, 96% (104 complaints) were acknowledged within 2 working days. This is up on previous months. Measures are being put in place for the divisions to make direct contact with complainants and resolve complaints immediately where appropriate and possible. The risk of a small decline in the compliance rate for acknowledgement was reported to the Board previously due to processes put in place to increase the number of complaints managed successfully on an On the Spot basis. This position is being closely monitored by the Corporate Management team. 100% 90% 80% 70% 60% % of complaints acknowledged within 2 working days What are we doing about it The Corporate Team monitor performance as a local KPI and this is reported to the Corporate Concerns Management Team meeting. Actual Plan Target Discussions are ongoing and awareness raising so other areas are aware of the need to promptly forward complaints. When we expect to be back on track As the margin for change is so small it is difficult to establish a date. Performance Report - January 2018 Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Page 35

217 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Exception Report: Complaint Response Safe Care Executive Lead Exception Report? National Target March 18 Plan Current Plan Previous Current Month Arrow Welsh Benchmark % of complaints closed within 30 working days % of complaints closed within 6 months Gill Harris Yes % 50.0% 42.9% 43.0% Dec-17 - Gill Harris No % 80.0% 97.0% 97.0% Aug-17 - Where we are As of the 31 st January 2018 there are 222 formal Concerns open, 111 of which are overdue, 17 overdue by more than 6 months. Of the 105 concerns opened in November 43% (45) were closed within the 30 working day target. What are we doing about it The total number of complaints open has reduced significantly and those new complaints received are increasingly being managed within the target. The Divisions continue to focus on this important agenda. This being led by the Nurse Director and supported by the Corporate teams The development of the Patient Advice and Support Service (PASS) in YGC is increasing opportunities to deal with complaints early and resolve issues for complainants quickly without the need to make a formal complaint. 60% 40% 20% 0% % of complaints closed within 30 working days Actual Plan Target When we expect to be back on track The embedding of collaborative working between Concerns Teams and the Divisions and the roll out of PASS, it is expected that we will be back on track by the end of January That is there would be no complaints overdue that it is reasonable to close within the target. 120% 100% 80% % of complaints closed within 6 months 60% 40% Actual Plan Target Performance Report - January 2018 Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Page 36

218 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Exception Report: Caesarean Section Safe Care Executive Lead Exception Report? National Target March 18 Plan Current Plan Previous Current Month Arrow Welsh Benchmark Maternity : Caesarean Section Rate Gill Harris Yes % 24.9% 29.1% 24.4% Jan-18 - Where We are: At 24.4%, the overall Caesarean Section rate for January 2018 shows a much improved performance with all three areas under the 24.9% target rate. What we are doing about it: West: A significant improvement was noted this month with the total CS rate 26.38%. Particularly pleasing to note was the reduction in the elective CS rate at 9.2%, compared to 13.57% last month. Central: This month has seen a further improvement in the number CS performed (39 compared to 42 last month) for the third consecutive month, reducing the overall rate to 23.78%. Sustained improvement has been noted in both the emergency and elective rates. We continue to monitor and promote Vaginal Birth After Caesarean (VBAC) clinics, this is evidenced by our 86% success rate this month and has been consistently over 85% for the last 5 months, and more hands-on involvement of consultant obstetricians on the labour ward in order to try and reduce the need for a CS. East: Following an unexpected increase last month, our CS rate has improved significantly in January reducing the overall rate to 23%. Our CS rate has now been below the national target for 4 out of the last 5 months. We continue to audit our indications for CS and promote VBAC. Our VBAC clinics are proving to be successful; our success rate has increased from 63% in September 2017 to 89% in January % 30% 20% 10% 0% Maternity : Caesarean Section Rate Actual Plan Target When we expect to be back on track: A plan of action is being drafted with the aim of achieving a sustained reduction in the CS rate across the Health Board. Performance Report - January 2018 Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Page 37

219 Introductory Exception Introductory Report: Report: Ward Harms Quality Dashboard Thematic Reviews In October 2017 BCUHB launched the Harm Dashboard, designed by nurses to save them time in accessing and analysing data, provide intelligence to support real time decisions to mitigate harm to patients, and improve care. Currently it surfaces data from various electronic systems relating to Falls, HAPU, infections and medication safety. Early feedback is positive, and it is being well used, which is testament to the engagement process. The graph below demonstrates the number of times the Dashboard has been used each month. 38% of BCUHB wards were harm free during January 2018 (i.e. no falls with harm, no HAPUs grade 3 and above, no catastrophic or major medication errors and no C Diff, MRSA, MSSA or E Coli bacteraemia infections) Acute sites contributed to 86% of all reported incidents Of all incidents that resulted in harm: 46 (42%) were infections (C Diff, MRSA, MSSA or E Coli)* 37 (34%) were HAPU (grade 3 and above)* and 26 (24%) were Falls resulting in harm There were 0 severe or catastrophic medication incidents reported *Please refer to the C.Diff, S.Aureus and HAPU Exception Reports for more details. This is a high level summary that will be included in the Quality, safety and Experience (QSE) Committee Report on a monthly basis. It is intended that in-depth analysis of the data will be provided to QSE Committee via Thematic Reviews to be presented quarterly. The first Draft of a Thematic Review will be presented for approval of format and content at QSE in March Performance Report - January 2018 Page 38

220 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Exception Report: Ward Staffing Safe Care Ward Staffing Levels Fill Rate (Medical & Surgical Acute) Executive Lead Exception Report? National Target March 18 Plan Current Plan Previous Current Month Arrow Welsh Benchmark Gill Harris Yes 100% 95% 95% 83% 81% Jan-18 - Ward Staffing Skill Mix Ratio Registered : Unregistered (Medical & Surgical Acute) Gill Harris Yes 60% 60% 60% 55% 56% Jan-18 - Where we are: The fill rates have fallen slightly at 81% in January 2018 compared to 83% the previous month. There are currently wte Registered Nurse (RN) vacancies and 45.35wte HCA vacancies across Secondary Care. Those staff in the recruitment phase of Trac will not impact the vacancy figures until they are in post (65 RNs). Each site continues to operate with additional escalation beds open. The overseas recruits from India have dropped significantly in numbers unfortunately. What are we doing about it: Staffing reviewed on each site daily and risks to patient safety mitigated by moving staff to support depleted areas, support via Specialist / Corporate Nurses where possible, additional hours supported and bank and agency. Safe Care module (eroster) operational in YGC and is being rolled out across YG. Risks to safe staffing easily identifiable with this system and can be used to inform where the greatest need for additional staff support is. Successful recruitment drive 20/21 st January where 80+ new graduate nurses were recruited across North Wales. They will commence employment in Aug / Sept Ysbyty Wrexham Maelor are also holding a recruitment day in February. There is also an ongoing skill mix review with OPD. When we expect to be back on track: End March/April will see last group graduate nurses in post. End Aug/Sept will see a further improvement. 100% 80% 60% 40% 20% 0% 65% 60% 55% 50% 45% Ward Staffing Levels Fill Rate (Medical & Surgical Acute) Actual Plan Target Ward Staffing Skill Mix Ratio Registered : Unregistered (Medical & Surgical Acute) Actual Plan Target Performance Report - January 2018 Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Page 39

221 Our Achievements - Effective Care I receive the right care & support as locally as possible & I contribute to making that care successful 40 Anglesey youngster thanks hospital staff at Ysbyty Gwynedd for her outstanding care The mother of a ten-year-old diagnosed with a life limiting condition has thanked staff at Ysbyty Gwynedd s Children s Ward for the outstanding care. Mali Ann Hughes, from Benllech, was diagnosed with type 1 Diabetes on 15 December Her mother, Karen Hughes, became concerned when her daughter started becoming increasingly thirsty and also feeling extremely tired. She said: About two weeks before her diagnosis we noticed that she was very tired, however she had been busy in the build up to Christmas so we just tried to get her to rest. Mali hadn t been drinking a lot of water in school so we reminded her how important this was so in the run-up to her diagnosis we noticed how much more water she was drinking but at this point we just thought she d taken note what we said. The night before diagnosis she had a pain her tummy and I made her an appointment with the GP the following the morning. Following examination Mali was sent to Ysbyty Gwynedd and at this point we had no idea what was ahead of us. Our journey from the GP to Dewi Ward, including now with Mali s Paediatric Diabetes team has been an extremely positive experience. They have been supportive to us all as a family, listening to our fears and needs and doing their utmost to give Mali the best care and reassurances with guidance and support. The doctors and nurses on Dewi Ward were so kind and caring towards us and particularly Mali, they understood she was scared and gave her reassurance that she would soon start to feel better Karen Hughes, Parent Performance Report - January 2018 Page 40

222 Effective Care Overview National Standards Effective Care Crude Mortality - rolling 12 months Risk Adjusted Mortality Index (Rolling 12 Months) based on RAMI 2017 Percentage episodes clinically coded within 1 month of the episode end date Number of Health & Care Research Wales clinical research portfolio studies (quarterly Year-To-Date figure) Number of patients recruited into Health & Care Research Wales clinical research portfolio studies Number of commercially sponsored studies (rolling 4 quarter sum) Number of patients recruited into commercially sponsored studies (rolling 4 quarter sum) % of GP locality cluster plans that have been agreed Executive Lead Evan Moore Evan Moore Evan Moore Evan Moore Evan Moore Evan Moore Evan Moore Morag Olsen Exception Report? National Target March 18 Plan Current Plan Previous Current Month Arrow Welsh Benchmark Yes - 1.6% 1.8% 1.8% 1.8% Dec-17 - No Aug-17 - Yes 95.0% Not submitted Not submitted 44.9% 46.4% Nov-17 7th No Q2-17/18 - No - 1,844 1, Q2-17/18 - No Q2-17/18 - No Q2-17/18 - No % 100.0% 100% 100.0% Q1-17/18-41 The indicators above are monitored at the Quality, Safety & Experience committee. An exception report is included for indicators which are not achieving the standard. Performance Report - January 2018 Page 41

223 Effective Care Overview Local Standards Effective Care % of procedures undertaken as a daycase British Association of Day Surgery (BADS) basket of procedures score Average Length of Stay (Elective Admissions) Average Length of Stay (Emergency Admissions) Average Length of Stay - Community Hospitals Executive Lead Morag Olsen Morag Olsen Morag Olsen Morag Olsen Morag Olsen Exception Report? National Target No % 80.0% 80.5% 81.4% Sep-17 - No % 85.0% 94.7% 96.7% Oct-17 - No - March 18 Plan Not submitte Current Plan Not submitte Previous Current Month Arrow Welsh Benchmark Dec-17 - No Dec-17 - Yes Jan The Quality, Safety & Experience committee monitors the indicators above. We have included an exception report for any area not achieving the standard. Performance Report - January 2018 Page 42

224 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Jan-17 Mar-17 May-17 Jul-17 Aug-17 Oct-17 Dec-17 Feb-18 Exception Report: Risk Adjusted Mortality Effective Care Crude Mortality - rolling 12 months Risk Adjusted Mortality Index (Rolling 12 Months) based on RAMI 2017 Executive Lead Evan Moore Evan Moore Exception Report? National Target March 18 Plan Current Plan Where we are RAMI 2017 model was introduced late 2017 and incorporates length of stay into the model s algorithm. RAMI for August 2017 is 97 which is below the expected target. However it remains affected by coding completeness. With crude mortality reported as a rolling 12 months the mean rate remains around 1.81% for Dec What are we doing about it Projects have been completed or are about to commence in the following areas: 1. AKI - due to commence 2. Stroke- in progress 3. Fractured neck of femur - in progress 4. RRAILS - in progress 5. ED Mortality - in progress Previous Current Month Arrow Crude Mortality - rolling 12 months Welsh Benchmark Yes - 1.6% 1.8% 1.8% 1.8% Dec-17 - No Aug Risk Adjusted Mortality Index rolling 12 months (2017 RAMI) Actual (RAMI 2016) Plan Target Actual (RAMI 2017) When we expect to be back on track Further changes will come at a slower pace as they require progressive work in key programme areas listed above. Due to the arrears in coding and the work required to implement these changes improvements in the RAMI will not be seen for at least 18 months. 2.0% 1.8% 1.6% 1.4% 1.2% 1.0% Actual Plan Target Performance Report - January 2018 Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Page 43

225 Exception Report: Clinical Coding Effective Care Percentage episodes clinically coded within 1 month of the episode end date Where we are The current coding backlog to reach the National Welsh Target is currently at 25,207 episodes What are we doing about it Agency coders are currently being utilised in addition to offering Health Board staff over time. During January 2018 the coding department 3,862 more episodes than were created. Executive Lead Evan Moore Exception Report? National Target Yes 95.0% March 18 Plan Not submitted Current Plan Not submitted Previous Current Month Arrow Welsh Benchmark 44.9% 46.4% Nov-17 7th Coding Backlog Improvement Trajectory West Central East Trajectory When we expect to be back on track It is anticipated that the coding completeness will be reaching Welsh Government target by Q2 of 2018/19. As the coding backlog is being cleared with oldest episodes to newest it will be some months until we see an improvement in the National 1 month completion target Episodes Coded Episodes Created Some areas of service are being coded now real time to improve data availability, as the coding backlog clears more areas will follow this model. 0 Performance Report - January 2018 Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Page 44

226 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Exception Report: Community Length of Stay Effective Care Average Length of Stay - Community Hospitals Executive Lead Morag Olsen Exception Report? National Target March 18 Plan Current Plan Where we are: The average length of stay (ALOS) in community hospitals in January 2018 was 29.1 days compared to 25.9 days in December This was due to beds being closed for fire safety works throughout the month of December in Mold which reduced the overall average for the Health Board. What are we doing about it: Continued focus on discharge planning and patient flow, and reducing average length of stay through maximising patient flow and optimising pathways and aim for a maximum length of stay of 21 days. Work to introduce SAFER in community hospitals and community nursing and demonstrating change is an improvement through quality improvement methodology with the support of the Programme Management Office. This includes ensuring Board Rounds are regular and effective and in line with recommendations for non-acute units. Introduction of Red2Green on pilot wards in Denbigh and Mold. Training from NHS Improvement planned for March 2018 for all areas. Focus on ensuring 100% EDD compliance, and demonstrating that this is based on an MDT decision Weekly 28 day length of stay scrutiny panel which is clinically led and involves the MDT and local authority and a weekly review of all delayed transfers of care to escalate blockages to appropriate managers of services Piloting of criteria led discharge in Denbigh Community Hospital Improving staff knowledge and understanding of the discharge policy, and strengthening performance management When we expect to be back on track: Significant focus and resource going into the reduction of lengths of stay in Community hospitals. Continued collaboration with multiple agencies to improve the length of stay, however, there are ongoing issues with the capacity of domiciliary care providers to support timely discharge across counties. Previous Current Month Arrow Welsh Benchmark Yes Jan Average Length of Stay - Community Hospitals Actual Plan Target Trimmed AvLOS: BCU Community Sites Performance Report - January 2018 Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Page 45

227 Our Achievements - Individual Care I am treated as an individual, with my own needs and responsibilities 46 New training drive to support people with substance misuse and mental health issues Betsi Cadwaladr Health Board is stepping up efforts to provide psychological therapy to people who have substance misuse and mental health problems. Staff from the Health Board and Gwynedd County Council have recently undertaken training in Cognitive Behavioural Therapy which will enable them to intervene earlier and deliver psychological therapies to people involved in substance misuse services in North West Wales. The Agored Cymru accredited training has also been delivered to staff in other counties of North Wales. Cognitive behavioural therapy (CBT) is a talking therapy that can help people manage their problems by changing the way they think and behave. The therapy can help people to deal with overwhelming problems in a more. positive way by breaking them down into smaller parts. Betsi Cadwaladr Health Board say that many people who have substance misuse problems will have one or more Common Mental Health Disorder such as Obsessive Compulsive Disorder, Depression or Anxiety and others. Many of these patients also have a history of trauma and meet the diagnostic criteria for Post-Traumatic Stress Disorder. Substance misuse patients often use drugs, alcohol or both to relieve the anxiety which they feel as a result of their mental health problems, explained John Sims, who works as a Cognitive Behavioural Psychotherapist at BCUHB and delivers the training programme which is accredited by AGORED Cymru. Cognitive Behavioural Therapy has the most overwhelming evidence base for use with patients who suffer from a range of Anxiety Based Disorders John Sims Cognitive Behavioural Psychotherapist Performance Report - January 2018 Page 46

228 Individual Care Overview National Standards Individual Care % of assessment by the LPMHSS undertaken within 28 days of the date of referral % of therapeutic interventions started within 28 days following an assessment by LPMHSS % of LHB residents (all ages) to have a valid CTP completed at the end of each month % of hospitals with arrangements to ensure advocacy available to qualifying patients Service users assessed under part 3 to be sent a copy of the assessment in 10 working days Executive Lead Andy Roach Andy Roach Andy Roach Andy Roach Andy Roach Exception Report? National Target March 18 Plan Current Plan Previous Current Month Arrow Welsh Benchmark No 80.0% 80.0% 80.0% 76.8% 80.9% Dec-17 4th No 80.0% 80.0% 80.0% 82.7% 81.8% Dec-17 6th Yes 90.0% 90.0% 90.0% 89.8% 89.3% Dec-17 5th No 100% 100% 100% 100% 100% Q2-17/18 1st No 100.0% 100.0% 100.0% 95.0% 100% Dec-17 1st 47 Individual Care Overview - Local Standards Individual Care Delayed transfers of Care per 10,000 population, Rolling 12 months Mental Health Non Mental Health aged over 65 The number of non-mental health bed days lost due to delayed transfers of care in the month Patients who leave ED without being seen Executive Lead Andy Roach Morag Olsen Morag Olsen Morag Olsen Exception Report? National Target March 18 Plan Current Plan Previous Current Month Arrow Welsh Benchmark No Jan-18 1st Yes Jan-18 7th No - 2,089 2,089 1,052 1,160 Jan-18 - Yes - 8.0% 8.0% 9.9% 8.5% Jan-18 - Where we have not achieved a target, we have included an exception report. Performance Report - January 2018 Page 47

229 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Exception Report: Delayed Transfers of Care Individual Care Delayed transfers of Care per 10,000 population, rolling 12 monthsnon Mental Health aged over 65 The number of non-mental health bed days lost due to delayed transfers of care in the month Executive Lead Morag Olsen Morag Olsen Exception Report? National Target March 18 Plan Current Plan Previous Current Month Arrow Welsh Benchmark Yes Jan-18 7th No - 2,089 2,089 1,052 1,160 Jan-18 - Where we are: In January the number of Non Mental Health delays increased from 76 to 88 this represents the fifth lowest month this year. It is interesting to note that although the days lost in January has gone up to 1,160 from 1,052 this still represents the 2 nd lowest number of days lost this year and the longer term rolling target is still being over attained. Behind the increase is a mixed picture across North Wales with the largest increases occurring in Gwynedd and Anglesey with 9 patients per County, Wrexham and Flintshire have showed a joint reduction of 4 although Wrexham remains the 2 nd highest after Gwynedd. Conwy and Denbighshire remain stable with an increase of 1 patient. It is thought that some of the delays are because capacity that was empty was filled after Christmas soaking up spare capacity to cope with additional Winter demand. Although the number of delays because of disagreement and choice has reduced from 36 to 30, the codes relating to Patient Placement still make up the largest group. The second largest group relate to Home Care delays and this is continuing to be reported from Local Authorities as a challenge. What we are doing about it: Work is ongoing with all 6 Local Authorities to review patients twice weekly and to act on delays or system blockages. Weekly reports are sent to the Chief Executive Officer. Delayed transfers of Care per 10,000 population, rolling 12 months Non Mental Health aged over ,500 2,000 1,500 1, Actual Plan Target The number of non-mental health bed days lost due to delayed transfers of care in the month 3,000 Actual Plan Target Performance Report - January 2018 Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Page 48

230 Exception Report: Mental Health Measure - CAMHS Individual Care % of assessment by the LPMHSS undertaken within 28 days of referral - Child Adolescent Mental Health Services % of therapeutic interventions started within 28 days following an assessment - Child and Adolescent Mental Executive Lead Morag Olsen Morag Olsen Exception Report? National Target March 18 Plan Current Plan Previous Current Month Arrow Welsh Benchmark No 80.0% 100.0% 100.0% 55.9% 65.4% Dec-17 - Yes 80.0% 100.0% 100.0% 77.1% 65.5% Dec-17 - Where we are In December 2017, 65% (53 children) were assessed within 28 days of being referred and 65% (36 children) started therapeutic interventions within 28 days of being assessed. What we are doing about it Development of Performance Dashboard regularly reviewed by Team Leaders and Service Managers. Regular review of job plans and activity to ensure clinicians are working to their job plans. Review of Crisis Services being undertaken including pathway and capacity. Regular caseload reviews and DNA/CNA reviews with necessary action. Regular reviews of closures to ensure cases are closed in a timely manner. Review of appointment system in West including template letters. Full implementation of CAPA (Choice and Partnership Approach) service model which will support structured approach to waiting list management. Weekly meetings held with the Service Manager/Team leads/admin to review the position. Recruitment to vacancies being prioritised. The division is working with finance colleagues to ensure resource allocation is aligned to service needs. When we expect to be back on track It is forecast that by implementing the above actions and provided capacity and demand remain at manageable levels all teams will meet both targets in May % of assessment by the LPMHSS undertaken within 28 days of referral - Child Adolescent Mental Health Services 100% 80% 60% 40% 20% 0% 80% 60% 40% 20% 0% Actual Plan Target % of therapeutic interventions started within 28 days following an assessment - Child and Adolescent Mental Health Services 100% Actual Plan Target Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Performance Report - January 2018 Page 49

231 Exception Report: Care & Treatment Plans Individual Care % of LHB residents (all ages) to have a valid CTP completed at the end of each month Executive Lead Andy Roach Exception Report? National Target March 18 Plan Where we are In December 2017, 86.6% (4,840 from 5,587) of eligible patients have a valid Care and Treatment Plan (CTP). Current Plan Previous Current Month Arrow % of LHB residents (all ages) to have a valid CTP completed at the end of each month 100% Welsh Benchmark Yes 90.0% 90.0% 90.0% 89.8% 89.3% Dec-17 5th This is broken down across the division as follows: Adult Community Mental Health 85% (3638 from 4281) OPMH Community Mental Health 91.5% (1079 from 1179) Learning Disability Services 96.9% ( 123 from 127) What are we doing about it There has been a change to our reporting formats. The reports for Part 1, 2 and 3 of the Mental Health Measure are now collated and sent by the information team. These reports also include waiting list information and any data cleansing requirements. Service Managers are accountable for following local action plans which improve targets. There is currently a caseload validation being undertaken in local teams which may impact the compliance during the validation. We anticipate this will take 6 months from commencement in January We are currently performing on target in Older Peoples and Learning Disability Services for the percentage of residents with a valid CTP completed. Adult services are non-compliant. 90% 80% 70% 60% 100% 90% 80% Actual Plan Target Benchmark Chart (Delayed Information) % of LHB residents (all ages) to have a valid CTP completed at the end of each month Sep-17 92% 92% 91% 91%90% 89% 89% HYWEL DDA CWM TAF ANEURIN BEVAN CARDIFF BCUHB When we expect to be back on track We expect to be back on track in all sub-specialties by the end of Quarter 4, 2017/18 70% POWYS ABMU Performance Report - January 2018 Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Page 50

232 Our Achievements - Dignified Care I am treated with dignity & respect and treat others the same 51 Successful language choice scheme improves patient care at Ysbyty Alltwen A successful language choice scheme which allows patients to be identified as Welsh speakers has improved patient care at a Porthmadog hospital. Last year Betsi Cadwaladr University Health Board s Welsh Language team developed a scheme where patients are asked whether they want to be identified as Welsh speakers. If yes, a Welsh speaking magnet is placed above a patient s bed to ensure that staff are aware that these patients prefer to receive their services and care in Welsh. The scheme in particular benefits our patients living with dementia and has been highlighted as part of the Welsh Government s Framework More than just Words for improving Welsh Language Services in health, social services and social care. Clinical Practitioner, Emma Owen, said the scheme has proven extremely popular with patients and their families. She said: The language choice scheme was introduced at Ysbyty Alltwen a year ago and the staff, patients and their families have welcomed this in the hospital. Research has shown that communicating in Welsh is particularly important for vulnerable individuals whose first language is Welsh, such as patients living with dementia who have been admitted to us in hospital. Research has shown that communicating in Welsh is particularly important for vulnerable individuals whose first language is Welsh, such as patients living with dementia who have been admitted to us in hospital. The language choice scheme has allowed us to identify those who wish to be communicated with in their preferred language and it has greatly improved our patient care Emma Owen Clinical Practitioner Performance Report - January 2018 Page 51

233 Dignified Care Overview National Standards Dignified Care % procedures postponed more than once, patient had procedure under 14 days or at their earliest convenience Executive Lead Morag Olsen Exception Report? National Target March 18 Plan Current Plan Previous Current Month Arrow Welsh Benchmark Yes 100.0% 95.0% 75.0% 2.0% 3.8% Dec-17 5th 52 Dignified Care Overview Local Standards Dignified Care Efficiencies: Patient admitted but procedure not carried out Total Cancellations Inpatient (Clinical and Non-Clinical) Total Cancellations for Consultant and Nurse Led Outpatient appointments Executive Lead Morag Olsen Morag Olsen Morag Olsen Exception Report? National Target March 18 Plan Current Plan Previous Current Month Arrow Welsh Benchmark Yes % 4.1% Oct-17 - Yes - 5.0% 5.0% 17.9% 12.2% Dec-17 - Yes - 5.0% 5.0% 10.4% 12.3% Jan-18 - The Finance and Performance committee scrutinises performance within this domain. Where we have not achieved the target, we have included an exception report. Performance Report - January 2018 Page 52

234 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Exception Report: Inpatient Cancellations Dignified Care % procedures postponed more than once, patient had procedure under 14 days or at their earliest convenience Efficiencies: Patient admitted but procedure not carried out Total Cancellations Inpatient (Clinical and Non-Clinical) Executive Lead Morag Olsen Morag Olsen Morag Olsen Exception Report? National Target March 18 Plan Where we are 3.8% of patients whom had their operation cancelled more than once underwent their procedure within 14 days. This is an increase from the previous month from 2%. Current Plan What we are doing about it Across the Health Board the process for bringing in short notice, standby patients has been streamlined with particular success in Ophthalmology in East, ENT in West and HDU in Central. However, use of standby patients may have a negative impact on the Treat out of Turn (TooT) numbers as they are called in based on their availability, not necessarily their clinical or wait priorities. The Theatre Transformation Group continues to monitor performance against these measures, with the Transformation Board escalating issues as required. Cancellation Reviews and Theatre Accountability Meetings continue. Unused elective slots are now being filled with Trauma patients; Patients are admitted earlier for anaesthetic screening. Scheduling is being reviewed to ensure patients are booked in turn of clinical priority and length of wait. When we expect to be back on track With continuation of the actions outlined above, it is expected that we will achieve the 5% target rate within Quarter 4 of 2017/18. Previous Current Month Arrow Yes 100.0% 95.0% 75.0% 2.0% 3.8% Dec-17 5th 7% 6% 5% 4% 3% 2% 1% 0% 12% 9% 6% 3% 0% Efficiencies: Patient admitted but procedure not carried out Actual Plan Target Total Cancellations Inpatient (Clinical and Non-Clinical) 15% Welsh Benchmark Yes % 4.1% Oct-17 - Yes - 5.0% 5.0% 17.9% 12.2% Dec-17 - Actual Plan Target Performance Report - January 2018 Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Page 53

235 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Exception Report: Outpatient Cancellations Dignified Care Total Cancellations for Consultant and Nurse Led Outpatient appointments Executive Lead Morag Olsen Exception Report? National Target March 18 Plan Current Plan Previous Current Month Arrow Welsh Benchmark Yes - 5.0% 5.0% 10.4% 12.3% Jan-18 - Where we are: The reduction of Hospital Initiated Cancellations (HIC) by 50% is one of the key performance indicators for the Outpatients Improvement Programme for 2017/18. The current data is not reliable and may not reflect the true position. We have identified and agreed BCUHB OPD specific HIC drop down codes, and these are now embedded into WPAS A HIC code implementation User Guide has been developed to support rollout Data from WPAS is available and will direct future improvement events in Centre by Pareto of top three issues. Initial data is showing that out of 48 codes, 10 contribute to 80% of issues, and 20.8% of the reasons give 80% of the HICs (see graph showing Pareto of HIC data extracted from WPAS). For full roll out in PIMS and Myrddin. What we are doing about it: Will need to scrutinise the OPD specific HIC data at weekly site planning cells and monthly Mission Control once the HIC codes embedded into all PAS systems. Scrutinise the data and Pareto the top 3 issues to identify key areas for focus across all sites, and compare to identify site-specific issues for focus Arrange workshops for full rollout to identify solutions to key issues and fully understand any inconsistencies across sites and specialties. Following the appointment of the programme manager and the receipt of the WHC on follow up priorities we will be re-focussing the OP improvement programme for 2018/19 When we expect to be back on track Due to the below barriers, timely rollout has been delayed, and may impact on future progress: Requires ongoing training and support, and commitment from IT colleagues - limited due to restructuring pressures from organisational change 3 different IT systems requiring three different approaches to resolve Issues with HIC report when capturing data on whole clinic liaising with NWIS to resolve but may take time. 15% 12% 9% 6% 3% 0% Total Cancellations for Consultant and Nurse Led Outpatient appointments Actual Plan Target Performance Report - January 2018 Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Page 54

236 Our Achievements - Timely Care I have access to services based on clinical need & am actively involved in decisions about my care Redevelopment work to start on Corwen Health Centre 55 Construction work as part of a 1.5m investment in the redevelopment of Corwen Health Centre is set to start. The redeveloped health centre will provide significantly improved healthcare and dental facilities for Corwen residents, with work scheduled to complete in the autumn. Once completed, the new centre will provide two additional consulting rooms for the town s GP practice, two new dental surgeries and a new multi-purpose treatment room. Normal services provided by Corwen Family Practice from the Health Centre will continue to be provided from temporary accommodation on site from Monday, February 19. The Health Visitor, Physiotherapy and Podiatry services will also be provided from the temporary buildings, from Monday, February 19. A reduced service will be available on Friday, February 16 from the Health Centre. Dental services will continue to be provided from its current location at the Health Centre while refurbishment work progresses. Dr Berwyn Owen, Chair of the Project Board said: Corwen residents will have noticed that work has already started on the site with the installation of temporary accommodation where services will be provided during the construction work. We hope that patients will understand the challenges of maintaining services from temporary buildings during the building work, and will join us in supporting staff through this period in the short term. We hope that patients will understand the challenges of maintaining services from temporary buildings during the building work, and will join us in supporting staff through this period in the short term Berwyn Owen Chair of the Project Board Performance Report - January 2018 Page 55

237 Timely Care Overview National Standards % GP practices Timely Care offering appts between 17:00 and 18:30 at least two days a week offering appts between 17:00 and 18:30 5 days a week open during daily core hours or within1 hour of daily core hours % of patients waiting less than 26 weeks for treatment Number of 36 week breaches- all specialties % of patient waiting less than 8 weeks for diagnostics % of new patients spend no longer than 4 hours in A&E (inc Minor Injury Units) Number of patients spending 12 hours or more in A&E % of red 1 call responses within 8 minutes Number of ambulance handovers over one hour % of patients newly diagnosed with cancer not via the USC pathway, treated within 31 days of diagnosis % of patients referred via the USC pathway definitively treated within 62 days of referral Percentage of the health board population regularly accessing NHS primary dental care % of stroke patients who have a direct admission to an acute stroke unit within 4 hours % of stroke patients who receive a CT scan within 12 hours % of stroke patients who have been assessed by a stroke Consultant within 24 hours % of stroke patients who have received a formal swallow assessment in 72 hours All patients overdue their target date on the Follow Up Waiting List Executive Lead Morag Olsen Morag Olsen Morag Olsen Morag Olsen Morag Olsen Morag Olsen Morag Olsen Morag Olsen Morag Olsen Morag Olsen Morag Olsen Morag Olsen Morag Olsen Morag Olsen Morag Olsen Morag Olsen Morag Olsen Morag Olsen Exception Report? National Target March 18 Plan Current Plan Previous Current Month Arrow Welsh Benchmark no % 99.0% 95.4% 95.4% Q3-17/18 - no - Not submitte % 70.4% Q3-17/18 - no % 91.0% 87.9% 87.9% Q3-17/18 6th Yes 95.0% 90.0% % 80.5% Jan-18 7th Yes 0 4,237 9,224 10,469 10,092 Jan-18 7th Yes 100.0% 100.0% 100.0% 91.4% 88.7% Jan-18 - Yes 95.0% 86.0% 84.0% 72.5% 72.4% Jan-18 7th Yes ,470 1,826 Jan-18 7th No 65.0% 65.0% 65.0% 73.3% 86.7% Jan-18 2nd Yes ,271 1,598 Jan-18 6th No 98.0% 98.0% 98.0% 98.2% 99.3% Dec-17 3rd Yes 95.0% 95.0% 94.0% 87.5% 88.0% Dec-17 4th Yes 54.7% 52.0% 51.0% 49.4% 49.4% Dec-17 6th Yes % 60.0% 38.1% 39.8% Jan-18 6th Yes % 100.0% 92.8% 89.9% Jan-18 4th No 82% % 82.00% Jan-18 - YES % 100.0% 97.1% 100.0% Jan-18 2nd Yes - 49,750 51,250 77,551 75,928 Jan-18 6th 56 Performance Report - January 2018 Page 56

238 Timely Care Overview Local Standards Timely Care The number of patients waiting more than 52 weeks for treatment Therapies Waits Over 14 weeks Out of Hours : Urgents triaged/assessed within 20 minutes Out of Hours : Non-urgents triaged/assessed within 60 minutes Admission on day of surgery % of all strokes thrombolysed % of all eligible patients thrombolysed Executive Lead Morag Olsen Morag Olsen Morag Olsen Morag Olsen Morag Olsen Morag Olsen Morag Olsen Exception Report? National Target Yes 0 March 18 Plan Not submitte Current Plan Not submitte Previous Current Month Arrow Welsh Benchmark 3,057 2,793 Jan-18 - No Jan-18 - Yes 98.0% 98.0% 98.0% 61.0% 65.0% Jan-18 - Yes 98.0% 98.0% 98.0% 64.0% 70.0% Jan-18 - No 75.0% 95.0% 95.0% 87.9% 78.4% Oct-17 - Yes % 12.0% 11.3% 3.0% Jan-18 - Yes % 100.0% 83.3% 100.0% Jan Where we have not achieved a target, we have included and exception report Please note, the Follow-Up Waiting List figure is inflated due to a data quality issue, following the implementation of WPAS. This requires validation and the correct figure will be published when this is completed. Performance Report - January 2018 Page 57

239 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17 Apr-17 May-17 Jun-17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17 Dec-17 Jan-18 Feb-18 Mar-18 Exception Report: Referral To Treatment Timely Care The number of patients waiting more than 52 weeks for treatment Number of 36 week breaches- all specialties % of patients waiting less than 26 weeks for treatment Executive Lead Morag Olsen Morag Olsen Morag Olsen Exception Report? National Target Yes 0 March 18 Plan Not submitte Where we are At the end of January 2018, 10,092 patients are waiting more than 36 weeks from referral to treatment across the Health Board. Current Plan Not submitte What we are doing about it Given the level of risk to delivery, increased scrutiny has been applied through the use of daily RTT cohort control totals. Weekly control totals by site and specialty continue to be monitored and managed at twice weekly access meetings. There is still high risk involved in delivering the plan and current areas of concern or under-delivery include Urology, Orthodontics and Maxillofacial. All teams continue to try to maximise opportunities for delivery within the agreed financial budget and continue to use outsourcing and insourcing solutions where appropriate. The delivery of additional schemes funded through the agreed Welsh Government (WG) funding is also tracked through the access meetings. For all February and March cohort patients, the teams have been instructed to ensure all un-booked capacity has been booked by the 16 th February When we expect to be back on track As of January the plan was to have reduced the end of March 36 week cohort to 19,229. Overall, the actual end of March cohort at the end of January was 17,234, showing an over-delivery of 1,995, demonstrating that BCU is currently on target to deliver its agreed end of year position with WG. Previous Current Month Arrow Welsh Benchmark 3,057 2,793 Jan-18 - Yes 0 4,237 9,224 10,469 10,092 Jan-18 7th Yes 95.0% 90.0% % 80.5% Jan-18 7th 100% 80% 60% 40% 20% 0% 8,000 6,000 4,000 2,000 0 % of patients waiting less than 26 weeks for treatment Actual Plan Target Number of 36 week breaches- all specialties 10,000 Actual Plan2 Plan1 Target Performance Report - January 2018 Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Page 58

240 Exception Report: Diagnostic Waiting Times Timely Care % of patient waiting less than 8 weeks for diagnostics Executive Lead Morag Olsen Exception Report? National Target March 18 Plan Current Plan Where we are: From a total of 1,400 of 12,395 (11.3%) patients experienced waits of over 8 weeks for their diagnostic test. Endoscopy: 764 patients from 2,644 (28.9%) Radiology: 601 patients from 8,174 ( 7.4%) Neurophysiology: 33 patients from 405 ( 8.2%) The rise in number of patients experiencing waits of more than 8 weeks for a diagnostic test was due to: Endoscopy Wrexham DCU loss of service capacity Endoscopy insourcing contract delay EMG recovery plan till Dec 2017 Radiology especially specialist MSK Ultrasound capacity is limited Continuing growth in demand What we are doing about it: Endoscopy lists in Modular theatre Wrexham Maelor commencing January 2018 Outsourcing of sessions continuing at Wrexham Maelor and Ysbyty Gwynedd Opening of third Endoscopy Suite at Ysybyty Gwynedd in March Nerve Conduction Studies are back on schedule Radiology using framework agreement for additional US capacity and seeking additional insource capacity. When we expect to be back on track: We do not expect to be back on schedule by the end of Quarter /18. Previous Current Month Arrow Welsh Benchmark Yes 100.0% 100.0% 100.0% 91.4% 88.7% Jan % 90% 80% 70% 60% 50% % of patient waiting less than 8 weeks for diagnostics Actual Plan Target Performance Report - January 2018 Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Page 59

241 Exception Report: Four Hour Target Timely Care % of new patients spend no longer than 4 hours in A&E (inc Minor Injury Units) Executive Lead Morag Olsen Exception Report? National Target March 18 Plan Current Plan Where we are The Health Board is in targeted intervention for USC performance overall and considerable senior focus is given to improving performance on a day by day basis. Performance at the end of January 2018 remained below the 80% milestone set for recovery and marginally worse than January However, the actual number of patients in North Wales who were seen, treated and discharged within 4 hours has steadily increased from November 2017 and this trend continues. In December 2017, 17,716 patients attended our Emergency Departments (ED) or MIU in month with 13,900 patients discharged, admitted within 4 hours of arrival compared to 16,960 attendances in December 2016 and only 13,025 patients completed their journey within 4 hours. Similarly in January 2018, 16,916 attendances with 12,311 completed in 4 hours compared to 16,155 patients in January 2017 with 12,285 completing in 4 hours. Therefore, we are treating more patients consistently within the 4 hours, conversely there are more patients attending ED. In addition we are seeing an increase in the number of patients accessing urgent care through direct access pathways such as acute medical and surgical admission. These patients are by-passing ED, but result in placing additional demand on the same bed stock as ED. Though this is the right thing to do for patients, the activity through our acute direct access pathways are not currently reported through National Measures. What we are doing about it Price Waterhouse Cooper have commenced their supportive role at the beginning of February. There are targeted action plans in place to address the 4 hour performance firstly in the short term to get the Health Board over the 80% target at the end of March 2018, and onto medium to long term sustainable ways of working. When we expect to be back on track The impact of the actions taken are being tracked to assess whether they are positively contributing to improvements in performance, however it is too early to see the impact of the new pathways. The aim to achieve over 80% month on month remains in place. Intelligence Triangulated Root Cause Understood Previous Current Month Arrow Welsh Benchmark Yes 95.0% 86.0% 84.0% 72.5% 72.4% Jan-18 7th Action Plan Set Actions Underway % of new patients spend no longer than 4 hours in A&E (inc Minor Injury Units) 100% 90% 80% 70% 60% 50% Actions Complete Actual Plan Target Performance Report - January 2018 Page 60

242 Exception Report: Twelve Hour Target Timely Care Number of patients spending 12 hours or more in A&E Executive Lead Morag Olsen Exception Report? National Target March 18 Plan Current Plan Previous Current Month Arrow Welsh Benchmark Yes ,470 1,826 Jan-18 7th Where we are 1,826 patients experienced waits of 12 hours or more in our Emergency Departments (ED) in January This is an increase of 356 patients compared to the reported 1470 for December 2017 and is indicative of the increased pressures on our EDs. What we are doing about it Price Waterhouse Cooper have commenced their supportive work at the beginning of February. Action plans have been agreed focused on the short, medium and long term changes required to deliver and sustain a reduction in the number of patients waiting more than 12 hours in our Emergency departments. A Health Board review of bed requirements is being undertaken on the back of the Ysbyty Glan Clwyd bed calculation recently completed. This will support the Health Board s future plans to improve and change how we deliver unscheduled care services across North Wales. 1,500 1, Number of patients spending 12 hours or more in A&E Actual Plan Target When we expect to be back on track The outcome from the additional actions and the winter resilience plan are intended to improve current performance Performance Report - January 2018 Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Page 61

243 Exception Report: Ambulance Handover Times Timely Care Number of ambulance handovers over one hour Executive Lead Morag Olsen Exception Report? National Target March 18 Plan Current Plan Previous Current Month Arrow Welsh Benchmark Yes ,271 1,598 Jan-18 6th Where we are 1,598 patients experienced ambulance handover delays of more than an hour in January 2017 reported against a total number of attendances to both our Emergency Departments (ED) and direct access urgent care pathways of more than 4,800. The number of patients delayed has increased by over 300 compared to December This again is indicative of the demand being placed upon our EDs across the Health Board and is reflective nationally both in Wales and in England. What we are doing about it The actions being taken under the four strategic themes of community response, escalation, capacity development and discharge combined with the winter resilience plan are aiming to impact on the flow through the unscheduled care system. These actions aim to improve access throughout the unscheduled care system which will enable shorter handover times for patients arriving at hospital by ambulance. Predictor tools of ambulance attendance have been developed from now until May These tools include attendance, admission and discharge and can be useful in aligning to staffing levels and preparing for the forthcoming week. In addition the work currently being supported by Price Waterhouse Cooper is designed to improve flow through ED and hence will undoubtedly have a positive impact on reducing the number of patients being delayed at handover or 60 minutes or more. 1,300 1, Number of ambulance handovers over one hour Actual Plan Target When we expect to be back on track We are seeking to improve this performance month on month to avoid patients waiting for handover while balancing the level of safe occupancy within the ED departments. Performance Report - January 2018 Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Page 62

244 Exception Report: Cancer Treatment (62) Timely Care % of patients referred via the USC pathway definitively treated within 62 days of referral Executive Lead Morag Olsen Exception Report? National Target March 18 Plan Current Plan Previous Current Month Arrow Welsh Benchmark Yes 95.0% 95.0% 94.0% 87.5% 88.0% Dec-17 4th Where we are 88% (95 out of 108) Urgent Suspected Cancer (USC) patients (ie those referred urgently with symptoms suggestive of cancer) were treated within 62 days of referral in December This is a smaller number of cancer patients treated following referral via the USC route than usual, due to reduced activity over the Christmas period. 2 of the 13 breach patients were on complex diagnostic pathways. What are we doing about it The remaining breaches have been reviewed and the following themes identified and actions taken: Delays to endoscopy USC waiting times remain a challenge across the Health Board, in particular due to the loss of physical capacity in Wrexham. Two mobile units have been operational since mid-january in order to restore this capacity. There have also been delays in the West as the planned third endoscopy suite has been delayed until March; weekend lists have now been agreed for every weekend to the end of March in order to reduce delays. Delays to first appointment Delays in three specialties, gastroenterology, dermatology and colorectal, led to breaches in December. Additional clinics have been held to reduce waits in these specialties and the straight to test service in colorectal continues Delays to urology surgery Additional capacity has been secured and funded in North West England. Additional in-house capacity is also being sought. 100% 90% 80% 70% 60% 100% 95% 90% % of patients referred via the USC pathway definitively treated within 62 days of referral Actual Plan Target Benchmark Chart (Delayed Information) % of patients referred as urgent suspected cancer seen within 62 days Sep-17 93% 88% 88% 87% 85% HYWEL DDA CARDIFF ANEURIN BEVAN When we expect to be back on track There remains a significant risk to achievement in 2017/18 in particular due to the pressures within endoscopy services across the Health Board. 85% 80% 75% 79% BCUHB CWM TAF ABMU Performance Report - January 2018 Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Page 63

245 Exception Report: Primary Care Dental Access Timely Care Percentage of the health board population regularly accessing NHS primary dental care Executive Lead Morag Olsen Exception Report? National Target March 18 Plan Current Plan Previous Current Month Arrow Welsh Benchmark Yes 54.7% 52.0% 51.0% 49.4% 49.4% Dec-17 6th Where we are The last 4 months performance for the Health Board are a follows: Sep 49.5% (343,643 patients) Oct 49.3% (343,162 Patients) Nov 49.4% (343,529 Patients) Dec 49.4% (343,597 Patients) The above figures do not include Health Board residents who attend out-of-area practices. What are we doing about it The Health Board: has commissioned additional activity with those contractors with capacity to deliver increased access during 2017/18 has completed a tender exercise to re-commission services in Dolgellau and other areas of the HB identified with low dental access and/or high oral health needs. Contract awards are pending ministerial approval Is encouraging contractors to implement NICE patient recall guidelines thus potentially freeing up capacity for additional patients. is examining recommissioning options following the sudden unexpected closure of a dental practice in Llangollen 55% 53% 50% 48% 45% Percentage of the health board population regularly accessing NHS primary dental care Actual Plan Target When we expect to be back on track Any significant recovery in access levels is not expected before April 2018 when services commissioned as part of the current tender process are anticipated to begin to come on stream. The sudden closure of Llangollen dental practice is likely to further delay a recovery in patient access levels. Performance Report - January 2018 Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Page 64

246 Exception Report: Rapid Stroke Care Timely Care % of stroke patients who have a direct admission to an acute stroke unit within 4 hours % of stroke patients who receive a CT scan within 12 hours % of stroke patients who have been assessed by a stroke Consultant within 24 hours % of stroke patients who have received a formal swallow assessment in 72 hours % of all strokes thrombolysed % of all eligible patients thrombolysed Executive Lead Morag Olsen Morag Olsen Morag Olsen Morag Olsen Morag Olsen Morag Olsen Exception Report? National Target March 18 Plan Current Plan Previous Current Month Arrow Welsh Benchmark Yes % 60.0% 38.1% 39.8% Jan-18 6th Yes % 100.0% 92.8% 89.9% Jan-18 4th No 82% % 82.00% Dec-17 - YES % 100.0% 97.1% 100.0% Jan-18 2nd Yes % 12.0% 11.3% 3.0% Jan-18 - Yes % 100.0% 83.3% 100.0% Jan-18 - Where we are The Health Board has received the latest SSNAP reports for the three acute admitting sites to the end of November This demonstrates that YGC has regained its previous B level and YG and Wrexham have retained their previous scores of D and C respectively. The QIMs performance remains challenged on the 4 hour access to ASU in line with challenges for managing flow for USC What are we doing about it The three sites have implemented the revised clinical governance structure recommended from the peer review and reporting progress against this action plan to the QSG and through to QSE. Progress was initially slow on the YG site, however this has improved significantly following the intervention of the site medical director who is chairing the site meetings. The re-design work on stroke resulted in the final stakeholder event being held at the end of January. The options appraisal is being analysed and will be included in the April 2017 board paper When we expect to be back on track The performance across each site and each patient pathway is being reviewed through a weekly escalation meeting so that learning can be applied for future patient pathways. While improvement is seen in CT times and therapy support post admission, the access to the ASU within 4 hours is not showing the expected improvement at this time and will need further integration into the USC improvement work. Performance Report - January 2018 Page 65

247 Exception Report: Follow Up Appointments Timely Care All patients overdue their target date on the Follow Up Waiting List Executive Lead Morag Olsen Exception Report? National Target March 18 Plan Where we are The January figures show slight improvement on the December position. However the issue in relation to WPAS duplication of follow up numbers is still to be resolved as an urgent issue. The recently received WHC relating to the priority actions for follow-up has been addressed through a local meeting with the National programme leads Current Plan What are we doing about it The Health Board is re-aligning its OP improvement programme to embrace the actions required in relation to the 4 specialties which form part of the WHC namely: Ophthalmology, Orthopaedics, ENT and Urology. The WHC focuses on specific conditions/pathways within these specialties which will form a subset of the data to improve the overall follow up waiting times. The programme leads will be submitting action plans for these pathways by the end of March 2018 with a view to delivering the outcomes expected by Dec 2018 in line with the National programme expected. Further improvement during 2018/19 will be dependant on resource allocation to deliver RTT and the follow ups associated with the additional new activity Previous Current Month Arrow 90,000 75,000 60,000 45,000 30,000 15,000 All patients overdue their target date on the Follow Up Waiting List 0 Welsh Benchmark Yes - 49,750 51,250 77,551 75,928 Jan-18 6th Actual Plan Target When we expect to be back on track In line with the National Planned Care programme we will deliver the expected outcomes for the identified pathways by December Improvement for the majority of the follow up waiting list will be aligned to resource allocation for follow up work arising from the IMTP budget setting process for 2018/19. Performance Report - January 2018 Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Page 66

248 Exception Report: Out of Hours GP Service Timely Care Out of Hours : Urgents triaged/assessed within 20 minutes Out of Hours : Non-urgents triaged/assessed within 60 minutes Executive Lead Morag Olsen Morag Olsen Exception Report? National Target March 18 Plan Current Plan Where we are: The GPOOH service received 12,575 calls in January 2018 compared to 12,113 calls in January 2017 (an increase of 3.8% or 462 calls). Between February 2017 and January 2018 the service received 139,100 calls, compared to 137,736 calls between February 2016 and January 2017 (an increase of 0.9% or 1,364 calls). 94% of triage nurse shifts were filled in January 2018 compared to 88% in December Performance against the Welsh Government requirement of 98% achievement against both standards has dropped again this month with: 65 % of URGENT calls triaged within 20 minutes (compared to 61% in December 2017). 70 % of ROUTINE calls triaged within 60 minutes (compared to 64% in December 2017.). What are we doing about it: This month on month increase in activity continues to impact on our ability to achieve and maintain the Welsh Government Standards. The 4 recently appointed new Triage Nurses started in January 2018 and will be fully trained to work autonomously by the end of March 20188/1/18. A further 3 new triage nurses were appointed in January 2018 and they will be commencing their training in the next few weeks. The continued increase in activity and the increase in patients with more complex medical needs will continue to prove quite challenging. Operational Managers, Senior Nurses and Medical Advisers regularly review the rotas against this increased level of activity and where necessary, will propose changes to divisional staffing rotas to the respective Quality, Safety and Patient Experience groups. When we expect to be back on track: With this in mind we continue to work on improving current performance levels month on month with a view to achieving the 98% requirement for both standards as soon as possible. Previous Current Month Arrow Welsh Benchmark Yes 98.0% 98.0% 98.0% 61.0% 65.0% Jan-18 - Yes 98.0% 98.0% 98.0% 64.0% 70.0% Jan % 80% 60% 40% 20% 0% 100% 80% 60% 40% 20% 0% Out of Hours : Urgents triaged/assessed within 20 minutes Actual Plan Target Out of Hours : Non-urgents triaged/assessed within 60 minutes Actual Plan Target Performance Report - January 2018 Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Page 67

249 Our Achievements - Our Staff and Resources 68 I can find information about how the NHS is open & transparent on its use of resources & I can make careful use of them Ysbyty Gwynedd dementia support worker recognised for going the extra mile A dementia support worker who has been described as a true ray of sunshine by her colleagues has received a healthcare staff award. Eirian Owen, who works on several wards at Ysbyty Gwynedd, including Glaslyn and Aran Ward, has received a Betsi Star Award from our Chief Executive Gary Doherty after being nominated by her colleagues. Elen Mitchelmore, staff nurse, was one of the two members of staff who nominated Eirian. She said: Eirian wholeheartedly goes the extra mile in demonstrating our values. She puts all patients first, she works as part of the team, and she values and respects all patients, staff, and relatives alike. Her caring attitude and calm, respectful manner always puts our patients living with dementia at ease. Nothing is too much trouble for Eirian. The patients look forward to seeing her every day and she certainly brightens up their day. Eirian, who is referred to by her patients as the lady in pink, has been praised for taking the time to sit and listen to patients and also play games and reminisce with them. Gwenllian Roberts, Staff Nurse on Aran Ward, has described Eirian as their star and is thrilled to see her colleague recognised for her efforts. She said: Eirian is a true ray of sunshine and I know when she is about the patients will be calm and co-operative. She is truly our star and it s fantastic she has been recognised for her hard work and dedication Gwenllian Roberts Staff nurse on Aran Ward Performance Report - January 2018 Page 68

250 Staff & Resources Overview National Standards Staff and Resources % staff absence due to sickness (rolling 12mths) % of total medical staff undertaking appraisals Executive Lead Martin Jones Exception Report? National Target March 18 Plan Current Plan Previous Current Month Arrow 69 Welsh Benchmark No 4.55% 4.55% 4.55% 4.87% 4.89% Dec-17 3rd Evan Moore No % 98.0% 98.9% 99.1% Jan-18 - % of staff (non-medical) undertaking an appraisal - PADR Finance - % variance against budget New Outpatient DNA rates for selected specialties Follow up Outpatient DNA rates for selected specialties Richard Jones Russ Favager Morag Olsen Morag Olsen Yes - 90% 90% 63% 62% Dec-17 - Yes 0.0% 2.2% 2.2% 1.8% 1.6% Jan-18 - Yes - 4.7% 4.8% 5.4% 6.7% Dec-17 3rd Yes - 6.6% 6.7% 6.7% 7.3% Dec-17 3rd The Finance & Performance committee scrutinises the indicators in the Staff & Resources domain. Where we are not achieving the required standard, we have included an exception report. The statutory duty to financially break even has been included to the national template. Performance Report - January 2018 Page 69

251 Staff & Resources Overview Local Standards Staff and Resources Mandatory Training overall percentage trained Agency & Locum Spend in 000's Theatre lists finishing 30 or more minutes before the scheduled end time Theatre lists starting 15 or more minutes after scheduled start time Executive Lead Martin Jones Russ Favager Morag Olsen Morag Olsen Exception Report? National Target March 18 Plan Current Plan Previous Current Month Arrow Welsh Benchmark Yes - 90% 87% 82% 82% Dec-17 - Yes - Not submitte Not submitte 2,300 2,200 Jan-18 - Yes % 20.6% 33.7% 43.6% Jan-18 - Yes % 13.5% 63.8% 63.7% Jan Performance Report - January 2018 Page 70

252 Exception Report: Staff Sickness Rate Staff and Resources % staff absence due to sickness (rolling 12mths) Executive Lead Martin Jones Exception Report? National Target March 18 Plan Current Plan Where we are Absence levels have increased to 5.26% for the month of December 2017 (4.89% rolling 12 months). This is the highest recorded level since January ,946 staff reported sick during the month of which 932 were referred to the CARE service for support and guidance. The highest level of absences were recorded in estates and facilities and additional clinical services, these are the staff groups with the lowest paid staff. What are we doing about it Workforce will continue to promote early intervention in the management of sickness absence. Research has demonstrated that the use of adjusted duties to allow an earlier return prevents the onset of depression and other mental health issues. Working in partnership with trade unions and managers, workforce will continue to support staff to stay in work while managing their ongoing health conditions. The link between older workers and increased levels of absence is demonstrated in the graph to the right. Currently only staff aged below 45 meet the Welsh Government target. A training package is also being rolled out to provide support and guidance for staff who may be required to work longer due to increasing pension ages. The emphasis is on maintaining health and wellbeing, financial planning and employment policies that allow staff to adjust to the changes. Previous Current Month Arrow Welsh Benchmark No 4.55% 4.55% 4.55% 4.87% 4.89% Dec-17 3rd 5.5% 5.2% 4.9% 4.6% 4.3% 4.0% % staff absence due to sickness (rolling 12mths) Actual Plan Target When we expect to be back on track Absence levels are traditionally cyclical with a rise during winter months. The Flu campaign has focussed on encouraging staff to protect patients, family, colleagues and themselves. In the midst of a flu outbreak it is important that WOD continues to support departments to proactively manage sickness absence and to promote employee health and wellbeing. It is unlikely that sickness levels will fall until spring. Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Performance Report - January 2018 Page 71

253 Exception Report: Financial Balance Staff and Resources Finance - % variance against budget Executive Lead Russ Favager Exception Report? National Target March 18 Plan Current Plan Where we are The Health Board Financial Plan includes a planned deficit of 26m for the financial year ( 2.2m per month). The financial position for January is a deficit of 1.9 million, which is 0.3m under the planned monthly amount. This is a further improvement on the previous months' run rates which were a deficit of 2.2 million in December, 2.6 million in November and 2.8 million in October. The year to date deficit is 34.7 million and an annual forecast deficit of 36 million has been reported to Welsh Government. What are we doing about it The Health Board's financial plan for 2017/18 includes a savings target of 35.4m. To date 44.9m of savings plans have been identified but 6.8m of these have a high risk rating of non-delivery and 3.7m a medium risk rating. A cumulative savings target of 32.0m has been profiled into January's savings plan and the reported savings to date are 30.1m resulting in an under achievement of 1.9m. Achievement of the 2017/18 Financial Plan is dependent on the full delivery of saving schemes. When we expect to back on track The Health Board's Financial Plan is currently being prepared and work has commenced on identifying savings opportunities for 2018/19. Further details on the financial position are contained in the Director of Finance Reports. Previous Current Month Arrow Welsh Benchmark Yes 0.0% 2.2% 2.2% 1.8% 1.6% Jan-18 - Performance Report - January 2018 Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Page 72

254 Exception Report: Staff Appraisal Staff and Resources % of staff (non-medical) undertaking an appraisal - PADR Executive Lead Richard Jones Exception Report? National Target March 18 Plan Where we are The PADR rate fro December 2017 was 62%, equating to 10,231 PADRs completed between 12/12/16 11/12/17 Current Plan What are we doing about it During December, work to implement the recommendations from the PADR audit continued to be put in place with a proposal for regular sampled auditing to begin in Quarter /18. The proposal ensures that each area of the organisation is audited in a cycle and by working closely with the ESR team, the audits will inform us of any gaps and re-occurring barriers that managers face. This information can then be incorporated into any training sessions and PADR communication within the organisation. Auditors within BUCHB were contacted regarding their approach to the sampling of the original PADR Audit in order to ensure a consistent approach. PADR continues to be covered on the Leadership and Development programmes, with sessions carried out on the Step Into Management programme on a rolling basis A bespoke session was also carried out with new managers in Theatres in YGC during December. When we expect to be back on track Each Director is responsible to discuss PADR within Accountability meetings and to take action with their local teams. Previous Current Month Arrow Welsh Benchmark Yes - 90% 90% 63% 62% Dec-17 - Performance Report - January 2018 Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Page 73

255 Exception Report: Staff Training Staff and Resources Mandatory Training overall percentage trained Executive Lead Martin Jones Exception Report? National Target March 18 Plan Current Plan Where we are During December 2017 Mandatory Training compliance was as follows: Level 1 compliance at 82% Level 2 compliance at 71% These figures are now reflecting the All Wales position of reporting compliance without Bank Staff figures. Although small increases the compliance rates continue to increase with level 1 just 3% short of the national target of 85% What are we doing about it We continue to monitor and report non-attendance figures with illustrations below for both Manual Handling/Violence & Aggression and Resuscitation Training:- Resuscitation Reduced to 6% for all Resuscitation courses although this figure increases to 10% for level 1 and 2 courses. Mandatory Training 10% for level 1 and 2 courses 3D workshops for managers implementing The Statutory and Mandatory training policy will commence again from March 2018, these interactive workshops are designed to engage managers and line managers with their responsibilities of the revised policy. When we expect to be back on track Consider the 1% increase bi-monthly we anticipate being within the 85% target within the first financial quarter of 2018 Each Director remains responsible for progressing this action within their teams. Previous Current Month Arrow Welsh Benchmark Yes - 90% 87% 82% 82% Dec-17 - Performance Report - January 2018 Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Page 74

256 '000 Exception Report: Agency and Locum Spend Staff and Resources Agency & Locum Spend in 000's Executive Lead Russ Favager Exception Report? National Target Yes - March 18 Plan Not submitte Where we are The total agency costs for January was 2.2m which is 1.5m lower than the average monthly expenditure of 3.7m in the last financial year. The January agency expenditure for the 3 hospital sites was 1.3m and mental health was 0.4m. Medical agency costs are 1.1m in January 0.4m lower than last month. Agency Nursing spend is 0.9m which is 0.2m higher than in December. Locums are paid via the Health Board s payroll and the total costs for January are 753k or 1.3% of total pay, a reduction of 91k from December. What are we doing about it The operational teams are working with the financial leads to reduce agency and locum costs, recruit to funded posts and fully utilise bank staff at reduced costs where available. This action is being progressed by the Nursing and Medical Director. When we expect to be back on track The return to lower rates of expenditure is dependent on the success of actions outlined above. Current Plan Not submitte 5.0 M 4.5 M 4.0 M 3.5 M 3.0 M 2.5 M 2.0 M 1.5 M 1.0 M.5 M.0 M 1, Previous Current Month Arrow Welsh Benchmark 2,300 2,200 Jan-18 - Agency Spend Ysbyty Glan Clwyd Other Mental Health & LDS Ysbyty Maelor Wrexham Ysbyty Gwynedd East Area Central Area West Area Medical Agency Nursing Agency Nurse - Qualified Agency Nurse - Unqualified Other Agency Locum Spend Women's Mental Health & LDS North Wales Wide Hospital Services 22 M Medical & Nurse Total Pay Chart 700 West Area 21 M M Central Area 19 M 18 M Ysbyty Maelor Wrexham 17 M 16 M 300 Ysbyty Glan Clwyd 15 M 14 M 200 Ysbyty Gwynedd 13 M 100 East Area 12 M 0 Total Nursing Pay Total Med Pay Projected Med Pay after Savings Projected Nurse Pay after Savings Performance Report - January 2018 Intelligence Triangulated Root Cause Understood Action Plan Set Actions Underway Actions Complete Page 75

257 76 NHS England Contracted Activity November 2017 Provider Provider Code Total Contract Value ( '000) Data Month Elective Inpatient & Daycase (inc. Endoscopy) Emergency Inpatient (inc. Maternity) New Outpatient Follow Up Outpatient Countess of Chester NHS Foundation Trust RJR 26,432 Sep ,719 3,799 Robert Jones & Agnes Hunt NHS Foundation Trust RL1 13,295 Sep ,359 Hywel Dda LHB 7A2 4,078 Sep Royal Liverpool and Broadgreen University Hospitals NHS Trust RQ6 5,016 Sep Wirral University Teaching Hospital NHS Trust RBL 2,591 Aug Shrewsbury & Telford Hospitals NHS Trust RXW 1,455 Aug Aintree University Hospital NHS Foundation Trust REM 3,150 Sep The Clatterbridge Cancer Centre NHS Foundation Trust REN 2,187 Jul University Hospital of North Midlands NHS Trust RJE 3,096 Sep University Hospital of South Manchester NHS Trust RM2 752 Aug Liverpool Women's NHS Foundation Trust REP 891 Sep Shropshire Community Health NHS Trust RID 255 Aug Performance Report - January 2018 Page 76

258 Appendix A Further Information 77 Further detailed information is available Further information is available from the office of the Chief Operating Officer which includes; performance reference tables tolerances for red, amber and green the Welsh benchmark information which we have presented Further information on our performance can be found online at: Our website Stats Wales We also post regular updates on what we are doing to improve healthcare services for patients on social media: Performance Report - January 2018 Page 77

259 Living Healthier Staying Well : Our Strategy for the Future - Mr Geoff Lang a LHSW coversheet v1.docx 1 Health Board To improve health and provide excellent care Title: Author: Responsible Director: Public or In Committee Strategic Goals Approval / Scrutiny Route Living Healthier, Staying Well : Our strategy for the future Mrs Sally Baxter, Assistant Director Health Strategy Mr Geoff Lang, Executive Director of Strategy Public (Indicate how the subject matter of this paper supports the achievement of BCUHB s strategic goals tick all that apply) 1. Improve health and wellbeing for all and reduce health inequalities 2. Work in partnership to design and deliver more care closer to home 3. Improve the safety and outcomes of care to match the NHS s best 4. Respect individuals and maintain dignity in care 5. Listen to and learn from the experiences of individuals 6. Use resources wisely, transforming services through innovation and research 7. Support, train and develop our staff to excel. The Strategy Programme is overseen by the Programme Executive Group and reports into the Strategy, Partnerships and Population Health (SPPH) Committee. The draft priorities paper for the strategy was approved for engagement by the Board on 19 October Following this, further discussions were held at SPPH Committee on 21 December and at Programme Executive Group meeting on 12 January. The final draft strategy paper was presented to the Board on 1 February and is now resubmitted following final refinements. Purpose: Significant issues and risks To submit to the Board the Living Healthier, Staying Well strategy summary paper for approval and formal launch. A detailed risks and issues log has been maintained by the Programme Office and any risks or issues requiring escalation are reported on a regular basis to the Programme Executive Group. The Group escalates any risks or issues as necessary for inclusion in the overall Programme

260 2 Equality Impact Assessment Recommendation/ Action required by the Committee Risk identified as CRR 08 on the Corporate Risk Register. The equality and human rights approach has been embedded in the strategy programme since inception. The EqIA assessment document was received by the Board in February. The Board is asked to Receive the report Approve the strategy paper for formal publication Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board Board Coversheet v7.0 February 2016

261 b LHSW Strategy Doc Final Draft - v9 SB pdf OUR STRATEGY FOR THE FUTURE Improving health, well-being and healthcare in North Wales 1

262 Section 1 INTRODUCTION AND CONTEXT 2

263 We are Betsi Cadwaladr University (BCU) Health Board and we work across North Wales. We work to improve health and well-being for everyone living here around 694,000 people. This number is increased by the large number of visitors whom we welcome into the area. We are responsible for: Improving health and well-being for all and Providing healthcare in GP practices, dentists, pharmacists and optometrists (eye care); community health teams, health centres, hospitals; mental health services We work together with other organisations that provide healthcare; for example, ambulance services are provided by the Welsh Ambulance Services NHS Trust. We also work closely with other partners in public services, the third sector and community groups. We also provide services and support for some residents of other areas who use our healthcare services (such as some parts of Powys, Shropshire and Cheshire) and some North Wales residents use services outside North Wales, including Bronglais Hospital in Aberystwyth, the Countess of Chester Hospital and Robert Jones and Agnes Hunt in Gobowen. We have been working hard to make improvements and have made progress in many areas. The proposals in this strategy will build on these improvements. This is our ten-year strategy. It is about meeting the needs of people now and in the future. This paper describes how health, well-being and healthcare might look in ten years time and how we will start working towards this now. We have identified the actions we will prioritise over the next three years to begin delivering our strategy. These actions are set out alongside the main areas of our strategy. 3

264 Why do we need a ten-year strategy? Having a clear and well thought out strategy will help achieve our objectives for the NHS in North Wales and contribute to sustaining safe, effective patient care. This will influence how our resources are allocated and how staff prioritise their time. Strategy is a set of choices and principles designed to help an organisation achieve long-term goals. 1 We need to think about the long-term impact of decisions we make. We are facing challenges that cannot be met by acting on our own, and that cannot be met by continuing to respond in the way we have done in the past. The Well-being of Future Generations (Wales) Act gives us the opportunity to think differently and to give new emphasis to improving the well-being of both current and future generations. The Well-being of Future Generations Act requires us to think more about the long-term, work better with people, communities and other organisations, seek to prevent problems and take a more joined-up approach. The Act puts in place seven well-being goals, and we need to maximise our contribution to all seven. 1 Monitor, Strategy Development Toolkit,

265 We need to change the way we work, ensuring we adopt the sustainable development principle defined within the Well-being of Future Generations Act this means taking action to improve economic, social, environmental and cultural well-being, aimed at achieving the seven goals. There are five ways of working which we need to think about when working towards this: We have sought to follow the 5 ways of working in developing this strategy. In each section you will see the symbols that show where there are examples of how the five ways have been followed. 5

266 Our well-being objectives One of our duties under the Well-being of Future Generations Act is to set well-being objectives for the Health Board. We think these should be our organisation s long-term strategic goals. When we talked to people about this strategy, we asked for their views about these. This has helped us refine our objectives. Our refreshed well-being objectives will be: To improve physical, emotional and mental health and well-being for all To target our resources to those with the greatest needs and reduce inequalities To support children to have the best start in life To work in partnership to support people individuals, families, carers, communities - to achieve their own well-being To improve the safety and quality of all services To respect people and their dignity To listen to people and learn from their experiences In achieving these objectives we will Use resources wisely, transforming services through innovation and research Support, train and develop our staff to excel We believe that aiming towards these objectives will help us define and maximise our contribution to the seven national well-being goals. More detail on how this will work is described on our website. 6

267 Involving you We have developed this strategy over the last year or so and co-produced this with many individuals and groups across North Wales. People have been telling us what they think about services and what we need to put in this plan. They have got involved through: BCU Health Board meetings Events Online surveys Feedback forms Our website: Thousands of people have contributed their time, their opinions and their feedback to help design this strategy together and we are very grateful for their support. We have put together a report on how people have been involved and the feedback they have given us. You can find this report at This is not the end of our conversation with people. As we take forward the priority areas described in this strategy, we will continue to work together with people to co-produce the detailed implementation plans. In some areas, there may be changes proposed which we want to talk to people about more formally, through consultation. We will keep our website updated with information on what is being discussed and how people can get involved. 7

268 Our principles In developing our strategy, we followed a number of key principles. These are set out below. We will continue to work with these principles as we implement the strategy. In everything we do: We promote equality and human rights We will actively provide Welsh language services to address the needs of our Welsh speaking population, in line with the Welsh Language (Wales) Measure 2011 We work together with local authorities, other services and organisations, including third sector We listen to what matters to people and involve them in decisions We will address the needs of individuals and their carers We use evidence of what works so we can improve health and learn We work to improve services We use our resources wisely (finances, buildings and staff) We will work with the principles of prudent healthcare Human rights represent all the things that are essential to us as human beings, such as being able to choose how to live our life and being treated with respect and dignity. It is our ambition to adopt a rights based approach which places human rights at the centre of our policies and practice, and the person at the centre of his or her own care. This approach is based on the values of Fairness, Respect, Empowerment, Dignity and Autonomy. We need to ensure we consistently use this approach in all that we do. 8

269 The recent report of the Parliamentary Review of Health and Social Care in Wales 2 described the Quadruple Aim - four goals to deliver the vision for health and social care in Wales. This is adapted from international evidence and builds on the Prudent Healthcare principles. We will ensure that our strategy programmes are consistent with and will help us work towards the Quadruple Aim, and the Welsh Government s new strategy for health and social care, when this is published. The Quadruple Aim: a. To improve population health and wellbeing through a focus on prevention; b. To improve the experience and quality of care for individuals and families; c. To enrich the well-being, capability and engagement of the health and social care workforce; d. To increase the value achieved from funding of health and care through improvement, innovation, use of best practice and eliminating waste 2 A Revolution from Within: Transforming Health and Social Care in Wales, The Parliamentary Review of Health and Social Care in Wales, January

270 Our challenges We face a number of challenges in the coming years which will affect the way we need to provide services People are living longer which is good Health needs are changing and we need to respond in a different way People need support to make informed choices about a healthy lifestyle More people have conditions like diabetes or heart disease More people are experiencing mental health issues More people are living with dementia Waiting times are too long and we need to see patients sooner Our workforce is changing and we face challenges in recruiting staff in a number of specialties and staff groups Public money is tight, so we need to be efficient and spend wisely Over recent years, we have faced some difficulties in dealing with the challenges we are experiencing and were placed in Special Measures by Welsh Government. We have been working hard to improve and have made progress in some areas, such as maternity services, and involving patients and the public. There are other areas where there is still much more to do and we recognise it will take time, commitment and support to make all the improvements that are needed. 3 There are other challenges which are affecting all public services - such as poverty, inequalities, jobs and economic growth, and climate change. These make the context in which we are working more difficult, and make it more important that we understand the impact of our actions on other organisations as well as our population. Environmental well-being we are the largest Health Board in Wales, and cover almost a third of the country s landmass. We can have a significant environmental impact which must be carefully managed. We are developing a more comprehensive sustainability plan which will support this. In our planning we will consider environmental infrastructure, how we can support a more resilient environment, and work to understand better and contribute positively to the natural environment. 3 Update on escalation status review of health organisations and additional support for Betsi Cadwaladr University Health Board, Cabinet Secretary for Health and Social Services, February

271 Our population Our resident population is around 694,000 people, living across an area of approximately 2,500 square miles, covering the local authority areas of Anglesey, Gwynedd, Conwy, Denbighshire, Flintshire and Wrexham. Source: Office for National Statistics, 2016 Mid-Year Estimates 11

272 The resident population of North Wales is expected to increase to 729,100 by Tourism significantly increases the population further. Gwynedd and Wrexham are expected to have the greatest increase in population; by contrast, the population of Anglesey is expected to decrease steadily. The estimated mid-year population for 2016 aged 65 and over was nearly 157,000 and the population aged 85 and over was 20,289. By 2036 the older population will have experienced a greater percentage increase than Wales as a whole, with an increase of around 34% in those aged 65 and over and an increase of 23% in those aged 85 or over. There has been very little change in the number of children in North Wales over recent years (with just over 124,000 aged 0-15 in 2016). Support in the early years is crucial - experiences during childhood can have a significant impact on health and well-being in later life. We are living longer average life expectancy is now 78 years for males and 82 years for females. The good news is that many people stay in good health for much of their lives. However, we need to do more to help everyone to have an active, happy and healthy life and to stay well as long as possible. Many more people will have long-term conditions such as diabetes or complex health needs. There will also be many more people living with dementia. There are also unacceptable differences in how long people live, and how many years of good health they will have. In areas which are better off, men can live up to 8 years longer than those who live in the poorest areas. For women, the difference can be up to 5 years. Men living in areas which are better off can have up to 13 years of better health than those in the poorest areas, while women can have almost 14 years of better health. We know that inequalities have an adverse impact on all of us. We need to target the investment of our resources to reduce these inequalities. More people are experiencing mental health issues one in four of us will be affected at some time during our lives. We need to do more to promote well-being, support people with long term mental health needs when care is needed, and facilitate recovery. 12

273 Future trends We have reviewed what we know about possible future trends in population and in health needs. We have also begun to model the impact on demand for our services as a Health Board. The Future Trends Report, Welsh Government (May 2017) provides some key messages which we have taken into account: On current projections, there is no clear trend of reduction in the gap between the most and the least deprived populations There are mixed trends in common illnesses, which may or may not continue, such as: Reduction in heart disease and arthritis Increase in diabetes and mental illness Little change in the occurrence of cancer in the population (although the numbers will increase due to population increases) A marked increase in the numbers of people living with dementia is likely Mixed trends are predicted in healthy lifestyle behaviours Smoking levels are likely to continue to reduce Obesity levels and the proportion of people eating less than the recommended volume of fruit and vegetables are likely to increase We have undertaken detailed modelling of the potential impact of demographic change on demand and activity in health care services assuming that we do nothing differently. This suggests that in ten years time, if we take no further action, we could need around 260 more hospital beds in North Wales. This is clearly unsustainable and adds emphasis to the need to change how we support our population, placing more emphasis on prevention of ill health rather than simply relying on treatment when needs are more serious. We are continuing to work on projections and to develop a detailed understanding of the impact of the priorities and actions within our strategy. This is a complex area as there are many factors which affect health and well-being, and consequently demand on healthcare. We will use the detailed work to support implementation plans and to review the impact of the early actions identified. 13

274 Getting it right for the future: focusing on outcomes We have to think about how the decisions we make now have an impact on the future. We must meet the needs of today without compromising the ability to meet the needs of future generations. We need to support the people of North Wales to achieve the best health outcomes in the longer term and start to put in place the actions that will achieve this. The proposals within our strategy are designed to help us deliver better outcomes for people - improvements in health and wellbeing. In the longer term, we will aim to see improvements in whole population health status. To deliver this, in the medium term, we will work to support changes in behaviour, practice and the environment. Our approach is based on the Public Health Outcomes Framework 4. Intermediate outcomes changes in behaviour, practice or Living conditions that support and contribute to health Years of Life and years of health Mental well-being A fair chance for health Ways of living that improve health Health throughout the life course Longer term outcomes changes in population Children have the best opportunity for a healthy start Families and Individuals have the resources to live fulfilled, healthy lives Resilient empowered communities Natural and built environment that supports health and well-being Healthy actions Healthy starts Health in the early years and childhood Good health in working age Healthy ageing Minimising avoidable illhealth 4 Public Health Outcomes Framework, Public Health Wales,

275 We cannot deliver these changes alone; we will need the contribution of many others to achieve the improvements we all want to see. There are many factors that influence our health and well-being. There are some areas that we can only influence indirectly; some areas where we can commission others or work in partnership to provide care and support; and some areas where we can directly provide services. 5 We will influence. We will commission and work in partnership. We will provide. Health and well-being Care closer to home People, their families, carers, and communities Care for more serious health needs Lifestyle Individual and family factors Social & community Living & working networks conditions Socio-economic factors 5 Factors adapted from Policies and Strategies to Promote Social Equity in Health, Dahlgren G., Whitehead M.,

276 This means our strategy will need to be supported by partnership working with people and organisations from across North Wales - partner organisations and other public services, the third sector, independent organisations. Individual and family factors We have structured our strategy around three main programmes which, in the main, fit around these three levels of influence. These are: Health Improvement and Health Inequalities we will use our influence to promote health and well-being, physical, mental and emotional, for all. We will focus on the broader aspects of health improvement and prevention, and seek to support those with the greatest health needs first. This sits alongside our contribution to the Well-being Plans being developed for the broader population by the Public Services Boards in North Wales. Care Closer to Home as and when people begin to need support or health care to stay healthy, we will provide as much of this close to people s homes as it is safe and effective to do so. Care Closer to Home will work with people to prevent, detect early and manage physical and mental health needs. This also recognises the broader factors that influence health. This sits alongside the partnership plans for provision of care and support to individuals and their carers for example, veterans, and people with learning difficulties or disabilities - which are being developed with the Regional Partnership Board. Care for More Serious Health Needs when health needs are more serious and people need hospital care, or care from more specialist teams working in the community. People want the safest and highest quality of care possible and a good experience. They will be treated by the right person, in the right place, at the right time and with the right facilities. 16

277 We recognise the importance of adapting our planning and delivery of services to the differing needs of people at different stages of life. There are two supporting frameworks which have been developed to reflect this: Children and young people supporting the best start in life Ageing well supporting people aged 50 and over to stay healthy and independent as long as possible Together with a further strategic framework to reflect the importance of addressing holistic health needs: Mental health and well-being All three of the supporting frameworks will be taken forward through partnership working, linked to the North Wales Regional Partnership Board. 17

278 SECTION 2: THE STRATEGY PROGRAMMES 18

279 HEALTH IMPROVEMENT AND HEALTH INEQUALITIES We want to work in partnership to support people to make the right choices so they can have a long, healthy life. Reducing health inequalities is an important part of this plan. We want to support the communities that need it the most. Poverty is not having enough money for food, clothes, heating and other basic needs. It can mean not having enough money to take part in activities that can support well-being. Poverty is one aspect of inequality and one of its effects. Poverty can affect people s well-being, health and life opportunities and can affect how long someone lives as well. As the largest employer in North Wales, we will take action to contribute to reducing poverty and the impact of poverty, as well as a service provider and commissioner. We will also work with partners in the Public Services Boards to develop and deliver local Well-being Plans that address the broader aspects of well-being economic, social, environmental and cultural. People have also told us their concerns about the inequalities in health experienced by people from specific groups. This includes people from different black and minority ethnic groups; disabled people; LGBT+ people; and people from different faith groups. Sometimes people experience poorer health outcomes. Sometimes information, appointments or actual care and treatment are not as accessible. Addressing inequalities: the Health Board will respect United Nations Conventions and Principles including the UN Convention for the Rights of Disabled Persons, which is designed to promote and protect the human rights of disabled people and ensure full and equal enjoyment of those rights. We will work with seldom heard groups and people with different protected characteristics to make sure we can adapt to respond to their needs. There are some important areas of work already happening which will support this, including these examples: 19

280 Developing support for carers, working in partnership with social services and the third sector, through the Regional Partnership Board Supporting the development of proposals to meet the needs of people with a learning disability better, also through the Regional Partnership Board Supporting accessible healthcare for people with sensory loss There are many innovative ways of working being developed to support the health improvement and health inequalities programme. For example, we are working with the creative arts sector in North Wales to support people to participate in many different activities which, evidence increasingly shows, have a positive effect on health and well-being. In the first years however there are improvements we must make in how we provide support to people to choose healthy lifestyles. 6 Ensuring a good start in life for all Promoting mental wellbeing, preventing mental ill health Preventing violence and abuse Reducing prevalence of smoking Reducing prevalence of alcohol misuse Promoting physical activity Promoting healthy diet and preventing obesity Protection from disease and early identification Economic & social inequalities, mitigating austerity Ensuring safe and health promoting natural & built environment 6 Ten key public health issues, Making a Difference: Investing in Sustainable Health and Well-being for the People of Wales, Public Health Wales,

281 These are the outcomes we want to achieve: People are healthy, active and do things to keep themselves healthy Interventions to improve people s health are based on good quality and timely research and best practice People have access to information and advice about services and opportunities that enable them to maximise their health & well-being Through smoking prevention measures and smoking cessation, people have minimal risk of developing smoking related diseases People are well supported in managing and protecting their physical, mental and social wellbeing People are aware of the significance of tobacco and alcohol consumption, poor diet and lack of physical activity as risk factors for chronic conditions and cancers Inequalities that may prevent people from leading a healthy life are reduced through programmes tailored and designed to meet needs People are supported to identify cancer at an early stage through screening, education and awareness programmes 21

282 How we will measure progress We will use a number of indicators to measure whether this programme is making the difference we intend. As measured by National Survey for Wales: - Decrease in Smoking prevalence - Increase in proportion of the population adopting all 5 Chief Medical Officer-recommended healthy behaviours Decrease in incidence and prevalence of diseases most commonly associated with unhealthy behaviours: - Cardiovascular diseases - Diabetes - Cancer - Respiratory disease Increase in uptake of interventions such as National Exercise Referral Scheme and Expert Patient programmes. Increase in uptake of social prescribing interventions supported by a positive evaluation of impact Increase in access to information services which support health, including Health Board provided Helplines Increase in Screening Uptake figures Decrease in number of Cancers diagnosed at late stage of progression Decrease in prevalence of suicide and self-harm How did we decide on these indicators? Each programme area of the strategy has developed a logic model this is a way of describing the intermediate and longer term outcomes we want to achieve, what we need to do to achieve those outcomes, and how we will measure progress. These are based on evidence of what works. You can find more information about the logic models on our website. 22

283 What we will do in the first three years We will: Promote well-being and support people to meet their own needs Step in early to stop problems happening or getting worse Enable people to make informed choices about healthy lifestyles like stopping smoking Launch our plan to prevent suicide and self-harm Support people become more active and enjoy using green spaces Enable people to take part in activities that promote well-being, like arts projects Target resources to where they will make the most difference Look at ways to contribute to reducing food poverty using local projects Work with housing providers to support tenants and people who are homeless Ensure people are not treated differently because of age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion and belief, sex, sexual orientation - and respond to their specific needs Support our staff s health and well-being and support the needs of people entering employment in the Health Board. Prudent healthcare principles: Targeting resources to make the most difference we will change the way we allocate resources to get the best value from our investments, so that we target areas of greatest need. This will include developing the value framework described later in this document 23

284 CARE CLOSER TO HOME People tell us they want to stay independent for as long as possible. They also want their care and support close to home, supported by family and community networks where available. We will support this where it is safe and effective to do so. It is important to have local health care professionals and members of the wider team that can meet needs in the right way at the right time. This includes GPs, pharmacists, specialist nurses and other community support, including dentists and optometrists. There will be other new roles to support the team, including close working with the third sector.. People will see the team member who is best placed to meet individual needs. Care will be developed around local areas, which will form the building block of future planning. An equitable range of services will be provided for all, although the way they are delivered will be tailored to meet local circumstances or geography. Some services will cover more than one area. We will expand the services of our community teams, with a single point of contact who will arrange access to the right team member or service for people. Services will be integrated, working closely with a wide range of partner organisations, and focusing on what matters to the person. We will maximise use of technology using health videos and apps whilst preventing people having to travel for appointments, particularly when they have a long-term health condition. We know that not everyone uses technology, and we will support people who do not have easy access. More help will be provided for carers, recognising their individual needs as well as those of the person they care for. We will invest in more modern, purpose-built facilities to bring services together under one roof, working with other public sector and third sector partners. We will use our premises, partner organisations or other community facilities to develop health and wellbeing centres in local areas. Our community hospitals will play an important part in the network of resources available to local areas. We will work with local communities to assess local needs and determine the best use of resources in the area to meet those needs. 24

285 We asked our stakeholders and the population what was important to them and they said: Having appointments and tests on the same day in the same place Only being assessed once Knowing where and who to go to for information Understanding where they are in the queue Not being asked the same questions multiple times Seeing the right person first time Based on this we have identified six programmes for change which we will use to take forward our vision for Care Closer to Home. These are: Cluster Model Primary Care Workforce Health & Wellbeing Centres Digital Healthcare & Technology Community Resource Teams Social Prescribing 25

286 The outcomes we want to achieve People can access the right information, when they need it, in the way that they want it and use this to improve their well-being People have easy and timely access to primary care services Health and care support is delivered at or as close to people s homes as possible People know and understand what care, support and opportunities are available and use these to help them achieve health and well-being To ensure the best possible outcome, people will have their condition diagnosed early and treated in accordance with clinical need Interventions to improve people s health are based on good quality and timely research and best practice People are safe and protected from harm through high quality care, treatment and support 26

287 How we will measure progress These are some of the indicators we will use to measure the progress we are making. Number of people engaging with social prescribing Number of community teams extended to include the wider stakeholders. The number of people using apps and health videos to help with self-management The impact of having telephone triage available to improve access for patients to Primary Care Increase in the number and breadth of services in Health and Well-being Centres Reduced travel when Telehealth is used for virtual outpatient appointments and other services Reduction in the rate of ambulance conveyances to hospital as alternative services and support are made available in the community Increase in the number of patients cared for within their own homes with reduced need for hospital admission Increase in the number of people discharged early from hospital appropriately and safely Increase in the number of patients discharged to their usual place of residence Direct feedback from patients rating the timeliness and quality of care received More people supported through end of life care to die at their place of choice 27

288 What we will do in the first three years We will: Deliver the Made in North Wales social prescribing framework in partnership with the third sector Support local services to work together better using the cluster model (working in local areas) Build on the resources in local communities Look at ways to use community hospitals and other places as health and well-being centres Work with local people to make best use of resources and develop the right plans for their area Support GP practices better, developing and using a toolkit to manage pressures Work with other organisations closely to develop community services Develop Community Resource Teams that work with specialists to support patients in their community Provide more support for carers within Community Resource Teams Use technology better including information and advice apps Develop new ways to identify and support people who have higher risks to their health Prudent healthcare: Public and professionals as equal partners through co-production working with local people to make the right plans for their area Reduce variation across North Wales through evidence-based approaches - through a clearer model that provides an equitable range of care and support services, supported by technology, founded on evidence of what works 28

289 MORE SERIOUS HEALTH NEEDS Our plan for care closer to home means that more care will be delivered outside hospital. When people have more serious health needs they want the safest and highest quality of care possible and a good experience. They want to be treated by the right person, in the right place, at the right time and with the right facilities. It is important that the services provided are evidence based and sustainable so that we can be confident about safety, quality and outcomes for patients. People have told us that they have to wait too long to access services, whether it is in the Emergency Department or for an operation. We will improve our services to reduce these waits. We will ensure that we have the right capacity in our hospitals to achieve access standards and meet future demand. To help us do this we will develop and adopt new and innovative ways of working and continually review the way resources are deployed to improve patient and carer experience, efficiency and productivity. For example, changing the skill mix of the work force and redesigning and developing new ways to access and deliver services. We know that improvements in efficiency and productivity alone will not be sufficient to reduce waiting times and we will implement the Care Closer to Home initiatives so that more people can have access to more services (where appropriate) out of the main hospital settings. In order to deliver services to meet future needs we will ensure that our three main hospitals at Ysbyty Gwynedd in Bangor, Glan Clwyd Hospital in Bodelwyddan and Wrexham Maelor Hospital provide core services to meet the needs of the population. Each hospital will continue to have: 24 / 7 emergency department Consultant-led maternity and children s services A wide range of medical and surgical care, both for planned care and emergencies Day case surgery, diagnostic tests and outpatient clinics 29

290 Where clinics (and some diagnostic services) do not need to be at one of the main hospital sites, we will increasingly provide them more locally in our communities. When people need emergency care, they will be able to be assessed at any of our Emergency Departments and most will be treated at the hospital they go to. Some might need to be transferred to another hospital for more specialised care. We know from the evidence that for some more specialist services people have better outcomes when treated in larger centres by highly specialist teams. Our aspiration is that we will widen the range of specialist care we provide in North Wales so that in ten years time people will have to travel outside the area less frequently. This will also help attract, retain and develop the specialist staff needed to provide high quality and sustainable care in our hospitals. We are already working to develop some services like this such as the new Sub-regional Neonatal Intensive Care Centre, and robotic assisted surgery. Sometimes people will still have to travel outside North Wales to get very specialised care which is better provided for a larger population - such as neurosurgery at the Walton Hospital, or specialised paediatric care at Alder Hey. We have strong partnerships with hospitals outside North Wales and we will continue to do so in the future. 30

291 The outcomes we want to achieve People have an accessible responsive and proactive health care system that supports them when they have a more serious health need People have the best possible outcome, conditions are diagnosed early and treated in accordance with clinical need People are safe and protected from harm through high quality care, treatment and support People know and understand what care, support and opportunities are available and use these to facilitate self-care and help achieve health and well-being Staff will always take time to understand what matters and take account of individual needs when planning and delivering care People will be cared for in the right place, at the right time, and by the most appropriate person People are supported to make the right choices so they have a long, healthy life Standardised, accessible and comprehensive data and information on service delivery 31

292 How we will measure progress These are some of the indicators we will use to measure the progress we are making. Waiting times for appointments and planned care; we will achieve the national standard as a minimum Diagnostic tests will be provided in 8 weeks Improved waiting times for cancer diagnosis and treatment services Reduction in outpatient follow-up appointments Reduction in Delayed Transfers of Care Improved performance against national indicators for Stroke services Increase the number of women commencing labour outside a Consultant led unit Increase the range of Patient Related Outcome Measures (PROMS) Increase the range of Patient Related Experience Measures (PREMS) Increase the range of secondary care services provided outside the 3 main hospitals Improved waiting times in Emergency departments, from ambulance handovers to assessment and treatment Increase the rate of survival within 30 days of emergency admission for a hip fracture Reduction in Healthcare associated infections Increased discharge to normal place of residence Reduced Mortality Rate Reduced re-admission rates 32

293 What we will do in the first three years We will: Make sure hospital services can meet increasing demand Improve care and response times in emergency departments Work with professionals to find ways to reduce waiting times Use hospital specialists better and make best use of resources Look at how we provide eye care and out of hours ENT (ear, nose and throat) services Do more orthopaedic work (e.g. hips and knees) Keep maternity units running safely, ensure women have a choice in where they give birth, and have a safe and comfortable environment Open the new Sub-Regional Neonatal Intensive Care Centre Look at urology services and explore robotic assisted surgery Open a centralised vascular service for major surgery (veins and arteries) Look at having one or two specialist centres to provide hospital care for people after a stroke Provide better support for people leaving hospital Support the work of the care Closer to Home programme, enabling more people to remain in their own homes Work towards improving hospital accommodation so that it is fit for purpose and addresses inclusive design principles Prudent health care: Prudent maternity care do only what is needed We will focus on developing community based maternity services in order to promote healthy lifestyles, midwife led care and birth in a midwife led unit, reducing the need for medical intervention. 33

294 MENTAL HEALTH AND WELL-BEING Mental well-being is concerned with how people feel about their lives and whether their lives are worthwhile. It is not just the absence of mental health problems it is broader than that. It is about how much control someone feels they have; resilience and support networks; participating and being included. There are 5 ways to well-being 7. Evidence shows these help improve well-being: 1. Connect with people around you like family, work colleagues and friends 2. Be active go for a walk, cycle, dance or garden. Moving makes you feel good 3. Take notice be curious, take time to notice the good things around you and be aware of the world 4. Keep learning try something new. Discover interests. It is fun and gives confidence 5. Give do something nice for a friend, volunteer or join a group. It makes you happy and connects you to community Anyone can experience mental health issues including depression and anxiety. These can affect work, life, relationships, health and well-being. In 2017, we developed a new strategy for mental health and well-being in North Wales. This is an all-ages mental health strategy, which was co-produced with service users and staff. The strategy will ensure there is promotion of health and well-being for everyone; prevention of mental ill-health and early intervention when needed; and delivery of joined-up and recovery-focused care. The strategy is being taken forward through the North Wales Together for Mental Health partnership board. You can find the full strategy on our website at BCU HB April 2017 Mental Health Strategy. We will provide high quality, person-centred care to people living with dementia and those affected by it, support the creation of dementia-friendly communities and listen and respond to people with dementia. 7 New Economics Foundation,

295 The outcomes we want to achieve 8 The impact of mental health problems and/or mental illness on individuals of all ages, their families and carers, communities, and the economy more widely is better recognised and reduced The mental health and well-being of the whole population is improved Inequalities, stigma and discrimination suffered by people experiencing mental health problems and mental illness are reduced Individuals have a better experience of the support and treatment they receive and have an increased feeing of input and control over related decisions Access to, and the quality of, preventative measures, early intervention and treatment services is improved and more people recover as a result The values, attitudes and skill of those treating or supporting individuals of all ages with mental health problems are improved 8 Together for Mental Health in North Wales,

296 How we will measure progress These are some of the indicators we will use to measure the progress we are making: The percentage of mental health assessments undertaken within 28 days from the date of receipt of referral The percentage of therapeutic interventions started within 28 days following an assessment Rate of calls to the mental health and dementia helplines per 100,000 of the population The availability of advocacy support in hospitals for all qualifying patients Number of people on GP dementia Registers Reduction in the number of out of area placements Increase in the number and breadth of services in health and well-being centres Real time feedback from service users and carers through a patient experience survey Reduction in the number of Delayed Transfers of Care Increase in the number of patients discharged to their usual place of residence Improved training rates for staff in safeguarding adults Improved training rates for GP practice teams in mental health and dementia care or other training outlined Reduction in use of section 136 powers for people in crisis 36

297 What we will do in the first three years We will: Promote the 5 ways to well-being Promote peer support and other services for people moving on from care Step in sooner to support young people with eating disorders Give better support to young people who self-harm Implement the plan to reduce suicide and self-harm for all ages Have more psychological therapies, including online services Widen our range of treatments for people experiencing mental health problems for the first time Have better community services available 24/7 Make mental health wards fit for purpose, safe and comfortable Deliver local care when possible Support people living with dementia and their carers In all that we do, ensure individual needs are addressed such as for people with co-occurring conditions, or people who are homeless Prudent health care: Public and professionals are equal partners through co-production To develop the strategy we worked in close consultation with our partners, and in particular listening closely to the experiences of people that have received services. Caniad (a local service user-led organisation who supports people who want to have their voices heard, influence decisions and help shape the services they use) helped, using a number of methods designed to capture the views of people with lived experience of mental health issues. 37

298 CHILDREN AND YOUNG PEOPLE We want to work in partnership with our communities including children, young people and their families so that all have the best start in life. We will put the United Nations Convention on the Rights of the Child (UNCRC) at the centre of everything we do. We will listen to children, young people and their families; we will include them in decisions and in the planning and design of our services for the future. We will support the first 1,000 days of life (from conception to a child s second birthday) as we know this gives children the best opportunity for a healthy start and makes a real difference to the rest of their life. Getting it right can also reduce lifelong health problems like heart disease, diabetes, and cancer. We want to reduce the impact of Adverse Childhood Experiences (ACEs), for example, parental separation or divorce, substance misuse in the home, or emotional neglect. We know that, in Wales, children who suffer four or more adverse experiences in childhood are more than twice as likely to be diagnosed with chronic disease as adults, compared to those who do not have such experiences. Preventing ACEs can improve health across the whole life course, having far reaching impacts for our future generations. 38

299 The outcomes we want to achieve Children s rights are met in line with the requirements set out in the United Nations Convention on the Rights of the Child Children are cared for, supported and valued Children are listened to and services are planned and provided based on what is important to them All children are, and feel safe All children learn and develop All children do not live in, and are not disadvantaged by poverty All children have the best possible start in life Children are resilient, capable and caring Children at raised risk of poor emotional well-being are quickly identified and early intervention and preventative action is tailored to their needs Services are age appropriate (with particular reference to teenagers) Children experience fewer Adverse Childhood Experiences, have early support when they occur and the impact on their lives is minimised Children are supported in transition (to adult services and between services) 39

300 How we will measure progress These are some of the indicators we will use to measure the progress we are making: Breast feeding rates Children aged 4 / 5 years are of healthy weight Immunisation and vaccination rates Reduced rates of infant Mortality Reduction in number of low birthweight babies Teenage pregnancy rates Increase the breadth and timeliness of services available to respond to children in crisis For those children in crisis improve the multi-agency response and breadth of services available in order to reduce the use of the Mental Health Act Reduce the prevalence of suicide and self-harm Increase in the number of staff trained in ACE recognition and mitigation Reduce waiting times for Specialist Child and Adolescent Mental Health Services (CAMHS) assessment and treatment, Neurodevelopmental assessment, and Acute Paediatrics Increase the community multi-agency provision to reduce inappropriate referrals to Emergency Departments and CAMHS Increased collaboration with partners (Education, Social Care, Third Sector, Housing) to improve outcomes for children, families and young carers Level of free school meals Young people not in education, employment or training (NEETS) 40

301 What we will do in the first three years We will: Keep putting children s, young people s and families rights at the centre of our work Improve support in the first 1,000 days of life Find more ways to support children s emotional health, mental well-being and resilience Focus on reducing childhood obesity and promoting healthy eating habits for future health and well-being Look at the crisis services we have for children and young people who have mental health needs Find ways to handle ACEs better and reduce the impact they have on lives Improve how we bring services together to support children with complex needs Improve how we listen to and engage with children and young people and their families 41

302 AGEING WELL The Older People s Commissioner for Wales recognises that people s rights can diminish as they get older. We want to ensure that older people s rights have parity with other age groups. By older people we mean people aged 50+. Many people within this age range will be in paid employment or in the early years of retirement. The age at which support needs may emerge for others will vary. The United Nations Principles for Older Persons set out 18 principles under five themes independence, participation, care, self-fulfilment and dignity. We will work to ensure we fulfil these principles. Older people say they want to stay as independent as possible, for as long as possible. They also want control over the support they get and decisions that affect them. We want people to benefit from health improvement activities throughout their lives so that they have fewer risks for the long term conditions when they reach older age. Older people say they want access to a range of activities and networks that help counteract loneliness and enable them to make a positive contribution to community life. When possible, we help people stay out of hospital or care homes. We recognise the important role of carers - both those people who care for an older person, and those many older people who are themselves carers, who need support to enable them to continue in this valued role. End of life care Facing death can be difficult for people, carers and families. It is important they have the care and support they need during that time. End of life care is not just an issue for older people and it is important that the needs of children, families and adults are also recognised and responded to. 42

303 The outcomes we want to achieve People aged 50+ and carers have access to information and advice about services & opportunities that enable them to maximise their health & well-being People aged 50+ and carers live in environments that are sensitive to their needs, support healthy ageing and enable them to be socially connected People aged 50+ and carers have appropriate access to high quality primary & community services within their local area People aged 50+ and carers have access to personalised integrated services to enable them to manage long-term conditions, dementia and mental well-being and complex needs People aged 50+ and carers have proactive community based clinical or social care interventions which avoid unnecessary admission to hospital People aged 50+ and carers are proactively supported to regain their motivation following an adverse life event / period of poor health / admission to hospital Quality of end of life care is optimised for people aged 50+ and later in life 43

304 How we will measure progress We will link the measurement of progress into the public health outcomes framework indicators for healthy ageing: Self-reported life satisfaction among older people More older people access appropriate health screening and immunisation opportunities Older people feeling lonely More older people have access to a health promoting diet More older people self-report being physically active Older people have a home appropriate to their needs Falls pathway that incorporates prevention through to treatment Reduction in fractured neck of femur For end of life care we will develop further measures which will include the following: Reduction in unscheduled admissions for people at the end of life Number of Advanced Care Plans developed 44

305 What we will do in the first three years We will: Make sure older people and carers have their rights respected and are involved in decisions Base our plans and services on evidence of what works Explore ways to reduce isolation Look at having people as health mentors in the community Communicate better with older people who may have specific needs arising from sensory impairment or dementia Make sure our plans work together with the Local Authorities ageing well plans When people are facing the end of their lives we will: Encourage people to talk Help them get the support they need Have information and advice that s easy to find and understand Develop guidance for staff giving people end of life care Work well with hospices Prudent healthcare: Public and professionals are equal partners through co-production: - support the initiative Dying Matters, encourage people to talk about their wishes towards the end of their lives, including where they want to die, and helping make advanced care plans Do only what is needed, and do no harm: - follow advanced care plans to provide medical care consistent with the individual s values and wishes. 45

306 WHAT DOES THIS MEAN FOR RESOURCES? Finance The NHS faces a significant challenge over the next three years, with published spending plans for the UK showing a real term budget reduction of 3.2% for Welsh Government. While it is assumed that the NHS budget will be protected over the medium term, it is estimated that the budget for the NHS in Wales will increase by substantially less than the required longer term growth of 2.2% identified by the Health Foundation who also noted that the NHS Wales is facing the most financially challenging period in its history. Welsh Government have announced funding for 2018/19 which provides for a gross uplift of 2% for the Health Board, which, after funding has been top sliced by WG for investments agreed across Wales, will become a net 1.46% uplift for the Health Board. The Health Board has a significant financial challenge before any decision to make discretionary investments through this strategy. Current analysis suggests that addressing this will require savings of 135m over three years. We will need therefore to change the use of existing resources and demonstrate clearly how changes will contribute to more efficient and effective services and support in the future. There are however significant opportunities for improvement to address the challenges: Developing a value framework linking the allocation of resources, productivity, and outcomes into a coherent approach. The value framework will concentrate on allocation how resources are distributed to different groups within the population, seeking to target resources where most needed; technical value productivity and efficient use of resources; and outcomes focusing on how well use of resources relates to individuals, concentrating on quality and safety Shifting resources to prevention and care closer to home, using evidence-based approaches that reduce the demand for more expensive and intensive care. Social prescribing, telehealth and other new ways of working can reduce the need for hospital care and reduce costs of managing long-term conditions. Developing health improvement interventions for which evidence demonstrates direct benefits for people, and reduced longterm costs of healthcare. Detailed modelling and forecasting work is being undertaken to support our three year plan, which will set out how the strategy will be implemented over the first three years. 46

307 Workforce We are the largest employer in the region, employing a large number of staff across a range of professional groups and occupations. Currently the organisation employs just over 17,000 staff. Low turnover, a large number of staff over the age of 50 and low numbers of staff under the age of 20, present workforce challenges for the Health Board. There are also significant difficulties recruiting staff in a number of specialties and staff groups. Our proposals in this strategy take account of the workforce challenges and address the specific issues within each area. The approach includes: Development of new roles such as the Physician s Associates, supporting doctors with diagnosis and management of health needs Develop a broader range of health, social care and other professionals and partners working together within a team, so that you will see the person who is best placed to meet your needs Supporting skilled staff to use their expertise to the best only do what only you can do Support and development of new roles to complement the healthcare team and give staff a broader range of skills Further integration of health and social care roles Efficient use of resources ensuring that sustainable service models are in place, and that staff have sufficient complex work to maintain professional competence Development of more specialist teams and centres to help attract and retain specialist staff Support all staff including non-clinical, support staff in continued professional development to excel in all that they do Build on our links with the Universities to maximise the opportunities for research, innovation and development Support and develop our volunteers to continue to play a valuable role in health and well-being Alongside continued implementation of our recruitment and retention strategy, we have developed a website called Train Work Live - North Wales, to attract, recruit and retain staff. Through training and development we will make a major contribution towards relieving poverty, by creating pathways into employment, also supporting young disabled adults into employment. We can also use research, learning and training to raise standards outside employment. We are committed to paying a living wage to all staff. We will develop our workforce so that it has the right skills and operates in a research-rich learning culture. 47

308 Together we will deliver an approach to organisational transformation and our ambition to adopt a rights-based approach, underpinned by inquiry-based practice, systems thinking, strengths-based working and an understanding of how internal culture and external context set the conditions for the organisation going forward. All of this contributes to our cultural ambition to promote and enhance the well-being of future generations through delivering effective, efficient and excellent services for communities across North Wales. 48

309 Estates implications Like the rest of the NHS in Wales, our estates and facilities need a substantial level of capital investment to ensure that assets are compliant with regulations, fit for purpose and support the development of safe, sustainable and innovative models of care. Significant investment is required to bring our existing estate up to desired standards and there are currently significant challenges in keeping premises operational, in hospital and community healthcare and also in primary care. We will therefore need to secure substantial investment to ensure that our estate is fit for the future and will enter into discussions with Welsh Government regarding the potential opportunities. We will also be seeking to ensure the efficiency of the estate we have. These are some of the major estates implications from our proposals: We will use existing and new community facilities to support health improvement and prevention initiatives such as community development initiatives in Bangor, Parc Eirias and Shotton We will share facilities with other public services and third sector groups, working closely together, providing a broader range of support and making best use of shared assets We will develop health and well-being centres within local areas, from local advice and information points through to larger premises or campus facilities which provide a wider range of healthcare services We will improve the environment for healthcare, including ensuring a safe and compassionate environment for mental health services We will improve facilities such as midwifery-led units to ensure a normal and comfortable birth experience We will modernise our hospital facilities to ensure they are fit for purpose We will develop centres of excellence in our main hospitals for more specialised services to be delivered in North Wales We will continue to work towards the adoption of inclusive design principles at all our premises We will pursue opportunities to rationalise our Estate, including the disposal of premises that do not support our developing models of care or are not economical to run We will consider environmental infrastructure, how we can support a more resilient environment, and contribute positively to the natural environment 49

310 What we will do in the first three years We will continue to implement our current major capital programme, with the following schemes funded through All Wales capital resources: Complete the Ysbyty Glan Clwyd Redevelopment Project Complete and open the Sub-regional Neonatal Intensive Care Centre (SuRNICC) at Ysbyty Glan Clwyd Complete the redevelopment of the Ysbyty Gwynedd Emergency Department Redevelop The Elms Substance Misuse Services premises in Wrexham Develop a Hybrid Theatre at Ysbyty Glan Clwyd to support the new complex vascular centre We will submit specific business cases for the following schemes: North Denbighshire Hospital Central Denbighshire primary care Waunfawr Surgery Substance Misuse Services Shotton and Holyhead Delivering sustainable Orthopaedic Services in our main hospitals Robotic Assisted Surgery We will develop a further long term programme of investment to ensure that: All our mental health services have facilities which are fit-for-purpose and can support the recovery focused model of care set out in our strategy Our primary and community services facilities reflect the broader health improvement agenda and support the Care Closer to Home programme We have a clear investment programme for the Wrexham Maelor Hospital site to address infrastructure risks and ensure the hospital is able to deliver future services. We will undertake similar work for Ysbyty Gwynedd. 50

311 WHAT NEXT? This paper sets out the headlines of our ten year strategy how and why we have developed this, our vision for the future and our priority areas. There will need to be significant investment of time, effort and commitment as well as resource to implement the strategy. We also know that the strategy will need to be responsive and flexible enough to address any new opportunities or challenges which may arise and that we will need to review, refresh and revise the strategy as we monitor and evaluate the implementation of the proposals. The implementation of the strategy programmes will be taken forward both within the Health Board and importantly linking with partnership forums to ensure robust collaboration and closer integration of our approach. The details of the actions for the first three years of this ten year strategy will be developed and set out within our three year plan for How to stay involved During the development of the strategy we have established relationships with a number of groups and individuals who have helped co-produce the proposals. We will continue to involve people in the work streams that will take forward the proposals and will receive valuable feedback which will help keep the strategy live. We would welcome more people being involved on an ongoing basis through the Health Board s Get Involved! Initiative at: bcu.getinvolved@wales.nhs.uk website We look forward to continuing the discussion as we work to improve health, well-being and healthcare in North Wales. 51

312 Medicines Management Annual Report - Ms Morag Olsen Pharmacy Medicines Management Annual report.doc 1 Health Board Title: Author: Responsible Director: Public or In Committee Strategic Goals To improve health and provide excellent care Pharmacy & Medicines Management Annual Quality and Safety Report Louise Howard-Baker, Assistant Director Pharmacy & Medicines Management (East Area); Dr Berwyn Owen, Chief Pharmacist Dr Evan Moore- Executive Medical Director Public (Indicate how the subject matter of this paper supports the achievement of BCUHB s strategic goals tick all that apply) 1. Improve health and wellbeing for all and reduce health inequalities 2. Work in partnership to design and deliver more care closer to home 3. Improve the safety and outcomes of care to match the NHS best 4. Respect individuals and maintain dignity in care 5. Listen to and learn from the experiences of individuals 6. Use resources wisely, transforming services through innovation and research 7. Support, train and develop our staff to excel. Approval / Scrutiny Route Purpose: Significant issues and risks Special Measures Improvement Framework Theme/ Expectation addressed by this paper Quality, Safety and Experience Committee (meeting held ) The purpose of the report is to provide an annual quality and safety report for Pharmacy & Medicines Management. Homecare Progress in addressing issues identified in Trusted to Care around Medicines Storage. Medicines Management NA

313 2 Equality Impact Assessment This does not require an EIA as this does not meet the requirements set out for a EIA. Recommendation/ Action required by the Board The Board is asked to note the annual report. Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board

314 3 Pharmacy & Medicines Management Annual Quality and Safety Report Background Pharmacy and Medicines Management supports the Health Board to ensure that all aspects of medicines use are safe, clinically efficacious and cost effective. The governance standards for medicines use are set out in the BCUHB Medicines Code; Formulary compliance and monitoring of clinical practice ensures that standards are achieved and maintained. There are 401 Whole Time Equivalent (WTE) pharmacists, pharmacy technicians, pharmacy assistants, clerical staff and 6 medicines management nurses working in the three acute hospitals, General Practices (GP), community hospitals and care homes to support the safe prescribing, dispensing and administration of medicines. In : They are on track to deliver savings of more than 9m. They will have dispensed more than 1,500,000 items for inpatients and patients going home from our hospitals, which are often complex regimes. More than 40,000 interventions will be made on inpatient prescriptions to ensure that patients get the right medication, at the right dose, at the right time, and by the right route. Stopped more than 21,000 medicines which are no longer needed by the patient. Prepared almost 100,000 doses of readymade antibiotics, pre-prepared syringes of high risk medicines, cancer treatments and parenteral nutrition for neonates and adults. This annual report has been set around the themes of the Health and Care Standards to deliver person centred care. Governance, Leadership and Accountability A small governance team works to support the Chief Pharmacist to deliver the corporate work on safe management of controlled drugs, technical services including quality control and assurance, formulary, Individual Patient Funding Requests, policies and procedures, procurement and Home Care services. Some expansion of the team to support homecare and procurement will maximise patient access, service quality and financial rigour. Staying Healthy 1.1. Health promotion Protection & Improvement 92% of BCUHB pharmacies have the Choose Pharmacy platform installed. This enables them to run a number of core and enhanced services such as the Common

315 4 Ailments Scheme, Discharge Medicines Review (DMR). In addition, 139 of 155 pharmacies are able to deliver the emergency medicine supply, which is taking pressure off GP practices, Emergency Department (ED) and out of hour s (OOH) services. The Community Pharmacy Level 3 smoking cessation enhanced service has been revamped, with a restructured payment that rewards a quit and the seasonal flu vaccination programme. With the recent introduction of the Maternal Smoking Cessation Support, a Community pharmacy Level 2 enhanced service has been re-introduced across north Wales to allow ease of access to nicotine replacement therapy for pregnant ladies and new mothers. Access to supervised consumption for substance misuse clients has been reviewed and the updated enhanced service has been offered to all community pharmacies, where previously it was commissioned from a limited number. The result should result in less leakage of methadone and sublingual buprenorphine in north Wales. At the end of November 2017, community pharmacists had administered 6681 flu vaccinations in BCU. Safe Care 2.1 Managing Risk and Promoting Health & Safety Three medicines-related Patient Safety Solutions have been issued in BCUHB reported compliance to Welsh Government with an action plan in place. Two notices remain open from 2016: PSN015 and PSN030.Both relate to medicines storage and are referred to in this report under 2.6 Medicines Management. Business continuity Drug shortages, which are frequent and often for sustained periods, are managed collaboratively by the procurement lead pharmacist, shared services and local clinical pharmacy team leads. A number of drug shortages are for drugs used in mental health and epilepsy and BCUHB is having to purchase these at a higher price. The financial impact is an additional 4 million for Since August, there has been a worldwide shortage of Clexane (Enoxoparin), used to prevent and treat venous thromboembolic events, which has provided a challenge as the different strengths come into and go out of stock on a weekly basis. A change management process planned in advance and approved by Drugs and Therapeutics Group to therapeutically switch treatments has allowed pharmacists to proactively substitute medicines prescribed to our in-patients thereby preserving stocks for cancer patients who are self-administering. Prescribing advice has been made available in a timely manner to clinicians to safeguard patients. Homecare Over the last 2-3 years, there has been a 46% growth in the number of medicines supplied directly to 2,244 patients via homecare in north Wales. The annual spend for 2016/17 was in excess of 11.5 million. Significant VAT cost savings of approximately 2.3 million have been achieved for the Health Board this year alone. BCUHB is working with Welsh drug contracting to work with a single Homecare supplier for optimal contract management and to maintain quality and standards. The

316 significant growth in homecare supplied medicines has been accommodated to date within existing pharmacy resources at the detriment to its core procurement services including in particular stock management across the acute sites. In order to continue to sustain delivery of further efficiencies and maximise the use of homecare for more high cost medicines it is now acknowledged that an investment is required for 2018/19 to fund a dedicated medicines homecare team. This will allow our site procurement teams to return to managing purchasing in line with the All Wales drug contract and manage their stock holding effectively in line with the Carter report. A business case has been submitted several times, but is yet to be approved. 5

317 Interventions In two of the three acute hospitals, pharmacists record their interventions onto a Welsh database on one day per month. This equates to more than 40,000 interventions per year based on the current reporting rates. The cost avoidance of actual reported interventions for 2017 was over 1m. 6

318 7 2.3 Falls Prevention Pharmacy & Medicines management is involved in the strategic falls programme, but currently work is restricted to reconciling medicines in falls clinics. The ambition is to extend this service to be able to undertake medicines optimisation. Ongoing work to address the overall prescribing of hypnotics and anxiolytics, a group of drugs recognised as contributing to falls, continues and demonstrates a sustained reduction. 2.6 Medicines Management Medicines Storage Trusted to care In August 2015 Welsh Government issued two Patient Safety Notices: PSN 015: The storage of medicines: Refrigerators. Followed by PSN 030: The safe storage of medicines: Cupboards. They document the legal standards, best practice and patient safety recommendations that apply to the safe and secure storage of medicines on hospital wards. Well-designed and appropriate storage of medicines can reduce waste, incorrect medicine selection, the incidence of missed doses and provide enhanced security to avoid tampering or diversion. Structured walkabouts were carried out with where possible with a matron and ward manager. All in-patient areas in BCUHB including Community Hospitals and have been visited.

319 8 None of the acute hospitals or areas is fully compliant with PSN 015 and PSN030 on the storage of medicines. PSN030 is currently under review by WG and we are waiting for clarification on a number of the recommendations. Across BCUHB there are some common areas where the wards are almost universally non-compliant. These are: No room temperature monitoring on wards to ensure medicines are stored correctly. This includes all treatment rooms and IV fluid stores within wards. Lighting levels are less than 1460 Lux. Patients own bedside lockers are not fixed to wall. Common structural issues include: The lack of doors or locks on medicine/ fluid storage areas in some areas where the individual cupboards are of good quality, locked and in a well manned or secure location, which is relatively low risk. In other areas it will be high risk and need prompt remedial action. Medicines storage cupboards. A number of these cupboards are wooden rather than metal. The level of risk posed by these cupboards will need to be assessed. Patients Own Drug (POD) Lockers. All in-patient areas have POD lockers but no site has facilities for patient own medicines in the emergency department. Provision should be made for patients that are going to be admitted. In addition it has been found that escalation areas do not have POD lockers. Following a risk assessment, a prioritised improvement/replacement programme is being put together with estates to rectify the non-compliant areas. The Health Board has taken part in a Welsh survey on Medicines Administration, Recording, Review, Storage (MARRS). All Ward areas completed the questionnaire, which will form the basis for an action plan to ensure non-complaint areas are addressed. Automated Medicines Storage 54 Ward areas across BCUHB have automated medicines cabinets installed, covering ED, OOH and admissions areas; Medicine and surgery; Critical care; Mental Health, Community hospitals and satellite dispensaries. The benefits offered by this type of storage are: Secure access metal vending machine Intuitive software with the ability to develop safety alerts Different levels of access for different users (unlimited users) Customisable per ward 24hr availability and security Live stock control Automatic ordering based on usage Full audit trails Can be used to store controlled drugs (e.g. in OOH) Controlled Drugs Oversight of controlled drugs use in BCUHB is undertaken by the Chief Pharmacist, who has the delegated role of Accountable Officer via the Controlled Drugs Local Intelligence Network. This Group, which is multiagency, undertakes and provides oversight, scrutiny and a governance function in relation to the safe management of Controlled Drugs across North Wales.

320 9 Prescribing Pharmacists are involved with teaching undergraduate doctors and to a limited extent, postgraduates. In 2017 Foundation Year 1 (FY1) prescribing assessments took place in Ysbyty Gwynedd and Ysbyty Glan Clwyd for the new intake of doctors. The assessments cover legality, calculations, antimicrobial prescribing guidelines, thromboprophylaxis prescribing and some high risk drugs e.g. insulin, opiates. Experience over three years has demonstrated that doctors who have not trained in BCUHB generally fail this test. The pharmacy team currently offer adhoc mentorship and support to enable prescribers to make improvements. Medicines administration Registered Nurses and Midwives The medicines management nurses deliver training to registered nurses and midwives which include: For newly registered and those returning to practice after a break - a medicine management workbook and competence assessment to complete while under preceptorship. This is in addition to insulin administration e-learning and competence assessment and a second independent checker competency. Back to basics of medicine management, which is a face to face session covering Nursing and Midwifery Council (NMC) guidance and Health Board policy, is completed every three years. It also covers IT medicine management resources accessible to all staff. Registered nurses and midwives who are required to administer intravenous medicines as part of their duties attend a full study day with subsequent updates at three yearly intervals. Teaching on the nurse bank induction and Health Care Support Worker (HCSW) education on their medicine management responsibilities including safe storage, identifying unacceptable practice and how to report concerns. Individuals involved in medication related incidents or those struggling with their competencies have one-to-one support and an individualised action following assessments of medicines management practice. Patient Group Direction (PGD) training to ensure compliance and understanding from an NMC, Welsh Government and Health Board perspective. More recently they have been teaching on the back to floor sessions held to update nurses in medicine management who have not been clinical for a length of time. Education for non-medical prescribers while on their university course covers governance, policies and requirements to go onto the Health Board s database and evidencing professional development annually, Once qualified and practising, updates are provided and the Medicines Management nurses facilitate or chair the Non Medical Prescriber (NMP) forums. Carers and medicines administration A prescription is the most common intervention that a patient will receive following a consultation with a clinician. The number of citizens/residents requiring support with medicines management is increasing and the care they require is becoming more complex.

321 10 In December 2014 a multi-organisational Task and Finish Group was established to agree standards of best practice, and standard operating procedures for the use of medicines for adults in all care settings for North Wales. The key driver of the initiative was the safety and well-being of the citizen/resident ensuring that no matter where/whom is providing care relating to medicines management the standard is the same and the training and competence of the workforce. The following four documents have been developed and approved for implementation by all the relevant parties: 1. A Joint Agreement for the Code of Practice for the Management of Medicines in health and social care settings. 2. Standards of best practice and standard operating procedures for medicines management for all care settings for adults. 3. BCUHB Pharmacy and Medicines Management Standard Operating Procedure (SOP) for medicines management in Domiciliary Settings in North Wales. 4. BCUHB Pharmacy and Medicines Management Standard Operating Procedure(SOP) for medicines management in Care Home Settings in North Wales These documents apply to: all BCUHB employees including HMP Berwyn Staff all Local Authority (LA) social services staff staff from commissioned services whom provide services to others involving medicines (includes domiciliary care, care homes) both LA run and Independent Sector) and day services) BCUHB and each of the LA s within its boundary will specify that all providers of the services involving medicines will be commissioned to provide standards of medicines management specified within the code of practice, the standards of best practice and SOP s for the handling of medicines. Further task and finish groups have been established to support the implementation of the documentation identifying accredited training and competencies for carers and HCSW. The output from these groups is a Joint Education Framework for HCSW and Care workers involved in Medicines Management for Adults. Medicines Information The Medicines Information (MI) service promotes the safe, effective, economical and rational use of medicines within our health board, with a strong emphasis on promoting quality patient care and ensuring patient safety. The MI Service is available Monday to Friday, 9-5 and is contactable via phone, in person or via , and a bilingual helpline is available for patients. It deals with a huge range of enquiries each year. In the last 12 months, 1805 enquiries were answered across the Health Board, advice was provided within agreed deadlines for over 95% of enquiries. These enquiries varied in complexity with over 65% requiring specialist skills and interrogation of multiple resources and professional judgement. They originated from a range of primary and secondary care locations and were asked by a range of healthcare staff of varying grades.

322 11 Adverse Drug Reactions and Medicine Related Adverse Incidents BCUHB is a Bevan Commission exemplar for medicines related admissions work and this continues to focus on improving the reporting, coding and collection of data. The Safe Medicines Steering Group re-established in 2016 and using incident and intervention data will be focusing quality improvement projects on three areas in 2018 to reduce risk of harm from high risk medicines. The areas are 1. Prescribing errors 2. Administration errors 3. Delayed and omitted medicines. Pharmacy & Medicines Management supports serious incident reviews involving medicines. Examples outputs from serious incident review are a new policy on the handling of methotrexate in BCUHB and another focused on workflow redesign of in a hospital dispensary. A route cause analysis following a serious incident involving methotrexate identified gaps in both prescriber and nurse knowledge which resulted in the daily administration of the medication to inpatients. Methotrexate is usually taken once weekly and can cause significant harm if administered daily. All prescriber and nurse induction training now includes the prescribing and administration of methotrexate and a policy was developed and approved, which required pharmacy to quarantine the patient s own supply and limits the hospital supply of methotrexate to a single dose at a time. There is also guidance for nurses not to administer methotrexate unless the prescription has been checked by a pharmacist. Welsh Government have commended BCUHB for the learning and subsequent actions taken to prevent further incidents. Policies & Procedures, PGDs 60 separate policies and procedures have been reviewed and approved including those from the recently opened HMP Berwyn, Non Medical Prescribing, and Medicines Optimisation by the Medicines Management team. A major update and review of Patient Group Directions (PGDs) was undertaken to maintain compliance to NICE PGD Guidance. Standardisation of practice across BCUHB has reduced the number of active PGDs and PGD booklets to less than 80. Vital PGDs were put in place in time for the major autumn immunisation programme, that supported an extended range of professional staff to administer flu vaccines. A task and finish group has been set up to undertake a major revision and update the BCUHB Medicines Code in B. Braun pump drug libraries BCUHB has undertaken a major programme to move to a new type of intravenous drug pump, which has smart technology to enable the safe delivery of medicines. Pharmacy has identified a range of intravenous drugs that are standardised across BCU. This has formed the basis of a general drug library that is being implemented at Ysbyty Gwynedd, Glan Clwd and Wrecsam Maelor. The number of drugs contained within this library will grow over time as increased standardisation occurs.

323 12 In addition to this BCU wide working groups in specialist areas such as oncology and critical care have been set up to develop drug libraries specific to these areas. The first phase has looked at areas of commonality in practice across BCU which is forming the initial general libraries for these areas. Work will continue on continually building these libraries through standardising practice. Effective Care 3.1 Safe & Clinically Effective Care DTG The BCUHB Drug and Therapeutics Group met on the first Wednesday afternoon of each month in The Group, has 35 members drawn from across BCUHB including primary and secondary care doctors, nurses (medicines management), midwives, a dentist, a physiotherapist independent prescriber, pharmacists (clinical and primary care medicines management),a patient, finance and Association of the British Pharmaceutical Industry (APBI) representative respectively. Of 53 applications for new drugs to be added to the Formulary, 52 were approved with decision on the others being deferred to obtain further information. Over the same period 191 applications were considered to treat individual patients with drugs which were not in the Formulary at the time of application; 31 of these were not approved. Applications came from prescribers across BCUHB. NICE & AWMSG Impact Assessment Group BCUHB is fully compliant with the directions of the Welsh Health Circular 2017 (001) to make NICE and All Wales Medicines Strategy Group (AWMSG) positively appraised drugs available with 60 days of the recommendation. In 2017, 72 new AWMSG/NICE drugs have had been assessed to see where they fit into a treatment pathway, who the most appropriate prescriber is likely to be and whether the prescribing should remain in secondary care or whether it is suitable for GP prescribing, either solely, or with a shared care agreement in place. From a financial perspective, the impact assessment includes service capacity and whether an existing treatment is likely to be replaced. The spend is monitored and resources are drawn down to the responsible budget holder. Of the 72 new drugs that have gone through this process there were: Number of drugs Speciality 43 Cancer 6 Rheumatology 4 Cardiology 3 Endocrinology 3 Respiratory 3 Dermatology 3 Sexual Health 1 Mental Health 1 Ophthalmology 1 Neurology

324 13 HMP Berwyn The abuse of prescription drugs within the prison population is wide-spread nationally. An estimated 7% of prisoners develop a problem with prescription drugs whilst held in prison, excluding those with an existing dependence prior to their custody. It is a priority for Pharmacy and Medicines Management to work with health professionals and prison staff to focus on prevention of abuse and possible death. Following the NICE NG5 Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes, pharmacy technicians are embedded into the admission process of receiving patients into the prison where they conduct medicines reconciliation supported by a pharmacist. An informed medication review by the GP then follows so that safe optimisation of the patient s medicines can taken place. Since the prison opened in February 2017, there were: 8504 medication orders dispensed by pharmacy staff; 1051 interventions made by pharmacy staff; 557 patients medicines reconciled with a pharmacy staff member; 210 check-ups conducted with patients in their rooms regarding their inpossession medication; One key aspect of medicines optimisation at HMP Berwyn involves the safe prescribing of medicines liable to misuse and abuse, such as analgesic, hypnotics and anxiolytics. Where there is no clear indication or where there are concerns for safety because of interactions, potential abuse or diversion, these may be gradually reduced until they can be withdrawn altogether. Ward technicians With agreement from the Assistant Director for Nursing, Ysbyty Wrecsam Maelor, pharmacy increased the Pharmacy Technician support (to 1WTE) to a busy medical ward in Wrexham on a trial basis. The aims were to support nursing staff in: Medicines Management Double checking controlled drugs, intravenous and subcutaneous medication to patients, including insulin and anti-coagulants i.e. high risk medication. Despite going through an appropriate training programme, there was a lack of clarity regarding the interpretation of the second registrant in NMC guidance and BCUHB s Medicines Code, so the second aim was postponed. The Medicines Code has now been amended to allow this second checking by a technician to go ahead. The outcomes from this exercise demonstrated fewer missed or delayed medication administrations, cost savings and improved flow of patients. The Medicines Safety Thermometer audits for the ward concerned show that on average 58% of patients are given all appropriate medication doses. The technician identified 1695 opportunities for omitted medicines for 23 patients for the duration of their inpatient stay. Only 4 actually occurred due to medication not being available (code 5 ). Two of the medicines were newly prescribed and the other two were for a cream, which was with the patient and a single dose of oral multivitamins. There were 7 single unsigned doses (0.41%), mainly from the 10pm medicines rounds. The technician also recorded her interventions during the three months. These included:

325 14 Medication charted which the patient no longer took (subsequently discontinued). Regular medication inadvertently not prescribed on admission (subsequently prescribed). Incorrect doses and/or frequencies prescribed (subsequently amended). The graph below demonstrates that the majority of take home medicines were completed within half an hour of receiving the signed prescriptions and patients could be discharged from the ward before 2pm. The cost savings were achieved by not re-supplying medicines that the patient had recently been issued. This was possible by using the GP record and having the time to counsel patients/relatives about their discharge medication. No. of discharges No. of items on discharge No. of items dispensed at discharge Cost of dispensed items Total cost of nondispensed items Work has also been on going on the Ysbyty Gwynedd site, to extend the role of the Pharmacy Technician. A two week pilot on two wards demonstrated a reduction of one hour were the pharmacy team took the lead in transcribing the take home (TTO) prescription and proactively preparing patients for discharge. An additional patient was ready each day for discharge before 11am.

326 15 Prescribing Indicators For , there are 14 primary care National Prescribing Indicators focusing on seven areas of prescribing and the reporting of adverse events (Yellow Cards). BCUHB s performance has improved in all but two; BCUHB has the lowest prescribing of opioid patches and this remained almost the same; pregabalin and gabapentin was the other indicator, where all other Welsh health boards saw growth. A social media campaign is running in north Wales to raise public awareness of PPIs and antimicrobial over use. The data on proton pump inhibitors below shows one area where BCUHB has made significant progress: Antimicrobial Stewardship BCUHB is no longer the highest prescribing Health Board in Wales for antibiotics in primary care. There have been reductions of prescribing in 5 of the 6 cluster areas, giving an overall reduction in total antibiotic usage of 7.6%. Clusters plans are focusing on the 10% of practices with the highest antibiotic prescribing rates to improve further.

327 16 The annual Public Health Wales report on antimicrobial prescribing in secondary noted a significant decrease in prescribing in Betsi Cadwaladr UHB across the time period; with no significant change in any other Welsh health board. They also highlighted a significant decrease of prescribing in Wrexham Maelor across the time period, and a step-wise decrease in prescribing in Ysbyty Gwynedd during 2013/14; but no significant change in any other hospital. Hepatitis C We are now able to treat hepatitis C with direct-acting antivirals (DAAs) thereby curing patients to prevent future complications such as cirrhosis further spread of the virus. In comparison to older regimens involving interferon, these agents have greatly improved cure rate, with a lower incidence of side-effects, and a shorter treatment duration of 8-12 weeks in most cases. The World Health Organisation has outlined an aim to eradicate hepatitis C by To achieve this, BCUHB will need to treat 194 patients per year. An all Wales guideline followed by Health Boards ensures that the most suitable and cost-effective regimen is chosen for each patient, and that all patients receive equitable access to treatment. So far in , forty one patients have so fa have either completed treatment, are currently on treatment or will be initiating it soon. 3.2 Communicating Effectively In 2017, Pharmacy and Medicines Management were successful in a bid for charitable funds to engage with the public around safe use of antibiotics and proton pump inhibitors and also targeting a reduction in waste prescription medication. Posters, leaflets, videos have been purchased and social media used to support our messages. We have worked closely with the area engagement officers and our Communication s team to support attendance at local events across the six counties. A BCUHB logo displayed on all materials has been designed.

328 Quality Improvement, Research and Innovation In the 12 month period to end of October 2017 the pharmacy teams supported 49 Clinical Trials of Investigational Medicinal Products (CTIMPs) across the three acute hospital sites, 20 of which were conducted at more than one site. Within this timeframe three new CTIMPs were opened; nine closed to recruitment with patients still receiving treatment; and eighteen CTIMPs were closed down. The role of Pharmacy is to safeguard subjects, healthcare professionals and BCUHB by ensuring IMPs are appropriate for use and are procured, handled, stored and used safely and correctly, and disposed of appropriately. Pharmacy must also ensure that procedures are in place to comply with the regulations and relevant guidelines and directives e.g. Good Clinical Practice (GCP) for clinical trials. Within the pharmacy family: 11 local and national completed audits were undertaken. There were 5 completed service evaluations of which two were submitted as dissertations for Masters level degrees. One research study was completed and submitted as a dissertation for an MSc in Clinical Pharmacy. Four service/quality improvement projects were completed. Dignified Care 4.2. Patient Information A bilingual medicines information helpline is provided for patients. The queries only made up 3% of those dealt with by Medicines Information, although it hasn t actively been promoted due to staffing shortages. These have now been resolved, so promotion of the Helpline will resume. The employment of a Community Continence Nurse by central area to create a formulary of continence devices, review patients in the community, offer advice and provide education and training to care home staff has resulted in savings from rationalising the range of products, and at the same time benefits for patients who have been discharged from specialist care and are living independently at home without district nursing input. The west have recruited a continence nurse starting January 2018 and the east area is looking to recruit a community continence nurse in Also in place in the west is a Community Stoma nurse who reviews patients in GP practices and also supports care home staff. This has significantly improved the care of patients within the community setting. MyNewts There are an increasing number of patients who receive nutrition and medication at home via a PEG (percutaneous endoscopic gastrostomy) tube. The Pharmacy department at Wrexham Maelor hospital have, for over 10 years, produced guidelines aimed primarily at Health Care Professionals covering the administration of medicines via PEG (and Nasogastric) tubes. This resource is available internationally via This year, in conjunction with Dietetics and Nutrition, a resource for patients and their carers, MyNewts was developed. MyNewts are available for all drug monographs and provide a step by step guide for patients/carers to administer each individual medicine prescribed. They include flushing volumes, if a feed break is recommended and other pertinent

329 18 information ensuring patients/carers are empowered to administer their medication safely. Patient & carer feedback has been very positive. Timely Care 5.1. Timely Access In 2016, Welsh Government issued a Patient Safety Notice relating to the Medicines reconciliation following the death of a patient who had been admitted into hospital, but an accurate and complete list of the medication had not been obtained. The rate of medicines reconciliation in 24 hours in BCUHB was approximately 72%. So, despite having pharmacy cover on the medical admission wards seven days a week, more than a quarter of patients do not have an accurate list of medicines. Funding has meant that pharmacists have been put in Emergency Departments to capture patients early, and reduce delays and omissions of critical medicines such as drugs for Parkinson s disease or epliepsy, while patients are waiting for an inpatient bed. MTeD (Electronic Discharge Advice Letters) Roll out of MTeD is almost complete across all specialities in the West. In the Centre Medicine, Children s, Mental Health and some Community Hospitals are using MTeD with plans to roll out across Surgery and Women s in early Wrexham continues to use EPOC to produce electronic discharges in acute Medicine with MTeD starting to be used on Surgical and Children s wards. More than 2300 discharge advice letters are sent electronically to GPs each month. Feedback from General Practice has been very positive and confidence in the system is sufficiently high that they no longer require a paper copy to be sent saving time and expense. Individual Care 6.1 Planning Care to promote Independence Collaboration with all six social services and community nurses to optimise medicines is reducing the number of carer visits to homes simply to administer medication, thus supporting better use of staff resource for visits to others Listening and Learning from Feedback Feedback All three acute sites have introduced the NHS Wales uniform for technicians and assistants although it is still voluntary for pharmacists. This followed feedback from patients that they often could not identify pharmacy staff. 100% of 28 patients surveyed in the west agreed or strongly agreed that that they were satisfied with their pharmacist consultation in a GP practice. In the east, any pharmacy staff leaving are asked to complete a leavers form and meet with the department listening lead. Any negative comments are brought to the senior managers meeting for discussion and action or resolution.

330 19 Complaints In 2017 there were: 5 AM/MP letters relating to medication 4 Formal complaints (3 west, 1 east) 1 formal CHC complaint (west) 3 OTS upgraded to Formal complaints (1 HMP Berwyn, 1 east) Staff and Resources 7.1 Workforce In line with BCU s 3 Year Plan, Medicines Management s service developments include proposals to further expand and extend the role of the medicines management team within the managed (primary and secondary care) and independent sector (community pharmacy). This will be achieved by increasing the workforce through a combination of skill mix and recruitment and training of qualified and unqualified staff. Appropriately trained and competent staff will be a prerequisite for delivery of a modernised workforce. The key drivers for our workforce are as follows: Modernisation of the workforce working within the primary and community setting. This will need the development of our pharmacists to release clinical capacity by delivering advanced clinical practice including independent prescribing and pharmacy technicians to develop safe, robust, efficient medicines management standardised processes within each GP practice. Significant changes to the community pharmacy contract are taking place as money is being moved from paying for items to be dispensed to more patient facing services. Increasingly, centralisation of dispensing is taking place in the independent sector, so in the future the majority of prescriptions will be dispensed within automated hubs to free capacity and reduce costs in the community sector. This offers opportunities for the health board to develop new enhanced services to be delivered by community pharmacists although there is a risk that there could be a reduction in the number of community pharmacies, which will likely impact on workforce. Integration of clinical pharmacists, pharmacy technicians and assistant technical officers within the clinical ward Multidisciplinary Team (MDT) and Pre-Operative Assessment Clinics (POAC) to ensure robust medicines optimisation and patient care, patient care and improved flow. Information Management &Technology (IM&T) development is slow and does not support the pace of change and demand. IM&T support is essential for full implementation of the following projects. o The Choose Pharmacy service o Optimal pace of change for developments such as Medicines Transcribing and electronic Discharge (MTeD) which improves and strengthen our communications and electronic links with GP practices and Community Pharmacies (CP). o Welsh Electronic Prescribing and Medicines Administration (WEPMA) which will lead to improved quality and safety of prescribing, and reduce the risk of medication administration errors. It will provide robust audit and reports.

331 20 To strengthen the corporate team to ensure that BCUHB medicines management complies with legislation and standards of best practice and to ensure the best use of Health Board resources by the safe introduction of new drugs and the monitoring of high cost/complex drugs. Mandatory Training 89.8% PADR rate 53% (This is much lower than in previous years. The east area pharmacy team have restructured their appraisal hierarchy and spent time with Workforce and OD training both appraisers and appraisees on how to use the new PADR paperwork, so this figure is now on the increase). Key Risks The key risks are relating to medicines management in BCUHB taken from the risk register are: Medicines reconciliation Medicines storage Medicines administration Prescribing Prescribing budget Homecare B. Braun pump library updates and maintenance It has been identified in the last 6 months that the time taken to develop, validate and maintain the drug libraries is significant and does require additional resource. Without this input there is a risk that future development may be hindered. It has also been recognised that there is significant variation in practice across BCU in administration of intravenous medications and obtaining standardisation across all areas will be very challenging and will require input from all specialties

332 Vascular Services Update - Dr Evan Moore a Vascular report.docx 1 Health Board Title: Author: Responsible Director: Public or In Committee Strategic Goals To improve health and provide excellent care Progress Report on the North Wales Vascular Service Mr Robyn Williams, Project Manager Dr Evan Moore, Executive Medical Director Public (Indicate how the subject matter of this paper supports the achievement of BCUHB s strategic goals tick all that apply) 1. Improve health and wellbeing for all and reduce health inequalities 2. Work in partnership to design and deliver more care closer to home 3. Improve the safety and outcomes of care to match the NHS best 4. Respect individuals and maintain dignity in care 5. Listen to and learn from the experiences of individuals 6. Use resources wisely, transforming services through innovation and research 7. Support, train and develop our staff to excel. Approval / Scrutiny Route Purpose: Significant issues and risks Executive Medical Director To update the Board on the provision of a networked vascular service across North Wales. Following the setting up of the Vascular Implementation Task & Finish Group by the Executive Management Group, this quarterly report is provided to update the Board as to the progress this implementation group is making. All risks identified by the Task & Finish Group will be included on the Corporate Risk Register Equality Impact Assessment Recommendation/ Action required by the Board No equality impact assessment is considered necessary for this update paper. The Board is requested to note and approve the work which has been undertaken to date. Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board

333 2 Betsi Cadwaladr University Health Board Update on North Wales Vascular Service October 2017 to January Network Vascular Consultant Posts Mr Hans Desmarowitz, Consultant Vascular Surgeon has taken up appointment. Mr Sean Matheiken has informed that he has taken up the offer of a consultant vascular post in the North West of England. Mr Soroush Sohrabi has confirmed that he will be taking up his appointment as Consultant Vascular Surgeon with the Health Board on 2 nd April Mr Edward Brown will commence as consultant vascular surgeon in September Miss Ursula Kirkpatrick, Consultant Vascular Surgeon at Ysbyty Maelor, Wrexham tendered her resignation and left the employment of the Health Board during January Her vacant position is now being covered by Mr Andras Palffy, Agency Locum Consultant Surgeon. The Vascular Network is currently in the process of recruiting two Consultant Vascular Surgeons. 2. Interventional Radiology Following placement of the advertisement for three Consultant Interventional Radiologists in both the BMJ and NHS Jobs no applications were received. These posts will be re-advertised during early February 2018 and will feature in a joint advertisement in the BMJ with the Consultant Vascular Surgeon posts. Closing Date will be 11 th March An Open Day for prospective candidates is planned for 8 th March If suitable applications are received, interviews are scheduled for 13 th April Clinical Director North Wales Vascular Network Professor Dean Williams, Consultant Vascular Surgeon has been appointed at competitive interview, to the post of Clinical Director - North Wales Vascular Network. 4. Service Model North Wales Vascular Network

334 3 Professor Dean Williams has undertaken a review of the Service Model for the North Wales Vascular Network, which was presented to the Vascular Implementation Group. The model received clinical approval though it was anticipated that further refinements would need to be made as the Network develops. All three DGH s will continue to provide vascular outpatient clinics, pre-operative assessment, diagnostics and day case surgery including vascular access for patients requiring haemodialysis. However, in line with national guidance and based on the local excellence already provided in North Wales, in-patient elective and emergency vascular services are to change. Ysbyty Glan Clwyd, Bodelwyddan, will be the single centre for the radiological and surgical interventions for patients with carotid and abdominal aortic aneurysm disease. Patients with diseases of the lower limbs related to the circulation will be managed at both Ysbyty Glan Clwyd and the limb salvage unit at Ysbyty Gwynedd with provision for elective and emergency admissions and in-patient treatments at both sites. Specialist diabetic foot and leg ulcer services based at Ysbyty Gwynedd will expand further to include a network of clinics serving the whole of North Wales. These arrangements will facilitate the planned changes to the vascular service and enhance the already globally recognised provision we have in North Wales. 5. Business Justification Case Confirmation of approval of the Business Justification Case from Welsh Government is still awaited, though it was anticipated that the public announcement was imminent. Arrangements are now being made with the Corporate Communications Department to produce a Communications Statement in response to the announcement. The date that the funding becomes available will have an impact on the date the Hybrid Theatre becomes operational as the Design and Building work can only be commenced from the time the funding becomes available. 6. Hybrid Theatre Equipment Selection Group The work of the Equipment Selection Group has been completed. The Procurement process can only be progressed from the date the funding is made available. Recommendation The Board is requested to note and approve the work which has been undertaken to date.

335 b Vascular appendix.pdf North Wales Vascular Services I wanted to provide colleagues with a brief update on the development of our tertiary arterial service. As you know the Health Board is committed to create a specialist arterial service for the population of North Wales. Following advertisement and a competitive interview process I am pleased to announce that Professor Dean Williams has been appointed to the position of Clinical Director North Wales Vascular Services. Dean brings a wealth of leadership experience and strong track record of clinical and academic success, and will lead the transformation of our services. We have successfully recruited three consultant vascular surgeons, have secured funding for additional interventional radiology facilities at Ysbyty Glan Clwyd and Ysbyty Gwynedd. In addition we are currently out to advert for two additional vascular surgeons and three interventional radiologists. We are waiting confirmation of funding from Welsh Government for our Hybrid theatre and expect to open this late 2018 or early In line with national guidance all three DGH s will continue to provide vascular outpatient clinics, pre-operative assessment, diagnostics, day case surgery including vascular access for patients requiring haemodialysis and have full support for emergency patients and in patients. As previously detailed the formation of our centre at Ysbyty Glan Clwyd will see, in-patient elective and emergency vascular services change for North Wales Ysbyty Glan Clwyd, Bodelwyddan, will be the single centre for the major radiological and surgical interventions for patients with carotid and abdominal aortic aneurysm disease. Whilst building upon and protecting the excellent lower limb services already provided from Ysbyty Gwynedd, patients with diseases of the lower limbs will be managed at both Ysbyty Glan Clwyd and the limb salvage centre at Ysbyty Gwynedd; with provision for elective and emergency admissions and in-patient treatments at both sites. Specialist diabetic foot and leg ulcer services based at Ysbyty Gwynedd will expand further to include a network of clinics serving the whole of North Wales. These arrangements will facilitate the planned changes to the vascular service and enhance the already globally recognised provision we have in North Wales. Dr Evan Moore Cyfarwyddwr Meddygol Gweithredol a Dirprwy Brif Weithredwr Executive Medical Director and Deputy Chief Executive T18B0199/8 th February 2018

336 Welsh Health Specialised Services Committee Joint Committee Approved Core Briefing WHSCC Joint Committee Core Briefing APPROVED.pdf WELSH HEALTH SPECIALISED SERVICES COMMITTEE JOINT COMMITTEE MEETING JANUARY 2018 The Welsh Health Specialised Services Committee held its latest public meeting on 29 January This briefing sets out the key areas of discussion and aims to ensure everyone is kept up to date with what s happening in Welsh Health Specialised Services. The papers for the meeting are available here Action Log & Matters Arising Members noted the action log. A presentation on the Integrated Commissioning Plan was to be considered in private session. Chair s Report The content of the Chair s written report was noted. Charles (Jan) Janczewski was appointed as an Independent Member of the Joint Committee and as a member and Chair of the Quality & Patient Safety Committee, all effective from 1 February Managing Director s Report Members noted the content of the Managing Director s report and in particular updates on: Inherited Bleeding Disorders Cardiac inter hospital transfers Appointment of an Information Manager to the WHSS Team Alternative Augmented Communication (AAC) Evaluation Members received an evaluation report of the AAC service undertaken by Dr Amanda Squire of Cardiff Metropolitan University which considered the progress of health boards in implementing the new service model, identified potential improvements in service delivery and outlined recommended funding levels for a further two years followed by a further evaluation in An indication had been received from Welsh Government that all future funding for AAC would come from the NHS; it was felt that this should be explored further to determine whether any funding was available for transfer from elsewhere, including the potential for funding from the Integrated Care Fund. WHSSC Joint Committee Briefing Version: 1.0 Page 1 of 5 Meeting held 29 January 2018