April 2015 Arhwilydd Cyffredinol Cymru Auditor Generl for Wles Governne in the NHS in Wles Memorndum for the Puli Aounts Committee
I hve prepred nd pulished this report in ordne with the Government of Wles At 1998. The Wles Audit Offie stff tht ssisted me in the preprtion of this report omprised Andrew Doughton, Stephen Lisle nd Crol Moseley under the diretion of Dvid Thoms. Huw Vughn Thoms Auditor Generl for Wles Wles Audit Offie 24 Cthedrl Rod Crdiff CF11 9LJ The Auditor Generl is independent of the Ntionl Assemly nd government. He exmines nd ertifies the ounts of the Welsh Government nd its sponsored nd relted puli odies, inluding NHS odies. He lso hs the power to report to the Ntionl Assemly on the eonomy, effiieny nd effetiveness with whih those orgnistions hve used, nd my improve the use of, their resoures in dishrging their funtions. The Auditor Generl, together with ppointed uditors, lso udits lol government odies in Wles, onduts lol government vlue for money studies nd inspets for ompline with the requirements of the Lol Government (Wles) Mesure 2009. The Auditor Generl undertkes his work using stff nd other resoures provided y the Wles Audit Offie, whih is sttutory ord estlished for tht purpose nd to monitor nd dvise the Auditor Generl. For further informtion plese write to the Auditor Generl t the ddress ove, telephone 029 2032 0500, emil: info@wo.gov.uk, or see wesite www.wo.gov.uk. Auditor Generl for Wles 2015 You my re-use this pulition (not inluding logos) free of hrge in ny formt or medium. You must re-use it urtely nd not in misleding ontext. The mteril must e knowledged s Auditor Generl for Wles opyright nd you must give the title of this pulition. Where we hve identified ny third prty opyright mteril you will need to otin permission from the opyright holders onerned efore re-use. If you require ny of our pulitions in n lterntive formt nd/or lnguge plese ontt us using the following detils: Telephone 029 2032 0500, or emil info@wo.gov.uk
Contents Introdution 5 1 The governne of NHS Wles in ontext 6 Orgnistion of helth servies in Wles 7 The sttutory frmework 11 Setting out wht is expeted 13 The operting environment 14 2 Key omponents of governne within the NHS in Wles 18 Aountility within the NHS in Wles 19 Monitoring nd reviewing performne nd delivery 21 Finnil stewrdship nd ontrol 27 Governne frmeworks within NHS odies 27 3 The wy tht governne rrngements in NHS odies re working in prtie 35 Overll perspetives 37 Opertion of the Bord nd Committees 38 Governne nd ssurne frmeworks 40 Informtion used to provide ssurne 43 Response to onerns nd orgnistionl lerning 46 Self-delrtions nd puli reporting 48 Appendies Appendix 1 Other hosted orgnistions in NHS Wles 52 Appendix 2 Helth Bord nd NHS Trust Bord Committees 53 Appendix 3 Helth Bord orgnistionl strutures 54 4 Governne in the NHS in Wles
Introdution 1 This memorndum hs een prepred following the Puli Aounts Committee s request for informtion out the governne rrngements in NHS Wles. The request ws mde s prt of the Committee s onsidertion of evidene into the governne rrngements t Betsi Cdwldr University Helth Bord. 2 The governne rrngements tht relte to NHS Wles re set out in n e-governne mnul 1 nd in numer of ssoited douments tht provide diretions, instrutions nd guidne within the wider poliy ontext of NHS Wles. 3 The memorndum hs drwn on this informtion to provide n overview of the governne rrngements tht relte to NHS Wles. It is in three prts: Prt 1 sets out the ontext nd lndspe in whih governne rrngements in the NHS in Wles opertes; Prt 2 desries the key omponents of the governne rrngements in the NHS in Wles; nd Prt 3 drws upon udit findings from ross Wles to provide some high-level ommentry on how the governne rrngements within NHS odies pper to e working in prtie. 1 http://www.wles.nhs.uk/governne-emnul/home Governne in the NHS in Wles 5
Prt 1 The governne of NHS Wles in ontext
Orgnistion of helth servies in Wles 1.1 There is omplex network of orgnistions nd entities involved in delivering NHS servies in Wles, nd in holding NHS odies to ount. There re seven Helth Bords whose prinipl funtion is ensuring the effetive plnning nd delivery of helthre in their lolity, nd three NHS Trusts who hve speilist ll-wles funtions. Exhiit 1 provides shemti summry of the min orgnistions involved, the flows of funding nd the lines of ountility. 1.2 Exhiit 1 lists the numerous orgnistions nd tivities tht re hosted y either Helth Bord or NHS Trust ut re tsked with delivering or plnning servies t n ll-wles level. Hosted odies re leglly prt of, nd re ounted for, within their hosting orgnistion ut they re outside of the host s usul mngement rrngements nd re not simply divisions within helth odies. 1.3 The sle of opertion of hosted orgnistions within NHS Wles vries onsiderly nd some fulfil signifint roles. The most notle of these re desried elow. Welsh Helth Speilised Servies Committee (WHSSC) 1.4 The WHSSC is joint ommittee of the helth ords in Wles nd is hosted y Cwm Tf University Helth Bord 2. The WHSSC reeives money from the other helth ords nd its min funtion is to pln nd seure tertiry servies suh s speilist hert surgery, mentl helth, renl neurosiene nd neontl servies for the popultion of Wles. In 2013-14 the Committee hd udget of 609 million. 1.5 The joint ommittee is not seprte legl entity to the helth ords. Whilst the ommittee ts on ehlf of the helth ords, the duty on individul helth ords remins, nd they re ultimtely ountle for the provision of speilised nd tertiry servies for residents within their re. The joint ommittee reports to eh helth ord on its tivities. The joint ommittee is lso ountle to the Welsh Government through the NHS performne mngement system. 1.6 The hief exeutive of Cwm Tf University Helth Bord is the Aountle Offier for WHSSC. Memership of the joint ommittee onsists of the helth ord hief exeutives, hir ppointed y the Welsh Ministers, vie hir, two non-offier memers nd four offier memers 3 employed y the hosting helth ord. The hief exeutives of the three NHS Trusts re non-voting ssoite memers of the joint ommittee. 1.7 The ore memership of the joint ommittee is the helth ord nd trust hief exeutives. This represents omplited rrngement where the helth ords nd trusts re effetively tking deisions out the ommissioning of speilist servies when these orgnistions re lso the providers of these servies. 2 The Welsh Helth Speilised Servies Committee (Wles) Regultions 2009, 17 Deemer 2009. 3 The vie hir nd two non-offier memers re ppointed y the joint ommittee from the pool of existing non-offier memers of the helth ords. Governne in the NHS in Wles 7
Exhiit 1 Digrm of the min entities involved in NHS Wles governne Ntionl Assemly for Wles Welsh Government Deprtment of Helth nd Soil Servies Integrted Delivery Bord Funding Aountility Hosting reltionship Welsh Amulne Servies NHS Trust This trust provides emergeny mulne servies ross Wles s well s non-urgent ptient trnsport nd helth ourier servie. Velindre NHS Trust Velindre hs two mjor divisions; Velindre Cner Centre nd the Welsh Blood Servies. It lso hosts numer of hosted odies Puli Helth Wles NHS Trust (PHW) PHW provides independent puli helth dvie nd servies to protet nd improve the helth nd welleing of the popultion of Wles. Hosted odies These odies sit within hosting orgnistions nd deliver/pln servies t n ll-wles level: Welsh Helth Speilised Servies Committee Emergeny Amulne Servies Committee NHS Wles Shred Servies Prtnership NHS Wles Informtis Servie Ntionl Speilist Advisory Group for Cner Ntionl Collorting Centre for Cner Ntionl Institute for Soil Cre nd Helth Reserh Clinil Reserh Centre The NHS Centre for Equlity nd Humn Rights Presription Priing Authority Lol Helth Bords There re seven of these orgnistions. Their ommissioning funtions inlude: - Plnning nd purhsing servies - Setting qulity requirements nd monitoring performne - Supporting improvement nd intervening if needed. Their servie provider funtions inlude: - Delivering helthre servies - Developing n internl qulity system - Developing stff - Continul improvement nd lerning from mistkes Lol providers [GPs, Dentists, Optiins, Phrmists] Soure: Wles Audit Offie reserh 8 Governne in the NHS in Wles
1.8 The hir is diretly ountle to the Minister for Helth nd Soil Servies for their personl performne. The hir is lso ountle to the helth ords in reltion to the funtions of the joint ommittee. Finlly, the hir is ountle to the hosting helth ord in respet of the WHSSC s ompline with the governne nd operting frmework. 1.9 The governne frmeworks overing WHSSC inlude Memorndum of Agreement tht defines the roles of the helth ords Aountle Offiers, hosting greement with Cwm Tf, stnding orders (tht form shedule to eh of the helth ords own stnding orders), shedule of reservtion nd delegtion of powers nd stnding finnil instrutions. 1.10 At the time of prepring this memorndum, review of the governne systems relting to WHSSC hd een ommissioned, with fous on: d the deision-mking proesses tht operte through the urrent governne model; eh element of WHSSC governne on its own terms inluding the Joint Committee; how WHSSC should est fit in the Welsh Government three-yer Integrted Medium Term Plnning proesses nd the Performne Mngement Frmework; nd how the Lol Helth Bords ould exerise their WHSSC responsiilities more effetively s oth ommissioner nd provider. 1.11 The review is due to ompleted y the end of 2014. NHS Wles Shred Servies Prtnership (NWSSP) 1.12 The NWSSP is hosted y Velindre NHS Trust. It provides rnge of servies sed ross Wles whih support NHS Wles in reltion to prourement, employment, ounter frud, primry re informtion nd dministrtion, udit nd ssurne, filities servies, legl nd risk servies, Welsh Risk Pool Servies nd workfore, edution nd development servies. 1.13 An NWSSP Committee determines the poliy nd strtegy, nd monitors the delivery of Shred Servies. The Committee is mde up of representtives of NHS odies ross Wles nd senior Shred Servies stff. The Diretor of Shred Servies is responsile for exerising the funtions delegted to him y the Lol Helth Bords nd Trusts in ordne with the poliy set y the NWSSP Committee. The Diretor is lso ountle to the Welsh Government s Diretor Generl for Helth nd Soil Servies. 1.14 Within Velindre NHS Trust there is single Audit Committee, nd s prt of the hosting rrngements, this Committee will meet to speifilly onsider shredservies mtters t ertin points in the yer. Governne in the NHS in Wles 9
NHS Wles Informtis Servie (NWIS) 1.15 The NWIS is hosted y Velindre NHS Trust, ws estlished in 2010 nd hs responsiility for the design, deployment nd mngement of ntionl IT systems within NHS Wles. NWIS hs ntionl remit to support NHS Wles through the use of ntionl ICT tehnologies y doing things one for Wles. It is lso involved in delivering opertionl ICT servies, informtion mngement nd mking etter use of IT skills nd resoures ross Wles. 1.16 The NWIS ws formed y ringing together the following orgnistions/ progrmmes: Business Servies Centre, Corporte Helth Informtion Progrmme, Helth Solutions Wles, Informing Helthre, Informtion Servies Division nd Primry Cre Informtis Progrmme. 1.17 The NWIS is heded y Diretor who is lso the Chief Informtion Offier for Helth within the Welsh Government. The Diretor of NWIS is lso ound y n ountility greement for governne ompline with the Velindre NHS Trust Chief Exeutive. Emergeny Amulne Servies Committee (EASC) 1.18 This is joint ommittee of the helth ords in Wles, estlished on 1 April 2014 4 to jointly pln nd seure emergeny mulne servies in Wles. The Committee met for the first time on 11 April 2014 nd hene the governne rrngements re still in their infny. 1.19 Cwm Tf University Helth Bord hosts the joint ommittee, whih took over the emergeny mulne-relted duties tht were previously provided y the Welsh Helth Speilised Servies Committee. 1.20 The Committee omprises Chir (ppointed y the Minister), Vie Chir, the hief exeutives of the helth ords nd the Chief Amulne Servies Commissioner. The hief exeutives of NHS trusts re ssoite memers. 1.21 The Chief Amulne Servies Commissioner leds ommissioning tem to seure nd monitor performne of emergeny mulne servies. The tem is employed y the hosting orgnistion. The stnding orders for the Committee re greed y the helth ords nd form shedule within eh of the helth ords own stnding orders. 1.22 The other hosted odies in NHS Wles re: the Ntionl Advisory Group for Cner; the Ntionl Collorting Centre for Cner; nd the Ntionl Institute for Soil Cre nd Helth Reserh Clinil Reserh Centre. 1.23 More informtion on these odies is provided in Appendix 1. 4 Emergeny Amulne Servies Committee (Wles) Regultions 2014, No. 566 (W. 67) 10 Governne in the NHS in Wles
The sttutory frmework 1.24 The sttutory frmework for NHS Wles omprises three ore omponents: Primry Legisltion: setting out the sttutory powers nd duties of the NHS; Sttutory Instruments: detiling the funtions of NHS odies; nd Stnding Orders: providing the rules y whih helth ords nd trusts work nd mke deisions. Primry legisltion 1.25 Most of the usiness of NHS odies will e onduted in ordne with powers ontined in the NHS (Wles) At 2006 5 nd the rrngements set out within the relevnt Constitution, Memership nd Proedures Regultions 6. All NHS odies in Wles must lso operte within the wider legisltive frmework governing ll UK orgnistions. 1.26 The NHS (Wles) At 2006 onsolidtes rnge of regultory requirements relting to the promotion nd provision of the helth servie in Wles. It sets out Welsh Ministers duty to promote helth servies nd the powers to help them do so inluding estlishing NHS odies, direting how the odies should perform their funtions nd intervening when things go wrong. 1.27 The 2009 NHS reforms in Wles, whih sw the retion of new integrted helth ords were ented using the powers onferred upon Welsh Ministers in the NHS (Wles) 2006 At, nd did not need fresh primry legisltion. 1.28 Setion 33 of the NHS (Wles) At 2006 enles Helth Bords, NHS Trusts nd Lol Authorities to enter into ny prtnership rrngements to exerise ertin NHS nd helth relted funtions s speified in the Regultions. These rrngements n only e mde if they fulfil the ojetives set out in the helth improvement pln of the NHS ody, re likely to led to n improvement in the wy urrent servies re provided, nd the prtners hve onsulted jointly with ll ffeted prties. 1.29 More reently, the NHS Finne (Wles) At 2014 hs introdued more flexile finne regime. It provides new legl finnil duty for Lol Helth Bords to rek even over rolling three finnil yers rther thn eh nd every yer. The At llows Lol Helth Bords to fous their servie plnning, workfore nd finnil deisions nd implementtion over longer, more mngele, period nd moves wy from regime whih enourges short-term deision mking round the finnil yer. The finnil flexiilities re, however, ontingent upon the ility of NHS odies to prepre suitly roust integrted medium-term plns, nd the forml pprovl of those plns y Welsh Ministers. 5 http://www.legisltion.gov.uk/ukpg/2006/42/setion/33 6 http://www.wles.nhs.uk/governne-emnul/regultions-onstitution-memership-nd- Governne in the NHS in Wles 11
Sttutory instruments, stnding orders nd other diretions 1.30 Sttutory instruments re reted y the exeutive rnh of government nd set out the funtions of NHS odies in Wles. There re urrently some 26 sttutory instruments 7 overing NHS odies nd Community Helth Counils in Wles. 1.31 Stnding orders re the rules y whih NHS odies operte nd mke deisions. Stnding orders for NHS odies in Wles should e sed upon the models determined y the Welsh Government 8. 1.32 The NHS (Wles) At 2006 llows Ministers to give diretions nd instrutions to helth odies. In ddition to sttutory instruments, these diretions nd instrutions n tke the form of: Welsh Helth Cirulrs these re now eing re-introdued (fter hving een repled in reent yers y Ministeril Letters) s mehnism for the Minister to issue guidne to NHS odies on wide rnge of issues; nd Aountle Offier Letters these re used to provide speifi diretion or dvie on issues of ountility, regulrity nd propriety nd nnul ounting exerises. 1.33 NHS odies hve legl duty to omply with ny diretion issued y Welsh Ministers. Instrution or guidne issued through Ministeril Letter or Welsh Helth Cirulr lso hs the sme legl stnding s diretion, nd should e treted s mndtory. 1.34 The Welsh Government s Deprtment for Helth nd Soil Servies my lso issue instrutions nd guidne to NHS odies. Instrutions my e speifilly to support key poliy requirement, or provide good prtie guidne on prtiulr spet of usiness. 7 http://www.wles.nhs.uk/governne-emnul/seondry-legisltion 8 http://www.wles.nhs.uk/governne-emnul/stnding-orders 12 Governne in the NHS in Wles
Setting out wht is expeted Priniples nd ore vlues 1.35 The NHS e-governne mnul identifies numer of ore vlues for the NHS in Wles, nmely: d e putting qulity nd sfety ove ll else; integrting improvement into everydy working; fousing on prevention, helth improvement nd inequlity; working in prtnership; nd investing in stff. 1.36 These ore vlues re designed to support good governne nd the hievement of high stndrds of re. Alongside these, speifi odes of Condut for Bord Memers nd NHS Mngers 9 hve een developed whih inorporte the Seven Priniples of Puli Life ( the Noln Priniples ). In ddition, there re poliies on speifi res, inluding whistlelowing nd ompromise greements desried within Openness nd Business Condut 10. Stndrds for servies 1.37 Doing Well, Doing Better Stndrds for Helth Servies in Wles 11 ontins 26 stndrds tht set out the requirements of ll servies in ll settings in the NHS in Wles. These stndrds were introdued in 2010, repling the previous ones lunhed in 2005. 1.38 The stndrds frmework is underpinned y supporting guidne for individul stndrds nd How to Guides whih give prtil dvie on how to implement them. A Governne nd Aountility module provides NHS Bords with frmework to monitor performne ginst the stndrds. This lrgely tkes the form of self-ssessment ginst mturity mtrix desriptions. 1.39 At the time of prepring this riefing, the Welsh Government ws undertking review of the Stndrds for Helth Servies in Wles. 1.40 The Stndrds for Helth Servies in Wles sit longside numer of other mehnisms tht set out wht is required in delivering servies to ptients. These inlude suite of Delivery Plns for speifi onditions suh s hert disese, stroke, dietes, respirtory helth nd eye helth mongst others. These plns typilly set out the key tions tht need to e tken to improve helthre outomes for ptients. Mny of these Delivery Plns hve repled Ntionl Servie Frmeworks tht hd previously een developed for these onditions. 9 http://www.wles.nhs.uk/governne-emnul/odes-of-ondut 10 http://www.wles.nhs.uk/governne-emnul/openness-nd-usiness-ondut 11 Welsh Government, Doing Well, Doing Better Stndrds for Helth Servies in Wles, 1 April 2010. Governne in the NHS in Wles 13
1.41 Other key mehnisms for setting out ptient-re requirements omprise: d The rnge of professionl stndrds nd regultions tht pply to speifi helth professions nd servies. Fundmentls of Cre 12 guidne whih ws produed y the Welsh Government in 2003 nd ontins set of inditors tht over fundmentl spets of qulity tht re importnt to nyone reeiving helth or soil re. The Ntionl Institute for Helth nd Cre Exellene (NICE) stndrds, guidne nd dvie on wide rnge of helth nd re servie res in Wles. The Qulity nd Outomes Frmework for generl prtitioners is voluntry frmework tht ims to rewrd GPs for providing good prtie. Prties re wrded points for providing evidene of good prtie overings four domins of generl prtie: linil, orgnistionl, ptient experiene nd dditionl servies. The operting environment Strtegi poliy frmework 1.42 There is omprehensive nd growing suite of poliy doumenttion tht sets out the strtegi diretion nd intent for the NHS in Wles. Together for Helth 13 is the five-yer strtegi vision for the NHS in Wles. It outlines the hllenges fing the helth servie nd the tions neessry to ensure it is ple of world-lss performne. The min ommitments in the vision re: d e f g servie modernistion, inluding more re provided loser to home nd speilist entres of exellene ; ddressing helth inequlities; etter IT systems nd n informtion strtegy ensuring improved re for ptients; improving qulity of re; workfore development; instigting ompt with the puli ; nd hnged finnil regime. 12 http://www.wles.nhs.uk/douments/ooklet-e.pdf 13 Welsh Government, Together for Helth: A five yer vision for the NHS in Wles, 2011. 14 Governne in the NHS in Wles
1.43 The poliy frmework for the NHS in Wles is now eing st within the ontext of prudent helthre, onept tht is sed round the priniples of: d e f doing no hrm; eliminting interventions with no linil enefit; rrying out the miniml pproprite intervention; orgnising the workfore to mximise the use of skills ross rnge of helthre professionls; promoting equity; nd identifying the ontriution tht individuls n mke to their own helth nd well eing. 1.44 In Otoer 2014 the Welsh Government lunhed Mking Prudent Helthre Hppen, we-sed resoure to explin the key onepts ehind prudent helthre 14. 1.45 A further key development hs een the introdution of n NHS Wles Plnning Frmework 15 in Novemer 2013, with updted guidne due to e pulished in the utumn of 2014. The frmework seeks to strengthen the plnning of NHS servies vi the prodution of medium-term (three-yer) plns tht integrte servie outomes, workfore nd finnil plnning, with the ims of: ddressing res of popultion helth need nd improve outomes; improving the qulity of re; nd ensuring est vlue from resoures. 1.46 The Frmework is supported y the estlishment of Welsh Government plnning funtion with defined remit of setting ntionl plnning requirements, onstrutively ssessing plns produed y NHS odies, nd monitoring delivery of those plns in wy whih is losely ligned to other elements of the Welsh Government s performne mngement regime. The pplition of the plnning frmework is disussed in more detil in Setion 2 of this memorndum. 1.47 Numerous other poliy douments support the overll vision set out in Together for Helth. The most signifint of these re: Our Helthy Future pulished in 2009 this sets outs the Welsh Government s ommitment nd long-term vision to help people of Wles led helthy lives with prtiulr emphsis on prevention nd erly detetion, ddressing inequlities nd reting helthy sustinle ommunities. 16 14 Mking Prudent Helthre Hppen http://www.prudenthelthre.org.uk/ 15 Welsh Government, NHS Wles Plnning Frmework, 2013. 16 Welsh Government, Our Helthy Future: Tehnil Working Pper, Otoer 2009. Governne in the NHS in Wles 15
d Setting the Diretion pulished in 2010, this doument re-emphsised the need to relne servies with stronger primry nd ommunity re servies nd less reline on institutionl forms of re. 17 Delivering Lol Helth Cre: elerting the pe of hnge lunhed in 2013, this pln uilt upon Setting the Diretion y setting out frmework for tion nd elerted hnge. 18 Working Differently-Working Together pulished in 2012, this sets pprohes to develop the required stffing models tht re required in integrted helthre orgnistions. 19 e Ahieving Exellene The Qulity Delivery Pln for the NHS in Wles pulished in 2012, this sets out the Welsh Government s vision of qulitydriven NHS nd the intentions of hieving exellene y 2016 20. It identifies key requirement for NHS odies to pulish n Annul Qulity Sttement to provide the puli with omprehensive soure of informtion nd ssurne on the qulity of their lol servies. f g Sfe Cre, Compssionte Cre: A Ntionl Governne Frmework to enle high qulity re in NHS Wles pulished in Jnury 2013, this doument desries the roles, responsiilities, nd systems tht should e in ple to seek nd provide ssurne on the qulity nd sfety of helth re servies 21. Sfe Cre, Compssionte Cre pulished in July 2013, this doument outlines the Welsh Government s response to the findings of the Mid Stffordshire NHS Foundtion Trust Puli Inquiry, nd sets out vision for high-qulity re in NHS Wles 22. h A Frmework for Assuring Servie User Experiene the frmework 23, introdued in 2013, provides ntionl pproh to mesuring ptient experiene s required y Ation 5 of the QDP. i Putting Things Right Introdued in 2011, this is set of regultions tht ims to ensure proper hndling of onerns out helthre servies. 24 The regultions im to provide single, integrted pproh to mnging omplints, inidents nd lims, sed on the priniple of investigte one, investigte well. These rrngements were sujet to n independent review tht reported in 2014 25. 17 Welsh Government, Setting the Diretion: Primry nd Community Servies Strtegi Delivery Progrmme, Ferury 2010. 18 Welsh Government, Delivering Lol Helth Cre: Aelerting the pe of hnge, 2013. 19 Welsh Government, Working Differently Working Together: A Workfore nd Orgnistionl Development Frmework, 2012. 20 Welsh Government, Ahieving Exellene The Qulity Delivery Pln for NHS Wles 2012-2016, 2012. 21 Welsh Government, Sfe Cre, Compssionte Cre A Ntionl Governne Frmework to enle high qulity re in NHS Wles, Jnury 2013. 22 Welsh Government, Sfe Cre, Compssionte Cre, July 2013. 23 Welsh Government, Frmework for Assuring Servie User Experiene: Ation 5 of Ahieving Exellene, The Qulity Delivery Pln, April 2013. 24 Welsh Government, Putting Things Right: Guidne on deling with onerns out the NHS from 1 April 2011, 2011. 25 Keith Evns, A review of onerns (omplints) hndling in NHS Wles: Using the gift of omplints, June 2014 16 Governne in the NHS in Wles
Funding flows 1.48 NHS Wles reeives nerly ll of its funding from the Welsh Government. This tkes the following forms: revenue llotions to lol helth ords to seure hospitl, ommunity nd primry re servies for their resident popultions; pitl llotions to lol helth ords nd NHS Trusts for opertionl nd strtegi pitl developments; nd trgeted funding for helth improvement nd other Welsh Government inititives. 1.49 Ptients will generlly reeive tretment within the Helth Bord they re resident or registered in. The funding for this tretment is within the Helth Bord s revenue llotion, so there is no requirement for ny flow of funding etween orgnistions for this tivity. 1.50 When ptients re treted in n NHS orgnistion other thn the Helth Bord in whih they re resident or registered, there is need for flow of funds etween orgnistions. For ptients treted y nother NHS orgnistion in Wles, the Welsh Government does not ditte the sis on whih the flow of funds is greed etween orgnistions. This is greed lolly etween the orgnistions, lthough the Welsh Government does operte n ritrtion proess for resolving disputes etween NHS Wles orgnistions in the limited situtions this rises. 1.51 The Welsh Government does hve n greement with the other UK ntions for the finnil rrngements rising when Welsh ptients reeive tretment in other prts of the UK (nd vie vers). Welsh residents treted in Englnd re pid for using the Pyment y Results triff where this pplies. Ptients treted in Sotlnd nd Northern Irelnd, nd in Englnd where the triff does not pply, re pid for t lolly greed rtes. Governne in the NHS in Wles 17
Prt xx Prt 2 Min prt heding... Key omponents of governne within the NHS in Wles
Aountility within the NHS in Wles 2.1 A numer of rrngements exist to formlly hold NHS odies nd those individuls working in them (nd the wider NHS) to ount for the delivery of servies nd greed outomes. Arrngements to hold individuls to ount 2.2 The Minister for Helth nd Soil Servies is held ountle for the performne of the NHS through the ondut of usiness within the Ntionl Assemly. Supported y offiils, the Minister hs the following roles: d e setting the poliy nd strtegi frmework for the NHS in Wles; greeing in Cinet, s prt of olletive disussion, the overll resoures for the NHS in Wles; determining the strtegi distriution of the overll NHS resoures; setting the stndrds nd performne frmework for the NHS in Wles; nd holding NHS leders to ount. 2.3 The Diretor Generl of the Welsh Government s Deprtment of Helth nd Soil Servies (the Diretor Generl) is lso the Chief Exeutive of the NHS in Wles. This person is ppointed y the Welsh Government s Permnent Seretry nd is oth the Aounting Offier of the NHS in Wles nd n Additionl Aounting Offier within the Welsh Government. 2.4 The Diretor Generl is ountle for their personl performne to the Permnent Seretry. As Chief Exeutive, this individul is ountle to the Minister, nd is responsile for providing the Minister with poliy dvie nd exerising strtegi ledership nd mngement to the NHS. 2.5 The Minister ppoints the Chir, Vie Chir nd Independent Memers to the Bords of NHS odies. These individuls re held to ount for their personl performne through nnul ountility greements linked to personl performne mngement rrngements. As prt of this proess the Minister will hold nnul pprisl meetings with Chirs of NHS odies. 2.6 The reshuffle of the Welsh Government Cinet in erly utumn 2014 resulted in the Deputy Minister for Helth eing given responsiilities for oversight of NHS delivery nd performne in Wles. His role inludes nnul (mid-yer) performne meetings with Chirs nd Vie Chirs of NHS odies tht will over ll spets of their orgnistions performne, nd the tions eing tken to seure improvements. Governne in the NHS in Wles 19
2.7 Chief Exeutives of NHS odies re formlly held to ount for their personl performne y their Bords, nd speifilly through the Chir. In reltion to their role s Aountle Offiers, they re ountle for finnil nd servie delivery performne to the Chief Exeutive, NHS Wles. These rrngements re set out in douments lled Aountle Offier Memornd 26. 2.8 Aountle Offier Memornd lso set out the reltionship etween the Chief Exeutive of NHS Wles, s the Aounting Offier, nd Aountle Offiers within NHS odies in Wles. The Chief Exeutive of NHS Wles my e summoned to the Ntionl Assemly s Puli Aounts Committee (PAC) to nswer questions relting to the ounts of NHS Wles or rising from wider exmintions into the effiient, effetive nd eonomil use of NHS resoures. Whilst the Chief Exeutive of NHS Wles will e regrded s the min respondent to ny PAC enquiries out the wider stewrdship of NHS funds, the PAC my lso require Aountle Offiers of NHS odies to pper efore them in their own right, depending on the mtter under onsidertion. Aountle Offiers of NHS odies my lso e lled to pper efore other sujet Committees of the Ntionl Assemly for Wles. 2.9 Individuls in NHS odies hve responsiilities nd ountilities defined within ler shemes of delegtion nd their performne will e reviewed through the personl performne mngement tht opertes in the NHS. In ddition, professionl stff re lso ountle to their professionl odies 27 in respet of the roles they perform. Arrngements to hold NHS orgnistions to ount 2.10 NHS orgnistions re held to ount for their performne nd the delivery of strtegi nd opertionl plns in numer of wys. Externl srutiny omes in the form of sttutory udit, inspetion nd review from: d e f The Auditor Generl for Wles Helthre Inspetorte Wles Community Helth Counils The Helth nd Sfety Exeutive The Puli Servies Omudsmn The Welsh Lnguge, Older People s, nd Children s Commissioners 2.11 There re well-defined rrngements for these externl review orgnistions to shre intelligene with eh other nd to o-ordinte progrmmes of review work. 2.12 Throughout the yer, the Welsh Government will undertke tivities to monitor nd review the performne of NHS odies in Wles. The Welsh Government s performne mngement rrngements re desried in more detil in the following setion. 26 http://www.wles.nhs.uk/governne-emnul/ountility-in-nhs-wles 27 Inludes odies suh s the Generl Medil Counil nd the Nursing nd Midwifery Counil 20 Governne in the NHS in Wles
Helth Professionl Ledership 2.13 Within the Welsh Government, there re lso numer of key roles tht olletively help guide nd inform the work of the Welsh Government y providing professionl nd medil dvie to the First Minister, the Minister for Helth nd Soil Servies nd memers of the inet, the Deprtment for Helth nd Soil Servies, deprtments of the Welsh Government, nd to externl orgnistions. The Welsh Government hs the following Chief Helth Professionls 28 : d e f g h Chief Medil Offier Chief Nursing Offier Chief Dentl Offier Chief Phrmeutil Offier Chief Optometri Advisor Chief Environmentl Helth Advisor Chief Sientifi Advisor (Helth) Therpy Advisor for Wles Monitoring nd reviewing performne nd delivery NHS Delivery Frmework 2.14 The Welsh Government set outs its delivery priorities for NHS odies within its NHS Delivery Frmework 29. The frmework sets outs numer of Tier 1 trgets nd stndrds whih re mpped to five qulity domins : d e Need nd prevention Servie user experiene nd ess Qulity nd sfety Integrtion nd prtnerships Allotion nd use of resoures (stff nd finne) 2.15 The Welsh Government mkes use of numer of mehnisms to monitor delivery nd to review performne ginst the Delivery Frmework nd other sttutory nd opertionl delivery requirements. These re summrised in Exhiit 2. 28 http://wles.gov.uk/topis/helth/mo/?lng=en 29 Welsh Government, NHS Wles, Delivery Frmework 2013-14 nd Future Plns, 2013. http://wles.gov.uk/topis/helth/pulitions/helth/strtegies/frmework/?lng=en Governne in the NHS in Wles 21
Exhiit 2 Mehnisms to monitor performne nd hold NHS odies to ount Welsh Government Integrted Delivery Bord NHS Delivery Frmework NHS Plnning Frmework Monitoring informtion Chir-Minister Meetings Qulity nd Delivery Meetings Joint Exeutive Tem Meetings Chief Exeutive Meetings Qulity nd Sfety Assurne Group Meetings Ntionl Qulity nd Sfety Forum Helth ords nd Trusts Soure: Wles Audit Offie reserh 2.16 Helth ords nd NHS trusts routinely sumit dt regrding finnes, performne nd qulity to the Welsh Government. The Welsh Government uses this informtion to help srutinise the performne in NHS Wles. The Welsh Government s Integrted Delivery Bord (IDB) meets monthly to onsider these dt nd is ttended y Welsh Government poliy leds, the Delivery Unit (see prgrph 2.22) nd the NWIS. 2.17 Every other month, the Welsh Government nd the Delivery Unit holds Qulity nd Delivery Meetings with helth ords nd trusts. These meetings re used to ring forwrd the issues disussed t IDB nd to seek ssurne tht ny onerns re eing ddressed. These meetings over delivery nd performne, finne, qulity nd sfety, s well s workfore issues. 22 Governne in the NHS in Wles
2.18 Qulity nd Delivery meetings tke ple within frmework of other regulr meetings nd forums tht omprise the following: d e Binnul Joint Exeutive Tem (JET) meetings, led y the Chief Exeutive of NHS Wles, in whih the Welsh Government meets with the exeutive tems of individul helth ords nd NHS trusts to review nd disuss orgnistionl performne. Following eh JET meeting, the Chief Exeutive of NHS Wles formlly writes to the Chief Exeutive of eh helth ord or NHS trust setting out the issues disussed, ny onerns identified nd speifying ny improvements or tions required. Monthly Chief Exeutive Meetings etween the Welsh Government nd ll trust/helth ord hief exeutives. Monthly Qulity nd Sfety Assurne Group Meetings, hired y the Deputy Chief Medil Offier with representtives from Welsh Government Poliy nd Performne divisions, s well s the Delivery Unit. The im is to monitor the qulity nd sfety of helthre servies through review of key inditors. Where onerns re rised, tion n e tken through the IDB. Bi-monthly Chirs nd Minister Meetings etween ll NHS trust nd helth ord hirs nd the Minister. A qurterly Ntionl Qulity nd Sfety Forum whih monitors implementtion of the QDP nd lso oversees the implementtion of Delivering Sfe Cre, Compssionte Cre. 2.19 The ove intertions re designed to omplement internl performne monitoring nd ssurne proesses within NHS odies whih re desried in more detil lter in this setion. Where the intertions identify onerns out performne, helth ords nd NHS trusts re responsile for tking the immedite remedil tion tht is required. 2.20 The Welsh Government s NHS Delivery Frmework sets out numer of esltion levels nd rrngements tht n ome into ply when there re onerns out n NHS ody s performne. These re summrised in Exhiit 3. Governne in the NHS in Wles 23
Exhiit 3 The esltion levels within the Welsh Government s NHS Delivery Frmework Esltion Level Performne Trigger 0 Lol delivery of ll trgets or within trjetory. Esltion Ation Monitoring De-esltion None required erned utonomy. 1 Helth ords/ trusts fil to hieve/mintin one deliverle. Helth ords/ trusts responsile for remedil tion plns rought forwrd to redress the position. Welsh Government ssures nd monitors implementtion of plns support from other orgnistion if neessry. Immedite removl of esltion tion upon hievement of pln nd return to improving Key Performne Inditors (KPIs). 2 Continued filure to hieve/mintin one or more key deliverles. Welsh Government instigtes Delivery Unit nd/other intervention. Welsh Government monitors effetiveness of orgnistionl response. Sustined improvement of KPIs uses removl of esltion tions. 3 Continued filure nd/or filure to mintin n greed improvement trjetory following intervention. Issues rised with Chief Exeutive NHS Wles to determine future requirements. Regulr reporting estlished etween Chief Exeutive NHS Wles nd helth ord/trust Chief Exeutive until improving trjetory estlished. Mintenne of greed improvement trjetories uses return to esltion level 2. 4 Continued filure to improve performne or filure to engge with the ntionl proess despite level 3 esltion. Ations, to e determined y NHS Wles Chief Exeutive, my inlude the following: Meeting with Chir, Vie Chir, Chief Exeutive, Bord Seretry nd/or relevnt Exeutives of helth ord/trust Introdution of speil mesure rrngements Review of exeutive effetiveness Review of Bord effetiveness Removl of pproprite funding strems Soure: Welsh Government 24 Governne in the NHS in Wles
2.21 In Mrh 2014, seprte ut omplementry set of esltion nd intervention rrngements 30 were introdued in order to support regulr informtion shring nd dilogue etween the Welsh Government, the Auditor Generl for Wles nd Helthre Inspetorte Wles. These tri-prtite rrngements onsist of twieyerly meetings to review the performne of NHS odies, nd to gree on how est to respond to ny issues ffeting NHS servie delivery, qulity nd sfety of re nd/or orgnistionl effetiveness. The rrngements permit more frequent meetings to e lled when neessry. Where onerns re identified, there re three possile levels of intervention, eh n esltion of the previous: Enhned monitoring this inludes more regulr monitoring of performne nd delivery, inluding more frequent meetings nd the requirement for written updtes nd sumission of evidene showing progress. Trgeted intervention tions my inlude mentoring senior offiils, ppointing new senior offiils on temporry sis, nd the rrying out of detiled reviews. Speil mesures these will e tken in exeptionl irumstnes nd my inlude suspending or removing the powers nd duties of senior offiils. Also, the Minister my use emergeny powers tht diret one NHS ody to tke over the funtions of nother for speified time. 2.22 It is importnt to note tht Exhiit 3 desries the rrngements whih urrently form prt of the Welsh Government s performne mngement rrngements for the NHS in Wles. These lso now inform the disussions tht re held s prt of the wider tri-prtite rrngements involving the Auditor Generl for Wles nd Helthre Inspetorte Wles, set out in prgrph 2.21. As the new esltion nd intervention rrngements ed in it my e neessry to review the esltion rrngements set out in the Welsh Government s NHS Delivery Frmework in order to hieve ler nd onsistent desriptions of esltion nd intervention tivity within NHS Wles. Support to improve delivery 2.23 The Welsh Government hs estlished Delivery Unit to support orgnistions tht re hving diffiulties with ertin spets of servie delivery. The Delivery Unit ws formed in April 2013 from predeessor orgnistions lled the Delivery nd Support Unit (DSU), Ntionl Ledership nd Innovtion Ageny for Helthre (NLIAH), the Ntionl Ptient Sfety Ageny (NPSA) nd the Clinil Governne Support nd Development Unit (CGSDU). The Unit s tivities re mixture of mndtory interventions (vi the Delivery Frmework esltion proess), nd work in response to requests for support from NHS odies. 30 Welsh Government, NHS Wles Esltion nd Intervention Arrngements, Mrh 2014. Governne in the NHS in Wles 25
The NHS Plnning Frmework 2.24 As indited in Prt 1 of this memorndum, n NHS Plnning Frmework ws introdued in Novemer 2013, with revised version due for pulition in Autumn 2014. The Frmework onfirms the importne of NHS odies estlishing lned medium-term plns nd sets out the evidene tht the Welsh Government expets to underpin plns. 2.25 Srutiny nd ssurne is ritil omponent of the system outlined in the Plnning Frmework. NHS odies re expeted to sujet their drft plns to pproprite internl srutiny efore they re sumitted to the Welsh Government for further rigorous testing nd ssessment. 2.26 Bsed on its ssessment of medium-term plns, the Welsh Government deides whether or not to llow helth orgnistions to hve three-yer flexiilities in their udgeting (s desried in the NHS Finne (Wles) At 2014). Orgnistions grnted the three-yer flexiility re not oliged to rek even every yer, ut must do so fter three yers. This flexiility is designed to give NHS orgnistions more sope to pln for the long term. If helth ord or NHS trust is not le to produe suitly roust medium-term pln, they will ontinue to operte on one-yer plnning yle until suh time tht they re le to produe three-yer pln of suffiient qulity. Flexiilities whih hve een grnted n e removed if there re signifint onerns out n NHS orgnistion s ility to meet its delivery trgets nd greed trjetories. 2.27 One yer on from the lunh of the plnning frmework, four NHS orgnistions in Wles hd entered the three-yer medium-term plnning rrngements, with the remining orgnistions greeing one-yer plns nd the steps tht were neessry to develop medium-term plns of the required qulity. 2.28 Updted guidne 31 pulished in the ltter prt of 2014 set out wht is required from NHS odies s the new plnning system moved into its seond yer, inluding further detil on the pln pprovl proesses, nd the tions tht re to e tken to strengthen the plnning disipline nd profession ross NHS Wles. 31 http://gov.wles/dos/dhss/pulitions/141031frmeworken.pdf 26 Governne in the NHS in Wles
Finnil stewrdship nd ontrol 2.29 Helth odies re lso sujet to rnge of frmeworks nd requirements in reltion to finnil ontrol nd stewrdship. Helth ords hve sttutory oligtions to meet their revenue resoure limit over three-yer rolling period (ie, not exeed the mount they re llowed to spend) nd hve three-yer pln in ple. NHS Trusts must rek even in-yer nd whilst they re expeted to hve three-yer pln in ple, this is not sttutory duty. The ullet points elow provide further detil on the min frmeworks nd requirements regrding finnil ontrol nd stewrdship: Welsh Helth Cirulrs nd Ministeril Letters (s explined in prgrph 1.32) provide requirements over nd ove those set out in sttute. d Mnging Puli Money (MPM) 32 sets out the min priniples for deling with resoures in puli setor odies. The Welsh Government is urrently updting the Mnging Welsh Puli Money (MWPM) ut odies re reommended to use the urrent MPM version until the updted MWPM is issued. The Finnil Reporting Mnul (FReM) 33 is the tehnil ounting guide tht sets out how puli odies should prepre their finnil sttements. The Mnul for Aounts (MFA) 34 is mnul tht sets out the ounting poliies to e followed y NHS odies nd provides priniples-sed guidne on how they should prepre nd omplete their nnul ounts. Chpter 3 detils the nnul reporting requirements for NHS odies to pulish their ounts nd n Annul Report, Annul Governne Sttement nd Annul Qulity Sttement. Governne frmeworks within NHS odies 2.30 Eh NHS ody in Wles is responsile for mintining pproprite governne rrngements to ensure tht it is operting effetively nd delivering sfe, highqulity re to ptients. Orgnistions nd servies should operte within roust frmework for deision mking nd ountility designed to hieve suessful delivery of their strtegi ojetives, in wy whih: d e upholds orgnistionl vlues nd stndrds of ehviour; omplies with regultory requirements, stndrds, diretions nd instrutions; seures the effiient, effetive nd eonomi use of resoures; sfegurds nd protets ssets, inluding its people; nd ensures good governne when working in prtnership with others. 32 HM Tresury, Mnging puli money, July 2013 33 HM Tresury, Government finnil reporting mnul 2014 to 2015 34 Welsh Government, IFRS Mnul for Aounts 2013-14 Governne in the NHS in Wles 27
The role of Bords 2.31 The Bords of NHS orgnistions need to govern their orgnistion effetively nd in doing so uild puli nd stkeholder onfidene tht their helth nd helthre re in sfe hnds. 2.32 The NHS Ledership Ademy 35 hs helpfully set out the key res in whih Bords need to demonstrte ledership within their orgnistions. These re summrised in Exhiit 4 s the ore roles whih Bords must undertke nd the enling ftors tht help them exerise these roles. 2.33 NHS Bords in Wles re omprised of the following memers: d e The Chir whose role is to mnge nd develop the Bord. The Chief Exeutive whose role is to e the Aountle Offier, nd e the opertionl leder of the orgnistion. Exeutive Diretors who hve dul role s Bord memers, nd opertionl exeutive leds for their prt of the orgnistion, with Medil Diretors, Nurse Diretors nd Diretors of Therpies hving speifi roles tht provide linil voie t the Bord. Independent Memers whose role is to provide independent thinking, ojetivity, governne nd expertise. Assoite Memers who ttend Bord meetings on n ex-offiio sis ut do not hve voting rights. 2.34 All Bord memers shre orporte responsiility for formulting strtegy, ensuring ountility nd shping ulture. They lso hve shred responsiility for ensuring tht the Bord opertes s effetively s possile. Chpter 4 of the Good Governne Guide for NHS Wles Bords 36 provides helpful further nlysis of the different roles plyed y Bord memers in delivering the NHS ody s ore roles. 35 NHS Ledership Ademy, The Helthy NHS Bord 2013: Priniples of Good Governne, 2013. http://www.ledershipdemy.nhs.uk/wp-ontent/uplods/2013/06/nhsledership-helthynhsbord-2013.pdf 36 http://ledershiplerning.demiwles.org.uk/uplods/tthments/nuppd63yp.pdf 28 Governne in the NHS in Wles
Exhiit 4 Bord Ledership Core Roles Enling ftors Formulte Strtegy Formulte Strtegy Compelling orgnistionl vision Qulity & ptient sfety t ore Longer term view (3 5 yers) Finnilly sustinle Workfore needs identified Whole system pproh Cler outomes nd milestones Understnding of externl ontext nd lndspe Ensure Aountility Rigorous nd onstrutive hllenge Cler responsiilities & ountilities for stff Tringulting informtion soures Reognising good performne Assurne nd ressurne where prolems & onerns re evident Bord Ledership Aurte nd timely informtion nd intelligene Shpe ulture Commitment to openness, trnspreny & ndour Outwrd looking Visile Set n exmple for rest of orgnistion Construtive enggement with internl nd externl stkeholders Soure: Adpted from NHS Ledership Ademy (2013) Governne in the NHS in Wles 29
Committees of the Bord 2.35 The Bord is required to ppoint ommittees to undertke speifi funtions on the Bord s ehlf or to provide dvie nd ssurne to the Bord in the exerise of its funtions. The Bord n estlish ommittee struture tht est meets its own needs, tking ount of ny regultory or Welsh Government requirements. As minimum, however, the Bord must estlish ommittees whih over the following key spets of ord usiness: d e f Qulity nd Sfety Audit Informtion Governne Chritle Funds Remunertion nd Terms of Servie Mentl Helth At requirements (where pplile) 2.36 With Bord pprovl, other ommittees nd su-ommittees my e estlished to ssist in the ondut of NHS orgnistions usiness. In ddition, Stnding Orders require Bords to form numer of dvisory groups tht llow Bords to tke ount of the interests of stkeholders in ommunities they serve, its offiers nd helth professionls, nd to support effetive prtnership working with other NHS odies nd lol uthorities. 2.37 All Bord ommittees normlly hve n Independent Memer s hir. Audit Committee memers re ll non-exeutive offiers, with exeutives in ttendne s pproprite. At lest one memer of the Audit Committee must hve finnil kground. It is importnt tht heks nd lnes re mintined in reltion to ommittee memership to void potentil onflits of interest, for exmple, y ensuring tht the Bord Chir is not memer of the Audit Committee. 2.38 In developing their governne rrngements nd ommittee strutures, Bords of NHS odies need to ensure tht they do not indvertently rete unonneted silos or overlpping funtions. They therefore need to ensure tht the priniples of integrted governne re properly onsidered nd tht their ssurne frmeworks llow the Bord to reeive holisti informtion tht links together orporte, linil, finnil nd informtion governne. 30 Governne in the NHS in Wles
Soures of ssurne 2.39 NHS Bords need to gin ssurne on the extent to whih their orgnistions re operting effetively nd delivering their strtegi vision nd ojetives. In prtiulr, ssurnes need to over: ompline with relevnt legisltion, regultions, stndrds nd other diretions nd requirements set y the Welsh Government; the reliility, integrity, nd seurity of the informtion olleted nd used y the orgnistion; nd the provision of high-qulity nd sfe helthre for its itizens, nd the effiient, effetive nd eonomil use of resoures. 2.40 These ssurnes need to extend eyond n orgnistion s own rrngements in order to over prtnership working nd the provision of shred servies s pproprite. 2.41 Bords n reeive ssurnes from wide rnge of soures, oth internl nd externl to the orgnistion. These re summrised in Exhiit 5. Exhiit 5 Soures of ssurne Internl ssurnes Internl Audit Self ssessment ginst the Stndrds for Helth Servies in Wles Clinil Audit Lol Counter Frud work Welsh Risk Pool Reports from ommittees nd dvisory groups Performne reports Inident reporting Complints monitoring Reporting ginst milestones in nnul nd medium-term plns Stff surveys Externl ssurnes Externl udit reports nd opinions, inluding nnul strutured ssessments of governne rrngements Helthre Inspetorte Wles reports, investigtions nd spot heks Community Helth Counil Royl Colleges Denery visits Puli Servie Omudsmn Older People s, Children s nd Welsh Lnguge Commissioners Externl dvisors nd peer reviewers Externl enhmrking exerises Soure: Wles Audit Offie nd Good Governne Guide for NHS Wles Bords Governne in the NHS in Wles 31
2.42 Within the soures of internl ssurne shown in Exhiit 5, it is worth highlighting numer of rrngements tht form fundmentl prt of NHS odies governne rrngements. These re explined further elow: d Internl udit this provides key soure of independent internl ssurne to Bords nd Chief Exeutives (s Aountle Offiers). Internl udit forms prt of the NWSSP desried in prgrphs 1.12 1.14. There is n nnul progrmme of internl udit work t eh NHS ody in Wles tht results in series of individul udit reports, nd llows the Hed of Internl Audit to produe n overll nnul opinion on the orgnistion s risk mngement, ontrol nd governne. The work of internl udit is overseen y the Bord s Audit Committee. Clinil Audit this is the systemti nlysis of the proesses nd proedures used in the delivery of helthre, ginst reognised evidene-sed stndrds nd prties. Clinil udit will typilly e undertken s prt of linil professionls edution nd development. However, its min purpose should e to improve the qulity of ptient re. As suh, Clinil Audit findings should e reported through the orgnistion s strutures to the Bord s prt of the NHS ody s rrngements for ensuring the qulity nd sfety of re. Welsh Risk Pool this is mutul orgnistion whih provides indemnity to ll Helth Bords nd NHS trusts in Wles nd forms prt of the NWSSP. The Risk Pool provides support to NHS trusts nd lol helth ords in the development of roust risk mngement systems, informed y speifi review work in the res of A&E, operting thetres nd mternity servies. Lol Counter Frud work Wles hs Counter Frud Servies (CFS) tem onsisting of experiened investigtors who del with lrge-sle, omplex fruds nd ll orruption issues in NHS Wles. Diretions lso stipulte tht NHS odies in Wles must nominte suitle person to t s their Lol Counter Frud Speilist (LCFS). The CFS Wles Tem provides support nd guidne to the network of LCFSs, who usully investigte smller vlue frud ses within their own helth odies. The LCFSs work with CFS Wles to help develop roust ounter frud ulture nd seure riminl, ivil nd disiplinry sntions when pproprite. 2.43 Externl ssurne n e mndted or ommissioned. There re key distintions etween the two nd it is importnt to note tht independent sttutory externl review work, suh s tht undertken y the Auditor Generl nd Helthre Inspetorte Wles, is designed to provide ssurne to itizens nd other stkeholders, nd not to the Bord. Tht sid, externl ssurne tivities typilly provide importnt insight, informtion nd reommendtions for improvement, nd Bords need to hve well-defined rrngements in ple to tke effetive tion in response to externl review findings. 32 Governne in the NHS in Wles
Risk mngement nd Bord Assurne Frmeworks 2.44 NHS odies need to hve well-developed proesses for oth identifying nd mnging the risks ssoited with the plnning nd delivery of helthre servies. Risk onsidertion should underpin the development of strtegi nd opertionl plns, deision-mking proesses nd the llotion of resoures. Risk-mngement proesses then need to e emedded into orporte nd opertionl working rrngements. 2.45 All helth ords nd NHS trusts re expeted to mintin orporte risk register detiling the prinipl risks for the orgnistion nd its hievement of strtegi ojetives. Eh Bord ommittee tkes the led for the risks ssoited with their portfolio, whilst the Bord mintins strtegi overview. Sitting elow the orporte risk register, there needs to e n pproprite suite of opertionl risk registers overing the min res of servie delivery. More rodly, the pproh to risk mngement requires the Bord to e ler out its risk ppetite, or tolerne to risk, nd the ontrols needed to mitigte those risks. 2.46 Bords need to underpin their pproh to risk mngement y hving lerly defined Bord Assurne Frmework. The formts of Bord Assurne Frmeworks n vry ut typilly they need to identify nd mp: d e f the orgnistion s strtegi ims nd ojetives; the risks to hieving eh ojetive (inluding likelihood, impt nd severity); the systems nd ontrols in ple to mitigte risks; the ssurnes needed y the Bord; gps in ontrols nd ssurnes; nd tions imed t ddressing these gps. The role of the Bord Seretry 2.47 The Bord Seretry plys ruil role within NHS odies in Wles. Independent of the Bord, the Bord Seretry is key soure of dvie nd support to the Chir nd other Bord memers. Ating on ehlf of the Chir nd Chief Exeutive, the Bord Seretry is expeted to led the design nd development of governne nd ssurne frmework for the orgnistion. 2.48 The Bord Seretry reports on dy-to-dy sis to the Chief Exeutive ut is ountle for the ondut of their role to the Chir. As dvisor to the Bord, the Bord Seretry s role does not ffet the speifi responsiilities of Bord memers for governing the orgnistion. Governne in the NHS in Wles 33
Trnsprent puli reporting 2.49 There is requirement for helth ords nd trusts to provide ssurne to the puli on the orgnistion s performne nd the qulity nd sfety of the servies provided. Chpter 3 of the Mnul for Aounts (referred to in prgrph 2.28) sets out the requirement for NHS odies to pulish n Annul Report nd ounts. The Annul Report should e supported y the following seprte sttements: Annul finnil sttements full set of udited ounts to inlude the primry finnil sttements nd notes, nd the udit opinion nd report. Annul Governne Sttement (AGS) setting out Bord memership nd responsiilities, the shedule of ommittee meetings, detils of internl governne nd risk frmeworks, soures of internl nd externl ssurne nd self-ssessment ginst stndrd 1 of Doing Well, Doing Better: Stndrds for Helth Servies in Wles Governne nd Aountility. Annul Qulity Sttement (AQS) providing the puli with informtion nd ssurne out the qulity nd sfety of their servies. 2.50 In ddition to the ove, puli informtion out the performne of helth servies in Wles n e found on My Lol Helth Servie 37, n online fility tht provides omprtive piture of performne of GP prties, hospitls nd helth ords ross rnge of mesures. The intention is to ontinue to evolve the informtion presented on this wesite s prt of journey of honesty nd inresing openness. 37 My Lol Helth Servie: http://mylolhelthservie.wles.gov.uk/#/en 34 Governne in the NHS in Wles
Prt 3 The wy tht governne rrngements in NHS odies re working in prtie
3.1 NHS odies in Wles re operting the governne rrngements desried in Prt 2 in prtiulrly demnding environment. This environment is hrterised y the need to deliver high-qulity, sfe servies within system tht is experiening hitherto unseen finnil onstrints nd inresing demnd. Exhiit 6 highlights the rnge of hllenges tht NHS Bords in Wles re urrently grppling with. Exhiit 6 Chllenges fing NHS Bords More people with long term onditions Finnil pressures Shifts in re settings Ageing popultion Vlue for money expettions Bords of NHS Orgnistions Rising puli expettions Stronger fous on prevention & well eing Performne trgets Workfore plnning hllenges Tehnologil dvnes in tretments Soure: Adpted from NHS Ledership Ademy 2013 36 Governne in the NHS in Wles
3.2 In this prt of the memorndum we drw upon our lol udit work t NHS odies to give high-level overview of how we see the governne rrngements working in prtie t helth ords nd trusts. Overll perspetives 3.3 There is no dout tht NHS odies in Wles re working hrd to ensure tht they hve governne rrngements in ple whih re fit for purpose, nd whih provide ssurne to themselves, the puli nd other stkeholders on the qulity, sfety nd vlue for money of the servies they provide. 3.4 The retion of lrge integrted helth ords in 2009 rought with it numer of speifi governne hllenges ssoited with the size nd omplexity of these orgnistions. Sine then, our lol udit work hs seen the governne rrngements of NHS odies ontinue to evolve to the extent tht, in the min, the neessry strutures nd proesses re in ple. 3.5 However, the key is the extent to whih these governne rrngements operte s intended. Whilst there is no pn-nhs Wles evidene of the very serious re filings tht were evident in Mid Stffordshire NHS Trust, there hve een worrying nd well-puliised prolems with governne nd linil re in individul orgnistions suh s the Betsi Cdwldr nd Aertwe Bro Morgnnwg University Helth Bords. In oth these orgnistions, work is still underwy in response to the filings tht hve een identified. 3.6 This shows tht there n e no ompleny on the prts of Bords of NHS odies in Wles, or the Welsh Government, in ensuring tht governne rrngements re suffiiently well developed to provide the neessry ssurnes on the qulity nd sfety of re nd finnil stewrdship of puli money. 3.7 Our work hs shown tht whilst most NHS odies hve the neessry governne strutures nd proesses in ple, ertin spets of these need to evolve further to ensure tht Bords re properly equipped to led their orgnistions through the hllenges tht they fe. 3.8 In the setions tht follow, we present high-level findings on: d e how effetively Bords nd ommittees operte; the overll shpe of governne nd ssurne frmeworks within NHS odies; the informtion soures tht re used to provide ssurnes to Bords nd ommittees; the extent to whih orgnistionl lerning is evident; nd the roustness of self-delrtions y NHS odies. Governne in the NHS in Wles 37
3.9 The findings re drwn from our nnul ssessments of the orporte governne rrngements in NHS odies whih hve een presented in Annul Audit Reports to NHS odies. These ssessments, re y their nture high level, lthough they hve permitted uditors to highlight whih spets of NHS odies governne rrngements need to e strengthened. Opertion of the Bord nd its ommittees Condut of meetings 3.10 In their oservtions t Bord nd ommittee meetings ross Wles, uditors hve typilly found the meetings to e well hired with inresing evidene of pproprite hllenge y Independent Memers. On osions, however, uditors hve oserved need for more roust pproh to e dopted in holding offiers to ount. 3.11 There is evidene tht NHS odies re dopting n inresingly trnsprent pproh to the ondut of their usiness. The Bords of NHS odies will meet in puli, nd whilst ommittee meetings in most NHS odies re in privte, the minutes of these meetings re susequently inluded in puli Bord ppers. 3.12 However, there is notle vrition etween NHS odies in the extent to whih ore usiness informtion is pled in the puli domin. Whilst most NHS odies will only mke Bord ppers puli, others suh s Crdiff nd the Vle University Helth Bord mke their ommittee ppers puli. 3.13 As would e expeted, the vst mjority of Bords nd ommittees re quorte when they meet, lthough uditors hve oserved osionl meetings where the sene of Independent Memers hs hindered the effetive ondut of the meeting. This rises wider issue out whether the time some Independent Memers hve is suffiient for wht n e hllenging nd time-onsuming role. 3.14 Bord development sessions re used to improve Bord effetiveness, review rrngements nd support development of the Bord nd its memers. However, the regulrity of independent memer indution trining nd riefing on prtiulr servie issues my not dequtely support newomers in eoming onfident in their role. 3.15 Self-ssessment is n importnt tool used y Bords nd ommittees to review their effetiveness. While the prtie of self-ssessment is widely dopted, the pproh is not lwys rried out on regulr sis or universlly pplied y ll Bords nd ommittees. 38 Governne in the NHS in Wles
Agend mngement nd qulity of ppers 3.16 The sheer volume of the usiness of some Bords nd ommittees n present signifint hllenges for NHS odies in terms of gend mngement. A lrge proportion of informtion presented to Bords nd ommittees is mrked for noting nd there is sope to more expliitly signpost ritil informtion in Bord ppers so tht time is used most effetively. This ould e hieved y ensuring the purpose of ppers presented t ommittee nd Bord is more lerly identified for exmple, for informtion, srutiny or disussion, pprovl or deision. 3.17 This is prtiulrly importnt given tht sets of Bord nd ommittee ppers inlude detiled nd often quite tehnil informtion nd typilly run in exess of hundred pges. Mking this informtion more digestile is n on-going hllenge nd shorter, more strutured highlight reports ould help etter fous the usiness of meetings nd ensure they run to time. 3.18 Internl rules for the ompleteness nd formt of ppers hve een developed with mny Bords nd ommittees using templte pproh. However, the qulity of ppers n still e vrile with some ppers not suffiiently ler out the key risks nd ssurnes provided. 3.19 Whilst the ove issues re lrgely dministrtive in nture, they re nonetheless ritil to the effetive running of the orgnistion. Lengthy nd undifferentited gends run the risk tht importnt issues sheduled for lter on in meetings get insuffiient ttention, or re deferred. Whilst this is not regulr ourrene it does osionlly our. Outomes from meetings 3.20 Bords nd ommittees need to lerly demonstrte in the forml reords tht they hve ppropritely responded to the informtion presented. This should ensure tht deisions re lerly nd formlly reorded, required tions re doumented in tion plns nd tht signifint issues nd risks re identified nd eslted when required. 3.21 The minutes of meetings form the forml reord of Bord nd ommittee disussions nd deisions, with tion logs used to trk the greed tions. Audit Committees hve lso estlished proesses for trking responses to internl nd externl udit reommendtions, lthough trking rrngements for other Committees, suh s Qulity nd Sfety, re often less onsistent or systemti. 3.22 Bords reeive the minutes from their ommittees nd these re inluded in the Bord ppers. Committee Chirs report to eh Bord meeting on the work of their ommittee, identifying nd eslting relevnt mtters. Some NHS odies hve lso introdued summry exeption reporting to more expliitly highlight ssurnes nd risks within the ommittee work progrmmes, lthough this prtie is not ommonple. Governne in the NHS in Wles 39
3.23 Our work hs lso identified tht there is sope for greter lrity round the outome of disussions during meetings, nd tht Bords ould do more to follow up on strtegi plns nd strtegies to ssess whether previously greed tions hve een hieved. Governne nd ssurne frmeworks Committee strutures 3.24 Helth Bords in Wles hve kept their ommittee strutures under review s they look to estlish the most effetive governne rrngements for their orgnistion. Whilst ll orgnistions initilly sed their ommittee strutures upon the model stnding orders s desried in prgrph 2.34, severl Helth Bords hve sine reviewed nd mended their Committee strutures to ensure etter informtion exhnge etween the different ommittees nd more integrted flow of ssurnes to the Bord. Typilly this hs involved the introdution of dditionl ommittees to support integrted governne nd to more expliitly review performne nd delivery. The urrent onfigurtion of key ommittees within NHS odies in Wles is summrised in Appendix 2. 3.25 The key hllenge for NHS Bords is to dopt ommittee struture in whih the vrious su-ommittees nd groups work together effetively to onstitute roust overll frmework for ssurne nd support. This is fundmentl to ensure tht there is ler line of sight etween opertionl servie delivery nd the Bord. 3.26 In the min the introdution of mended ommittee strutures within Helth Bords hs helped strengthen governne rrngements, lthough tht is not universlly the se. Even where strutures hve een mended, there n still e hllenges round ensuring there is n effetive flow of informtion etween ommittees, nd ultimtely to the Bord. This is, however, something tht NHS odies re wre of nd it remins n re of on-going review. 3.27 There re prtiulr hllenges for Qulity nd Sfety Committees. Unlike the Audit Committee whih hs well-emedded progrmme of ssurnes provided y rnge of expert ssurne providers, the ssurnes provided into Qulity nd Sfety Committees re more relint on ssurne flows from rnge of su-committees nd mngement groups. This presents dditionl hllenges round ensuring there is n effetive flow of informtion to the ommittee. Given tht so muh of n NHS orgnistion s usiness n e lssed under the theme of qulity nd sfety, there is lso n on-going hllenge in keeping the gend for this ommittee mngele whilst ensuring tht importnt qulity nd sfety issues re dequtely onsidered. 40 Governne in the NHS in Wles
Exeutive nd opertionl mngement strutures 3.28 All NHS odies hve estlished ler exeutive mngement struture with ountilities lloted ross tem of Exeutive Diretors. There re, however, some vritions in the orgnistionl strutures tht hve een dopted y NHS odies nd in prtiulr Helth Bords. Orgnistionl strutures tht inlude defined ommunities or lolities re evident in numer of helth ords nd most offer the sope for oterminosity with lol uthorities, prtiulrly for the provision of primry re nd ommunity servies. In others there hve een more expliit ttempts to se the orgnistionl struture round defined linil res or pthwys. 3.29 A key hllenge, prtiulrly for lrge Helth Bords is to ensure tht their orgnistionl strutures re predited on ler lines of ountility for opertionl mngement nd delivery. In the min, NHS odies in Wles hve hieved this nd hve voided some of the prolems tht hve een desried reently t Betsi Cdwldr University Helth Bord 38 where prtiulr hllenges were evident in reltion to: lines of ountility nd performne mngement rrngements t opertionl levels; ensuring dequte mngement t the hospitl site level within n orgnistionl struture sed round linil progrmmes; nd the flow of ssurnes from wrd to ord. 3.30 Orgnistionl strutures within the lrger helth ords re desried more fully in Appendix 3. Risk mngement nd Bord Assurne Frmeworks 3.31 Bords of NHS odies in Wles need to tke view on diverse rnge of risks. Audit work hs indited tht NHS odies pprohes to risk mngement hve ontinued to evolve suh tht risk registers re more expliitly mking the onnetions etween strtegi ojetives, orporte risks nd vrious soures of ssurne. However, these rrngements re t different levels of mturity ross Wles nd for some NHS odies more work is needed in this re. 3.32 The understnding of wht onstitutes frmework of ord ssurne hs mtured over reent yers nd NHS odies hve ontinued to refine their ssurne systems, ounting for Welsh Government guidne nd the requirements for qulity ssurne s set out in Sfe Cre, Compssionte Cre, ntionl governne frmework 39. 38 Joint Review undertken y Helthre Inspetorte Wles nd the Wles Audit Offie: An Overview of Governne Arrngements in Betsi Cdwldr University Helth Bord, June 2013 39 Welsh Government, Sfe Cre, Compssionte Cre: A Ntionl Governne Frmework to enle high qulity re in NHS Wles, Jnury 2013 Governne in the NHS in Wles 41
3.33 However, the doumenting of lol frmework rrngements does vry in depth, rnging from sttement of priniples to more expliit desription of ontrols nd ssurne mehnisms. Some Helth Bords suh s Aneurin Bevn University Helth Bord hve pitorilly desried their overll governne nd ssurne frmework (Exhiit 7). Exhiit 7 Aneurin Bevn University Helth Bord Governne nd Assurne Frmework Soure: Aneurin Bevn University Helth Bord http://www.wles.nhs.uk/sitesplus/866/pge/52736 42 Governne in the NHS in Wles