IMPLEMENTING THE OUTCOME OF THE SOUTH WALES PROGRAMME THROUGH ACUTE CARE ALLIANCES AND DEVELOPMENT OF THE SOUTH WALES HEALTH COLLABORATIVE

AGENDA ITEM 3.3 9 September 2014 IMPLEMENTING THE OUTCOME OF THE SOUTH WALES PROGRAMME THROUGH ACUTE CARE ALLIANCES AND DEVELOPMENT OF THE SOUTH WALES HEALTH COLLABORATIVE Executive Lead: Chief Executive Author: Chief Executive Contact Details for further information: Adam Cairns, 029 2074 45681 SITUATION The outcome of the South Wales Programme (SWP) was confirmed in March 2014 and, since that time, attention has focused on moving from strategy to implementation on the future configuration of consultant-led maternity and neonatal care, inpatient children s services and emergency medicine (A&E) for South Wales and South Powys. Through this report, the Board will receive the SWP legacy and handover statement, an update on the establishment of three acute care alliances and their associated governance arrangements, and their relationship with the South Wales Health Collaborative. BACKGROUND The South Wales Programme (SWP) was a joint programme of work between five health boards providing healthcare services in South Wales and South Powys Abertawe Bro Morgannwg, Aneurin Bevan, Cardiff and Vale, Cwm Taf, and Powys and the Welsh Ambulance Services NHS Trust (WAST). The services reviewed through the programme were consultant-led maternity and neonatal care, inpatient children s services, and emergency medicine (A&E), due to their fragility in terms of their ability to deliver safe and sustainable models of care. Extensive work was undertaken over a two year period to prepare plans for the future configuration of services, central to which was clinical leadership, engagement and professional advice, complemented by broader stakeholder engagement and formal periods of engagement and consultation. Decisions on the outcome of the programme were taken by health boards and WAST at special board meetings held in February 2014 and the collective position of all partner organisations was confirmed in March 2014. Further background information, including post consultation documentation, communication updates and reports from the SWP Board continue to be available via the SWP website http://www.wales.nhs.uk/swp/home Implementing the outcome of the SWP Page 1 of 6 Board Meeting 9 September 2014

ASSESSMENT South Wales Programme Legacy and Handover Statement Implementation of the outcome of the SWP is being progressed through three acute care alliances (ACAs) and supported by the South Wales Health Collaborative (SWHC). Further detail on the ACAs and SWHC is provided later in this report. A legacy and handover statement has been prepared at Appendix 1, legacy and handover statement (http://www.cardiffandvaleuhb.wales.nhs.uk/opendoc/246651 ), to provide the context within which the ACAs and their constituent local health boards will take the SWP from strategy into implementation. The statement highlights the work that needs to be taken forward in implementation planning and the critical issues that will influence each ACA s success. Specifically, the legacy and handover statement: Confirms the recommendations agreed by the constituent local health boards (LHBs) and community heath councils (CHCs), and endorsed by WAST; Confirms the commitments made to individual LHBs and CHCs in support of the outcome of the SWP; Highlights the need for ongoing review, monitoring and implementation of the equality impact assessment (EIA) action plan and the requirement for health boards to prepare a final analysis EIA report; Highlights the need to maintain and build upon clinical engagement and leadership, and CHC and stakeholder engagement, in the implementation of current plans and in the development of other change proposals; Records the outcome of the Gateway review process and the need to prepare for a follow up review on recommendations in respect of implementation plans, roles and responsibilities, and capturing the lessons learned to carry forward into implementation; Confirms the requirement for ACAs, through their implementation planning, to undertake a more detailed bottom up costing exercise for both capital and revenue cost implications; Notes continuing work on the potential impact of the SWP outcomes on other hospital services, i.e. acute medicine and surgical services, and the need for ACAs to consider the outcome of this work within their respective geographical areas; Highlights work to prepare a transport action plan to minimise challenges posed by public transport in accessing hospital care and which ACAs and health boards will need to take into account within implementation planning; Notes the need for health boards and ACAs to prepare risk registers as part of the governance arrangements for the ACAs and which incorporate residual risks from the SWP; Reports on lessons learned from the SWP and the need for health boards/acas to consider how these lessons might inform the governance and operational arrangements for the ACAs and the interface with the SWHC. The legacy statement aims to support the health boards and ACAs deliver the implementation of the outcome of the SWP and establish the basis on which further service change can be achieved. Implementing the outcome of the SWP Page 2 of 6 Board Meeting 9 September 2014

Acute Care Alliances In taking their decisions on the outcome of the SWP, all SWP partner health boards and WAST supported the creation of three acute care alliances (ACAs) across South Wales and South Powys. Hywel Dda Health Board has also supported the introduction of the ACAs. These ACAs will ensure that hospitals no longer work in isolation but instead work more closely together across health board boundaries as part of a network providing care to patients. Hywel Dda University Health Board has joined the South West ACA and this will support the implementation of both the SWP recommendations and support the joint planning that is underway between Hywel Dda and Abertawe Bro Morgannwg (ABM) health boards. South Powys residents will use the services of all three ACAs as appropriate and the governance arrangements supporting the ACAs will reflect this. The ACAs will be population focused and will work together on implementing the outcome of the SWP and on service planning and delivery, particularly where the catchment population crosses over LHB boundaries or are on the borders between ACAs: South West ACA will primarily focus on the provision of acute hospital services from Neath Port Talbot Hospital; Singleton and Morriston Hospitals; Prince Philip Hospital; Glangwili Hospital; Withybush Hospital, and Bronglais Hospital. South Central ACA s primary focus will be on the acute hospital services provided by Prince Charles Hospital; Royal Glamorgan Hospital; University Hospital of Wales Cardiff; University Hospital Llandough, and the Princess of Wales Hospital (POWH). Whilst POWH is included in the South Central ACA due to its geographic position to the alliance and its close working relationships with hospitals in Cwm Taf, the commissioning responsibility for the Bridgend population and the accountability for the delivery of services within POWH remain with ABM University Health Board. South East ACA is primarily focused on the pathway to the establishment of the Specialist and Critical Care Centre (SCCC), which is expected to be completed in 2018-19 as a new base for some services currently provided at Nevill Hall and Royal Gwent hospitals. This ACA will work closely with the South Wales Central ACA particularly in respect of services provided to the heads of the valleys and South Powys. Princess of Wales Hospital, although part of the South Central ACA, will maintain links with the South West ACA where there are close clinical ties and where many patients receive tertiary care. Similarly, Prince Charles Hospital, whilst part of the South Central ACA, will work closely with the planned SCCC, Nevill Hall Hospital and Ysbyty Ystrad Fawr to serve the population of the Heads of the Valleys and South Powys and maintain clinical relationships across this area. Implementing the outcome of the SWP Page 3 of 6 Board Meeting 9 September 2014

Governance Arrangements The principles and governance arrangements for each of the ACAs are described in the document attached at Appendix 2. At ACA level, the governance structure will have three levels: ACA Chief Executives Delivery Group, ACA Implementation Team and ACA Clinical Implementation Group/s. The ACA structure will link with that of the SWHC through the SWHC Board and SWHC Executive Steering Group. A broad description of responsibilities follows for each of these groups and the terms of reference are included with Appendix 2: SWHC Board acts as the collective sponsor for regional programmes of work; agrees the priorities for, and shapes the direction and delivery of, the collaborative work programme and ensures it remains consistent with meeting the needs of patients; ensures the work programme is consistent with national strategy and policy and that it makes links with associated clinical developments in partner organisations and other parts of NHS Wales; makes clear recommendations to individual health boards on decisions that need to be taken or major issues affecting the collaborative work; drives forward the programme of work which emerges from programme/project scoping and supports the implementation of agreed changes following public engagement and consultation. SWHC Executive Steering Group monitors the implementation of service change plans within and across the three ACAs; considers the potential impact of implementation plans on other service areas and across the region; oversees the delivery of the SWHC work programme and provides assurance to the SWHC Board. ACA Chief Executives Delivery Group provides assurance to individual boards that plans are being implemented in line with the agreed service model/governance framework; reviews and scrutinizes any proposed recommendations for individual boards prior to reporting to boards for formal approval; supports alignment of decision making across boards; identifies any issues that may interface or impact on another ACA and ensures this is discussed with all South Wales Chief Executives through the SWHC structure; ensures early and systematic engagement with CHCs. ACA Implementation Team plans implementation of agreed service models and ensures delivery; agrees work programme of ACA Clinical Implementation Groups (CIG); Implementing the outcome of the SWP Page 4 of 6 Board Meeting 9 September 2014

signs off detailed implementation plans from ACA CIGs and ensures they are aligned with individual boards, with other CIGs and with other ACAs; ensures effective stakeholder engagement; links with the SWHC via lead executives and into local health board planning groups via lead executives and senior clinicians; ensures availability of appropriate resources and support. ACA Clinical Implementation Group/s develops implementation plans for the ACA for paediatrics, maternity/neonates and emergency medicine, in accordance with the outcome of the SWP; develops agreed changes, and participates in a review mechanism to test models as they are developed; links into individual health board planning groups for that speciality/service to ensure it is aligned; scopes impact of detailed plans on other services and recommends to the ACA Implementation Team ways of aligning these; ensures ongoing effective clinical engagement in the work of the CIG and maintains effective communication of the outcome of the work to wider staff groups. A key role of the ACAs is to implement the outcome of the SWP. The legacy and handover statement highlights the work that needs to be taken forward in implementation planning and is underpinned by the extensive range of documentation produced to inform the SWP. South Wales Health Collaborative The SWHC works on behalf of six health boards - Aneurin Bevan, Abertawe Bro Morgannwg, Cardiff and Vale, Cwm Taf, Hywel Dda and Powys and undertakes work programmes with a regional focus as directed by health board chief executives. The SWHC provides objective input into change programmes and in supporting the ACAs in delivering agreed changes. The SWHC team together with each health board s ACA executive lead has formed an Executive Steering Group, chaired by the SWHC Director, to oversee the implementation of service change plans within and across ACAs and consider the potential impact of implementation plans on other service areas and across the South Wales and South Powys area. Consideration is being given as to whether the SWHC should have a broader all Wales responsibility as many of the work programmes being undertaken have a national focus rather than a regional perspective e.g. Pathology Collaborative, Major Trauma network and support for the Emergency Medical and Retrieval Service (EMRTS). RECOMMENDATION The Board is asked to: Implementing the outcome of the SWP Page 5 of 6 Board Meeting 9 September 2014

CONSIDER and NOTE the SWP legacy and handover statement; CONSIDER and APPROVE the governance arrangements for the ACAs. Financial Impact Quality, Safety and Experience Standards for Health Services Risks and Assurance Equality and diversity Two phases of high level costing work were undertaken to inform and be part of the assurance mechanism for the recommendations from the SWP Board and the subsequent decision making by health boards. The legacy and handover statement confirms the requirement for ACAs, through implementation planning, to undertake a more detailed bottom up costing exercise for both capital and revenue cost implications. The aim of the SWP was to create safe and sustainable specialist hospital services: quality and safety were two of the benefit criteria applied throughout the process of option appraisal and to inform recommendations and decision making. The service models for emergency medicine, inpatient children s services, neonates and maternity were developed through clinical reference groups (CRGs). The CRGs based their recommendations on the publications of Royal Colleges, and other medical colleges, and there was good engagement with the colleges (or their Welsh representatives) through clinical conferences and consultation. The National Clinical Forum (NCF) also scrutinised the models in some detail with reference to college standards and strategic publications. The report provides assurance against Standard 8 care planning and provision, contributes to the good governance elements of Standard 1, and, also, contributes to the delivery of overall standards. The SWP risk register was regularly updated and reported to the SWP Board. With decisions confirmed on the outcome of the SWP, and implementation to be managed through the ACAs, it is important that residual risks are carried forward via the governance arrangements for the ACAs. The final SWP risk register confirms the status of each risk and highlights those for inclusion on the risk registers for the ACAs. The Equality Impact Assessment post consultation analysis formed an important element of the decision-making process by health boards and must be taken into account during the implementation phase and mitigating action evidenced through this process. The EIA is an ongoing process and should be subject to continuing assessment and management through the LHBs and ACAs. A stage three final analysis document will need to be produced by the ACAs/LHBs to present the final decision, the reasons behind the decision, outline any proposed mitigations, and describe how the implementation of the outcome of the SWP will be monitored and reviewed. Implementing the outcome of the SWP Page 6 of 6 Board Meeting 9 September 2014

APPENDIX 1 SOUTH WALES PROGRAMME LEGACY AND HANDOVER STATEMENT (AUGUST 2014) PURPOSE This legacy and handover statement provides the context within which the Acute Care Alliances and their constituent Local Health Boards will take forward the South Wales Programme from strategy into implementation. The statement highlights the work that needs to be taken forward in implementation planning and the critical issues that will influence its success. The statement addresses:- The recommendations of the South Wales Programme (SWP) and commitments made to the NHS, Community Health Councils and the public regarding the reconfiguration of services within South Wales and South Powys; The need for ongoing review, monitoring and implementation of the Equality Impact Assessment action plan to mitigate potential adverse impacts of the SWP on the population as a whole and in particular those with protected characteristics; Continuing engagement with Community Health Councils, clinical leaders and other stakeholders; The Gateway Review process undertaken to date and the recommendations of the Assurance of Action Plan (AAP) review; The continuing work that considers the potential impact of the SWP outcomes on other hospital services, i.e. acute medicine and surgical services; The transport review that informed the SWP and the resulting action plan to minimise the challenges posed by public transport to accessing hospital care; Management of the potential risks associated with implementation; SWP LEGACY AND HANDOVER STATEMENT (FINAL 15 AUGUST 2014) PAGE 1

APPENDIX 1 Lessons learned from the SWP and how these might inform the process of implementation The legacy statement aims to support the LHBs and Acute Care Alliances develop and deliver implementation of the outcomes of the SWP and establish the basis on which further service change can be successfully achieved. RECOMMENDATIONS AND COMMITMENTS OF SOUTH WALES PROGRAMME The Programme Board made a number of recommendations that have been agreed by the constituent LHBs (Abertawe Bro Morgannwg, Aneurin Bevan, Cardiff & Vale, Cwm Taf, Powys), Community Health Councils and endorsed by the Welsh Ambulance Services NHS Trust. 1. New systems of care which network hospitals and their services more firmly together must be developed to strengthen the delivery of services across the whole of South Wales and South Powys. This will allow all the skills, expertise and facilities within that network to be maximised to the benefit of all patients. The Welsh Ambulance Services NHS Trust will be an important partner in the development and success of the new arrangements, particularly in delivering pre-hospital assessment and care and ensuring that when patients require hospital care, they are conveyed to the most appropriate facility; 2. Three such networks or alliances should be established for the wider South Wales area (including Hywel Dda) based around three major acute centres at Morriston Hospital, UHW and the SCCC (when built). These alliances will need to develop new systems of governance to ensure that clinical and financial accountabilities are appropriately ascribed and that clinical services are safely delivered. It is recognised that there will need to be continuing engagement with stakeholders as these alliances develop; 3. In recognition of the need to balance the risks (as articulated by, amongst others, the National Clinical Forum) associated with a greater number of centres providing these services with a clear public preference to maintain access in as many places as possible, it is recommended that the key services affected, namely specialist accident and emergency, inpatient paediatrics, neonatal services and consultant-led maternity services should be located on 5 sites; 4. Following the engagement and consultation exercise, Option 3 (University Hospital of Wales Cardiff; Morriston Hospital, Swansea; the planned Specialist Critical Care Centre, Cwmbran; Prince Charles Hospital, Merthyr Tydfil and Princess of Wales Hospital, Bridgend) is the recommended starting point for SWP LEGACY AND HANDOVER STATEMENT (FINAL 15 AUGUST 2014) PAGE 2

APPENDIX 1 the transition to three alliances. This represents the start of a process of closer joint working across Health Boards to deliver new models of care that create sustainable services in the longer term. In order to develop a transition and implementation plan, our planning assumptions include the following:- within an alliance, centred around the University Hospital of Wales, the Royal Glamorgan Hospital becomes a beacon site for developing a new and innovative model of acute medicine that maximises the opportunity of delivering the widest range of medical care in a local hospital setting; the Royal Glamorgan Hospital will also develop a significant role in diagnostics and ambulatory care supporting the wider network of hospitals within a South Wales Central Alliance and accelerate a different local delivery model for paediatric assessment services in Royal Glamorgan Hospital for the Rhondda and Taff Ely populations. The Paediatric Clinical Reference Group will be asked to lead this work; the Royal Glamorgan Hospital, Princess of Wales Hospital and Prince Charles Hospital (and their host Local Health Boards) will work closely together and with Cardiff and Vale University Health Board, to ensure services for patients are appropriately staffed and developed in a safe and sustainable way. 5. The South Wales Programme Clinical Reference Groups, will be maintained, and others will be established, to ensure clinical leadership remains at the heart of service redesign; 6. Where the evidence points clearly to improved outcomes for patients, and where proper engagement has occurred to ensure a shared understanding of clinical benefits, the principle of clinical pathways determining location of treatment will be extended across other services. All current and future decisions made about service reconfiguration will be consistent with the alliance model and the joint arrangements that will be established to strengthen local service delivery; 7. On the basis of the operational and workforce requirements, some changes will need to be made urgently and certainly ahead of the development of any potential capital solutions, Local Health Boards and the Welsh Ambulance Services NHS Trust will work together to develop a transition and implementation plan that ensures continuity of service delivery during the transition to the networked arrangements. This transition and any urgent change required should be consistent with Option 3; SWP LEGACY AND HANDOVER STATEMENT (FINAL 15 AUGUST 2014) PAGE 3

APPENDIX 1 8. The NHS in Wales will work with the Wales Deanery to align the allocation of trainees to the alliances so that education can be optimised - delivering an effective blend of learning across the full range of health services; 9. Health Boards will work together urgently to collectively commission training providers to develop and deliver advanced practitioner roles locally to support the implementation of the new service models; 10. Health Boards and NHS Trusts will work together to develop new systems that facilitate cross-organisational working for clinical staff whilst preserving clear lines of governance and accountability to employers. ACTION: Acute Care Alliances (ACAs)/Health Boards (HBs) to take account of the full range of recommendations within their implementation plans. COMMITMENTS A number of commitments have been made to individual Local Health Boards and Community Health Councils in support of the outcomes of the SWP. These include:- Health Boards Aneurin Bevan UHB:- the need to work closely with Local Authority partners and the Welsh Ambulance service to implement the new pattern of service Abertawe Bro Morgannwg UHB:- the need to mitigate any adverse impacts on the UHB during the implementation phase the further work required in relation to the alliances and their governance arrangements Cardiff and Vale UHB:- the need to work closely with primary and community care in delivering out of hospital care the new models of service must be delivered within the resources available the potential impacts on Cardiff and Vale residents will require ongoing engagement with the CHC Cwm Taf UHB:- strengthening of primary and community care to support the programme of change SWP LEGACY AND HANDOVER STATEMENT (FINAL 15 AUGUST 2014) PAGE 4

APPENDIX 1 a safe and sustainable non-consultant led model of care for Emergency Medicine and Paediatrics must be developed on the Royal Glamorgan Hospital (RGH) site before or at the same time as consultant led services change resolution of the outstanding issues relating to maternity and neonatology at RGH the relationship between the RGH and Princess of Wales Hospital (POWH) is important and must be built upon Powys tlhb:- need to continue the engagement of Powys tlhb in the implementation planning need to maintain a focus on accessibility for the Powys population and the importance of the Ambulance service WAST:- financial implications of the SWP should be met through commissioning a sufficient lead in time to recruit and establish capacity WAST remains a full partner in the planning and delivery of the new models of service. Whilst not specifically highlighted within all health board responses, general themes run through the assurances required during implementation: Working closely with WAST and local authority colleagues Mitigating adverse impacts for health boards and ACAs during implementation as far as possible Developing primary and community infrastructures across all health boards and ACAs Delivering new models of service within the resources available Community Health Councils The Community Health Councils in the SWP area have supported the recommendations of the SWP Programme Board and the decisions of the LHBs. Some CHCs have sought assurances in conjunction with their approval and these will be taken into account through local arrangements. ACTION: Acute Care Alliances (ACAs)/Health Boards (HBs) to have continuing liaison with CHCs within their implementation planning. SWP LEGACY AND HANDOVER STATEMENT (FINAL 15 AUGUST 2014) PAGE 5

APPENDIX 1 EIA ACTION PLAN The Equality Impact Assessment (EIA) post consultation analysis document was received by all health boards and WAST in February 2014 and taken into account in determining decisions on the outcome of the SWP. This composite plan and local impact assessments must be taken into account during the implementation phase and mitigating action evidenced through this process. The EIA is an ongoing process and should be subject to continuing assessment and management through the LHBs and ACAs. A stage three final analysis document will need to be produced by the ACAs/LHBs to present the final decision, the reasons behind the decision, outline any proposed mitigations, and describe how the implementation of the outcome of the South Wales Programme will be monitored and reviewed. ACTION: Acute Care Alliances (ACAs)/Health Boards (HBs) to prepare stage 3 final analysis EIA document. CONTINUING ENGAGEMENT WITH CLINICAL LEADERS, COMMUNITY HEALTH COUNCILS AND OTHER STAKEHOLDERS A key feature and success of the SWP has been in the important areas of clinical leadership, Community Health Council engagement, and public engagement and consultation. The quality of the engagement and consultation process adopted by the SWP resulted in a Certificate of Best Practice from the Consultation Institute and there has been no referral to the Minister in respect of this consultation. The ACAs will need to consider and agree how this level of engagement and leadership will be maintained at a local and regional level and how the interface with the South Wales Health Collaborative will be managed. Clinical leadership has been provided in the SWP through the creation of multiorganisational, multi-professional Clinical Reference Groups (CRGs) that were established to advise on the models of service locally and regionally in respect of the specialties that were within the scope of the SWP. The CRGs were very successful in not only developing clinical models that provide safe and sustainable services and meet expected standards but were also instrumental in the engagement of politicians, the public and the media in accepting the need for change and supporting the options for change. The ACAs will need to consider how this is maintained and built upon in the implementation of current plans and importantly in the development of other change proposals that may be contentious. In addition to the SWP arrangements, NHS SWP LEGACY AND HANDOVER STATEMENT (FINAL 15 AUGUST 2014) PAGE 6

APPENDIX 1 Wales is currently reviewing the role and function of Clinical Networks and Welsh Government will be consulting upon national clinical advisory mechanisms following their review of the advisory machinery at a national level. These will need to be taken into account by LHBs in setting up the ACAs and its access to quality clinical advice. Whilst Community Health Councils are LHB population based they have collectively engaged very well in cross-border and regional issues undertaking a pragmatic but sometimes challenging approach to the issues facing the NHS in South Wales. Together, the CHCs have learned the benefit of collaboration and recognised that local solutions to the challenges facing clinical services may not be sufficient. The SWP has provided the basis of this collaboration and the ACAs will need to consider when and how this relationship will be maintained and further developed during transition and implementation. The Welsh Government is undertaking a review of the current Engagement and Consultation Guidance in light of the service reconfiguration that has been undertaken across NHS Wales. The ACAs will need to take the outcome of this review into consideration in the future. In terms of public engagement and consultation, we have learned the importance of establishing and maintaining ongoing dialogue with the public we serve. Whilst the SWP generated an unprecedented response to a formal public consultation on a small number of services, it became very evident through the process that the public seeks and appreciates ongoing discussion on health service issues which may not need to become the subject of a formal consultation. The ACAs will need to determine how they engage with the public and other stakeholders on proposals that are in development in support of local arrangements within the ACA partners. ACTION: ACAs to consider how: clinical engagement and leadership, and CHC and stakeholder engagement, will be maintained and built upon at a local and regional level in the implementation of current plans and in the development of other, potentially contentious, change proposals the interface with the South Wales Health Collaborative will be managed to take account of the outcome of the respective reviews of the national clinical advisory structure and clinical networks (due late 2014) GATEWAY to take REVIEW account of the Welsh Government review of the engagement and consultation guidance The SWP was subject to a Gateway Review in October 2013 and a number of recommendations were made to strengthen the outcome of the programme. These were mainly in relation to the decision making process and governance arrangements and these recommendations formed the basis of an action plan aimed SWP LEGACY AND HANDOVER STATEMENT (FINAL 15 AUGUST 2014) PAGE 7

APPENDIX 1 at achieving the goals of the Programme and improving the delivery confidence rating. In March 2014, an Assurance of Action Plan (AAP) review was undertaken as part of the ongoing gateway review process. This review considered the progress made against the action plan and the programme plan for the remainder of the work. This AAP review resulted in recognition of significant progress having been made since the initial gateway review with an improved rating and only three recommendations:- 1. Prepare and deliver 2014/15 implementation plans for the first wave of service changes; 2. Set out the implementation roles and responsibilities of the Health Boards, Alliances and the South Wales Health Collaborative; 3. Capture the lessons learned from the programme to carry forward into implementation A follow up review of the recommendations will be undertaken in September and LHBs and Alliances will need to demonstrate implementation of recommendations one and two whilst the SWHC will capture the lessons learned for presentation to the review team. ACTION: ACAs/HBs to prepare evidence to demonstrate implementation of AAP recommendations 1 and 2. FINANCE A Finance work stream supported the South Wales Programme through the consultation phase and leading up the Programme Board recommendations. The main output of this work was two phases of high level costing work undertaken to inform, and be part of the assurance mechanism for, the Programme Board s recommendations. These were:- Phase 1 the costings that supported the consultation documentation and process, which focussed solely on some of the direct cost impacts (medical and midwifery staffing and ambulance conveyancing costs) of the services being consulted on; Phase 2 following the completion of the consultation, but before the recommendation of the Programme Board, an additional costing exercise was undertaken building on that undertaken in phase 1 above, but also taking into account other expected cost implications for changes in activity flows for the services within the initial scope of the programme, plus an assessment of the similar impact for some of the potential knock on service impacts, especially in relation to acute medicine and emergency surgery services. This additional exercise also further estimated the potential hospital site based capital costs SWP LEGACY AND HANDOVER STATEMENT (FINAL 15 AUGUST 2014) PAGE 8

APPENDIX 1 for each of the options and also attempted to provide an organisational / commissioning LHB impact of the estimated revenue costs impact. It was always agreed and accepted, however, that a much more detailed bottom up costing exercise would be required, for both capital and revenue costs implications, following the recommendations of the Programme Board, subsequent agreement by LHBs, and would need to form part of the detailed implementation planning within the Acute Care Alliances. More detail will also need to be available and provided in terms of the proposed future service models, workforce, performance (including productivity and efficiency) requirements and other resource and infrastructure requirements. This will now need to be progressed through the ACAs. ACTION: ACAs to undertake more detailed bottom up costing exercise for both capital and revenue cost implications. ACUTE MEDICINE AND SURGICAL SERVICES The changes to emergency medicine, paediatrics and maternity services as a consequence of the SWP and other drivers for change impacting on acute hospital services mean that it is now necessary to review the configuration of surgical specialties and acute medicine. Clinical Reference Groups have been established to develop sustainable service models for core surgical disciplines and acute medicine and these are working together to ensure that their outputs are aligned. The Surgical Steering Group has been established to co-ordinate the planning activities of three sub-groups. These are: Head & Neck Surgical Specialties: ENT Ophthalmology Oral & Maxillo Facial Surgery General Surgical Specialities: General Surgery Vascular Urology Gynaecology Trauma & Orthopaedics (T&O): The British Orthopaedic Association (BOA) has been commissioned to carry out a comprehensive review of unscheduled and elective orthopaedic surgery in Wales using its Getting it right first time programme. The T&O CRG is in discussion with the BOA to see if this review, which has strong support from SWP LEGACY AND HANDOVER STATEMENT (FINAL 15 AUGUST 2014) PAGE 9

APPENDIX 1 the group members, could inform the work to develop service models for South Wales. The Acute Medicine clinical reference group (CRG) was also established to develop options for the provision of acute medicine in the context of the regional and local hospital models recommended through the SWP. These CRGs are at different stages in terms of the proposed models but their outcomes will be provided to the ACAs in order that they have a strategic service framework within which to develop locally appropriate service reconfiguration plans. ACTION: ACAs to receive the outcomes of the work of the acute medicine CRG and surgery CRG and to consider within service models across their respective localities. HEALTH AND TRANSPORT ACTION PLAN The South Wales Health & Transport Accessibility Group was established by Welsh Government to help support the implementation of new service configurations agreed by LHBs, initially focussing on the outcome of the SWP. The group will consider the patient and public transport implications stemming from actual and proposed changes to hospital services and, where appropriate, develop measures to mitigate any adverse impacts identified. This includes action by the LHBs to mitigate the impacts of service reconfiguration or by the local authorities and transport providers to improve access by public transport. The work of the group has been informed by the SWP EIA. The group s membership includes representatives from each of the health boards and WAST and the group s work is being captured in an action plan, which will be finalised in the summer 2014. The ACAs and health boards will need to take account of the action plan within its implementation of the SWP. ACTION: ACAs/HBs to take account of the health and transport action plan within implementation plans. RISK MANAGEMENT The South Wales Programme risk register was regularly updated and reported to the Programme Board. With decisions confirmed on the outcome of the SWP, and implementation to be managed through the ACAs, it is important that residual risks are carried forward via the governance arrangements for the ACAs. The main themes that need to be considered through implementation relate to clinical workforce (capacity, training, skill mix); pace of implementation; continued review of SWP LEGACY AND HANDOVER STATEMENT (FINAL 15 AUGUST 2014) PAGE 10

APPENDIX 1 the financial impact; ongoing engagement and communications; and equality impact assessment. ACTION: ACAs/HBs to prepare risk registers as part of their implementation planning and which incorporate key themes from the SWP. LESSONS LEARNED FROM THE SOUTH WALES PROGRAMME A separate report is being developed to capture the detailed lessons learned from the Programme in response to the recommendation made through the Assurance of Action Plan review conducted in March 2014. This legacy statement highlights the main areas of learning to inform the processes adopted by the ACAs and the potential arrangements for and interface with the South Wales Health Collaborative. Governance of Local Health Board collaboration The governance arrangements adopted by the South Wales Programme Board were based on the principle of consensus agreement on issues with individual Local Health Boards retaining sovereignty rather than devolving responsibility for some decisions to the Programme Board. This approach worked well when consensus could be relatively easy to achieve but proved challenging when some of the participating LHBs felt disadvantaged or compromised. This effect was more acutely evident during the latter stages of the programme when definitive recommendations and decisions were required to conclude what had been a very long programme of work. The governance of decision making by the ACAs and, where appropriate, the South Wales Health Collaborative is a fundamental issue to address in their establishment. Governance of Community Health Council collaboration The challenges of collaborative working and decision making to Community Health Councils are similar to those of Local Health Boards. The role of the CHC is to represent the interests of the public in its relevant Local Health Board area and, in particular, work with its LHB in the planning of NHS services, development and consideration of proposals for service change and the decisions affecting the operation of services. Three significant issues relating to collaborative working emerged through the conduct of the South Wales Programme:- SWP LEGACY AND HANDOVER STATEMENT (FINAL 15 AUGUST 2014) PAGE 11

APPENDIX 1 What is significant change and how and why this is determined differently by individual Community Health Councils; What issues should be subject to engagement rather than formal public consultation and how is this determined; How may consensus decision making be achieved by CHCs. These issues are likely to arise when ACAs propose changes to services that cross LHB/CHC boundaries and have a disproportionate effect on communities they represent. These challenges will be fed into the review of guidance that is planned by Welsh Government but will need local consideration within an ACA boundary. Data quality and interpretation One of the most challenging aspects of the South Wales Programme was the differences in data capture and interpretation of activity amongst the LHBs. It was evident that there were particular challenges to obtaining the necessary data on current patient flows and demands. A great deal of effort went into gathering the appropriate data, merging datasets and data tidying where necessary. Datasets that were used include the Emergency Department Data Set (EDDS), Admitted Patient Care (APC) data set, Badgernet neonatal data, and National Community Child Health Database. The neonatal and emergency medicine activity was for the calendar year 2012, whilst the paediatric and obstetric activity covered the period 1 st April 2011 to 31 st March 2012. A particular difficulty arose from differences in data capture and definitions between hospitals and a number of steps were taken regarding data inclusion and cleansing, to minimise any potential errors in the data on patient demand that was subsequently used in the developed models. In particular considerable time and effort was spent on mapping patient demand to correct clinical groupings and thus future patient pathways within the EDDS data (based on thorough data matching methods). This could be a significant risk to ACAs planning and delivery if the data sources and activity data underpinning services under consideration by the ACAs are not common across the LHBs involved. The SWHC team is in discussion with the NHS Wales Informatics Service (NWIS) regarding the issues of data consistency etc and how this might be improved. Independent expert advice and scrutiny The SWP used independent expert advice and scrutiny where this was possible in order to validate the internal work conducted by the team. This included the School of Mathematics, Cardiff University, regarding data management and modelling; Swansea University regarding the Transport Review; Opinion Research Services in the interpretation of the engagement and consultation responses, and the SWP LEGACY AND HANDOVER STATEMENT (FINAL 15 AUGUST 2014) PAGE 12

APPENDIX 1 Consultation Institute in respect of best practice and compliance with engagement and consultation guidelines from Welsh Government. The ACAs will need to consider whether independent advice is required to inform some of their work in the future and how this might be obtained. The SWP has also been subject to a Gateway review process with two reviews undertaken in October 2013 and March 2014. The ACAs will need to consider the appropriateness of gateway reviews going forward and how these may be undertaken. Equality impact assessment The approach to the equality impact assessment ensured a thorough process which combined the benefits of collaboration whilst also ensuring health boards met their individual legal responsibilities under the Equality Act. An evidence document was prepared to inform and support the consultation and this was followed by a comprehensive post consultation analysis which demonstrated good consideration of equality issues and potential mitigations. The structure of the EIA document provides a common core and baseline for future engagement and consultation exercises. ACAs and health boards will need to be mindful that equality impact assessment is a continuous process and will need to ensure continuing assessment, management and review through the implementation phase and beyond. Consideration will need to be given as to how equality impact assessment is mainstreamed within service planning both locally and in collaborative arrangements. Data collection, quality and consistency, for services and patient/staff profiling, were identified as needing improvement in order to understand the impact of proposed changes and to inform future EIAs. ACTION: ACAs/HBs to take account of learning from the South Wales Programme to inform the governance and operational processes adopted by the ACAs and the potential arrangements for and interface with the South Wales Health Collaborative CONCLUSION This legacy and handover statement provides the context within which the ACAs and their constituent local health boards will take the SWP from strategy into implementation. It aims to support ACAs and health boards in implementation of the outcome of the SWP and establish the basis on which further service change can be achieved. The membership of the ACAs will include all the health boards that were partners within the SWP - Abertawe Bro Morgannwg, Aneurin Bevan, Cardiff & Vale, Cwm Taf, Powys and will also include Hywel Dda University Health Board. Whilst Hywel SWP LEGACY AND HANDOVER STATEMENT (FINAL 15 AUGUST 2014) PAGE 13

APPENDIX 1 Dda was not a partner within the SWP, it has supported the introduction of the ACAs and these new arrangements will support the joint planning between Hywel Dda and Abertawe Bro Morgannwg health boards and other work to be taken forward on a collaborative, regional basis. SWP LEGACY AND HANDOVER STATEMENT (FINAL 15 AUGUST 2014) PAGE 14

APPENDIX 1 KEY ACTIONS Work to be taken forward in implementation planning Relevant documents Lead Deadline Comments Ensure that the recommendations of the SWP and commitments made to the NHS, Community Health Councils and the public are implemented Ensure that local and general commitments/assurances are met Equality Impact Assessment: produce a stage three final analysis document to present the final decision, the reasons behind the decision, outline any proposed mitigations, and describe how the implementation of the outcome of the South Wales Programme will be monitored and reviewed. Consideration will need to be given as to how equality impact assessment is mainstreamed within service planning both locally and in collaborative arrangements. Consider and agree how clinical leadership, Community Health Council engagement and public engagement will be maintained at a local and regional level Consider how the interface with the South Wales Health Collaborative will be managed. Recommendations of the South Wales Programme Letters from Health Boards and Community Health Councils EIA documentation ACAs HBs ACAs HBs ACAs HBs ACAs ACAs SWP LEGACY AND HANDOVER STATEMENT (FINAL 15 AUGUST 2014) PAGE 15

APPENDIX 1 Development of clinical models and the case for change: consider how clinical engagement is maintained and built upon in the implementation of current plans and in the development of other change proposals that may be contentious Gateway Review: follow up review of the AAP recommendations will be undertaken in September and LHBs and ACAs will need to demonstrate implementation of recommendations one and two. SWHC will capture the lessons learned for presentation to the review team. Report of Gateway Review Report of AAP review ACAs ACAs SWHC The ACAs to consider the appropriateness of gateway reviews going forward and how these may be undertaken. ACAs Receive outcomes of work of acute medicine and surgery CRGs and consider within service models across respective localities Health and transport action plan: ACAs and health boards to take account of the action plan within its implementation of the SWP. Prepare risk registers to incorporate residual risks which will need to be carried forward via the governance arrangements for the ACAs Governance of decision making to be considered during the establishment of ACAs and, where ACAs ACAs HBs Programme risk register ACAs HBs SWP LEGACY AND HANDOVER STATEMENT (FINAL 15 AUGUST 2014) PAGE 16

APPENDIX 1 appropriate the South Wales Health Collaborative. Data sources and activity data underpinning services under consideration by the ACAs should be common across the LHBs involved. The ACAs to consider whether independent advice is required to inform some of their work in the future and how this might be obtained. HBs ACAs SWP LEGACY AND HANDOVER STATEMENT (FINAL 15 AUGUST 2014) PAGE 17

APPENDIX 2 ACUTE CARE ALLIANCES PRINCIPLES AND GOVERNANCE ARRANGEMENTS AUGUST 2014 PURPOSE The establishment of three Acute Care Alliances (ACAs) was approved by all health boards, and endorsed by the Welsh Ambulance Services Trust, and this will be the mechanism through which the outcome of the South Wales Programme (SWP) will be implemented, monitored and reviewed. This document outlines the proposed principles and governance arrangements for the Acute Care Alliances. At this stage, the detail within this document is high level and is intended as the basis for the development of detailed implementation plans and governance arrangements. This document should be read in conjunction with the SWP Legacy and Handover Statement (August 2014). BACKGROUND AND CONTEXT Decisions on the outcome of the SWP were finalised in March 2014 and Chief Executives have confirmed that implementation of service reconfiguration for South Wales and South Powys will be through the ACAs when they are established. The ACAs will be population focused and will work together on implementing the outcome of the SWP and on service planning and delivery particularly where the catchment population crosses over LHB boundaries or are on the borders between ACAs: South West ACA will primarily focus on the provision of acute hospital services from Neath Port Talbot Hospital; Singleton and Morriston Hospitals; Prince Philip Hospital; Glangwili Hospital; Withybush Hospital, and Bronglais Hospital. South Central ACA s primary focus will be on the acute hospital services provided by Prince Charles Hospital; Royal Glamorgan Hospital; University Hospital of Wales Cardiff; University Hospital Llandough, and the Princess of Wales Hospital (POWH). Whilst POWH is included in the South Central ACA due to its geographic position to the ACA and its close working relationships Acute Care Alliances: draft principles and governance arrangements August 2014 1