COFNODION Y CYFARFOD BWRDD IECHYD PRIFYSGOL CYMERADWYO/ APPROVED MINUTES OF THE UNIVERSITY HEALTH BOARD MEETING Date and Time of Meeting: 1:30PM THURSDAY 22 ND JUNE 2017 Venue: THE ARTS BUILDING, UNIVERSITY OF WALES TRINITY ST DAVID, LAMPETER CAMPUS, CEREDIGION SA48 7ED Present: In Attendance: Mrs Bernardine Rees, Chair, Hywel Dda University Health Board Mrs Judith Hardisty, Vice Chair, Hywel Dda University Health Board Cllr. Simon Hancock, Independent Member Mr Adam Morgan, Independent Member Mr David Powell, Independent Member Ms Delyth Raynsford, Independent Member Mr Don Thomas, Independent Member Mr Steve Moore, Chief Executive Mr Joe Teape, Deputy Chief Executive & Director of Operations Ms Rhian Davies, Assistant Director of Finance, deputising for Mr Stephen Forster, Director of Finance Mrs Lisa Gostling, Director of Workforce & Organisational Development Dr Philip Kloer, Medical Director & Director of Clinical Strategy Mrs Karen Miles, Director of Planning, Performance and Commissioning Ms Jill Paterson, Interim Director of Commissioning, Primary Care, Therapies and Health Science Mrs Mandy Rayani, Director of Nursing, Quality & Patient Experience Mrs Joanne Wilson, Board Secretary Ms Sarah Jennings, Director of Governance, Communications & Engagement Mrs Libby Ryan-Davies, Transformation Director Dr Iain Robertson-Steel, Hospital Director Withybush General Hospital and County Director, Pembrokeshire Mr Grant Duncan, Welsh Government Dr John Morgan, Chair, Hywel Dda Community Health Council Ms Nicola O Sullivan, Head of Patient and Public Engagement Ms Rhian Burgess, Head of Communications Mr Sam Dentten, Deputy Chief Officer, Hywel Dda Community Health Council, deputising for Mrs Alyson Thomas, Chief Officer, Hywel Dda Community Health Council Mr Hector Walker, Local Mental Health Support Services Lead (part) Dr Graham O Connor, Consultant Psychiatrist and Medical lead for Older Adult Mental Health (part) Dr Warren Lloyd, Associate Medical Director and Clinical Director, Mental Health & Learning Disabilities (part) Mr Tom Alexander, Service Transformation and Partnerships Manager, Mental Health & Learning Disabilities (part) Ms Anna Rumney-Turner, Carer representative (part) Ms Carys James, Ceredigion Local Authority (part) Ms Clare Moorcroft, Committee Services Officer (Minutes) Page 1 of 12
Agenda Item PM(17)115 PM(17)116 PUBLIC FORUM The Chair, Mrs Bernardine Rees, advised of two questions received from Mr David Williams for the Public Forum section of the Board meeting. The second of these questions related to the volunteers who were undertaking work in the grounds of Withybush General Hospital and Mrs Rees expressed her thanks to these volunteers for their commitment. Mr Joe Teape echoed Mrs Rees sentiment and provided a full and detailed response to Mr Williams questions. Mrs Rees noted the questions and response would be provided directly to Mr Williams and would be made publically available on the Health Board s website. Mrs Rees further advised of ten questions from Ms Paula Taylor, which had been received at relatively short notice. Mrs Rees had agreed with Ms Taylor that written responses to all of her questions will be provided by the end of next week. Mrs Rees thanked those who had submitted questions, and undertook to provide a formal written response to all the questions raised and to ensure that responses are available on the University Health Board s website. INTRODUCTIONS & APOLOGIES FOR ABSENCE Mrs Bernardine Rees, Chair, Hywel Dda University Health Board welcomed everyone to the meeting, particularly Mrs Mandy Rayani, the Health Board s substantive Director of Nursing, Quality & Patient Experience and Dr John Morgan, recently appointed Chair of Hywel Dda Community Health Council (CHC). Mrs Rees explained that this Public Board meeting had been called to consider two significant items and that a date identified for a Board Seminar had been utilised for the meeting. The following apologies for absence were noted: Action BR Professor John Gammon, Independent Member Mrs Julie James, Independent Member Mr Paul Newman, Independent Member Mr Mike Ponton, Independent Member Mr Stephen Forster, Director of Finance Mrs Alyson Thomas, Chief Officer, Hywel Dda Community Health Council Ms Hilary Jones, Chair, Stakeholder Reference Group Dr Owen Cox, Local Medical Committee (LMC) Representative PM(17)117 PM(17)118 DECLARATION OF INTERESTS No declarations of interest were made. TRANSFORMING MENTAL HEALTH SERVICES Mrs Libby Ryan-Davies presented the Transforming Mental Health Services report, introducing colleagues from the programme who would Page 2 of 12
be contributing to this agenda item. The Transforming Mental Health Services (TMHS) presentation began with a video focused on reaching out to those affected by mental health issues. Mrs Ryan-Davies advised that the first of the Board responsibilities, as outlined in the report s recommendations, is to approve Stage 1 of the TMHS consultation process (pre-consultation engagement) as complete. Members were reminded that it had been a two year process to reach this point and Mrs Ryan-Davies outlined the pre-consultation engagement work undertaken, which had included: Workshops with staff, local mental health forums, collaboration with the CHC; leading to the development of the Paper presented, which had launched the conversation with the public; Broader engagement, using a number of different methods including workshops and focus groups; Independent evaluation by University of Wales Trinity Saint David (UWTSD) which brought together themes, data and information. The options development stage had necessitated the formation of an options development group, with multi-stakeholder involvement and composition. The remit of this group had been to: Ascertain a baseline of current services; Develop scoring criteria/weightings; Develop options from the data collected; Develop the clinical case for change. Initially, 18 options had been identified which, following SWOT (Strengths, Weaknesses, Opportunities, Threats) analysis, were reduced to 7. These 7 options were tested by means of scoring, staff feedback and key focus groups. Option testing workshops with all stakeholders had resulted in reconsideration of scoring and weighting. Throughout the process, the Health Board has worked with the Consultation Institute, which advised in December 2016 that the final options did not have sufficient differences for consultation purposes and suggested that a co-designed model be developed with stakeholders. The Health Board had worked with the CHC and Consultation Institute to design the programme scope, which has resulted in the documents being presented and the request that the Board approve progress to the next stage of the consultation process. Mrs Nicola O Sullivan detailed the engagement and co-production undertaken, noting the 10 key themes which had been utilised in weighting the criteria to score options: Responses to Change Accessibility to Mental Health Services Understanding and Managing Crisis Workforce issues Rurality and Mental Health Services Page 3 of 12
Systems and Management Collaboration Values and Attitudes Engagement, Research and Knowledge-Sharing Desired Outcomes Mrs O Sullivan advised that the stakeholder event had been extremely interactive, and had looked at topics from a service user s perspective. Members heard reflections and testimonials from partners including staff which confirmed their positive impressions of the engagement process. Mrs O Sullivan emphasised that it is important to acknowledge the contribution from all partners. Ms Carys James assured Members that the case for change is supported by all three Local Authorities, and that they have been fully represented on the programme group. Ms James added that the TMHS programme embraces the principles of the Well-being of Future Generations Act. Mr Hector Walker advised that he is a Counselling Psychologist working in Pembrokeshire and Carmarthenshire, undertaking a combination of clinical work with patients, supervision of staff and managing teams. Mr Walker had been invited to be involved in the TMHS programme and had contributed to the options development group, the scoring process and preparations for the consultation process. In change processes there is a risk that staff do not feel involved, however Mr Walker stated that in his and others opinion, the opposite had been the case with regard to the THMS programme. This sense of involvement and ownership is extremely important to front line staff. Mr Walker concluded by stating that the proposals represent a very exciting way forward and future. Dr Graham O Connor advised that, whilst he would not be directly affected by the changes being proposed, it had been very worthwhile to be involved in a process where meaningful changes are being discussed. Dr O Connor had been a member of the Local Medical Committee, whose views have contributed to the change process and he looked forward to the next stage. Anna Rumney-Turner recounted a scenario around barriers to access, and stated that attitude is the most important issue in making services and clinical environments suitable for service users. Whilst service users and their carers have certain frustrations, they did feel that these have been listened to during the engagement process. Mr Sam Dentten advised that the CHC had welcomed the opportunity for involvement and outlined the engagement process to date. Mr Dentten stated that the TMHS programme had a genuine sense of co-production, which was unprecedented and for this he commended the Health Board. Whilst at this point, the reaction of the public is unknown, Mr Dentten was looking forward to the next stage. The CHC will continue to monitor the process to ensure that the Health Board is gathering views Page 4 of 12
appropriately. Mrs O Sullivan acknowledged the involvement of and input from other parties who were not able to attend the meeting today, and outlined the approach and methods to be used going forwards. Dr Warren Lloyd welcomed the opportunity to present today, and reflected on the history of mental health services in the region. Dr Lloyd thanked the Health Board, staff, patients, service users, carers, Local Authorities, CHC and all stakeholders for their contributions. Members were introduced to the proposed co-designed service model, with four key cornerstones, all focused on the needs of the individual: 24 hour services; No wait for a response to need; Community focus; Recovery and resilience. Dr Lloyd also outlined the CONNECT philosophy, in relation to staff, local population and partners: Community; Open access; Needs led; Nothing about us without us; Engagement; Collaboration; Timely help and support. Members were advised that there are certain givens in the proposed service model one Central Assessment Unit & Treatment Unit and four Community Mental Health Centres (CMHC) (1 per county plus 1 in Carmarthen). One of the areas of influence/issues to be consulted upon is whether there is a centralised 24 hour single point of contact (location to be confirmed) or one in each of the county centres. The other areas of influence were outlined as follows: Opportunities to support families and carers; Opportunities to consider Social Enterprises being involved in CMHCs; Non NHS Staffing roles (peer mentors, volunteers, etc); Working in partnership; Transport provision; Investing in digital technology; Indicators of outcome. Dr Lloyd detailed the Clinical Case for Change, from a clinician s perspective, emphasising the current service is unsustainable and suggested if change is not made, the Health Board will have missed an opportunity. National and international collaboration was outlined, and Members were informed the proposed model is intended to align with Page 5 of 12
the Health Board s Strategic Objectives, specifically Strategic Objective 7. Dr Lloyd particularly highlighted the collaboration with West Wales Action for Mental Health (WWAMH). Dr Lloyd concluded by presenting a number of quotes from other clinicians who had been involved with the TMHS programme. Mr Tom Alexander, Project Manager for the TMHS programme, presented a case study Megan s Story which aimed to bring to life the various challenges being faced within mental health services. In the story, Megan had contacted the emergency services, stating that she felt suicidal and is found by police. The police take Megan to A&E where she is assessed by a GP who states that Megan needs to be admitted to hospital. Mental health beds are unavailable, so the police take her to a place of safety. A bed is found in due course, in another hospital. No transport is available, so the police take her in a patrol car. Megan is given a bed, however by this time it is early morning and she falls asleep whilst the paperwork is being completed. Under the proposed new model, Megan contacts an identified point of contact and speaks to a trained mental health professional, who is able to make an initial assessment over the phone. Megan is referred and a recovery/crisis bed found for her, where she receives further assessment. Megan speaks to the mental health team at the centre about her problems, which include money worries, and the team develops a proactive plan around these including Third Sector involvement. Megan s parents are contacted and visit, and Megan is discharged 48 hours later with a full community-based treatment plan. Mr Alexander noted that the current model results in delays and additional distress for patients, whilst the new model will provide early intervention, a proactive plan and a person-centred package of care. Mrs Ryan-Davies stated that the information within the papers presented to Board sets out the process going forward. Requirements in terms of the consultation project plan were outlined and Mrs Ryan-Davies emphasised that the Health Board will continue to work closely with the Consultation Institute. Members were informed that the TMHS programme has been awarded best practice by the Consultation Institute on the basis of the work undertaken to date. Ms Rhian Burgess outlined the resources currently available from the Health Board website, which represents a dedicated section of the website and a large library of supporting information which will evolve as the consultation progresses. Dr Lloyd detailed his final thoughts on lessons learned during the process thus far: Transformation requires commitment; Honesty and openness is required which can be challenging for all concerned; The lived experiences of patients, service users, families need to be prized; Our staff are our greatest asset for positive change; Page 6 of 12
Our fiercest critics are now are most powerful advocates for change; Dr Lloyd concluded by advising that the TMHS programme is a finalist in the NHS Wales Awards 2017, in the category Citizens at the heart of service re-design. Mrs Rees congratulated all of those present and the wider team on the work undertaken during the last two years to get to this point. The team was also commended for managing to translate the information into a user-friendly format. Mrs Judith Hardisty stated that she was amazed and overwhelmed by the level of commitment of those involved and commended the plans as a major step forward. Whilst implementation following consultation will be challenging, the achievement should not be underestimated. Cllr. Simon Hancock echoed these comments, expressing admiration for the team spirit and approach exhibited. Cllr. Hancock emphasised that mental health is as important as physical health and hoped that the approach being taken will help to remove the stigma around mental health issues. Dr Iain Robertson-Steel praised the exemplary presentation, stating that it provided huge learning opportunities for others, whilst agreeing that implementation will be challenging. Mrs Lisa Gostling noted that the Health Board has stated the aim of being a clinically-led organisation and suggested that the TMHS programme is a perfect example of a clinically-led process. Mr Steve Moore acknowledged that significant progress can be made through engagement and emphasised that the strategic direction should not be a secondary consideration. Whilst it is possible to cope on a day to day basis without a strategy, ultimately this results in managing decline. A strategy provides a sense of purpose and optimism for an organisation. Mr Moore welcomed the suggestions around sharing innovative/best practice and adopting good practice from elsewhere, adding that whilst it takes time to make progress, the proposals represent a meaningful and positive change. The Board: APPROVED completion of Stage 1 of the consultation process (preconsultation engagement and options development); APPROVED commencement of Stage 2 of the consultation process (formal consultation) for a period of 12 weeks commencing 22 nd June 2017; APPROVED the Transforming Mental Health Project plan inclusive of Consultation Scope, Consultation Plan, and Public Consultation documents. PM(17)119 TRANSFORMING CLINICAL SERVICES STRATEGIC PROGRAMME Mrs Rees introduced the Transforming Clinical Services (TCS) Programme, noting that this programme is beginning the same engagement process the Transforming Mental Health Services programme has been on already. Dr Phil Kloer introduced a presentation, entitled Transforming Clinical Services Strategic Programme advising that the purpose of this agenda item was to recommend to Board Members the launch of the TCS engagement process. Dr Kloer stated that a great deal of work has taken place during Page 7 of 12
the last six months in order to reach this stage; it is now intended to embark upon a 12 week engagement process. Dr Kloer outlined the context for the Transforming Clinical Services (TCS) programme, emphasising the opening mission statement that the TCS should be Safe, Sustainable, Accessible and Kind. Dr Kloer highlighted the Drivers for Change: health inequalities in terms of life expectancy the ageing population the remoteness and rurality of parts of the region recruitment challenges the Health Board s recurrent financial deficit He also outlined that the Health Board has a number of assets, including its workforce, an interested and involved public, links with local universities and neighbouring health boards, location and associated quality of life opportunities. It was noted, however, that it is not sufficient to promote wonderful locations in recruitment campaigns; the Health Board also needs to offer exciting and worthwhile career opportunities in order to attract and retain staff. Members were reminded that the Transforming Mental Health Service (TMH) programme had demonstrated what can be achieved by working with the public and other stakeholders. Dr Kloer continued the presentation by outlining areas where the Health Board must make improvements, and the approach to change, which employs the four principles of prudent healthcare. Dr Kloer commended the vision outlined in Megan s Story in the TMH consultation document and suggested that a similar approach might be used within the TCS programme. Mrs Ryan-Davies continued the presentation by detailing progress since October 2016, including establishment of the Transformation programme and the Clinical Services Strategy Group, and production of the scoping document in February 2017. Mrs Ryan-Davies then outlined the TCS programme scope, as follows: 3 defined programmes of work: - Transforming Out-of-Hospital Care - Transforming Urgent & Emergency care - Transforming Planned Care alongside well-established programmes for transforming Mental Health and Women & Children s services Each programme of work will have 4 key areas of focus: - demand - workforce and new ways of working - new models and best practice - infrastructure requirements These will be underpinned by key enablers communication and engagement, data and evaluation, IT, Workforce & OD, Estates and Finance. Page 8 of 12
Members were reminded that the Health Board has been working with the Advisory Board s Global Health Forum, to network with sites of innovation internationally. Other organisations have and are facing the same challenges as the Health Board and opportunities exist to learn from their experiences, and there are areas of innovation within the Health Board which can be shared with others. The programme scope directly links with the planning framework and the development of the Health Board s Integrated Medium Term Plan (IMTP). Mrs Ryan-Davies explained that development of the TCS allows examination of the whole healthcare system. The TCS Strategic Programme Structure was outlined; Mrs Ryan-Davies stated that this is set out in more detail within the Project Initiation Document, and explained the governance structure and arrangements for the programme. Mrs Ryan-Davies outlined the defined approach to transformation with the three principles of Discover, Design and Deliver and how these will look in practice. The Phase 1 Road Map outlined tasks to be undertaken by the November 2017 Public Board meeting; with further detail provided in the GANTT chart contained in the PID. Ms Jennings then explained that in terms of both the governance and Quality Assurance, the Medical Director and Transformation Director have worked with the governance team to ensure that it was integral to the wiring diagram of the overall HDdUHB governance. Ms Jennings explained the reporting structure to the Health Committee and Board and Members were assured that links to the Stakeholder Reference Group and Healthcare Professionals Forum will be established. Ms Jennings added that in the Health Board s desire to listen and to develop the best model possible, it will work with The Consultation Institute and CHC to ensure external quality assurance. Members were reminded of the magnitude of the process being undertaken, and that the decisions being made will affect the healthcare of the next generation. It is vital that the Health Board has the courage to engage fully and honestly with all stakeholders, in order to take the next step into the future. Whilst the Health Board is not new to the process of engagement, there is a need to be honest about which services are fragile and which are potentially unsustainable. Members attention was drawn to the Communications and Engagement strategy, Activity Log of engagement events and methods, together with resources available from the Health Board website: http://www.hywelddahb.wales.nhs.uk/tcs Mrs Rees thanked all of those involved in producing the presentation and papers presented to Board. Mrs Rees highlighted that there is no template for the proposed new service model, because this is a genuine engagement process and the model will emerge from the conversation with the public and other stakeholders. Mr David Powell welcomed the information provided and stated that he was very positive in terms of the direction of travel, which represented a significant development. However, Mr Powell suggested that more information was Page 9 of 12
needed around short-term activities and regional planning. Dr Kloer agreed with Mrs Rees comment that this process must be entered into with an open mind. Whilst the challenge ahead should not be underestimated, the engagement process is concerned with shaping the future of healthcare. Dr Kloer suggested that there will be certain proposals emerging from the engagement process which may not require substantial consultation before implementation, although these will obviously be discussed with the CHC. There is also existing collaboration, for example with ABMUHB, which will continue although it may well also arise within discussions as part of the engagement process. Mr Adam Morgan emphasised that the need for change should not be underestimated; the TCS programme represents a means of managing quality and safety issues on a long term basis. Mr Morgan stated that there must be a mechanism for flagging any quality and safety issues which are identified during the engagement exercise and ended by highlighting that all of those involved in the process must be comfortable with not having a clear sense of what the new service model will look like at this point. Mr Dentten stated that the CHC do have concerns about the double-running of the TCS engagement and TMHS consultation processes, the challenge in terms of timescales and the risks to resources and capacity. However, the CHC welcome their involvement in the process thus far and are happy to assist in any way. Mrs Hardisty, whilst inspired by the presentation, noted that the Health Board need to continue to deliver existing services and suggested that consideration be given to whether additional support is required and how this might be discussed with Welsh Government. Dr Robertson-Steel agreed that delivering the day-to-day service represents a major challenge and emphasised the need to address staffing issues in both primary and secondary care. Dr Robertson-Steel stated that whatever the future model, it is vital that the Health Board make its best estimate of staffing levels, particularly in those areas where it is difficult to recruit, as there are long lead-in times for training health professionals. Mrs Rees agreed that there is a need to consider workforce models. Miss Jill Paterson welcomed the inclusion in TCS of primary care and community services and acknowledged the issues within primary care which are resulting in the need to use innovative approaches/models. Whilst Miss Paterson recognised that the actions taken are currently often reactive, the TCS should provide long term opportunities and potential solutions. Mr Moore, referencing CHC concerns around double-running of processes, recognised the risk involved and stated that it compels discussion and clarity around the transformation message. Members were reminded that the Health Board s escalated status provides Welsh Government the opportunity to provide support in taking forward these vital programmes. Mr Moore emphasised the importance of recognising that the Board are custodians of the health service for future generations and that the Health Board must be honest about the fragility of services and challenges in terms of finance and sustainability. As has been indicated in the presentations given today, public and stakeholder input is vital. In terms of the potential for operational distraction, whilst Mr Page 10 of 12
Moore recognised the need to acknowledge this as a potential risk, he noted that it would have to be faced at some point. Mr Moore was hopeful that there was sufficient stability in key services to cope with this challenge and stated that there are other measures being discussed currently which will assist, for example nursing workforce plans. There are also short term actions, for example projects within the Primary Care Clusters, which will help with long term plans. Mr Moore stressed the continued need to work towards an agreed IMTP for 2018/21. Mrs Rees drew Members attention to the membership of the Health Strategy Committee, advising that whilst this group is clinically-led, membership includes clinicians other than doctors and nurses. Mrs Rayani noted that there is not necessarily consistency in terms of nursing representation on the Programme Groups and it was agreed that this would be addressed. Members noted that the Independent Member on the TCS Programme Sub-Committee, Mrs Julie James, would also chair this group. Mrs Rees suggested two additional recommendations, as detailed below. The Board: APPROVED the commencement of the 12 week formal engagement exercise (Stage 1) on the Health Board s Issues Paper co-produced with Senior Medical leaders and the Community Health Council; APPROVED the Terms of Reference for the Health Strategy Committee; APPROVED the governance arrangements and the establishment of the Transforming Clinical Services Programme as described within the Project Initiation Document including the establishment of and the terms of reference for: - The Transforming Clinical Services Programme Sub-Committee - The Transforming Out of Hospital Programme Group - The Transforming Urgent & Emergency Programme Group - The Transforming Planned Care Programme Group NOTED both the Transforming Women & Children s Programme Group and the Transforming Mental Health Programme Group have already been established and are working to extant TORs; DELEGATED authority to the Transforming Clinical Services Programme Sub-Committee to approve the Communications and Engagement Group, which will be co-designed with the Community Health Council; APPROVED that the Transforming Clinical Services Programme Sub-Committee is chaired by an Independent Board Member; APPROVED each Programme Group having an identified Independent Board Member on the Group to provide assurance to both the programme Sub-Committee and the Board that the work is progressing in accordance with the Board agreed timeframe; APPROVED the TCS programme communication and engagement plan, including the approach and methods proposed; REQUESTED that the emerging solutions be presented to Board on 21 st November 2017; REQUESTED that an update report be provided to the July and September 2017 Board meetings. PK/LRD Page 11 of 12
PM(17)120 DATE AND TIME OF NEXT MEETING 9.30am Thursday 27 th July 2017, Bridge Innovation Centre, Pembroke Dock, Pembrokeshire. Page 12 of 12