Aneurin Bevan University Health Board Planning and Strategic Change Committee A Meeting of the Planning and Strategic Change Committee was held on Tuesday, 19 th December 2014 in Seminar Room 4, Conference Centre, Health Board Headquarters, St Cadoc s Present: Chris Koehli (Chair) - Independent Member (Finance) Richard Bowen - Director of Planning Dr Paul Buss - Interim Medical Director Prof. Helen Houston - Independent Member (Community) David Jenkins - Chair of the Board Prof. Siobhan McClelland - Vice Chair of the Board Judith Paget - Chief Executive Joanne Smith - Independent Member (Community) Prof. Janet Wademan - Independent Member (ICT) In attendance: Mark Ash - Finance Business Partner Caroline Bird - Service Group Manager, Unscheduled Care Bobby Bolt - Deputy Chief Operating Officer Peter Carr - Divisional Lead for Performance and Planning Allan Davies - Director of Planning Mr Aled Evans - Consultant Trauma & Orthopaedic Surgeon Deb Jenkins - Directorate Manager, Trauma & Orthopaedics Dr Sally Lewis - Primary Care Clinical Director Sian Millar - General Manager, Scheduled Care Division Dr Caroline Mills - Clinical Director of Scheduled Care Ian Morris - Assistant Director of Planning Julie Poole - Directorate Manager - Orthopaedics Nicola Prygodzicz - Assistant Director of Finance Dr Liam Taylor - General Nurse, Stroke Services Apologies: Alan Brace - Director of Finance Dr Gill Richardson - Director of Public Health Jamie Marchant - Interim Chief Operating Officer 1
PSCC 1219/01 Welcome and Overview The Chair welcomed everyone to the meeting. PSCC 1219/02 Declarations of Interest There were no Declarations of Interest made relating to items on the agenda. PSCC 1219/04 System Transformation: Primary Care The Chair welcomed Dr Sally Lewis, Sian Millar and Dr Liam Taylor to the meeting. Dr Sally Lewis provided a brief overview on system transformation within Primary Care which focused on the following principles and themes going forward: Health Inequalities and priorities Living Well, Living Longer update Smoking cessation progress GMS contractual changes 14/15 GMS contractual negotiations 15/16 GMS issues Access, Workforce, Workload Eye Care Oral health A Framework for the Intervention to Reduce Health Inequalities was in place that would aid in supporting and building a healthy public and create supportive environments; it would also strengthen community actions and aid in realigning health services. Dr Liam Taylor provided an update on the GMS Contractual Changes for 2013/14 and the three national priority areas which were the End of Life Care Plan, Poly Pharmacy and Cancer Pathways in particular Lung and GI. The Committee noted that the Network Development Plans and Clinical Governance Practice Self Assessment Toolkit was part of year 1 of a 3 year work programme. The Consolidation of Network Development was part of the General Medical Services Contractual Negotiations for 2015 and 2016 with the emphasis on service sustainability to strengthen MDT working. 2
Further development of horizontal integration was required to enhance the needs assessment and there was a plan for more effective, local collaborative working between the nursing profession, local authorities and the third sector bodies. The GMS Contractual Changes for 2015-2016 would assist in reducing bureaucracy in the contract and increase transparency of practice and network plans and investment. The Chair asked what action the Division was taking in relation to referrals and in particular Trauma and Orthopaedics, which were recorded the highest in Wales for the Health Board. Dr Lewis responded advising that this was a major issue and there was a need to review the knee pathway from when the GP identified the problem through to patient discharge. Dr Lewis explained that knee pain was not a chronic condition and due to concerns with regard to RTT and patient experience, feedback indicating that 20% of patients had regretted having had surgery, that she had been involved, from a Primary Care perspective, with the Trauma and Orthopaedic pilot for Knee Osteoarthritis (KO). The Committee noted that there was an issue with inappropriate referrals from GPs when the procedure was not adding value to the patient outcome. Discussion ensued on how this matter could be approached differently in relation to referral management in Gwent and in particular the development of a suite of information for use by GPs. The Committee discussed the cost to the Health Board of inappropriate referrals and how the process could be made more productive using prudent and value based principles. The Committee recognised that the GP was not best placed to advise a patient on major surgery and it was agreed that more focus was required on this issue and 3
that a structured group should be set up to investigate further. Action: B Bolt Professor Janet Wademan commented that patient expectation and Clinician expectation should be aligned. Richard Bowen provided an update in relation to the ongoing operational pathway work which was being supported by ABCi. Bobby Bolt provided an update with regard to Eye Care advising that 1598 patients would have been treated in the Glaucoma Assessment Service by 31 st March 2015 in the Ophthalmic Diagnostic and Treatment Centres. The Committee noted the Health Board was the first organisation in Wales to explore this option which would reduce referral triage by 13% to 1300. Bobby Bolt explained the plan going forward for Primary Care Services, the need to do things differently and to prioritise the needs of the local population i.e. Cardiac Rehabilitation was a priority and the Division had been encouraging active patient involvement in decision making and educating them to staying well. Bobby Bolt concluded that the issues for Planning and Strategic Change Committee were: Living Well, Living Longer Smoking Cessation Estates ODTCs Diabetes Service Respiratory Services Referral Management Primary Care Plan and Network Development Social Services and Well-being Act The Chair thanked Dr Sally Lewis, Dr Liam Taylor, Bobby Bolt and Sian Millar for a very informative presentation and for attending the meeting. Dr Sally Lewis, Dr Liam Taylor, Bobby Bolt and Sian Millar left the meeting. 4
PSCC 1219/05 RTT Delivery Plan: Cardiology: Improving Waiting Times and Developing a Sustainable Service The Chair welcomed Dr Stephen Hutchison and Caroline Bird to the meeting. Dr Stephen Hutchison explained that Cardiology faced significant pressures due to the loss of a Consultant, which had resulted in lost capacity and had impacted on waiting times. Caroline Bird provided an overview of the progress with regard to the case for improving waiting times and developing sustainable services following the additional investment for the service that had been approved by the Board on 23 rd July 2014. The in-year focus had been to reduce the waiting times for first new outpatient appointments and the delays for follow up outpatient appointments. It was recognised that there was an increasing demand in Echocardiography and that reducing waiting times for Echocardiography was a key priority due to patients experiencing difficulty in obtaining an appointment unless the request was reviewed by a Consultant. A system had been set up in Obstetrics and Gynaecology where a number of slots had been allocated to the specialty for them to manage which was reporting to be working well. Cardiology was a complex service and the Division were working with ABCi to understand the demand and develop a system to support this. Caroline Bird explained that the Division had undertaken a session with Primary Care with regard to treating patients closer to home, which included a number of developments in Cardiology. One of the initiatives was a Cardiac Services dashboard with the first stage of this providing live waiting list times in the form of a Blackberry Advice Line or call back. Should a patient have a concern they would be fast tracked using an e- referral which would improve efficiencies by providing a patient reminder service by call back or e-mail. Plans 5
were also in place to continue and increase virtual clinics where possible. Dr Paul Buss commented that it would be an ideal opportunity to develop and train an alternative staffing model in the form of a Physician s Assistant, which could aid in transforming the healthcare system and would help in continuing to develop the relationship between acute services and Primary Care. Action: A Phillimore The Chair asked about patients who Did Not Attend (DNA). Caroline Bird responded advising that the Directorate were working on a range of actions to ensure that all lists we filled and as a result the DNA had reduced from 12% to 3%. It was agreed that a wider exercise would be completed to determine the DNA rate across all clinics. Action: C Bird Dr Steve Hutchison and Caroline Bird left the meeting. PSCC 1219/06 Service Sustainability: Family and Therapies The Chair welcomed Sian Millar, Peter Carr and Mark Ash to the meeting. Sian Millar explained the difficulties faced with regard to the shortage of numbers across middle grade doctors in Paediatrics and Obstetrics and Gynaecology. She outlined the workforce requirements which would enable the Family and Therapy Services Division to implement a 1 in 11 rota, for Obstetrics and Gynaecology and Paediatrics, as stated by the Welsh Deanery and the continued provision of these services on both acute sites until the SCCC was commissioned. Sian Millar advised that the division had been working through options for potential solutions to move towards the Deanery requisite and outlined that there were 24 training posts in Obstetrics and Gynaecology that could potentially do 1:11 as an interim on 2 tiers and 15 non training grades that could also be moved around the system. A 1:11 rota on a single site was realistic however, would require a high capital spend for centralisation but RGH was limited on capacity. 6
The Committee acknowledged that the single site option to consolidate acute services on the RGH site was not an option due to the position with the financial position and the limited discretionary capital budget. It was noted that only essential work on RGH was being permitted as it would be a false economy to spend large amounts of capital on a building that would ultimately be demolished as part of the Clinical Futures Programme in 5 years or so. The Committee agreed that the workforce option to fill rota gaps by increasing the numbers of available medical workforce through the appointment of a Hybrid Consultants for Paediatrics, Specialty Doctors or Hybrid Consultant for Obstetrics and Gynaecology was the only realistic and preferred option. This option allowed for a flexible plan to move into the Specialist Critical Care Centre and was supported by the Committee. Sian Millar explained that as part of the Three Year Plan, the underlying deficit for the Division of 1.6 m included the cost of three Neonatal Consultant posts at 360k. In addition the workforce option for Paediatrics and Obstetrics and Gynaecology ranged from from 700k and 935k in 2015-16k and 1.3m and 1.5m recurrently. A detailed analysis of the options available had been undertaken for maintaining services and what was required to invest in additional posts to sustain these services at both Nevill Hall and Royal Gwent Hospitals. An exercise had also been carried out to indentify the potential for centralisation however, the scale of infrastructure changes required were such that these could not be delivered before late 2017, and as such would be difficult to justify, even if the capital was made available, given that the SCCC was anticipated to be opening in early 2019. The Committee recognised that the additional posts would have a significant revenue consequence and that their recruitment was not without risk. The Committee endorsed the Plan which would also be included in the Integrated Medium Term Plan. Action: Jamie Marchant/Sian Millar 7
Sian Millar, Mark Ash and Peter Carr left the meeting. PSCC 1219/07 RTT Delivery Plan Orthopaedic Services The Chair welcomed Mr Aled Evans, Julie Poole and Caroline Mills to the meeting. Julie Poole provided an overview of how scheduling of Orthopaedic Services was managed on a weekly basis and how the utilisation of theatres was monitored to ensure theatre lists were utilised to the maximum. She explained that a monitoring tool was used to review planned activity against actual deliverable outcomes and a review of all cohort stages of the pathway were in place. A review was undertaken every week to analyse the previous week cancellations in order to learn lessons and continuously improve systems and processes. Julie Poole provided an update on the changes that had been undertaken within Scheduling with the introduction of dedicated phone lines and the relocation of schedulers to work more closely with secretaries and Consultants, which reduced delays to the system and improved communication. A number of recent successful changes had been made, for example the Long Term Virtual hip and knee follow up which was having an impact and would reduce outpatient demand by 1,600 in 2015 and 3,500 to 2018, which increased productivity by 50 patients per session. Together with the setting up of virtual clinics for all subspecialties would prevent several thousand outpatient appointments, increased productivity and would reduce the requirement to backfill sessions. Caroline Mills explained that going forward there was a purpose built Trauma and Orthopaedics building based at St Woolos that was being utilised for 5 day working however, this could be extended to 7 day working to streamline Trauma provision in line with the Clinical Futures model ahead of the SCCC. Caroline Mills advised that a major challenge, nationally, was the limited number of specialist staff, spread thinly across multiple sites and limited ongoing specialist 8
support especially in community. There had been a lot of focus nationally on the front end of the pathway which had resulted in better clinical standards and performance being sustained. A number of actions had been taken forward by the Division in relation to managing demand by applying Prudent Healthcare principles by ensuring patient engagement and choice were core themes and that the Division was mindful of INNU s when planning services and that there was more work to be done in Primary Care. Mr Aled Evans emphasised that if a proportion of budgets were to be transferred from Secondary Care to Primary then the aim would be for the delivery of Orthopaedics Services to be in Primary Care. This would require working closely with Neighbourhood Care Networks and that a major issue would be in relation to theatre capacity. Caroline Mills advised that a Plan had been developed that recognised demand and capacity was complex and acknowledged that continuing the same cycle each year was not acceptable and that clinical engagement was required to work differently. The Committee recognised that this was work in progress and would be further developed following wider engagement with stakeholders e.g. GPs, Rheumatology, Public Health, which was paramount to success. The Chair said that evidence based targets should be established against a set of measures that were achievable, implemented and rolled out. Action: Aled Evans/Julie Poole/Caroline Mills Mr Aled Evans, Julie Poole and Caroline Mills left the meeting. PSCC 1219/08 Update on Three Year Plan Richard Bowen provided an overview of the current position with regard to the revisions required for the three year plan and highlighted that the focus going forward would be on developing the service change plans. The Planning Team would be working with 9
Divisions to translate the plans into robust outcomes and to develop a framework for deliverability. Action: Richard Bowen PSCC 1219/09 Update on Renal and Vascular Services The Committee received the update on the South Wales Health Collaborative Work Programme, which had been presented to the Chief Executives meeting on 19 th November 2014 and noted the update with regard to the Vascular Service Model. The Committee agreed that further work was required to understand the impact of the decision on the Specialist Critical Care Centre (SCCC). Action: R Bowen PSCC 1219/10 Minutes of Meeting held on 11 th November 2014 The minutes of the meeting held on the 11 th November 2014 were approved as an accurate record. PSCC 1219/11 Date of Next Meeting It was confirmed that the next meeting of the Committee would be on Friday 12 th February 2015 at 9.00am in Seminar Room 4, Health Board Headquarters, St Cadoc s Hospital, Caerleon. 10