Operational Plan 2017-18
(HIW) is the independent inspectorate and regulator of healthcare in Wales Our purpose To check that people in Wales are receiving good care. Our values Patient-centred: we place patients, service users and public experience at the heart of what we do Integrity: we are open and honest in the way we operate Independent: we act and make objective judgments based on what we see Collaborative: we build effective partnerships internally and externally Professional: we maintain high standards of delivery and constantly seek to improve Proportional: we act efficiently, effectively and proportionately in our approach. Our Priorities Through our work we aim to: Provide assurance: Promote improvement: Influence policy and standards: Provide an independent view on the quality of care. Encourage improvement through reporting and sharing of good practice. Use what we find to influence policy, standards and practice. Mae r ddogfen yma hefyd ar gael yn Gymraeg. This document is also available in Welsh. 2 Crown copyright 2017 WG30949 Digital ISBN 978 1 4734 9833 4
Operational Plan 2017-18 Foreword I am pleased to introduce our Operational Plan for 2017-18. This plan reflects the mature organisation HIW has become over the past four years. Over this time we have increased the volume of activity we have undertaken. Additionally, we have developed more focussed and bespoke reviews and inspections to respond to the issues of which we have become aware. Similar to last year, this plan provides information on the broad areas we plan to review, but reflects the way in which we manage our work programme to respond to risks and intelligence from the public, from our partner organisations and from healthcare providers themselves. The specific detail of what we plan to do is listed in our Commitment Matrix Annex A. During the next year there are a number of legislative changes we will need to respond to including the changes to the dental regulations and the possibility of legislative change following The Green Paper: Our Health, Our Health Service. We also see the cessation of the current model of midwifery supervision which has been hosted by HIW. The final annual report for this function will be published in 2017-18. We continue to develop our communication tools to share our findings with a greater breadth of people and increase the opportunities to share our findings at conferences and events to create a larger impact from our findings. We will also continue to produce reports on high level themes to make it easier for policy makers and healthcare providers to learn from others. If you have any comments on our work, your experience, or on healthcare services in general please feel free to contact us. Dr Kate Chamberlain Chief Executive 3
How we make our decisions With the introduction of the Wellbeing for Future Generations (Wales) Act in April 2016, we will continue to uphold our values by focussing on the long term care for patients, working collaboratively with partners, patients and the community to drive improvement through independent review. This will help create a Wales that we want to live in, now and in the future. Our work is structured to support the delivery of our activities in three key areas: regulation of independent healthcare inspecting the NHS mental health. The collective combination of these activities supports the three priorities we aim to achieve: provide assurance promote improvement influence policy and standards. Using Intelligence The way in which we make decisions and decide where to focus our activities needs to be risk based and intelligence led. There are a number of environmental factors we consider. Our population demographic is changing, people are living longer and this places pressures on health services which are compounded by rising public expectations. Financial resources both for health services and HIW are scarce. We have to find ways to do more with less. The ways in which care is provided is evolving in order to deal with these changes in the operating environment. Therefore the complexity of service change is itself a factor we need to consider when assessing risk. Legislative changes to the regulatory framework including changes to the dental regulations. We must use what we know about services and the information we have available, such as: Vulnerability of the client group or complexity of the service. Evidence and intelligence about an organisation built up over time. Specific data and information routinely available to HIW. Issues and concerns shared within by our partners. Previous HIW reviews. Public concern. National priorities, new standards or quality requirements. Recognised inequalities. Blind spots. 4
Operational Plan 2017-18 We need systems and processes into which we can feed this information to ensure our decisions are consistent and based on evidence. To achieve this we use: Relationship managers for each NHS organisation to review intelligence and evidence to support the future planning process. Memoranda of Understanding and Information sharing protocols with other organisations to allow us to share information correctly. An Intelligence Map to provide clarity on the information that is used on a regular basis. Organisational records for each health board/trust and for independent providers. Our Risk & Escalation Committee 1. Consultation Document Date of issue: 22/05/2015 Responses by: 30/07/2015 Strategic Plan 2015-18 This plan ensures we meet our statutory requirements and review areas of concern identified by our relationship managers. It also builds on the responses we received to the consultation we conducted into our Strategic Plan 2015-16 to 2017-18. The key points highlighted in the responses focussed positively on our intention to investigate and publish National Thematic Reviews in a number of specific areas over the three year period, and included suggestions of additional areas that could be explored either as part of this strategic plan or for future years consideration. This plan and previous years plans have built on this suggestion by conducting a greater number of bespoke and in depth reviews, such as the Ophthalmology Review 2 conducted in 2016-17. This review received significant attention and provided the opportunity to establish relationships, and share a best practice approach with key stakeholders. The functions and powers of HIW were considered by Ruth Marks in her 2014 review, The Way Ahead: To Become an Inspection and Improvement Body. The report makes several recommendations for HIW and for Welsh Government. In June 2015, the Welsh Government published a Green Paper called Our Health, Our Health Service which included a section on the future of inspection of health and social care. In 2017-18 we will continue to work with Welsh Government to evaluate the current legal framework and identify where improvements can be made. We are also developing approaches to working more closely with the Care and Social Services Inspectorate for Wales, and in 2017-18 we will undertake another joint review. Number: WG25325 Welsh Government Green Paper Our Health, Our Health Service Date of issue: 6 July 2015 Action required: Responses by 20 November 2015 Digital ISBN 978 1 4734 3673 2 Crown Copyright 2015 1 http://hiw.org.uk/about/plans/operating/?lang=en 2 http://hiw.org.uk/reports/natthem/2017/?lang=en 5
Delivering our responsibilities: Regulation of independent healthcare Registration, inspection and enforcement action are the methods through which HIW regulates the independent health sector in Wales in accordance with the Care Standards Act 2000, the Independent Health Care (Wales) Regulations 2011; the Independent Health Care (Fees) (Wales) Regulations 2011 and other legislation (see Annex B). We regulate and inspect a broad range of independent healthcare providers ranging from those who use lasers to full private hospitals. Our core activities for 2017-18 are listed below. Registration and inspection of independent clinics, hospitals and medical agencies. Registration of independent mental health and learning disability establishments. Registration and inspection of premises using class 3B or 4 laser or intense pulse light machines. Pursuit of enforcement action when regulatory breaches are identified in a registered setting. Identifying and dealing with potential unregistered providers. We continue to manage concerns brought to our attention relating to the independent sector. In addition, 1 April 2017 will see the Private Dentistry (Wales) Regulations 2017 replace the 2008 regulations. This change will mean that Individual dentists will no longer be required to register with HIW to provide private dental care in Wales. Instead all dental practices where private dental care is provided will have to register with HIW. Also Dental Care Professionals (DCPs) who provide private direct access care from their own practice will have to register with HIW if they want to provide these services in Wales. This change will improve quality and safety by aligning the standards for Private Dentistry with the Health and Care Standards (the standards of healthcare applied in NHS dental practices) ensuring consistency as far as possible with the National Minimum Standards for Independent Health Care Services in Wales. 6
Operational Plan 2017-18 Delivering our responsibilities: Inspecting the NHS HIW inspects services provided by the NHS across Wales to test whether care is provided in accordance with the Health & Care Standards. Many of HIW inspections are unannounced although for practical reasons this is not always possible. We have published a statement setting out the rationale for whether our inspections are unannounced or announced. We also undertake a proportion of our visits outside of office hours. Inspections test care against three specific domains: quality of patient experience. delivery of safe and effective care. quality of leadership and management. HIW is continuing to evolve its inspection and review approach. For example, over the past few years we have moved from a high number of single ward inspections to a variety of broader multi-site multi-ward hospital inspections. During 2017-18, the hospital inspections will continue to focus on particular themes such as those identified by our intelligence. We conduct appropriate follow up activity where necessary and a statement on our approach to undertaking follow-up activity is also published. In addition to its core inspection programme HIW may undertake a number of specific investigations. We will publish an annual report for each health board and NHS trust summarising the key themes from our findings. We take a strategic view of the NHS by reviewing clinical governance. This high level approach allows us to form a judgement on whether the organisations are effectively managing their responsibilities, and are learning lessons (from adverse events) and improving. Our findings feed into the NHS Wales Escalation and Intervention Arrangements. We work with the Wales Audit Office (WAO) to support the assessment of governance 3. This has been recently demonstrated through our joint reviews of governance with WAO in Betsi Cadwaladr University Health Board. An Overview of Governance Arrangements Betsi Cadwaladr University Health Board A summary of progress against recommendations made in June 2013 July 2014 Archwilydd Cyffredinol Cymru Auditor General for Wales 3 http://hiw.org.uk/about/workingwithother/mou/workingtogether/?lang=en 7
HIW works with other bodies to examine healthcare in other settings such as the clinical review of deaths in prison settings undertaken with the Prison and Probation Ombudsman and the reviews of Youth Offending Teams led by Her Majesty s Inspectorate of Probation. During 2017-18 we will continue to undertake thematic work. We will conduct further thematic work in areas including mental health in the community, and also discharge arrangements from secondary care settings. We will continue to conduct inspection programmes in primary care, specifically in dentists and GP practices, and we will continue our work on Ionising Radiation (Medical Exposure) Regulations. During 2017-18 we will pilot and implement an inspection framework to test whether relevant standards of care are being met within NHS surgical services. 8
Operational Plan 2017-18 Delivering our responsibilities: Mental Health The focus of this work area is to ensure the most vulnerable individuals in society are protected, cared for and treated appropriately in environments conducive to their recovery. HIW visits hospitals in both the NHS and the independent sector as part of our work programme. We also visit services provided in the community to review Community Treatment Orders and are planning a thematic review of community mental health services in 2017-18. Our core activities are listed below. Inspection of NHS and independent mental health and learning disability establishments with appropriate follow up activity. Provision of the Mental Health Review Service 4 and processing requests for Second Opinion Appointed Doctors (SOADs). Monitoring the implementation of the Mental Health Measure. Monitoring the implementation of the Deprivation of Liberty Safeguards (DOLS). Monitoring the use of the Mental Health Act. In addition, Welsh Ministers can commission HIW to conduct an independent external review when an adult known to mental health services commits a homicide. During 2017-18 we will publish a summary report of our findings from inspections of mental health services to supplement our annual reports on monitoring the use of the Mental Health Act and the implementation of DOLS. We will publish Key Performance Indicators for supporting the SOAD function in the annual report for 2017-18. 4 http://hiw.org.uk/about/whatwedo/mentalhealth/mentalheatlhreview/?lang=en 9
Enablers For HIW to sustain an impact in the healthcare landscape in Wales we need to invest in continual improvement and development of our organisation and the functions and methodologies that underpin our reviews. Public and Patient Engagement HIW works closely with patients, service users, carers and families, and the general public. Some examples of how we do this are below. Using members of the public as volunteer lay reviewers within our inspection and review teams. Working with patients, service users, carers, their families and representative groups and as members of our Advisory Board. Seeking views and perspectives from patients as an integral part of our inspection methodology. Public consultation on our plans and work programme. During 2017-18 we will evaluate the use of voluntary lay reviewers, a change we introduced for 2016-17. We will continue to develop our methods of communication to maximise the impact of our work, including presenting at conferences and seminars to support wider learning. In addition, to support improvement, we will publish our overarching inspection methodology which will describe how we inspect the NHS and independent healthcare services. We will also publish all the inspection tools we use. 10
Operational Plan 2017-18 Collaborative working We will continue to work effectively with complementary organisations to ensure the work we undertake supports the improvement of service delivery. Typically this will include professional regulators such as: The General Medical Council and the Nursing and Midwifery Council. Patient representative organisations such as the Older People s Commissioner and the Community Health Councils. Wider UK regulators such as the Health and Safety Executive. During 2017-18 we will continue to develop memoranda of understanding with other organisations if needed. We will continue to monitor the operation and impact of our existing memoranda of understanding. HIW will continue to use stakeholder reference groups to ensure the credibility of our work. In addition, using peer reviewers on our inspections ensures we are testing against current practice. This approach allows best practice to be shared more widely. During 2017-18 HIW will continue to be an active participant and host for the Inspection Wales programme. This initiative maximises the collaborative working between the Wales Audit Office, Estyn, Care and Social Services Inspectorate Wales and HIW. Similarly, HIW will continue to actively support the Wales Concordat Cymru. The four Inspection Wales partners are planning to take forward various pieces of work during 2017-18 on the theme of youth services. Each organisation has a different role and remit in relation to young people but is working with its partners to deliver a series of linked reports or outputs. This work may also present an opportunity for a joint summary report drawing together common themes. This activity is the first national thematic review involving joint working between all four Inspection Wales partners. As well as working effectively across Wales we seek to influence the inspection and regulation environment internationally. We will continue to hold membership of the UK and Ireland Five Nations Group, the UK Heads of Inspectorate Forum and the European Partnership of Statutory Organisations. Using intelligence effectively We will continue to progress the use of intelligence within HIW, providing clarity about which sources are used and what benefit they provide. Moreover, during 2017-18 we will hold two healthcare summits to share intelligence with other linked organisations in order to inform our contribution to the NHS Wales Intervention and Escalation Framework. We will also implement the actions outlined in our Intelligence Strategy. 11
The Organisation HIW s greatest asset is its staff. During 2017-18 we will continue to invest in appropriate training to develop our leadership capability and professional skills and to embed the HIW Learning and Development Strategy. In addition, during 2017-18 we will continue to invest in our systems and processes to ensure they are efficient and effective. During 2017-18 we will review our internal governance frameworks to ensure they are appropriate and make changes as required. The Advisory Board During 2017-18 we will consider how best to refresh our National Advisory Board and will draw on the experience of our current Board members to ensure that we have an advisory system which helps to keep the voice of patients, carers and families at the heart of what we do. Performance Standards We continue to be explicit about the standards of service we provide. Where immediate assurance is required following an NHS inspection, letters will be issued to the Chief Executive of the organisation within 2 days. Where urgent action is required following an inspection in the independent sector, the service will issued with a non-compliance notice within 2 days. We will publish all reports 3 months after an inspection as stated in our publication policy. We will publish our performance against these standards in the Annual Report for 2016-17 which will be published by end of July 2017. 12
Operational Plan 2017-18 Annex A: Commitment Matrix The following table is a list of HIW s specific commitments for 2017-18. Deliverable Measured by Influencing policy and standards Support improvement Providing assurance Delivering our responsibilities: Regulation of independent healthcare 1. Process applications to register, or changes to registration, in a timely manner. Ensure all applicants can demonstrate they meet relevant regulation and minimum standards. 2. Conduct a programme of visits to suspected unregistered providers As required Deliver a programme of inspections in independent settings Approximately 37 laser Approximately 32 non-laser including mental health 3. Ensure that concerns and Regulation 30/31 notifications are dealt with in a timely and professional manner Registration applications determined within 12 weeks of full and complete submission Number of visits undertaken Number of inspections undertaken Number of reports published 3 months following inspection Number of concerns received Number of Reg 30/31 notifications received Analysis of source and action taken 4. Support legislative developments including: Implementation of the Private Dentistry (Wales) Regulations 2017 Relevant legislative development following Our Health, Our Health Service Delivery of implementation plan following new dental regulations Responses to consultations regarding legislative developments 13
Deliverable Measured by Influencing policy and standards Support improvement Providing assurance Delivering our responsibilities: Inspecting the NHS 5. Undertake a broad inspection programme in the NHS informed by intelligence and an assessment of risk including approximately 22 focussed inspections across the acute sector 11 specific follow-up inspections 40 GP inspections 100 dental inspections 5 IR(ME)R inspections 6. Continue our programme of thematic work including Discharge Community mental health 7. Continue our joint inspection work with UK agencies Approximately 16 death in custody reviews with the Prison and Probation Ombudsman Up to 3 joint reviews with HMI Prisons and HMI Probation 8. Conduct a high level review of each NHS body through Further development of the Relationship Management function Producing an Annual Report for each Health Board and NHS Trust Number of inspections undertaken Publication of terms of reference of each project Publication of thematic review Number of inspections undertaken Publication of health board and NHS trust annual reports 14
Operational Plan 2017-18 Deliverable Measured by Influencing policy and standards Support improvement Providing assurance 9. Publish annual reports summarising the themes and issues arising from our work. In particular Publication of reports Hospital Inspections Primary Care Mental Health Act Annual Monitoring Report Deprivation of Liberty Safeguards (DOLS) Annual Report IR(ME)R Local Supervising Authority Annual Report HIW overarching Annual Report 10. Undertake a programme of inspections in NHS and independent mental health settings including approximately 7 NHS mental health units 18 independent mental health units 60 Mental Health Act visits 3 specific follow-up inspections 14 inspections of Community Mental Health Teams (linked to thematic) 11. Provide a Second Opinion Appointed Doctor service for about 750 SOAD requests Number of inspections undertaken Publication of Key Performance Indicators 15
Deliverable Measured by Influencing policy and standards Support improvement Providing assurance 12. Investigate homicides as commissioned by Welsh Government Publication of Terms of Reference Publication of final report An Enabling Organisation 13. Continue to develop our methods of communication to increase the impact of our work Number of conferences presentations 14. Hold 2 Healthcare Summits during 2017-18 15. Refresh the National Advisory Board 16. Publish reports from all our inspection and review activity in accordance with our performance standards. 17. Evaluate and publish our review methodology 18. Continue our joint work with other UK and international agencies on joint inspections and influencing best practice 19. Evaluate the use of voluntary lay reviewers Media coverage Clear audit trail of healthcare summits Description of advisory mechanics on our website Publication of reports Publication Schedule Publication of HIW performance against targets Methodology published Participation in joint work Progression of joint thematic on Youth with Inspection Wales Evaluation with recommendations for future action 16
Operational Plan 2017-18 Annex B: Legislation NHS Health and Social Care (Community Health and Standards) Act 2003 Health and Social Care (Community Health and Standards) Act 2003 (Healthcare Inspections) (Wales) Regulations 2005 Inspection of NHS services and services provided on behalf of the NHS Hospitals Primary Care Community Services 17
Independent Care Standards Act 2000 Independent Health Care (Wales) Regulations 2011 Independent Health Care (Fees) (Wales) Regulations 2011 Private Dentistry (Wales) Regulations 2017 Regulation and Inspecton of Independent Healthcare (including enforcement) Regulation and Inspection of private dental practices Independent Hospitals Independent Clinics Lasers 18
Operational Plan 2017-18 NHS and Independent Mental Health Act 1983 Mental Capacity Act 2005 Ionising Radiation (Medical Exposure) Regulations 2000 Controlled Drugs (Supervision of Management and Use) (Wales) Regulations 2008 Mental Health (Wales) Measure 2010 Inspection of settings where ionising radiation is used Review of notifiable incidents Hospitals Dentists Mental Health Act Review Service include Second Opinion Appointed Doctors (SOAD) Deprivation of Liberty Safeguards (DoLS) Hospitals Primary Care Community Services Compile, maintain and publish a register of controlled drugs accountable officers NHS health boards and trusts Independent hospitals 19