NHS Wales Delivery Framework 2011/12 1

1. Introduction NHS Wales Delivery Framework for 2011/12 NHS Wales has made significant improvements in targeted performance areas over recent years. This must continue and be associated with a greater focus on prevention, quality, outcomes and patient experience. This will occur at a time of financial constraint and the NHS will therefore need to take concerted action to drive up efficiency and productivity levels. This framework sets out the priorities for improvement and delivery in 2011/12. It also clarifies the national support which will be available to enable local improvement. Finally, it defines an escalation process which reinforces the accountability of Health Boards and Trusts for delivery. 2. Core Delivery Targets These are arranged into two groups:- Tier 1 which will be subject to very close attention by Health Boards, Trusts and Welsh Government (through National monitoring). These are the key priorities where immediate improvement is necessary or where performance at defined target levels must be sustained. Tier 2 are equally important but are either subject to longer term delivery trajectories (extending into 2012 /13 or beyond) or will be subject to regular local (and more periodic national) monitoring. Both tiers will be supported by relevant data monitoring arrangements and should form the basis of local reporting to Boards. In setting out these priorities it is important to emphasise the strategic importance of Prevention and Health Promotion. This is a critical area and our work will, over future years, enable improvements in the health of the population and a reduction in health inequalities. In light of the commitments identified within the Manifesto, the focus for the rest of 2011/12 must be to ensure that local strategic public health frameworks have been rigorously developed and that clear priorities are identified for 2012/13 and beyond. The plans, nationally, will include extended programmes of work in relation to Early Years and locally will involve a continuous focus on inequalities. Tier 1 Priorities Area Deliverable Assessed Reduction in emergency admissions and readmissions plus bed day usage for chronic conditions (link to Quarterly review of data via unscheduled care) PEDW measurement. Setting the Direction Establishment of locality networks with one area managing an indicative budget Evidence of multi disciplinary team working to support the frail elderly Implementation and achievement of Primary Care HR matrix supporting shift in services into the community Key outcome measure for 2012 onwards: Increase in the number of people living at home or their usual place of residence in particular those with a mental health illness or who are >75yrs. Dignity in Care Linked to the Older Persons Commissioner Report. Minimum requirement to ensure that all Boards deliver against the 12 key actions identified and demonstrate improvement in the older persons experience across the full range of their services. Monitoring against action plans and the annual Fundamentals of Care audit report. NHS Wales Delivery Framework 2011/12 1

Quality in care Further reduction in C Difficile and MRSA against agreed local targets. Minimum 20% improvement against baseline with an improvement range between 20-60% Elimination of pressure sores Local targets agreed by LHB based on their baseline position and improvement plan Monthly data linked to Fundamentals of Care and links to 1000 lives+ reporting. Hospital acquired pressure sore reduction measured through 1000 lives+ and Fundamentals of Care Mortality Rates Access Unscheduled Care Cancer Demonstrable reduction in the mortality rate for stroke, cardiac, major trauma and fractured neck of femur patients (30 day post event). (Local targets to be agreed by LHBs based on their baseline position and improvement plans) 95% of patients will be waiting less than 26 weeks for treatment with a maximum wait of 36 weeks For Orthopaedics, we will ensure that no patient will wait longer than 36 weeks for treatment by the 31 st March 2012 (exc major spines) Delivering the 95% 4-hour standard across all units in Wales * Continue to deliver the 65% Cat A response times (with an internal stretch target of 70%) Minimum expectation that 95% of all cardiac arrest, stroke and major trauma patients are handed over within 15 minutes. Delivery of the 31 (98%) and 62 day (95%) cancer standards. Establish a monitoring system to demonstrate increased survival rates at 1 and 5 years. Mortality data measurement to be agreed and in place by end of quarter 3. To include baseline data for wider benchmarking by year end. Monthly monitoring and year end position. Focus On pathways. Weekly /monthly monitoring and year end position. Weekly and monthly monitoring Final assessment at end of year to demonstrate overall achievement. * Develop dashboard of outcome measures in Q2 Monthly /Quarterly monitoring (weekly if non-compliant). Survival data currently two yrs out of date therefore use 1 yr survival initially (via WCISU). Stroke Efficiency & Productivity Sustain 95% compliance against each of the four acute stroke care bundles whilst introducing outcome focused measures for TIA and early rehabilitation in Q3. (Stretch target: 24 /7 thrombolysis across Wales). Short Stay Surgery Day surgery; 80% of planned surgical interventions under the BADS 50 will be treated on a day case basis. The percentage for all surgical procedures under taken by Day case will improve Admission on day of surgery to become the norm unless clinically determined supported by pre-operative assessment for all patients. Reduced bed days /Improved length of stay (case mix sensitive) with a particular focus on orthopaedics and emergency medicine. Monthly monitoring Pilot TIA and rehab care bundles in Q3 onwards. Year end position. Reviewed monthly /quarterly to ensure continuous improvements as specified in the National Efficiency and Productivity Report (July 2011) NHS Wales Delivery Framework 2011/12 2

Efficiency & Productivity cont. Resource Utilisation Theatre productivity; improvements on turnaround times Outpatients; new service models to be developed to improve efficiency and outcomes for both new and follow-up patients. Demand management /threshold management: with a particular focus on orthopaedics, emergency admissions and one other local priority. Annual targets of : Financial balance Remain within resource limits and within capital resource limits Achieve annual local Sickness and Absence workforce target Show reduction in annual total pay spend National data collection from Q3. Priority focus this year will be orthopaedics. National metrics to be agreed in Q3 onwards. Measurement systems to be agreed in Q3, linked to QOF quality measures Monthly ongoing monitoring to maintain focus. Monthly data HR and Financial flows Tier 2 Commitments Area Deliverable How will this be measured Child Poverty Demonstrated improvement against locally agreed partnership targets linked to child poverty. LHBs to show reduction in: Annual measure through already established data flows Targets Infant mortality Low birth weight Teenage conceptions Prevention and Health promotion Primary Care Unscheduled Care Focused improvement in: Reduction in smoking Reduction in number of falls in older people Reduction in the burden of alcohol misuse- Locally determined Improved health at work via national assessment Improvement in management of Vascular risk Manifesto Commitment: work towards improvements in improved access to GPs, evening and weekends. Each locality area will develop plans to implement locally agreed pathways for planned services through review of outpatient referral data and also emergency services through review of emergency admission data Continue to improve DTOC (Target to deliver and sustain nationally agreed LHB reductions) Continuous improvement in handover performance for all patients <15 mins. Clinical outcomes linked to major trauma and acute illness particularly fractured neck of femur and Focus On pathway Through NPH data flows, Statistical data Local improvement data, 1000 lives plus and nursing dashboard. Local targets to be agreed based on baseline position and improvement plan Annual primary care report. Quarterly reporting within organisation. Annual assessment through QOF process Monthly assessment Measurement of this will be developed within the year as part of the commitment to measure clinical outcomes Focus On pathway NHS Wales Delivery Framework 2011/12 3

Mental Health End of Life Care Clinical leadership to support high quality clinical care Sustain CPA delivery (100% Enhanced and 95% standard) and crisis resolution targets (95% assessed prior to admission 100% assessed after admission) whilst improving delivery against the intelligent targets for dementia and depression Increase in the number of patients who receive care in the preferred place of care as agreed within their care plan. Improved clinical care will be evidence based and driven by clinical leaders Organisations will produce an annual clinical governance report to include R&D activity Maintain monthly data flows to support delivery. 1000 lives+ monitoring used to demonstrate progress against intelligent targets. Local targets need to be agreed by LHB based on their baseline position and improvement plan Data flow to be secured. Year end assessment likely. Commitment to system thinking, service improvement and best practice linked to the evidence base. Clinical Leadership measures to be developed Corporate requirements Evidence of Workforce redesign Investment in staff linked to Value statement Development of intelligence and information to support more effective deployment of staff Work to achieve the Platinum Corporate Health Standard by 2013 Agreed Health and Safety intervention plans (H&SE Sept 2011) together with improved H&S competence at board level To be monitored through review of NHS internal Board reporting and normal returns to WG Respond to H&S audits within agreed timescales Delivery of the key areas of the all- Wales information services EMPI, NADEX, IHR, WCP, MHOL, WCCG Utilise ICT to improve delivery of high quality clinical services To be monitored through review of NHS delivery of project plans Some of the Tier 1 priorities have been developed within the 1000 lives programme reflecting our focus on quality and outcomes. This will continue and we will increasingly prioritise clinical indicators of progress. More generally the 1000 lives programme will continue to support our quality improvements utilising appropriate methodologies. Progress will be monitored locally with periodic national reporting arrangements. 3. Assurance and Monitoring Process While the LHBs and Trusts are accountable to their citizens and Boards for their delivery, Welsh Government has a key role to play in ensuring that organisations deliver and implement national guidance and Ministerial priorities. The delivery of these key priorities will be ensured though a combination of the following processes: Monthly CEO meetings Bi-annual Joint Executive Team meetings (JET) Regular meetings between Minister and LHB /Trust Chairs. These will also be supported by monthly meetings with executives of organisations to discuss details around delivery, efficiency and clinical quality improvement against Tier 1 and selective Tier 2 priorities based on the principles of earned autonomy and assurance and will be supported by 1000 Lives + reporting mechanisms. The timing of the monitoring cycle is summarised below and wherever possible administrative processes will be kept to a minimum. NHS Wales Delivery Framework 2011/12 4

Weekly / monthly NHS Monitoring cycle NHS Corporate business Tier 2 Tier 1 Monthly / quarterly / yearly based on earned autonomy Updates at Board level 1000 lives plus Continuous local reporting to ensure no surprises 4. Delivery and Accountability Arrangements There may be times when performance within an organisation gives cause for concern and WG s level of involvement will be proportionate to the level of non-delivery. This will be assessed by utilising a risk based approach to performance management, intervening only when there is a level of continued or significant risk of non-delivery. The greater the risk at an organisation level, the more closely WG will monitor and intervene. When considering the appropriate level of scrutiny for each organisation WG will consider the following points to ensure that it is proportionate: How to tailor scrutiny to those areas of greatest impact. Scrutiny and intervention will be tailored in frequency, intensity and scope. The level of scrutiny will be based on the assurance requirements of WG, and the Minister for Health and Social Services. The overall objectives of the delivery framework will be to ensure successful delivery of the required milestones with assurance of ongoing sustainability. LHBs /Trusts will be required to provide an assurance that they are delivering against the national requirements. This is particularly relevant for non compliance against standards set but not yet delivered from previous years e.g. access (esp. orthopaedics) and unscheduled care. The WG approach will be proportionate and based on the principle of earned autonomy. Organisations that do not meet the required standards will be subject to a clear escalation process. This will be in four stages and follows the same process already described in the orthopaedics plan to CEOs. Timescales of escalation will be relevant to the reporting timescales of individual indicators. The escalation framework is noted below: NHS Wales Delivery Framework 2011/12 5

Escalation within the Delivery Framework Escalation Performance Level trigger 0. Local delivery of all targets and/ or within trajectory. Escalation Action Monitoring De-escalation None required earned autonomy and minimal monitoring beyond that required for national returns. 1. Immediately on failure to achieve / maintain one or more 2010/11 deliverables. Tier one initially. WG indicates the additional monitoring requirements. Potential weekly telephone calls between responsible WG lead and /or DSU. Plans brought forward to redress the position with immediate effect WG/DSU/other organisation monitors implementation of plans and effectiveness of solutions, Executive highlight report. Support from other agencies if required. Immediate removal of escalation action upon achievement of KPIs. 2. Continued failure to achieve / maintain one or more key deliverables WG instigates DSU (or other) intervention. WG and DSU will be actively involved in determining the necessary changes within the LHB / Trust to deliver required outcomes WG Director to join weekly telephone calls, and monitor effectiveness of organisational response and DSU intervention Sustained achievement of all KPIs causes removal of all escalation actions 3. Continued failure and /or a failure to maintain an agreed improvement trajectory following DSU intervention Issues raised with Chief Executive NHS Wales. Meeting required between LHB CEO, NHS CEO and NHS Director of Ops to determine future actions. Regular reporting established between CEO NHS Wales and LHB Chief Executives until improving trajectory established. Maintenance of agreed improvement trajectories causes return to escalation level 2. 4. Continued failure to improve performance or failure to engage with the national process despite level 3 escalation Actions to be determined by NHS Chief Executive which may include the following: Introduction of `special measure arrangements Review of executive effectiveness Review of Board effectiveness Removal of appropriate funding streams. NHS Wales Delivery Framework 2011/12 6

5. Local Responsibility for Delivery Patients across Wales need to feel confident that, when they access healthcare services, their local NHS organisation will deliver the services they need in an effective and timely manner without harm or variation. We all need to be confident that the best possible use is made of the resources invested in healthcare services without waste and the Welsh Government need to be confident that NHS organisations are contributing effectively to the achievement of these goals. Local Boards /Trusts will therefore need to take ownership for delivery and service modernisation and be accountable through their boards and the Welsh Government for health services to their local communities. Chief Executives, as the designated Accountable Officers, are required to ensure that risks to the achievement of their organisation s objectives and the fulfilment of their statutory responsibilities are identified; that the significance of the risk is assessed; and that appropriate action is taken. This needs to be communicated and regularly updated as part of internal controls but also as part of assurance requirements with WG. As set out in the requirement for completing the Statement on Internal Control the standards for Health Services in Wales - Doing Well, Doing Better are the key framework for demonstrating achievement and areas for improvement across areas of the organisation. The diagram below represents how this is likely to work in practice: The Board reviews its performance towards the achievement of its purpose and desired achievements The Board identifies the key purposes and desired achievements for the organisation. Locality/Directorate/Department/Team and individual objectives will directly link to these The Board evaluates the effectiveness of its risk and assurance arrangements OBJECTIVES The Board establishes and communicates its approach to risk including its risk appetite ASSURANCE Citizen Led NHS RISKS The Board receives evidence to satisfy its assurance needs CONTROLS The Board identifies its risks (both opportunities and threats) at a corporate level and this process is repeated at all levels The Board articulates its assurance needs to demonstrate controls are effective to manage risks. Management designs and operates its system of internal control NHS Wales Delivery Framework 2011/12 7

6. Supporting the NHS to Deliver Two arms length NHS bodies, namely NLIAH and the DSU, will continue their role in supporting the NHS to develop and deliver continuous improvement. The annual work plans of these bodies will be closely aligned to the risk assessment process to provide targeted and effective support to assist organisations in delivery. This will be a mixture of mandatory (via the escalation process) and invitational support. Further work on clarifying the respective functions will be concluded shortly. Public Health Wales will also play a key role through their policies and strategies to support LHBs to deliver their statutory duties in the delivery of public health to their local populations. Important Note: Manifesto Commitments Developmental areas as part of the Government s manifesto commitments will be assessed and planned for implementation based on a five year delivery framework. Many of the target areas are already priorities within this year's AQF and will form part of ongoing service improvements. Other areas are new and will require development and potential legislation to take forward. The NHS will be consulted and involved in the timing of implementation and expectations on delivery. NHS Wales Delivery Framework 2011/12 8