Bundle Health Board - public 10 April 2018

Transcription

1 Bundle Health Board - public 10 April am Coleg y Bala, Bala LL23 7RY Agenda attachments Map.doc 1 B18/1 Joint Chairs' Welcome and Introductions 2 B18/2 Apologies 3 B18/3 Declarations of Interest 4 B18/4 Minutes of Meeting Held on for Accuracy, Matters Arising and Review of Actions B18.4 Minutes CHC Board to Board v. 03.doc 5 B18/5 Mental Health Update - Mr Andy Roach (Presentation) 6 B18/6 Urological Cancer - Dr Evan Moore (Verbal Update) 7 B18/7 Staff Recruitment and Retention - Mrs Reena Cartmell B18.7 Nurse Staffing Board Report.docx 8 B18/8 Financial Position - Mr Russ Favager B18.8a Finance Report - Month 11 Board Report.docx B18.8b Draft Interim Financial Plan docx 9 B18/9 Infection Prevention "Safe Clean Care" - Mrs Reena Cartmell (Presentation) 10 B18/10 Date of Next Meeting Tuesday am

2 Agenda attachments 1 Map.doc

3 4 B18/4 Minutes of Meeting Held on for Accuracy, Matters Arising and Review of Actions 1 B18.4 Minutes CHC Board to Board v. 03.doc Minutes Board to Board CHC v0.03 Page 1 of 6 Betsi Cadwaladr University Health Board (BCU) and North Wales Community Health Council (NWCHC) Joint Board Meeting Minutes of the meeting held on in Neuadd Reichel, Bangor Present: Health Board Dr Peter Higson, Chairman Mr Gary Doherty, Chief Executive Cllr Cheryl Carlisle, Independent Member Mr John Cunliffe, Independent Member Ms Jenie Dean, Independent Member Mr Russell Favager, Executive Director of Finance (part) Cllr Bobby Feeley, Independent Member Mrs Marian Wyn Jones, Independent Member Mr Geoff Lang, Executive Director of Strategy Mrs Grace Lewis-Parry, Board Secretary Mrs Lyn Meadows, Independent Member Dr Evan Moore, Executive Medical Director Miss Teresa Owen, Executive Director of Public Health Prof Michael Rees, Chair, Healthcare Professionals Forum Mrs Bethan Russell-Williams, Independent Member Prof Jo Rycroft-Malone, Independent Member (University Mr Ceri Stradling, Independent Member (part) Mr Adrian Thomas, Executive Director of Therapies & Health Science Community Health Council Mr Mark Thornton, Vice Chair NWCHC Mr Geoff Ryall-Harvey, Chief Officer Ms Eleanor Burnham, Chair Wrexham Local Committee Mr Alan Dixon, Chair Ynys Môn Local Committee Mrs Stephanie Howard, Vice Chair Flintshire Local Committee Mrs Nerys Jones, Vice Chair Wrexham Local Committee Mrs Rita Jones, Flintshire Local Committee Cllr Eryl Jones-Williams, Gwynedd Local Committee Mrs Menna Llewellyn Williams, Chair Gwynedd Local Committee Mr Peter Rendle, Ynys Môn Local Committee Mr Roger Williams, Chair Conwy Local Committee In Attendance: Mrs Sally Baxter, Assistant Director Health Strategy (part) Mrs Reena Cartmell, Deputy Director of Nursing Mrs Kate Dunn, Head of Corporate Affairs Mr Gwilym Evans, Vice Chair Stakeholder Reference Group Mr Nigel Lee, Secondary Care Director Translator/Observers Agenda Item Action B17/12 Welcome and Apologies Mr M Thornton and Dr Higson opened the meeting and welcomed those present.

4 Minutes Board to Board CHC v0.03 Page 2 of 6 B17/13 Apologies Apologies were received on behalf of the Health Board from Mrs Margaret Hanson, Mrs Gill Harris, Mr Martin Jones and Ms Morag Olsen. Apologies were received on behalf of the Community Health Council from Mrs Carol Williams, Dr Garth Higginbotham, Dr Tak Matsuda, Dr Sibani Roy and Mrs Jackie Allen B17/14 Declarations of Interest None declared. B17/15 Minutes of the previous meeting held on B17/15.1 The draft minutes were approved as a correct record pending an amendment to B17/9.1 raised by Cllr Jones-Williams to ensure the minute captured the importance of technology such as Skype, Video Conferencing and Telemedicine. B17/15.2 Mr Ryall-Harvey raised a matter arising regarding urology in terms of digital records and catherisation, noting that a meeting was scheduled and there was a good level of progress. B17/15.3 Mr Ryall-Harvey raised a matter arising regarding the report into boredom and loneliness in community hospitals, and confirmed there had been a detailed response from the Executive Director of Nursing & Midwifery. Dr Higson asked that the report and the Health Board s response be publicised. Comms Team B17/16 Special Measures Update B17/16.1 Mr Doherty reminded members that as part of Special Measures, there were a range of areas where the Health Board was expected to make improvements and that a progress report for Phase 3 was due to be submitted to Welsh Government at the end of November. The Health Board continued to receive monthly updates from the Special Measures Task & Finish Group and to also have a deep dive focused report on a particular theme every other month. He was unable to give an indication as to when the Board may expect to come out of Special Measures and whilst significant progress had been made in many areas there also remained more work to be done for example a significant piece of work would be the implementation of the Together for Mental Health strategy and evidencing service improvements as a result. B17/16.2 Cllr Jones-Williams made reference to an event in Dolgellau community hospital regarding dementia in men and felt this was an excellent example of a community hospital showing innovative practice. It was also noted that the winner of the Healthcare Support Worker of the year award was also from Dolgellau hospital. B17/17 Financial Position Month 6 and Financial Recovery B17/17.1 Mr Favager reminded members that when the Health Board set out its financial plan for it was mindful of the challenges facing it and the need to ensure that quality and safety of services were not compromised. The Health Board therefore approved an Interim Financial Plan which set a deficit budget as a planning assumption of 26m; following a need to deliver savings of 35.4m. At the month 6 position the Board

5 Minutes Board to Board CHC v0.03 Page 3 of 6 was in a 25m deficit situation with the most significant pressures being pay (predominantly around use of agency due to number of medical and nursing vacancies); individual care packages and drug costs (particularly ophthalmology). Mr Favager also indicated that Welsh Government (WG) had recently set a medical agency cap which was likely to result in improvements in the Health Board forecast position although the impact on services would need to be managed. Mr Favager added that a key headline for members was that if the Board were able to recruit substantively to all the vacant posts it would save 1m per month. B17/17.2 Mr Ryall-Harvey indicated that the CHC could see the efforts being made with regards to recruitment and accepted the related challenges. He reported that the CHC had flagged its concerns over the agency cap although appreciated why it had been introduced by WG. Mr Doherty responded that the cap already applied in England, and also that each case would be risk assessed and a judgement made taking into account the needs of the services. Ms Burnham felt that the Board should be focusing on retaining its existing substantive workforce, and Mrs Llewelyn-Williams added that succession planning could be improved. Mr Doherty responded that the Board was certainly not complacent around its workforce issues and there was potential for more pace across all elements of recruitment, and in terms of succession planning the Board did review its staffing profile to develop modelled scenarios. Mr Thornton was pleased to see a statement regarding delivery of the financial plan whilst not compromising quality and safety. He also enquired as to what HRG4+ related to and Mr Favager confirmed this related to specialist services and the associated tariff system in NHS England. B17/18 Living Healthier Staying Well Update B17/18.1 Mrs Baxter was in attendance. Mr Lang introduced the agenda item confirming that the paper set out aspirations regarding the Board s long-term direction of travel. It was confirmed that he and Mrs Baxter were attending the CHC Board meeting within the next week which would provide a further opportunity for detailed discussion. A presentation was given which incorporated: 7 principles of the Strategy (prosperity; resilience; health; equality; cohesiveness; global responsibility and culture/welsh language) Well-being objectives and how they apply to the Act Population Health outcomes framework Vision of how the Board will support patients, families, carers and communities Initial priority workstreams Care closer to home Areas for delivery in terms of people with more serious health needs Engagement materials and questions to initiate a conversation Next steps B17/18.2 Mrs Baxter gave an overview of the approach to engagement through a range of events and opportunities utilising a range of materials. She indicated that specific groups were being targeted such as engaging with stroke groups on best models of care for stroke patients. B17/18.3 Mr Ryall-Harvey felt that poverty was a significant factor in health and well-being and it should be reflected that the NHS was a driver for addressing poverty in communities, together with other partners. Mrs Llewelyn-Williams acknowledged the work undertaken to date by the Health Board and looked forward to the strategy

6 Minutes Board to Board CHC v0.03 Page 4 of 6 development. She outlined her concern that adequate consideration needed to be given to transport issues to ensure equality of access to services for those in the more deprived areas, and also the essential services provided by some branch surgeries in poorer areas. Finally she wished to acknowledge the excellent health promotion work undertaken in Dolgellau. Mr Lang accepted the points around accessibility of services and assured members that this had been taken into account when discussions took place regarding the options and models for the organisation of stroke and orthopaedic services for example. Ms Burnham welcomed the paper, and noted that the North Wales Police now had officers trained in mental health. Mr Lang added that some Community Psychiatric Nurses were based with police officers and there was training to help them better support people with mental health issues. Dr Higson agreed that transport would need to modernise in conjunction with the Ambulance Service, and there needed to be increased use of telemedicine. Cllr Jones-Williams referred to a pilot where ipads were funded to encourage and enable young carers to use Skype and other mechanisms to get advice and support. Cllr Carlisle was aware of this project. B17/19 Seasonal Plan / Winter Resilience B17/19.1 Mr Lang presented the report, stating that all members would be all familiar with the format and content and that more recently the organisation had tried to overlay the winter plan with a range of other approaches and the need to review how systems coped with pressures over the whole year and not just the short winter period. Mr Lee stated that there was a focus within communication messages with the general public about the importance of keeping healthy and reducing infection through good practice, eg; hand washing. He also reported that clinically-led Safety Huddles had been introduced on each District General Hospital site which focused on risk. B17/19.2 Ms Burnham enquired whether there was a particular issue relating to infection prevention and control at the Wrexham Maelor site. Mrs Cartmell responded that year on year it was known it was likely there would be a norovirus outbreak on site, and a range of interventions and actions had been developed through engagement with clinicians and colleagues. Mrs Llewellyn-Williams welcomed the increase in the number of beds in Ysbyty Alltwen to 23 and indicated that the staff were pleased with this development. She went onto refer to the temporary closure of an orthopaedic elective surgery ward in Ysbyty Gwynedd last year and expressed concern that this must have contributed to longer waiting lists. Mr Lee confirmed that some ring-fenced orthopaedic beds were closed last year but there were no plans to do so this year as it was not desirable to interrupt routine elective surgery. [Mr Favager and Mr Stradling left the meeting] B17/20 Welsh Government White Paper Services Fit for the Future B17/20.1 Mr Ryall-Harvey felt that the White Paper commended the Scottish CHC model. He outlined the importance of the advocacy role of CHCs and in undertaking engagement exercises. It was expected that the Welsh Government interpretation of consultation responses would be received before Christmas. Mr Thornton indicated that the CHC s response to the consultation had very much been guided by the public. Mr Doherty confirmed that the BCU response had been agreed by the whole Board and that he and the Chairman had also been party to a range of all Wales conversations. [Cllr Jones-Williams left the meeting]

7 Minutes Board to Board CHC v0.03 Page 5 of 6 B17/21 Complaints Management : Update on Performance B17/21.1 Mrs Cartmell presented the paper and reported that there had been a focus on addressing the backlog of concerns with a managed plan and trajectories to improve the 30 day target. Table 1 in the paper demonstrated there was a positive downward trend although it was accepted there was significant work still to do. It was recognised that effective communication with individuals who had raised a concern was essential, and Mrs Cartmell indicated that it was hoped to be able to provide a single point of contact for each complainant. Ms Burnham outlined a personal experience and suggested that concerns were often not considered or dealt with soon enough and that outcomes would be better if issues were resolved quickly. Mrs Cartmell outlined the principle of On The Spot complaints which was a key part of the complaints process, but which did need the support of clinicians to make happen. Mrs Howard and Mrs Llewellyn-Williams stressed the importance of training and educating staff to provide them with the skills to resolve matters face to face. Mr Doherty wished to add that every week he received letters from patients and families thanking staff members and teams on exemplary care. Professor Rees raised the issue of mediation and felt this was something that could be used more effectively. Mr Thornton thanked Mrs Cartmell for the update and welcomed the renewed vigour in terms of complaints performance. B17/23 Recruitment and Retention of Medical and Nursing Staff [Agenda item taken out of order at Chairs discretion ] B17/23.1 Dr Moore provided a verbal update, highlighting areas such as vascular surgery, obstetrics, psychiatry and Emergency Departments where vacancies had either been filled or there was good progress and an increased level of confidence. He noted that those areas that remained challenged such as breast radiology, histopathology, dermatology and rheumatology, did reflect the national picture. He accepted that some of the agency rates in BCUHB were very high, but assured members that the Board was committed to developing a model that was less reliant on locum doctors, and Mrs Cartmell outlined work that was ongoing with schools of nursing and universities. Mr Thomas stated that the Health Board had had a good presence at recent Career Wales events, and there were also opportunities to be explored through increased roles for advanced practitioners. [Dr Moore left the meeting] B17/23.2 Ms Burnham enquired about opportunities for health care support workers to undertake additional training to move into nursing. Mrs Cartmell confirmed that they would always be encouraged to develop and that a career framework was being developed for this staff group. Ms Burnham also asked whether there was any anticipated workforce issue as a result of Brexit, and Mr Doherty responded that this was being watched with interest and there could potentially be a loss from the workforce and difficulties in recruiting to certain specialties. There was a noted UK reduction in the number of staff coming into the workforce from Europe. In response to a further point regarding Welsh Language within the workforce, Miss Owen reported that the Welsh Language team had been nominated for an award regarding the appointment of the Welsh Language Tutor and the positive impact this had had for staff. B17/22 Dementia Strategy : Update B17/22.1 Mr Thomas outlined that all members would be aware and supportive of the need for a Dementia Strategy, and he confirmed that a multi-disciplinary group had been

8 Minutes Board to Board CHC v0.03 Page 6 of 6 established to oversee the development, with the support of user representatives. There would be a supporting action plan to the strategy, which was due to be discussed at the Quality, Safety & Experience Committee in December. Mr Thomas also made reference to John s Campaign and the Forget-me-Not project. Mrs Llewellyn-Williams recognised the positive and innovative work being done within community hospitals with regards to dementia. Dr Higson asked that a briefing note be prepared and circulated. AT B17/24 Date of Next Meeting Tuesday 10am. Dr P Higson suggested that the meeting be held in Bala. KD Summary Action Plan Minute Action Agreed Ref B17/15.3 Share through media contacts the publication of the CHC report into Loneliness and Boredom in Hospital and the Health Board s response. Officer(s) Responsible Communications Team B17/22.1 Progress Update The press team had flagged up the publication with media contacts but had not picked up on noticeable coverage. Prepare and circulate a briefing on progress with the Dementia Strategy Progress Update Briefing circulated on Adrian Thomas Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board North Wales Community Health Council is the operational name of the Betsi Cadwaladr Community Health Council

9 7 B18/7 Staff Recruitment and Retention - Mrs Reena Cartmell 1 B18.7 Nurse Staffing Board Report.docx 1 Board to Board BCUHB / Community Health Council 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 Nurse Staffing Levels (Wales) Act Preparedness Mrs Gaynor Hales Health Board Project Lead - Nurse Staffing Act Mrs Reena Cartmell Deputy Director of Nursing Mrs Gill Harris, Executive Director of Nursing and Midwifery 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. This report was prepared for the BCUHB Board meeting on The purpose of this report is to update the Board on progress and actions required to: Meet the legal duties 8 th April 2018 when the BCUHB Health Board is accountable for ensuring compliance with the duties contained within the Nurse Staffing Levels (Wales) Act Inform the Board of BCUHB 2018 Acute Nurse Staffing Establishment Review. Update the Board of the nurse vacancy profile and actions taken. Significant points to draw to the Boards attention to: 1. The progress made to ensure the nurse establishment on the Act wards meets the statutory duties the Act places on Health Board s as outlined within the report. 2. The Boards responsibilities in relation to the Act. 3. The further action taken to address nursing vacancies within the Health Board.

10 2 Special Measures Improvement Framework Theme/ Expectation addressed by this paper Equality Impact Assessment Recommendation/ Action required by the Board to Board meeting Leadership and Governance Strategic and Service Planning Engagement No EQIA required To invite a discussion on the paper Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board

11 3 Betsi Cadwaladr University Local Health Board Nurse Staffing Report Situation The purpose of this paper is to inform the Board of the challenge facing the Health Board with regards to Registered Nurse recruitment with a particular focus on our District General Hospitals. In addition, this paper will inform the Board of the following: Preparedness for the 8 th April 2018 requirements of the Nurse Staffing Levels (Wales) Act 2016; Application of the Chief Nursing Officer (CNO) Nurse Staffing Guiding Principles as part of the BCUHB Nurse Ward Establishment review; Roll out of the Safecare Programme and the actions in place to monitor e roster efficiency for safe rosters. The overall Registered Nurse workforce within the Health Board is 4988 wte. At present we are reporting an overall Registered Nurse vacancy factor of 10 % (500 wte). Whilst our recruitment initiatives are in place, this paper will attempt to summarise the impact of a reduced Registered Nursing workforce, which is significant for the safety of our services. Background BCUHB has a statutory duty to provide assurance regarding the provision of high quality, safe compassionate care to comply with the All Wales Nurse Staffing Act by the 8 th April Essential to this is the right staff, with the right skills, at the right time with a sufficient supply of nurses to meet patient acuity and dependency, which our day to day operational service demands. Ensuring appropriate ward nurse staffing levels and skill mix is vital to support the delivery of safe, high quality care. Since April 2014 the Health Board has implemented the CNO Nurse Staffing Guiding Principles and this has been monitored closely in conjunction with nurse staffing vacancies and safety of e rosters. Further to this, nurse staffing reviews have previously been undertaken which have provided an opportunity to consider: Budgeted establishment; Actual establishment; Ward staffing rosters; Professional judgement; Nurse to patient ratio; Local knowledge of patient acuity; As from 8 th April 2018 all Health Boards in NHS Wales will have a statutory duty to ensure sufficient nurses (the number of registered nurses - those having a live registration on sub parts 1 or 2 of the Nursing and Midwifery Council register) are in

12 4 place to assure the provision of safe, sensitive, effective and efficient care for patients. In March 2016 the Nurse Staffing (Wales) Act of the National Assembly for Wales became law. Its purpose, to ensure minimum safe nursing staffing levels are in place on our acute wards in Local Health Boards and NHS Trusts across the NHS in Wales. To meet the April 2018 implementation date the Health Board produced a Nurse Staffing Levels (Wales) Act action plan. This had been developed to ensure full preparedness for the Act with key actions discussed and agreed in a newly formed Nursing Safety and Efficiency Group. Further Welsh Government guidance on duties 25b were published in September 2017 and the action plan was updated accordingly to take account of the requirements within the guidance. The duties imposed by the act are:- Section 25B Duty to calculate and take steps to maintain nurse staffing levels. The Duty for Local Health Boards to calculate and take all reasonable steps to maintain nurse staffing levels and inform patients of the levels. Section 25B(3) of the Act Medical and Surgical inpatient wards are defined within the guidance as: An area where patients aged 18 and over receive active treatment for an acute injury or illness requiring either planned or urgent care, medical intervention or surgery, provided by or under the supervision of a consultant physician or consultant surgeon (Exclusions are identified in appendix 1). The Board Is required to : Designate a person to be responsible for calculating the nurse staffing levels in settings where section 25B of the Act applies; Determine which ward areas meet the definitions of the adult acute medical and surgical inpatient wards; Receive and agree written reports from the designated person on the nurse staffing level for each adult medical and surgical inpatient ward at a public board on an annual basis and at any other time when the designated person deems this to be required; Ensure that systems are in place to record and review every occasion when the number of nurses varies from the planned roster; and Agee the operating framework which will o Ensure there are systems and processes in place and specify the decisions in relation to maintaining the nurse staffing level;

13 5 o Specify the actions to be taken, and by whom, to ensure that all reasonable steps are taken to maintain the nurse staffing level on both a long term and a shift by shift basis; and o Specify the arrangements for informing patients of the nurse staffing level on each ward along with the date it was agreed by the Board. Review the Boards scheme of delegation and if appropriate job descriptions of directors, in order to ensure that the responsibilities necessary to comply with the Act are clearly reflected. Designated Person Section 25B(1)(a) sets out where a Local Health Board provides nursing services in a clinical setting to which the section applies, it must designate a person, known as the designated person to calculate the nurse staffing level for the setting. The designated person must act within the governance framework of the LHB on behalf of the Chief Executive Officer. In view of the requirement to exercise nursing professional judgement when calculating nurse staffing levels, the designated person should be a registered nurse who understands the complexities of setting a nurse staffing level in the clinical environment and should be of sufficient seniority within the organisation, it is recommended that this role is designated to the Executive Director of Nursing and Midwifery. Director of Workforce Is required to ensure there is an effective system of workforce planning, based on the Welsh Planning System, in place to deliver a continuous supply to meet the required numbers. The system must ensure active and timely recruitment. Director of Operations Is responsible for developing, implementing and reviewing the organisation s operational framework that will enable the use of appropriately skilled, temporary nursing workforce. The movement of staff from other areas within the organisation and the effective management of escalated or closed beds. These processes should be reflected in the Board s escalation policy and business continuity plans. Director of Finance Is responsible for ensuring the agreed nurse staffing level is funded from the Health Board s revenue allocation and it takes into account the actual salary points of staff employed. Reasonable Requirements Required establishment means the total number of staff to provide sufficient resource to deploy a planned roster following the use of a triangulated method that will enable nurses to provide care to patients that meets all reasonable requirements

14 6 in the relevant situation. The ward manager and any students should not be included in the establishment calculations. Duty to Calculate Nurse Staffing Levels The number of nurses required to provide care to patients that meets all reasonable requirements in the relevant situation. Consideration can also be taken of nursing duties that are undertaken under the supervision of, or delegated to another person by, a registered nurse. The Designated person (Executive Director of Nursing and Midwifery) is responsible for calculating the Nurse Staffing Level for every acute medical and surgical adult inpatient wards ensuring the use a triangulated approach. The Nurse Staffing Level must be calculated on a minimum of a six monthly basis or and more frequently if the use of the ward changes which alters the Nurse Staffing Level, or if the designated person deems it necessary. The evidence and rationale used to determine the Nurse Staffing Level must be recorded. The Nurse Staffing Level for each ward must be presented to the Board annually and written reports must be provided if there is a change of use/service that has requires a change to the Nurse Staffing Level. The agreed Nurse Staffing Level must be funded from the Local Health Board s revenue allocation, and must take into account the Actual staff employed on wards. Ensure there are systems in place to record and review every occasion when the number of nurses deployed varies from the planned roster. Method of Calculations The method of calculation is a triangulated approach, which brings together three sources of information to determine how many nurses are required to staff a ward. Professional judgment Using the workforce planning tool to determine a ratio of nurses to patients that will meet all reasonable requirements of care (Welsh Levels of Care) Consider the extent to which patients well-being is known to be sensitive to the provision of care by a nurse or nurse sensitive indicators As per the graphical representation of the triangulated approach (Figure 1), equal weighting is given to all of the information that informs the process. The guidance is clear that during the process of calculation there is no pre-determined hierarchy in terms of the evidence. The designated person will make that determination based on an analysis of all the information collected about the ward. For example, the acuity data may suggest a ward is over established but the ward has many single occupancy rooms and a vulnerable patient population prone to falls as indicated by a review of the quality data. It would be reasonable in this example for the professional

15 7 judgement and quality indicators to be the determining factors in setting the nurse staffing level. The designated person may calculate different nurse staffing levels in relation to different periods of time and depending on the conditions in which care is provided by a nurse. Figure 1 PATIENT ACUITY NURSE STAFFING LEVELS PROFESSIONAL JUDGEMENT QUALITY INDICATOR Informing Patients Requirement to inform patients of the nurse staffing level both on the ward where the level applies and in its public board papers. The planned roster of the nurse staffing level should be published at ward level. Information should be provided in an easily accessible format that patients can understand and be compliant with Welsh Language Standards. They should also have access to Frequently Asked Questions on the Nurse Staffing Level which includes information about how to raise concerns about the Nurse Staffing Levels. National Reporting Health Boards are required to provide assurance to the Welsh Government and the Public with regards to compliance. Therefore, every participating ward must be monitored to ensure compliance with the Act. Further to the above Act requirements the Health Board continues to experience a significant number of Registered Nurse vacancies, which is exacerbating the requirement to meet safe staffing levels. Therefore, the importance of ensuring rapid nurse recruitment is essential.

16 8 Assessment Nurse Establishment Review An acute nurse staffing establishment review has been completed in January 2018 and is the first of our twice yearly staffing reviews to comply with the All Wales Nurse Staffing Act. This review is based on a triangulation methodology to include the CNO nurse staffing principles, professional judgement and harm data to determine the planned nurse staffing required to safely staff our acute wards. Based on this review, whilst adjustments are required in a small number of wards, overall the budgetary establishment was sufficient to meet the planned RN nurse staffing for our acute wards, based on the core bed numbers. This data was presented to the Quality, Safety & Experience Committee meeting in March Further work is underway to include new skill mix and roles including therapies within teams. The calculation for each ward establishment used a triangulated approach based on :- The number of funded beds. The use of the All Wales National Acuity Tool data from June 2017 Audit. Professional Judgement taking into account - The qualifications, competencies, skills and experience of the nurse providing the care. - The effect of temporary staff on the nurse staffing levels. - The effect of the nurse s considerations of a patient s cultural need. - Considerations of a multi-professional team dynamic. - The potential impact on nursing care of a ward s physical condition and layout. - The turnover of patients receiving care and the overall bed occupancy. - Care provided to patients by other staff or health professionals, such as healthcare support workers. - Any requirements set by a regulator to support student and learners. - The extent to which nurses providing care are required to undertake administrative functions. - The complexity of the patients needs in addition to their medical or surgical nursing needs, such as patients with learning disabilities. - Delivering the active offer of providing a service in Welsh without someone having to ask for it. The CNO guiding principles nurse to patient bed ratio on days (excluding ward manager)

17 nurse patient bed ratio on nights - 60/40 split Registered Nurse (RN) / Healthcare Support Worker (HCSW) skill mix % headroom (RNs) before triangulation - 22% headroom (HCSW) - Band 7 Supervisory - Acute Wards over 21 beds to have 2 band 6 s - 1:1 WTE per bed Indicators where patient well-being is particularly sensitive to care provided by nurses. - Patient falls with harm - Pressure ulcers hospital acquired (as defined by Welsh Government) - Medication never events Whilst the Health Board is on track to ensure our acute wards meet the Nurse Staffing Act April 2018, we also recognise the importance of maintaining compliance with the CNO Guiding Principles. Therefore, BCUHB has undertaken a Nurse Establishment Review to ensure planned rosters meet the guiding principles across our acute general wards within our service. The programme of work firstly established the budgetary requirement for each ward to consistently meet the CNO Nurse Staffing Guiding Principles taking into account professional judgement, whilst also monitoring the quality of care given to ensure patient safety is maintained. Work is ongoing, applying patient acuity on a daily basis via the roll out of safecare; application and review of professional judgement including ward environment layout and taking into account the minimum requirement of 1:1 WTE bed ratio. This enables the actual budgetary establishment per ward to be professionally reviewed to meet safe nurse staffing levels to deliver safe care. Further to the planned nurse staffing to meet our roster requirements, is the additional staff required to provide nursing care for unexpected high patient acuity based on enhanced care (1:1 care) and also the additional nursing staff required for escalation beds on each acute site. The SafeCare live nurse staffing dial highlights the high acuity and the limited deployment options due to current nurse vacancies. Nursing Establishment Review Outcome The Nurse Establishment Review January 2018 highlighted that the Health Board have a sufficient budget within the current ward establishments to ensure compliance with the Act and CNO guiding principles based on the agreed number of funded beds. However, the pressure on the ability to deliver safe care and balance the nurse staffing budget is due to the high number of unfunded escalated beds across secondary care and the high number of RN vacancies.

18 10 In addition, three specialties, where the wards have a secondary function, have been identified as requiring further analysis to ensure equity of approach across the LHB in determining the additional staffing requirements :- Renal- Haemodialysis and peritoneal dialysis support Hyper acute Stroke Respiratory with Non Invasive Ventilation beds Acute cardiology Nursing Vacancies and Operational Context It is essential that whilst we recognise the additional pressures to planned nursing rosters due to escalated beds, it is imperative we meet our planned nursing staffing requirements for safe patient care. Therefore, nurse recruitment into our funded established rosters is a high priority. Table 1: The following data provides an up to date high level summary per District General Hospital (DGH) (WTE rounded up). DGH Beds escalate d Registered Nursing Vacancies HCSW vacancies *Registered Nurses in process for recruitment HCSW in process for recruitment Registered Nurses awaiting Vacancy Control Group (VCG) approval YWM % YGC % YG unknown unknown 10% MH Nil (7 HCAs) 11% The above table highlights the up to date local data as at 12/02/2018. It is to note the 52 escalation beds on the Ysbyty Wrexham Maelor (YWM) site require an additional 26 wte Registered Nurses and a further 20 Healthcare Assistants (HCAs) to support this increased activity. Escalation bed costs have also overall averaged at 73k per month based on agency usage to support this escalation. This is further exacerbated by the patient acuity scoring and the early adoption of Safecare on the Ysbyty Glan Clwyd (YGC) site is on track for full roll out to all three DGHs. This Safecare dial is used at each safety huddle and is an example of an average day on the site. Increasing efficiency throughout the recruitment process is vital to speed up and reduce the number of nurse vacancies across the organisation. We recognise our Registered Nursing workforce is presently unable to consistently fill the planned nurse staffing rota and this is further exacerbated for acute sites by additional escalation beds to meet operational pressures. Overall Nurse RN Vacancy %

19 11 Additional factors for further consideration include the DGH average length of stay data (Table 2) and datix reporting (Table 3) below highlighting the trend against each site. Table 2. Table 3. So far in comparison to last year there has been an increase of 14.64% of incidents reported against Adverse events that affect nurse staffing levels from 2016 to It is also important to note that the nurse vacancy profile does not support the escalation beds, which are in demand due to operational pressures. Therefore, it is also important to review the potential harm indicators, which are now available at ward level following the introduction of the Harms Ward Dashboard. Table 4. Harm Free Care Harm free care data is presented as the percentage of days in each month where harm occurred on the acute sites. For example February 2017 Ysbyty Gwynedd (YG) had 50% (14 days) of harm free care, whereas YGC only had 39% of the days harm free during the same month. This has been plotted over time so we can see a changing trend as well as comparing between the 3 acute sites.

20 12 80% Ysbyty Gwynedd Ysbyty Glan Clwyd Wrexham Maelor 70% 60% 50% 40% 30% 20% 10% 0% Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan A harm free day is classed as below: 1. No falls with harm. 2. No Grade 3+ Hospital Associated Pressure Ulcers (HAPUs). 3. No Severe or Catastrophic medication errors. 4. No infections. Nurse Recruitment To support recruitment within the Health Board the employment brand Train Work Live North Wales and associated marketing materials have been widely promoted. One of the key aims of our new recruitment website and employment brand is to support the reduction of vacancy rates, reduce agency and locum expenditure and increase substantive staff to our organisation by providing a local, national and international platform on which to showcase BCUHB as an employer of choice. A newly formed Corporate Recruitment Group Chaired by Workforce & Organisational Development (WoD), which supports this work has been developed which provides a strategic approach to attraction, recruitment and retention across BCUHB. The group supports a number of sub-groups for each profession at an operational level to ensure a consistent and planned approach on behalf of the organisation. The work of the corporate recruitment group and subsequent development of a draft Attraction, Recruitment and Retention Strategy, sets out our approach to Recruitment and attraction activities over the next 5 years. Activities include: Volume recruitment days, Corporate calendar of careers events, Marketing materials and investment in digital media platforms for targeted attraction and recruitment activities.

21 13 All Health Boards and Trusts across the UK continue to compete for appropriately qualified people to fill current vacancies and address the issues of an aging workforce. In BCUHB approximately 35% of the Workforce are over the age of 50 of which 7.5% are 61 or over. Workforce Profile <=20 Years BCUHB Age bands (Headcount) >=71 Years There are significant vacancies across the Health Board. For example within nursing and Midwifery, there are currently approximately 500 Registered Nurse vacancies which is around 10% of the workforce. This is a real challenge for the Health Board and across the NHS in the UK. From October to December 2017, the Health Board spent 2.9m on Nursing and midwifery agency alone. To be able to compete in this labour market, we need to ensure that we can provide an attractive package and ensure that our attraction methods stand out in order to reduce the reliance on agency and locum staff. As part of the Attraction Strategy supported by the Executive Management Group (EMG) in 2016 it was agreed that increased activity was required to support recruitment campaigns, attendance at job fairs, conferences and other recruitment attraction activity. The Nursing and Midwifery challenges are significant. Over the next five years there are likely to be approximately 230 nursing and midwifery staff leaving each year (this figure includes retire and returns). Approximately 170 nurses qualify each year through our WEDS education commissioning route and are appointed to BCUHB. However, unfortunately the education commissioning numbers requested by BCUHB to WEDS continues to result in a significant gap. Taking into consideration the retirement profile and the recruitment attraction activity in place this still leaves a significant gap each year, with a projection of approximately 246 Registered Nurse vacancies in 2023 (based on 2017 needs). Uncertainties around the effect of Brexit have resulted in more challenges in recruiting EU national staff, although it is acknowledged that this is a small group in

22 14 BCUHB. Recruitment from overseas will only provide one element of efforts to reduce vacancies. Recruitment Efforts to Date New employment brand Introduction of our new employer Brand Train, Work Live North Wales. Introduction of the new BCUHB Recruitment Website, with the introduction of BCUHB videos supporting all professions. Introduction of the BCUHB Corporate Recruitment Strategy group to lead on the implementation of the Attraction, Recruitment and Retention Strategy. Focused Digital Marketing Social Media / Facebook Nurse Recruitment Days Four targeted nurse recruitment days and two student nurse recruitment days each year have been agreed. So far the Nurse Recruitment days (Jan, Feb and July) have resulted in 64 Nurse Job appointments within mental health, adult and paediatrics. Three Student nurse Recruitment days have resulted in 50 appointments. Overseas Nurse Recruitment Overseas International recruitment to India took place in March 2017 with 75 applicants offered positions within acute, community and mental health services. However, this number has now reduced to 37. This has been a slow process due to issues regarding language requirements and obtaining work visas. It is anticipated that we will start to see some of the nurses coming to work for us in the next couple of months. The Return to Practice (RTP) course at Bangor and Glyndwr Universities remains popular, with 28 RTP students on the course and new cohorts commenced in May and June Marketing events through job fairs Raising the profile of BCUHB through marketing via attendance at Careers Fairs & Open Days across UK - Royal College of Nursing (RCN), Royal College of General Practitioners (RCGP) conference and supporting the all Wales recruitment campaigns). Work continues jointly with Bangor University to maximise clinical learning placements, opportunities and identifying additional clinical placement areas for students and the Glyndwr placement initiative. Further engagement with Academic Institution/s- nurse conference attendance and videos for students are being developed and Return to Practice Initiatives. Using on-line advertising campaigns such as RCN Bulletin.

23 15 Further recruitment initiatives in place: Focusing on Time to Hire to increase efficiency throughout the recruitment process is vital to speed up and reduce the number of nurse vacancies across the organisation. Therefore, the Executive Team have approved the Centralisation of Nurse Band 5 recruitment. This will ensure the fast tracking of candidates. One stop Bank Nurse Recruitment approach for each geographical area is now also in place. Recommendations to the Health Board Meeting Further targeted recruitment across the UK including a blend of national adverts and recruitment days. 2. Focused recruitment activity around Return to Practice professionals in conjunction with our local Universities. 3. Scope out opportunities around alternative professional support the Nurse gaps such therapists. 4. Targeted intervention to significantly reduce the time to hire with shared services, hiring managers and mandated recruitment requirements including induction with the centralisation of Band 5 Nurse recruitment. 5. No vacancy control required for nurses until budgeted establishment is met. 6. Agree a core bed establishment for this increased activity and recruit substantively. 7. Work within WEDs to support the Glyndwr university offer for their noncommissioned nurse training to a level which will enable safe placements. Next steps Complete the roll out of Safecare across all sites Develop and implement Nurse Staffing Levels (Wales) 2016: Operational Guidance. Hold roadshows to inform all staff of their individual responsibilities. Participate in the CNO bi-annual audit

24 16 January February March/April May/ June June July August/September October/November December - Acuity audit undertaken. - Formal presentation of annual report to the Board of the nurse staffing level of each ward covered by section 25B. - Validation and sign-off of the January acuity audit data. - January acuity audit data available. - Nurse staffing level calculated using the triangulated approach. - Board to be updated if the nurse staffing level is changed for any ward covered by section 25B, following the routine bi-annual recalculation. - Acuity audit undertaken. - Validation and sign-off of the June acuity audit data. - June acuity audit data available. - Nurse staffing level calculated using the triangulated approach. Ongoing capture and monitoring of pertinent data relating to the agreed quality indicators and professional judgement criteria. Also, ongoing review and recording of any variation from planned rosters

25 17 Appendix 1. Exclusions Acute admission/assessment/surgical decision units that have short term admissions for assessment purposes that re demonstrably different to acute medical/acute surgical inpatient wards. Intensive care units High dependency units Day surgery units/wards Coronary care units Renal dialysis units Maternity services Mental Health Services Learning Disability Services Day care unit/wards Rehabilitation Wards. However Section 25(B)(c) gives the Welsh Ministers the power to make regulations to extend the duty to calculate nurse staffing to other settings.

26 18 Appendix 2. Summary of Nurse Staffing Levels Health board/trust: Betsi Cadwaladr University Health Board Period reviewed: December 2017 April 2018 Number of adult acute Site: YGC Site: YWM Site: YG Site: medical and surgical Medical Surgical Medical Surgical Medical Surgical Medical Surgical inpatient wards where Number Number section 25B applies: Nurse staffing level per ward where section 25B applies (*) RN (wte) 1wte ward sisters/ch arge nurse and manager s are supernu merary and has been added HCSW (wte) TOTAL (wte) Nurse staffing level per ward where section 25B applies (*) RN (wte) 1wte ward sisters/c harge nurse and manage rs are supernu merary and has been added HCSW (wte) YGC - Ward 1 (24) YWM Bersham (21) YGC - Ward 2B (14) YWM Cunliffe (23) YGC - Ward 4 (24) YWM Mason (27) YGC - Ward 9 (24) YWM Evington (21) TOTAL (wte)

27 19 YGC - Ward 10 (24) YWM Erdigg (27) YGC Ward 12 (24) YWM Morris (27) YGC Ward 19 (24) YWM Lister (27) YGC Ward 2A (15) YWM Fleming (23) YWM Pantomime YGC Ward 5 (24) (27) YGC Ward 6 (27) YWM ENT (14) YWM Prince of YGC Ward 6ABH (24) Wales (21) YGC Ward 8 (24) YWM Bonney (15) YGC Ward 19a (14) YG Glyder (18) YG Tryfan (24) YG Moelwyn (28) YG Prysor (13) YG Hebog (27) YG Aran (30) YG Glaslyn (26) YG Ogwen (24) YG Tegid (28) YG Dulas (30) YG Enlli (16) YG Ffrancon (12) Board/ Executive level Authorisation Designat ed person Gill Harris Director of Operation s Morag Olsen Director of Finance Russell Favager

28 20 Date presented to the Board by designated person 5 April Gill Harris Executive Director of Nursing & Midwifery (*) Points to consider: Uplift of 26% has be included applied to RN and HCSW wte, to cover staff absences 1wte ward sisters/charge nurse and managers are supernumerary and has been added (denotes number of beds)

29 8 B18/8 Financial Position - Mr Russ Favager 1 B18.8a Finance Report - Month 11 Board Report.docx Board to Board BCUHB / Community Health Council To improve health and provide excellent care Title: Finance Report Month 11 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 was subject to scrutiny by the Finance and Performance Committee prior to submission to the Board meeting held on 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 11, there is an adverse variance against plan of 11.9m ( 35.7m 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

30 Achievement of the forecast deficit of 36m remains challenging and is dependent on the delivery of the recovery actions as well as the continued implementation of additional controls across the Health board. Special Measures Improvement Framework Theme/ Expectation addressed by this paper Equality Impact Assessment Recommendation/ Action required by the Board to Board The Health Board is forecasting a cash shortfall because of the deficit, and has received Support of 32m from Welsh Government leaving a shortfall of 4m. The management of cash remains a priority during March. Costs associated with implementing improvements arising from Special Measures are included within departmental budgets. Not applicable To invite a discussion on the paper 2

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

32 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 was subsequently 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

33 4. Revenue Forecast Position 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) (23,800) (35,700) ,500 36,691 35, ,818 58,730 51,848 % Cash balance at month-end 000 7,300 7,300 8,387 Forecast Risk 1.4 Revenue position At Month 11, the Health Board has overspent by 35.7m ( 1.0m in month 11). Of this, 23.8m relates to the Health Board s planned budget deficit and 11.9m represents an adverse variance against the financial plan. The adverse variance reflects under delivery of planned savings across the Health Board, along with activity and cost pressures predominantly within the divisions of Mental Health and Learning Disabilities (MHLD) and unscheduled secondary care. Month 11 saw a further improvement in the monthly run rate down from 1.9m to 1.0m. This is a significant achievement from the high position of a 4.8m monthly overspend in June However more needs to be done across the organisation to ensure that the run rate continues into 2018/2019. Ysbyty Glan Clwyd, Wrexham Maelor and the East Area Team are of particular concern regarding delivering their control totals.. In Month 11 there were further improvements in Out of Area Placements and Medical Agency costs. Despite these, 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%) in March Due to overspends in the first half of 2017/2018 it was necessary to identify further recovery actions. As at Month 11 savings and recovery plans of 45.0m have been identified. 31.3m relate to cash releasing schemes. As at Month 11 a total of 35.3m of savings have been delivered and ongoing action is required across the Health Board to ensure delivery of the forecast outturn of a deficit of 36m or better. 5

34 4. Revenue Forecast Position 1.6 Forecast revenue position and risk assessment Action has been taken across the Health Board to improve the expenditure run rate. These 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 revenue position reflects pressures in a number of key areas including unscheduled care, care packages, non-achievement of recovery actions around escalation beds, out of area packages, 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 11, 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 28 February was 8.4m including 7.8m of cash held for capital purposes. The revenue cash balance 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 was requested from the Welsh Government. The Welsh Government has confirmed cash support of 32m leaving a cash shortfall of 4m. The shortfall will be addressed through the management of working capital though this will impact on the Public Sector Payment Target. 1.8 Key actions being taken The Financial Recovery Group (FRG) meets regularly to oversee and monitor the delivery of the actions from the Financial Recovery Plan approved by the Board. Further financial improvement opportunities have been identified; and opportunities to reduce, avoid or defer expenditure have been explored and implemented where appropriate. Maintaining the momentum on the reduction of agency staff remains a key financial risk, although the Health Board has seen a reduction in the monthly Medical Agency costs of a further 0.3m during the month. Expenditure on Nurse Agency remains a financial 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 with robust approval mechanisms, 6

35 4. Revenue Forecast Position and work is continuing 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 has been assessed as part of the planning cycle for 2018/19 and development of the IMTP and this remains a significant concern moving into 2018/

36 2. Revenue position 2.1 Financial performance by division The table below provides an analysis of the Month 11 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) (0.9) 0.6 Contracts (2.9) (2.9) Provider Income Secondary Care Mental Health Corporate (0.7) (0.7) Reserves (3.4) (3.4) Variance from Plan (0.1) Planned Deficit 23.8 Total (0.1) 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 0.6m due to pressures in the East Area in particular, although the division achieved a balanced position in month. Key pressures 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 materially offset by underspends within the Dental Service, Therapies and Palliative Care. Contracts are reporting a favourable variance due to improvements in both the WHSSC contract and local contracts with English providers. 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 and the risk is estimated to be circa 3.6m for the year. Secondary Care Division continues to overspend in Month 11 and has a total overspend to date of 9.0m due to undelivered savings and other cost pressures mainly 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 although the monthly position has improved with a reported overspend of 0.3m ( 0.7m in Month 10). The year to date 8

37 4. Revenue Forecast Position overspend within YGC of 4.8m compares to 1.6m for the same time last year. Unscheduled care accounts for 3.5m of the 2017/18 position to date. Mental Health and Learning Disabilities (MHLD) has a year to date overspend of 9.1m 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 overspend of 0.6m in month, this is below the year to date average monthly run rate of a 0.8m. 9

38 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 (9.3) (1.8) Primary Care Drugs Pay (Health Board provided services excluding out of hours) Clinical Supplies (excluding drugs) General Services & Supplies Clinical Supplies - drugs (0.7) 49.7 (2.0) (0.4) (0.0) 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 5.6m 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 a review of Oracle orders to ensure only business critical spend is being incurred. 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

39 4. Revenue Forecast Position Subjective trend analysis Spend YTD 'm Variance YTD 'm In month variance 'm 13 Month Trend Narrative Commissioned Services (1.2) (1.7) 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 continued to grow over the year, mainly reflecting out of area placements, but a reduction in these, combined with improvements in local contracts has seen an underspend in the month. 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 (113.5) (3.1) 0.1 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 (1,283.6) Total This includes the annual depreciation and impairment charges. Depreciation is charged in equal instalments 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 35.7m against a planned variance of 23.8m. 11

40 2. Revenue position Pay Payroll expenditure year to date is 645.9m including Health Board delivered primary care functions, incorporating Managed Practices and the Out of Hours Service. The year to date payroll expenditure excluding Managed Practices and Out of Hours is 630.3m which is an adverse variance against plan of 4.0m. 62M 60M 58M 56M 54M 52M 50M 48M 46M 44M 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 Substantive Agency Bank Overtime Average Substantive Average Bank Average Overtime Average Agency The year to date expenditure on agency staff is 31.7m which is an average of 2.9m per month, representing 5.0% of total pay. This is a reduction against the monthly average of 3.8m for 2016/17, reflecting the significant improvement in Medical Agency costs that has continued throughout the financial year. The table overleaf provides the trend on agency costs for the previous thirteen months and demonstrates the variability in this area of expenditure. Medical and Dental pay (excluding primary care services) is 2.8m overspent as at Month 11 (Month 10: 3.0m), which reflects the cost pressures arising from agency doctors. The Health Board has implemented the All Wales cap on Medical agency costs. This is led by the Executive Medical Director and will continue to be closely monitored going forward. Nurse agency costs were marginally lower than in January. Ongoing pressures arising from unscheduled care and significant recruitment difficulties remain. However targeted action overseen by the Executive Director of Nursing is being undertaken in areas of high usage to focus on a further reduction in costs whilst maintaining quality and the safety of patients. 12

41 13

42 3. Savings Requirement 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. 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 comprising of 32.4m from the original savings proposals and 12.6m from the financial recovery plan. The forecast delivery of savings for 2017/18 is 41.8m. 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 additional 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 to further strengthen the arrangements. Assurance arrangements are in place through the PMO Steering Group which will oversee delivery for both this financial year and planning for 2018/19. 14

43 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 from the original financial plan. 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. Risks Risk level Explanation 000 Unidentified/under delivery of savings 0.5 To achieve the revised deficit the Health Board will be required to continue to deliver the challenging savings and recovery target. Continuing Healthcare Packages (CHC) Primary Care Prescribing Change in tariff methodology in England (HRG4+) and risks to the WHSSC contract The Health Board is experiencing significant ongoing pressures in relation to both the underlying number and cost of care packages, including the timing of settlement of the cases provided for retrospective claims. 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 Free Nursing Care fees has been calculated and factored into the Health Board s financial position. The impact has been offset by one off funding from the Welsh Government. The Health Board received 13.3m of resource from Welsh Government to reduce waiting times by the end of March 2018 and expected the following to be achieved: RTT for over 36 week waits to no more than 4,237 breaches, with a material reduction in over 52 week numbers; Diagnostics zero eight week breaches in all disciplines; Therapies no one waiting over 14 weeks for therapy services; Allocation of the funding came with the qualification that should the Health Board not achieve the expected levels of improvement then Welsh Government reserve the right to recover some, or all of this funding. There is a significant risk to the Health Board s year-end financial position should any non-performance be recovered in 2017/

44 5. Balance Sheet 5.1 Cash The closing cash balance as at 28 February was 8.4m which includes 7.1m of cash held for capital expenditure. The revenue balance is within the internal target set by the Health Board. The Welsh Government has confirmed cash support of 32m leaving a shortfall of 4m. This shortfall will be addressed through the management of working capital balances, prioritising payments to staff, GPs, care homes and small or medium sized enterprises 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 11, 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 Accounts Receivable The management of amounts due to the Health Board is a key focus of the cash management arrangements. Monthly monitoring of amounts outstanding is undertaken to ensure that recovery is in place. Debts over 90 days are a particular focus and include staff salary overpayments for which instalments are agreed.. 16

45 5.2 Capital expenditure The Capital Resource Limit at Month 11 is 72.8m. There is significant investment in a number of key projects including the YGC redevelopment, the SURNICC, the 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 51.8m against the plan of 58.7m. The year to date slippage of 6.9m will be recovered in Month 12 and the Health Board is forecasting to achieve its capital resource limit, subject to risks associated with any funding adjustments. 17

46 6. Conclusion and Recommendations 6.1 Conclusions The Health Board full year forecast at Month 11 remains a deficit of 36m, which has been notified to the Welsh Government. 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 continued improvements in the underlying run rate although there are a number of known risks to achieving this as outlined in Section 4. The issue of the potential significant financial impact of HRG4+ on WHSSC commissioned services has not 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. The Health Board received 13.3m of resource from Welsh Government to reduce waiting times by the end of March 2018 and expected the following to be achieved: RTT for over 36 week waits to no more than 4,237 breaches, with a material reduction in over 52 week numbers; Diagnostics zero eight week breaches in all disciplines; Therapies no one waiting over 14 weeks for therapy services; Allocation of the funding came with the qualification that should the Health Board not achieve the expected levels of improvement then Welsh Government reserve the right to recover some, or all of this funding. There is a significant risk to the Health Board s year-end financial position should any non-performance be recovered in 2017/2018. The outcome of the Supreme Court Judgment in relation to Continuing Healthcare fees has now been factored into the Health Board s financial projections and Welsh Government funding has been received to mitigate the impact. Achieving the financial plan, while not compromising the quality and safety of services, is an important element in developing trust with Welsh Government, the Wales Audit Office, Health Inspectorate Wales and the public. Moving into 2018/2019 management focus needs to be on continued adherence to the controls and processes that flow through the organisation including compliance with the entire budget and not only current areas of overspending. This includes the clear scheme of financial delegation through Standing Financial Instructions (SFIs) that need to be robustly adhered to. The Health Board will need to manage the identified cash shortfall during March

47 6.2 Recommendation to the Board meeting 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. 19

48 1 B18.8b Draft Interim Financial Plan docx Board to Board BCUHB / Community Health Council 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 2018/19 Draft Interim Financial Plan Russell Favager, Executive Director of Finance Huw Thomas, Finance Director: Operational Finance Russell Favager, Executive Director of Finance Public. While the budget will support the Health Board in achieving all of its strategic goals, its primary purpose is to ensure that resources are used wisely. 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. The Executive Team and the Finance and Performance Committee reviewed the Draft Interim Financial Plan before recommending it for adoption by the Board at its meeting on For discussion. The 2018/19 Draft Interim Financial Plan was presented for consideration by the Board on the 28 March 2018 following discussion at Finance and Performance Committee on 22 March The plan is in draft form until it is agreed by the Board; and is an interim plan as the Board is not empowered to approve a deficit budget and is therefore interim pending agreement by Welsh Government. The Health Board has two statutory duties to achieve: To ensure that its expenditure does not exceed the aggregate of the funding allocated to it over a period of 3 financial years (the first of which commenced on 1 April 2014 and ended on 31 March 2017, the second of which will end on 31 March 2018), and To prepare a plan to secure compliance with the above duty, 1

49 providing healthcare and improving the health of the population, and for that plan to be submitted to, and approved by the Minister (required for the first time in 2014/15). The Health Board has, in agreement with Welsh Government, not submitted a three-year plan to date. While a three-year plan has been developed for the period from 1 April 2018, this will not be a balanced plan over the three year period. As a result of this, Welsh Government will not be in a position to approve the plan. The Health Board s deficit for 2014/15 was 26.6m, the deficit for 2015/16 was 19.5m and the deficit for 2016/17 was 29.8m. The deficit for 2017/18 is forecast to be 36m. The cumulative three-year deficit for the period ending 31 March 2018 is therefore expected to be 85.3m. This draft interim financial plan proposing a deficit budget of 35m after delivery of 45m (4.5%) savings ( 23m cost containment and 22m cash releasing). The Board should note this budget does not secure delivery of performance targets including RTT, this is subject to separate conversations with Welsh Government. The plan presented is the first year of what will need to be a four year recovery period. While this first year is focused on financial stability: reducing the Health Board s underlying deficit from 49m to 35m; recovering the position will require a focus on financial turnaround and transforming services over a longer period. The plan clearly outlines areas of inefficiency which contribute to the underlying deficit and developing a turnaround strategy to address these areas will need to be an immediate focus for the Board. As in previous years, the Health Board is not empowered by Welsh Government to approve a budget in deficit. Consequently as such an action will be a novel and contentious action, the Chief Executive as Accountable Officer will formally write to Welsh Government to outline that the Interim Financial Plan will result in the Health Board breaching its statutory duty to balance over a three-year basis. Special Measures Improvement Framework Theme/ Expectation addressed by this paper Notwithstanding the statutory requirement for a three-year plan; the Health Board s own Standing Orders require an annual budget to be agreed by the Board in advance of the financial year. This report therefore provides the Board with an outline of the budget which is to be considered. Leadership and governance themes 2

50 Equality Impact Assessment Recommendation/ Action required by the Board to Board The EqIA has been completed as part of the Annual Operating Plan. To invite discussion on the report. Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board 3

51 2018/19 Draft Interim Financial Plan Russell Favager Executive Director of Finance Betsi Cadwaladr University Health Board 4

52 1. Executive Summary 1.1 Purpose of report Looking after taxpayers money properly and within the resources delegated by the Welsh Government means getting two things right at the same time: delivering outcomes sought by Ministers and living up to the values demanded in the public service 1. As part of this, financial discipline is an essential part of the organisation s governance and control framework, and as such setting a budget for the financial year is critical. The Health Board s Standing Orders require that the Health Board approve the budget and the financial framework, together included within this report. A budget must be approved in advance of the start of a financial year. The Board should be mindful of the Deloitte 2 report into Financial Governance arrangements at the Health Board, which concluded: The ongoing deterioration in the financial position of the Health Board is fundamentally due to it not fully embracing the service transformation agenda in recent years. We believe that tackling this agenda effectively is imperative if the HB is to remain financially sustainable. And In our view, change management arrangements at the HB are not fit for purpose and remain a significant obstacle towards delivering sustainable change. Over the period of this budget, and the coming three-year financial period more generally, it is imperative that the Health Board embrace a more transformational approach in its strategic and operational planning and delivery. This report sets out the resources delegated to the Health Board by Welsh Government, and, based upon the current service configuration, the anticipated commitments against these resources alongside the expected savings which will be delivered over the year. 1.2 Report summary This document sets out in Section 2, the regulatory, governance, financial and organisational context in which the Health Board operates. Understanding the Health Board s context is critical to understanding the resources available; the financial commitments; and the ability of the Health Board to deliver savings and manage its finances. Section 3 briefly summarises the goals and strategic priorities of the Health Board. Section 4 outlines the long term financial outlook for the Health Board, and demonstrates how the underlying deficit can be recovered over the medium to long term. 1 Managing Welsh Public Money, Welsh Government, January Financial Governance Review of Betsi Cadwaladr University Health Board, Deloitte,

53 Section 5 includes the proposed draft budget for 2018/19, pending agreement from the Board. As a deficit budget is being recommended, Welsh Government have been informed of this in advance of the Board s meeting on 28 March Section 6 outlines the Health Board s ring-fenced budgets, detailing the two most significant: Mental Health and General Medical Services. Expenditure on Mental Healthrelated services far exceed the ringfence calculation. Savings are explicitly expected from within these allocations, but those savings will be reinvested within the ring-fenced allocations. Section 7 provides the Board with assurance over the Health Board s approach to delivering savings. Section 8, reviews the key risks which are considered as potential areas of concern, and which could affect the Health Board s ability to deliver against its plan. This section also highlights to the Board its approach to mitigating these risks and managing within the approved resources. The report concludes with Section 9, in particular this section provides the Board with an assessment of the key governance and assurance issues arising as a result of preparing the financial plan; and the implications for the Board in approving a deficit budget. The recommendations which follow in Section 10 clarify the decisions which the Board will need to consider and take at its meeting. 1.3 Budget summary The proposed budget, summarised in Section 5.1, is shown in a waterfall chart overleaf. This demonstrates how the Health Board moves from the forecast outturn for 2017/18 of 36m to a brought forward underlying deficit of 49.1m. Following Welsh Government allocations; assessment of cost pressures; financial pre-commitments; cost containment and cash releasing savings, the recommended budget will lead to a planned budget deficit of 35m for 2018/19. This budget is presented as the recommended budget, but this is dependent on the Board s appetite for delivering transformational change over the medium term; and an assessment of the achievability of savings plans in the shorter term. In summary the proposed budget is a 35m deficit budget after delivery of 23m containment of future costs and 22m cash releasing savings ie 45m (4.5%) of savings. The Board should note that this budget does not secure delivery of performance targets including RTT, this is subject to separate conversations with Welsh Government. Similarly this financial plan does not include any new investment for the Operational Plan from core allocation, alternative funding sources are being identified for any new schemes which will also require a business case and funding agreed in advance before commencing. 6

54 Figure 1: Summarised budget 1.4 Governance and assurance Given the Health Board s unique position; the implications of the Special Measures Improvement Framework; and the recommendation of a deficit budget, a detailed understanding of the Health Board s governance and assurance requirements is critical. Furthermore, despite following the processes expected in setting budgets; such as consulting with budget managers; and identifying risks; the Executive Director of Finance is unable to assure the Board that the requirements of the Health Board s governance framework have been met given that the IMTP is not balanced over the coming three year period. As the Health Board is not empowered to approve expenditure in excess of the resources allocated to it by Welsh Government, by its nature, Board approval will be novel or contentious. As such, the Chief Executive will formally write to notify the Chief Executive of NHS Wales as required in the Accountable Officer s Memorandum. 1.5 Conclusions The in-year proposed deficit for 2018/19 is currently noted as being 35m. Any decision to invest additional funding in the 2018/19 plan, including the delivery of key performance measures (RTT etc) will increase this deficit, or will require additional savings to be delivered or additional funding to be provided by Welsh Government. The Health Board s financial position is not acceptable, and the Health Board must plan on the basis of providing excellent health services within the constraints of the available resources. This requires a balance between managing clinical risk and corporate risks to provide safe services which are delivered efficiently and effectively. 7

55 Nonetheless, the delivery of safe services of a high quality cannot be compromised in pursuit of rapidly achieving financial balance. The allocation of funding from Welsh Government will bring with it clear expectations on the Health Board s performance against our Tier 1 targets. As a result of this, the Health Board will remain focused on directing resources to deliver against priority areas. The Board needs to improve its productivity and performance, and this will be an immediate area of concern. As opportunities to improve are identified, these will need to be pursued vigorously. The Health Board needs focus on addressing the challenges of implementing effective change management; while remaining focused on patient experience through delivering safe services of a high quality. Clearly, the issues facing the Health Board have built over the long term; and our improvement trajectory will likewise take time. The first stage of this improvement is to stabilise our financial and performance position. The plan presented is the first year of what will need to be a four year recovery period. While this first year is focused on financial stability: reducing the Health Board s underlying deficit from 49m to 35m; recovering the position will require a focus on financial turnaround and transforming services over a longer period. The plan clearly outlines areas of inefficiency which contribute to the underlying deficit and developing a turnaround strategy to address these areas will need to be an immediate focus for the Board. 8

56 2. Context 2.1 Regulatory and governance The NHS Finance (Wales) Act 2014 came into effect on 1 April 2014 giving additional resource flexibilities to Health Boards to balance their income and expenditure over a three-year rolling period from 2014/15. The Act also required Health Boards to prepare a rolling three-year IMTP, approved by the Cabinet Secretary. The recent Parliamentary Review 3 reinforced recent developments with the Value agenda, outlining that: A key aim therefore should be to maximise the value of care and by being more efficient to enable resources to be directed to the areas that have a bigger impact on health and wellbeing. Recommending that the quadruple aim of improving population health and wellbeing; experience and quality; wellbeing capability and engagement of the workforce; and increasing the value of care should be vigorously pursued. These will be considered through the refinement of the strategy and planning documents over the coming year. The Executive Director of Finance, on behalf of the Chief Executive, is required under the Standing Financial Instructions to prepare and submit budgets for approval and delegation by the Board. The budget is required to: Be in accordance with the aims and objectives set out in the Integrated Medium Term Plan and Medium Term Financial Plan, and focussed on delivery of safe quality patient centred services; Accord with Commissioning, Activity, Service, Quality, Performance, Capital and Workforce plans; Be produced following discussion with appropriate budget managers; Be prepared within the limits of available funds; Take account of ring-fenced or specified funding allocations; Take account of the principles of sustainable development; and Identify potential risks. Section 7 provides the Board with a summary of the Health Board s consideration and response to the implications of the regulatory and governance framework on the budget setting process. 2.2 Financial context Resources Despite the continued impact of public sector austerity on the funding allocated to Welsh Government, funding growth has been maintained to the Health Board in each year since 2013/14, and this has been maintained into 2018/19. Figure 2 demonstrates the Health Board s funding and deficit position since its formation. 3 The Parliamentary Review of Health and Social Care in Wales, January

57 Figure 2: Health Board Revenue Resource Limit ( m) since 2009/10 (Closing Revenue Resource Limit, including approved Non-Recurrent funding) The Health Board s cumulative deficit to 31 March 2018 is expected to be 111.9m. Likewise the Health Board s position against the 3 year cumulative breakeven duty is expected to be 85.3m by 31 March Figure 3: Health Board cumulative deficit and position against three-year duty 2014/ / / /18 m m m m Planned Annual deficit Forecast/Actual Annual deficit Annual variance (0.2) 10.0 Total cumulative deficit year rolling deficit The implications of this are considered further in Section Savings delivery The Health Board has largely delivered its historic savings from transactional, rather than transformational savings. While this is not sustainable in the longer term, it is consistent with the picture elsewhere in the UK 4, where analysis shows that productivity improvements are not being realised within the acute sector in particular 5. The Health Foundation 6 indicated that Health Boards would need to realise real efficiency savings of 4 Sustainability and financial performance of acute hospital trusts, NAO, December A perfect storm: an impossible climate for NHS providers finances? Health Foundation, March The path to sustainability, Health Foundation, December

58 1.5% in order to balance their positions over the coming decade. That challenge is in addition to the requirement to contain costs over the medium term Future projections In setting out the challenges facing the Health Service in Wales over the coming 15 years, the Health Foundation 7 has outlined two key drivers: a growing ageing population alongside a growth in chronic conditions. The impact of age on the costs of healthcare is clear. The average population of the six counties of North Wales is expected to grow by 6.1% between 2011 and 2031; but the population over 65 is expected to grow by 30.8% over the same period 8. The multiplier effect of a growth in the population cohort which is linked with requiring higher cost healthcare paints a stark picture of the demand on the service over the medium to long term. The growth in demand is clearly linked to a number of chronic conditions, which are responsible for a significant proportion of Health Board spending. In addition to demographic and health pressures, inflationary pressures contribute to the overall funding requirement on the Health Board Conclusions This demonstrates that the ability of organisation to deliver incremental improvements is limited. Clearly, the increased cost pressures cannot be met by increased funding at the same level, and there is a need to look differently at how we operate within these demands and financial constraints. Fundamentally, this will require a rethink on the historic approach used to deliver savings and a need for transformational improvements and configuration changes within many of our services. 2.3 Organisational context The Health Board commissioned a review by Deloitte in , which concluded that the current model of clinical care in North Wales is not financially sustainable or affordable. The implications of this were the need to move from a provider-focussed organisation to one that operates more as a system manager, planning more effectively for population health and secondly placing a greater emphasis on prevention and management of care out of acute hospital settings. As a result of this, the Health Board s operational management structure was changed to reflect three Area Teams (East, Centre and West), each coterminous with two Local Authority boundaries; a Secondary Care Team; Mental Health and Learning Disabilities; and Estates and Facilities. These changes were made over 2015/16, but appointments to posts within the structure were paused as the management structure was subject to review as a result of the Special Measures regime. Despite these appointments, changes have not been made with sufficient pace to move care into the community or to commission care more effectively to address the allocation of resources. 7 The path to sustainability, Health Foundation, October Source: Demography 2016, Public Health Wales 9 Betsi Cadwaladr University Health Board IMTP Service Redesign, Deloitte, December

59 The Health Board has been subject to a number of reviews over recent years, and this plan ensures that key elements of these reviews are addressed. In June 2015, The Health Board was placed in Special Measures as a result of significant concerns. It was made clear that the process of re-building could not be achieved by the Heath Board alone. The Wales Audit Office concluded in their 2017 Structured Assessment 10 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. This was supplemented by the 2017 Deloitte report which concluded that the ongoing deterioration in the financial position of the Health Board is fundamentally due to it not fully embracing the service transformation agenda in recent years. 2.4 Opportunities for change and improvement The opportunities provided by the Health Board operating within a planned healthcare system have yet to be fully exploited. Exploiting these opportunities will require a new approach. It is clear that the Health Board has significant opportunities to address its efficiency and eliminate waste. The Deloitte report 11 highlighted opportunities of between 74m and 117m. This work has been updated by the Health Board during 2017/18 and are analysed below. 10 Structured Assessment 2017, Betsi Cadwaladr University Health Board, WAO, January Betsi Cadwaladr University Health Board, Review of Financial opportunities, December

60 Figure 4: Productivity and cost reduction opportunities Area Opportunity Minimum m Maximum m In-Hospital Theatres Workforce Inpatients Total in-hospital Improving Health Out of hospital District nursing Community hospitals Community hospital outpatients Mental Health Continuing healthcare Primary Care referrals A&E non-emergency attendances Other primary care Total out of hospital Corporate Workforce Medicines management Procurement Estates Total corporate Total Conclusions The value framework, detailed in Section 4, offers a suitable approach to population health management through linking the allocation of resources; productivity and outcomes into a coherent approach which enables a common understanding across the Health Board. Inherently, the quality and safety of care is therefore closely aligned with finance. The challenge for the Health Board, therefore, is to provide safe care of a high quality which minimises waste and maximises value. That said, and while the Health Board is ambitious about its future, it needs to be realistic about its capacity to deliver large scale changes which would be required to deliver the transformational improvements needed to the services it provides. 13

61 3. Planning framework 3.1 The Health Board s strategic goals The Health Board s medium term strategy and annual plan have been developed alongside the financial plan. This plan includes the financial implications of continuing the current service model together with inflationary and expected growth levels alongside transactional savings. In order to focus the Health Board s planning towards the achievement of its purpose and vision, the Board has set a number of strategic goals. These form the planning framework and for reporting against the progress being made - they will be supported by measurable objectives which will be published and reported against to demonstrate improvements and the benefits for the citizens of North Wales. The Board have agreed the following priorities for action for 2018/19: Figure 5: Key Priorities for Action in 2018/19 Health Improvement and Health Inequalities Care Closer to Home Primary Care Community Care More Serious Health Needs Urgent and Emergency Care Planned Care and Women s Services Mental Health and Learning Disabilities Children and Young People Ageing Well Major Health Conditions Options for further investment will be considered in this plan however at this stage no new investment from core funding is being proposed with alternative funding sources being identified for any new schemes being proposed. It is also very clear that such investments cannot be commenced without business cases agreed and depending upon the level of investment and implications on the overall financial position of the Health Board may require Welsh Government sign off given the Health Board s deficit position. The expectation is that funding requirements determined as critical priorities will be identified for funding from the Welsh Government transformation fund. 14

62 4. Long term financial plan 4.1 Health Board inefficiency Whilst the Board has made significant savings over the years these have not been to the full extent, or recurring nature required to achieve sustainable financial balance. This shortfall has contributed to the current financial deficit position. The Health Board s underlying deficit is calculated in Section 5. However, this assessment does not allow the Board to focus on recovering the underlying position. Consequently, the position has been reassessed based on known service inefficiencies when compared with peer groups across Wales and based upon the Health Boards strategy of promoting health and well-being and care closer to home, with more health service needs being met outside of hospitals. The following tables provide an assessment by both service line and site; and service line and cost driver. Figure 6: Health Board inefficiency by specialty and site Specialty Group Specialty Total YG YGC YWM Other sites Surgical General Surgery Urology Trauma & Orthopaedic ENT Ophthalmology Dental Medical Gastroenterology Respiratory Medicine Geriatrics Women & Family Paediatrics Obstetrics Gynaecology Midwifery Oncology Haematology Clinical Oncology A&E A&E Mental Health Mental illness Medium secure Forensic Psychiatry Elderly Mental Illness Community Community Hospitals TOTAL

63 Figure 7: Health Board inefficiency by specialty and cost driver Service Area Specialty Total Medical Staffing Nurse staffing Outpatients Diagnostics Operating Theatres and prosthetics Critical Care Ward costs Drugs and pharmacy Outsourcing Surgical General Surgery Urology Trauma & Orthopaedic ENT Ophthalmology Dental Medical Gastroenterology Respiratory Medicine Geriatrics Women & Family Paediatrics Obstetrics Gynaecology Midwifery Oncology Haematology Clinical Oncology A&E A&E Mental Health Mental illness Medium Secure Forensic Psychiatry Elderly Mental Illness Community Community Hospitals TOTAL It is significant to note that 28.2m (57%) of the inefficiency relates to staffing costs, which will be challenging to recover over the short term. 4.2 Financial turnaround and transformation Over the coming three year period, the Health Board will need to ensure that it has stabilised the financial position; demonstrably improved the position through turnaround and transformation; and demonstrate financial and service sustainability in the longer term. Figure 8: BCUHB Transformation path The Health Board s Special Measures status has had an impact on the organisation s ability to deliver transformational change of its services, but such change will be critical in 16

64 order to deliver the savings necessary to deliver medium term financial sustainability. Opportunities for savings have been identified, refreshing the work undertaken by Deloitte on whole-system technical efficiency undertaken in This work has determined c 180m of opportunities which are available to the Health Board. 4.3 Value The Health Board has committed to incorporating Value as a key driver to service planning and change. Delivering value requires a focus, not only the more traditional concepts of productivity and efficiency, but also on outcomes. The nature of the scale of the requirements over the medium term within the Health Board, covering quality, performance and productivity, demands that the approach taken is different to that utilised historically. This will require the culture of the organisation, at and across all levels, to be one that challenges all aspects of service delivery. There are significant opportunities to deliver greater value, through a focus on the three key principles of value; through a focus on reducing waste; through embedding the principles of Prudent Healthcare; and the Wellbeing of Future Generations Act. Value is focused on the individual patient, as it is inherently related to their outcomes from the treatment they receive. It therefore brings in the concepts of quality, safety and outcomes within its remit. This is a fundamental shift from a managerially-focused response to delivering efficiency and productivity. Operating across an integrated planning healthcare system, the Health Board is uniquely placed to address the challenge of addressing the three elements of value as a combined whole. At its simplest, delivering value requires us to deliver better outcomes for less resources. However, delivering this challenge is complex, and the Health Board will need to focus on the three key elements of value: 1. Allocative value / Value for the population: An assessment of how best value can be provided to the population through identifying overuse and underuse of resources; 2. Technical value / Value for the taxpayer: An assessment of how cost per unit is reduced; 3. Personalised value / Value for the individual: An assessment of the outcomes of care for individuals. Given the Health Board s current position on the transformation path, the main focus is currently on driving technical value. Over the duration of the three year planning cycle, further progress needs to be made on allocative and personalised value. 17

65 Figure 9: Value contribution It is expected that this will result in the development of cases for value-based change. These will then be implemented through the existing Programme Management Office framework. Figure 10: Implementing value-based change Workstream strategy Gathering information Analyse data Report data Engage with stakeholders Develop PID and QIA Implement programme Monitor Building the case for value-based change Implementing change / Programme Management Office As part of this work, the key service lines which are inefficient for the Health Board will be reviewed, and plans developed to address these will be incorporated into recovery plans. These will be incorporated into a series of improvement cycles. Based on lessons learnt in Cwm Taf and Aneurin Bevan Health Boards, the process will involve projects developed with a 60-day cycle providing for a planned, organised and structured way to develop clarity around an issue and pushing through change. The nature of the scale of the requirements over the medium term within the Health Board, covering quality, performance and productivity, demands that the approach taken is different to that utilised historically. This will require the culture of the organisation, at and across all levels, to be one that challenges all aspects of service delivery. 18