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Bundle Finance, Performance & Workforce Committee 25 October 2018
0 Agenda1 Agenda FPW 25 October 2018.docx
1 PART 1 - PRELIMINARY MATTERS1.1 Apologies for absence1.2 Welcome and Introductions1.3 Declarations of Interests1.4 To receive and confirm the Minutes of the meeting held on 20 September 2018
1.4 Draft Unconfirmed FPW Minutes 20 Sept 2018 v2 GR.docx
1.5 Action Log1.5 Action Log FPW 25 October 2018 v2 GR.docx
1.6 Matters Arising2 PART 2 - KEY ITEMS FOR DISCUSSION2.1 To receive a quarterly update report on CAMHS Performance
2.1 CAMHS update FPW 25 Oct 18 GR.doc
2.2 To receive an updte report on the Deep Dive undertaken in Facilities2.2 Update Report on Facilities Deep Dive - FPW 25 Oct 2018 V2 GR.doc
2.2.1 Appendix 1 Sickness deep dive report FPW 25 Oct 2018 GR2.2.1 Appendix 1 Sickness deep dive report FPW 25 Oct 2018 GR.docx
2.2.2 Appendix 2 Five year CRES History FPW 25 Oct 2018 GR2.2.2 Appendix 2 Five year CRES History FPW 25 Oct 2018 GR.docx
2.2.3 Appendix 3 Benchmarking report FPW 25 Oct 2018 GR2.2.3 Appendix 3 Benchmarking report FPW 25 Oct 2018 GR.docx
2.2.4 Appendix 4 Waste performance Report FPW 25 Oct 2018 GR2.2.4 Appendix 4 Waste performance Report FPW 25 Oct 2018 GR.docx
2.2.5 Appendix 5 Porter service redesign FPW 25 Oct 2018 GR2.2.5 Appendix 5 Porter service redesign FPW 25 Oct 2018 GR.docx
2.2.6 Appendix 6 Facilities work plan 18-20 FPW 25 Oct 2018 GR2.2.6 Appendix 6 Facilities work plan 18-20 FPW 25 Oct 2018 GR.xlsx
2.3 To receive a quarterly update report on the organisational risks assigned to the Committee2.3 Org Risk Register, FPW 25 Oct 2018 GR.doc
2.4 To receive a Clinical Deep Dive into Urology2.4 Clinical Deep Dive Urology Paper FPW 25 Oct 2018 GR.doc
2.5 Update report on cancer breaches- FPW 25 Oct 20182.5 Update report on cancer breaches- FPW 25 Oct 2018 GR.doc
2.5.1 Appendix 1 - Monthly Cancer Performance Report Aug 18wj2.5.1 Appendix 1 - Monthly Cancer Performance Report FPW 25 Oct 2018 GR.docx
2.6 INNU update report FPW 25 Oct 2018 GR2.6 INNU update report FPW 25 Oct 2018 GR.docx
3 PART 3 - OTHER MATTERS3.1 To review the Forward Look for 2018/19
3.1 Forward Look FPW 25 October 2018 GR.doc
3.2 To confirm any itmes to be referred to other Committees3.3 Any Other Urgent Business3.4 Date and Time of Next Meeting: Thursday, 22 November 2018, at 1:00 pm
0 Agenda
1 1 Agenda FPW 25 October 2018.docx
CWM TAF UNIVERSITY HEALTH BOARD
FINANCE, PERFORMANCE & WORKFORCE COMMITTEE
The meeting of the Finance, Performance & Workforce Committee will be held on Thursday 25 October 2018 at 1pm in the Rhondda & Cynon
Rooms, Ynysmeurig House, Abercynon.
MR MEL JEHU
CHAIRMAN
AGENDA
ATTACHED
PART 1 - PRELIMINARY MATTERS
1.1 Apologies for absence
Oral
1.2 Welcome and Introductions
Oral
1.3 Declaration of Interests
Oral
1.4 To receive and confirm the Minutes of the meeting held on
20 September 2018
Paper
1.5
Action Log
Paper
1.6
Matters Arising
Oral
PART 2 – KEY ITEMS FOR DISCUSSION
2.1 To receive a quarterly update report on CAMHS Performance
Paper
2.2 To receive an update report on the Deep Dive undertaken in Facilities
Paper
2.3 To receive a quarterly update report on the organisational
risks assigned to the Committee
Paper
2.4 To receive a Clinical Deep Dive into Urology
Paper
2.5
2.6
To receive an update on cancer performance
To receive an update report on Interventions Not Normally Undertaken (INNU)
Paper
Paper
PART 3 – OTHER MATTERS
3.1
3.2
3.3
3.4
To review the Forward Look for 2018/19 (Chair)
To confirm any items to be referred to other Committees
(Chair)
Any other Urgent Business (Chair)
Date and time of next meeting
1pm, Thursday 22 November 2018, Ynysmeurig House, Navigation Park, Abercynon
Paper
Oral
Oral
1.4 To receive and confirm the Minutes of the meeting held on 20 September 2018
1 1.4 Draft Unconfirmed FPW Minutes 20 Sept 2018 v2 GR.docx
Agenda item 1.4
‘Unconfirmed’ Minutes of meeting held 20 September 2018
Page 1 of 11 Finance , Performance & Workforce Committee Meeting
25 October 2018
Finance, Performance & Workforce Committee Meeting
‘Unconfirmed’ Minutes of the meeting held on
20 September 2018 Ynysmeurig House, Abercynon
Present
Mel Jehu Independent Member (Chair) Paul Griffiths Independent Member
Keiron Montague Independent Member (In part) Robert Smith Independent Member
Dilys Jouvenat Independent Member
In attendance
Ruth Treharne Deputy Chief Executive/Director of Planning &
Performance Alan Lawrie ‘Interim’ Director of Primary, Community and Mental
Health Jo Davies Director of Workforce &
Organisational Development (OD) John Palmer ‘Interim’ Chief Operating Officer
Steve Webster Director of Finance & Procurement
Alan Roderick Assistant Director of Performance & Information Marcus Longley Chair of Cwm Taf University Health Board
Emma Samways Internal Audit & Assurance Hywel Daniel Assistant Director of Workforce & OD
Emma Walters Corporate Governance / Committee Secretariat Jacqueline Maunder Governance Lead, Corporate Services
Donna Hill Medical Engagement Officer (In part)
FPW/18/096
WELCOME AND INTRODUCTIONS
Mel Jehu WELCOMED everyone to the meeting, particularly Dilys Jouvenat
who had become a new Member of the Committee and was attending her
first meeting today. The Chair also WELCOMED Hywel Daniel, Donna Hill, Emma Samways and Marcus Longley to the meeting.
FPW/18/097
APOLOGIES FOR ABSENCE
Apologies for absence were RECEIVED from Robert Williams and Gwenan
Roberts.
Agenda item 1.4
‘Unconfirmed’ Minutes of meeting held 20 September 2018
Page 2 of 11 Finance , Performance & Workforce Committee Meeting
25 October 2018
FPW/18/098
DECLARATIONS OF INTERESTS
There were no additional declarations of interest.
FPW/18/099
MINUTES OF THE LAST MEETING
The minutes of the meeting held on 19 July 2018, were RECEIVED and APPROVED as a true and accurate record.
FPW/18/100 MATTERS ARISING
Page 3, Workforce Dashboard, Jo Davies AGREED to confirm whether the
information relating to the work being undertaken on medical agency spend had been circulated to Members.
Page 8, Single Cancer Pathway Performance, Marcus Longley confirmed
that he had discussed with Kamal Asaad and that further correspondence
had been received from Welsh Government. John Palmer advised that a significant amount of work was being undertaken in this area, with a
workshop also being held today.
FPW/18/101 ACTION LOG
Members RECEIVED and REVIEWED the Finance, Performance & Workforce Committee Action Log.
John Palmer advised that in relation to Clinical Efficiency reports, a clear
domain on clinical quality and efficiency was now in in place on Clinical Business Meeting agenda’s along with a matured platform in place in
relation to the Planned Care Board. John Palmer suggested that this was now treated as a discharged item (completed – removed from the
action log).
John Palmer advised that in relation to Interventions Not Normally
Undertaken (INNU), a discussion had been held at the last Efficiency, Productivity & Value Board in relation to Cross Cutting Themes, one of
which was in relation to Value Based Healthcare. Members NOTED that some specific targets were in the process of being set which would be
monitored at Clinical Business meetings. John Palmer AGREED to have a discussion with Kelechi Nnoaham (Director of Public Health) on when he
would be in a position to provide an update to the Committee on progress made.
Jo Davies provided Members with an update in relation to the triangulation
of the performance, workforce and finance dashboards. Members NOTED that a deep dive approach on the proposed triangulation had been
undertaken in Medicine and one meeting had been held to discuss the
comparison of data, which identified some slight anomalies between workforce and finance.
Agenda item 1.4
‘Unconfirmed’ Minutes of meeting held 20 September 2018
Page 3 of 11 Finance , Performance & Workforce Committee Meeting
25 October 2018
Members NOTED that in light of the complexity of the work required and
the lack of headroom to give this focus, this item would be deferred for a
few months (action log updated).
In relation to the development of a central Service Level Agreement (SLA) schedule, John Palmer AGREED to send a note to Members outside of the
meeting outlining current SLA processes. Members NOTED that an update on SLAs was also included in the Commissioning update report which was
presented to the Committee on a twice yearly basis (action log updated).
FPW/18/102
ADDRESSING THE IMPACT OF NHS WALES MEDICAL AND DENTAL AGENCY AND LOCUM DEPLOYMENT IN WALES
Donna Hill was in attendance for this item.
Jo Davies presented the report and reminded Members that Welsh
Government (WG) issued a Welsh Health Circular (WHC) in November 2017
which introduced 2 levels of cap for internal and external agency, and it had been agreed that the Finance, Performance & Workforce Committee
would receive the report for approval of submission to WG.
Members NOTED that it had been agreed to change the frequency of reporting into WG from monthly to quarterly and that the report presented
today reported on the April – June position. Members NOTED that the format of the report had changed slightly as a result of the data issues
identified in the previous report with further discussions taking place in relation to further refinement of the report moving forward.
Members NOTED that the purpose of the report was to provide assurance
to WG on performance against the cap, highlight the issues being faced by the Health Board and identified the actions being taken locally and on an
All Wales basis.
Members NOTED that performance between April – June 2018 was positive
and showed an improved monthly spend of £200k per month, which meant that the demand for Agency Locums had reduced. Members NOTED that
primary care agency was not included in this report, but was being included in the Finance report, which was why there was a discrepancy in the data.
Members NOTED the actions being taken by the Health Board to improve
the position, which included Medical Director challenge to any requests being received and a review of procurement arrangements for agency
locums which had resulted in a tender exercise being undertaken. Members NOTED that a positive response had been received from the
Directorates in relation to the process that had been put into place.
Members NOTED that monthly scrutiny committees were being held and
deep dives were being undertaken into high cost areas, with Accident & Emergency (A&E) being one area of focus.
Agenda item 1.4
‘Unconfirmed’ Minutes of meeting held 20 September 2018
Page 4 of 11 Finance , Performance & Workforce Committee Meeting
25 October 2018
Members NOTED that issues were being experienced with neighbouring
Health Board’s offering higher rates of pay to Locum Doctors which would require further discussion with WG. It was felt that the South Wales
Programme continued to impact on the Health Board compared to other areas, particularly within A&E and Obstetrics & Gynaecology. Members
NOTED that discussions were being held with All Wales Directors that clear intervention was required from Welsh Government regarding capping of
rates with a more joined up approach required. Members NOTED that a discussion would also be held with WG regarding Primary Care Locums who
were currently excluded from the rate cap on an All Wales basis.
Keiron Montague arrived at 2.00pm.
Paul Griffiths expressed his concern in relation to the issues being experienced on rate caps and advised that it would be helpful to have a
total agreement on this on an All Wales basis and questioned whether there
were any incentives in place to stick to the cap. Paul Griffiths also expressed concern in relation to the rates of pay being offered in some areas. Donna
Hill advised that the rate being charged was to the agency and not the employee.
Members NOTED that there was currently no national pay rate for Out of
Hours and the rate being offered to Middle Grade Specialty Doctors was low in Wales.
Members NOTED that the delays experienced in some areas regarding visa
applications had not been an issue for the Health Board, however, there had been some delays in overseas doctors undertaking English tests.
Marcus Longley expressed concern in relation to the Health Board requiring
twice as many hours of staff to cover compared to neighbouring Health
Boards. John Palmer advised that 30-50% of these hours were being used within A&E and advised that the whole A&E rota was being filled with
agency locum staff. Members NOTED that teams were working extremely hard to keep the department functioning efficiently.
Members NOTED the next steps that would now be taken, including
continued discussions with WG on rate caps, a discussion at the October Primary & Community Care Committee regarding Primary Care/Out of
Hours rate caps and the introduction of the new procurement system. Members NOTED that update reports would continue to be presented to
the Committee moving forward.
Members RESOLVED to: • RECOGNISE the complexity of the work being undertaken,
• NOTE the requirement for CTUHB to submit a quarterly report to
Welsh Government in respect of Agency Locum usage, and in
Agenda item 1.4
‘Unconfirmed’ Minutes of meeting held 20 September 2018
Page 5 of 11 Finance , Performance & Workforce Committee Meeting
25 October 2018
particular the requirement to achieve a 35% reduction in Agency
Locum spend over a 12 month period,
• Retrospectively APPROVE the Agency Locum/Additional Duty Hours report submitted to Welsh Government which set out the progress
made in Cwm Taf UHB (CTUHB) in Quarter 1 (Apr-Jun 2018), against the agency locum framework.
FPW/18/103
MONTH 5 FINANCE UPDATE
Steve Webster presented the report which had been refined further
following comments and advice received from Paul Griffiths on the report format and content. Members NOTED that there was now a section at the
front of the report which identified the key messages. Members AGREED that they found the revised format of the report very helpful and much
easier to understand what the key issues were.
Paul Griffiths extended his thanks for the ongoing refinement of the report
and advised that the report would need to be considered as a dynamic document and may need further changes. Steve Webster added that the
Finance Academy across Wales was also undertaking a review of financial reporting across Health Boards in Wales and offered to undertake a tutorial
session with any Members of the Committee, particularly new Independent Members, on finance. Marcus Longley suggested that this could be
discussed further at the next Board Development Session.
In presenting the report, the following key points were highlighted: • There was a forecasted breakeven position in month and year to
date, • There was an overspend against the delegated position of £1.6m,
mainly in relation to phasing and Month 5 being a 5 week month, and high spend against the medical and nursing agency position,
Members NOTED that consideration was being given to phased
budgets for 5 week months for next year, • The delegated overspend was being offset by slippage and the
overspend was largely recurrent, with some elements being non-recurrent, for example, reserves,
• The key area of concern was the recurrent position, and Members NOTED that there was currently a forecasted recurrent deficit of
£6.2m and that an urgent improvement was required in light of the number of changes that would be taking place next year regarding
Transformation and Bridgend, • There had been more slippage in some areas than anticipated,
including the number of retrospective Continuing Health Care (CHC) claims and review of payments in Powys,
• It was likely that funding would be received from Welsh Government for winter pressures, which would take the Health Board to a
forecasted position of £1m underspend. Members NOTED that the
Executive Team would be meeting to discuss priority areas of spend,
Agenda item 1.4
‘Unconfirmed’ Minutes of meeting held 20 September 2018
Page 6 of 11 Finance , Performance & Workforce Committee Meeting
25 October 2018
• Further work would need to be undertaken on savings plans to help
improve the recurrent position, for next year in particular,
• A review would need to be undertaken on the increase in spend in Personal Injury and Medical Negligence claims with 5 months of
higher costs being experienced. Members NOTED that a Scheme of Delegation was in place for reviewing claims and the Claims Scrutiny
Panel regularly undertakes a review of trends.
Paul Griffiths suggested that in light of the concerns raised in relation to the Medical Staffing expenditure and Claims expenditure, deep dive reports
were developed in these areas and presented back to a future Committee.
Members RESOLVED to: • NOTE the report and the update provided,
• REQUEST that deep dive reports were presented to a future Committee on Medical Staffing and Claims Expenditure.
FPW/18/104 PERFORMANCE DASHBOARD
Ruth Treharne presented the report which provided the Committee with a summary of current performance across a range of indicators and key
issues.
The following key points were NOTED:
Unscheduled Care • Performance against the 4 hour target for August was 87.7%.
Members NOTED that work was being undertaken to improve performance at Prince Charles Hospital (PCH) and an improved
performance was now being seen, • August performance against the 12 hour target was 201 patients
waiting, which was a significant increase compared to the same
period last year, • There had been no cancelled patients as a result of unavailability of
beds, • 91.8% performance was achieved against the 15 minute handover
target. John Palmer advised that performance in this area was very symbolic for the Health Board and any breaches of the target were
monitored, • The numbers of patients classified as Delayed Transfer of Care for
August remained stable at 28.
Referral to Treatment • Members NOTED that as of the 23 July 2018, the Health Board was
now aware of the full cohort of patients, • The final reported position on 36 week wait performance was 229
patients, with challenges in orthopaedics, general surgery and
urology, which would continue to be closely monitored,
Agenda item 1.4
‘Unconfirmed’ Minutes of meeting held 20 September 2018
Page 7 of 11 Finance , Performance & Workforce Committee Meeting
25 October 2018
• The confirmed final position for 26 week performance was 91.4% for
August.
Diagnostic Waits
• The final reported position for August was 211 patients waiting over 8 weeks for diagnostic and cardiology tests,
• Members NOTED that some operational issues had been experienced with MRI at PCH which may have an impact on the position and that
a discussion may need to be held with WG on bringing forward the capital bid for a replacement scanner into this year.
Follow Up Outpatients Not Booked (FUNB)
• Members NOTED that work continued to be undertaken by the operations team to address the position. The review undertaken
within ophthalmology identified that 80% of patients still needed a follow up appointment so the scale of the challenge could not be
underestimated. Members NOTED that the Executive Board had
agreed to fund additional resource to address the backlog issues.
Cancer Performance • The 31 day target was not achieved in July with a performance of
98% for July which equated to 3 breaches, which were all in lung services and were patients waiting for tertiary surgery,
• The 62 day target was also not achieved during July, with a performance of 83.8% and 13 breaches, 9 of which were in urology.
Members NOTED that a deep dive was being undertaken within urology which would be presented to a future meeting of the
Committee.
Stroke Performance • During July, there had been 65 patients with a confirmed stroke and
the thrombolysis rate was 10.8%. Members NOTED that the Delivery
Unit was undertaking a review of thrombolysis rates which would be completed by 9 October and Ruth Treharne advised that a deep dive
report on thrombolysis rates would be presented to a future meeting.
Mental Health Performance • Members NOTED that Part 1a and Part 1b were compliant overall
with a slight improvement in community treatment plan performance. Waiting list initiatives were being considered to
improve performance further.
Child and Adolescent Mental Health Service (CAMHS) Performance • Members NOTED that a detailed report on CAMHS performance
would be presented to the October meeting and a response was awaited from Welsh Government as to whether the Health Board’s
bid for waiting list initiative funding had been approved.
Agenda item 1.4
‘Unconfirmed’ Minutes of meeting held 20 September 2018
Page 8 of 11 Finance , Performance & Workforce Committee Meeting
25 October 2018
Paul Griffiths asked whether consideration could be given to changing the
format of the report so that key headlines were included at the start of the
report to help Members understand and focus their attention on the key issues.
Ruth Treharne AGREED to consider how best to capture this in future iterations of the report. Keiron Montague added that it was also quite
difficult to see some of the data contained within the main dashboard as the font was so small.
In response to the concern raised by Mel Jehu regarding Cwm Taf patients
waiting a significant amount of time for treatment at other Health Board’s, Ruth Treharne advised that performance within Cardiff & Vale UHB was
improving and commissioning mechanisms were regularly used to discuss performance issues with other Health Board’s.
In relation to FUNB, Marcus Longley questioned when there would be an
improvement in the position. John Palmer advised that it was difficult to
predict when an improvement would be seen and advised that with funding it could take between 12-18 months and more than two years without
funding. Members NOTED that further funding would be sought after the initial piece of work undertaken. John Palmer AGREED to provide Marcus
Longley with a trajectory of the predicted improvement.
In relation to CAMHS, Marcus Longley questioned why performance was poor when there was only one referral being made per day. Alan Lawrie
advised that the number of referrals this year had increased and that the position should improve marginally during October and November.
Following discussion, Members RESOLVED to:
• NOTE the report and the update provided, • NOTE that the report would be refined further to include an Executive
Summary at the start of the report.
FPW/18/105 WORKFORCE DASHBOARD
Jo Davies presented the report which provided an update on the key
workforce metrics for July and August 2018, with historic trends shown as appropriate. Members NOTED that the report was in a slightly different
format and would continue to be refined moving forward.
Members NOTED that there had been 4 areas of improvement and 3 areas where performance had deteriorated, which included sickness absence,
turnover rates and return to work compliance.
Members NOTED that turnover rates continued to be an area of concern, with particular concerns in relation to Nursing turnover. Members NOTED
that the main issue was the retirement of nursing staff. Members NOTED
that in all 3 categories, the number of not known reasons was quite high,
Agenda item 1.4
‘Unconfirmed’ Minutes of meeting held 20 September 2018
Page 9 of 11 Finance , Performance & Workforce Committee Meeting
25 October 2018
and some focussed work was being undertaken on this. It was NOTED
that there had been an improvement in recruitment activity.
Jo Davies provided Members with an update on the work being undertaken
on Employee Engagement activity. Members NOTED that the staff survey return had been disappointing at 29%, even though a significant amount
of work had been undertaken to try to improve the position. Jo Davies advised that at present it was not possible to tell if response rates were
higher within areas which were experiencing issues and advised that directorate specific reports would be developed once the final report was
issued in early October. Members NOTED that personal development reviews (PDR) compliance had improved to 75%. Members NOTED that
in relation to the staff survey, if more than 11 responses were received in one area, the Directorate would be identified. Jo Davies advised that the
process was anonymous.
Members NOTED that a Medical Engagement event was being held on the
17 October which would be attended by Dr Andrew Goodall and colleagues from Bridgend and that a Chief Executive “Buzz Event” for Senior Managers
would be taking place on the 24 September, in which Senior Managers from Bridgend had also been invited. Members NOTED that the Staff
Recognition Event was about to be launched for next year with a request made from a member of staff for a more regular process to be put into
place.
In relation to Sickness Absence, Members NOTED that the rolling average was reducing, however, there had been an in month increase. Members
NOTED that the position would continue to be monitored; and further work would be undertaken to improve return to work compliance.
Members NOTED that a review was being undertaken on the increase being
seen in the use of temporary staff, particularly Health Care Support
Workers which was a fully established area. Members NOTED that reasons for the increase included cover for vacancies, sickness absence and
increased supervision.
Dilys Jouvenat questioned the difference between available training slots compared to the actual number of training slots required. Jo Davies advised
that progress had been made in improving level 1 compliance and work was now being undertaken on improving compliance against levels 2 & 3.
Jo Davies added that a significant piece of work had been undertaken to identify the exact levels of training required for each member of staff.
Paul Griffiths questioned whether the Health Board were confident that staff
were content in their work, particularly in light of the increase in sickness absence, the reduction in PDR compliance and the increase in staff leaving
the organisation with no reasons being recorded as to why they have left.
Jo Davies advised that there were some positives to be considered including the improvement in sickness absence rates against the all Wales position,
Agenda item 1.4
‘Unconfirmed’ Minutes of meeting held 20 September 2018
Page 10 of 11 Finance , Performance & Workforce Committee Meeting
25 October 2018
staff were still joining the Health Board and the Health Board does
benchmark well against a number of areas.
John Palmer advised that a discussion could be held with staff side
colleagues on their opinions of how staff were feeling and advised that there may be areas where further work was required to improve staff
morale, particularly within areas which had intense environments. John Palmer added that the staff recognition event was very successful and
reflected the positive work being undertaken by staff within the organisation. Paul Griffiths questioned whether a benchmarking exercise
could be undertaken on staff morale against other Health Board areas.
Members NOTED that an Internal Audit Review was being undertaken on Retention of Staff which had been given a limited assurance rating.
Members NOTED that the review identified that further work was required in undertaking exit interviews. Jo Davies advised that she would be happy
to share the report with Committee members.
Members RESOLVED to:
• NOTE the update provided.
FPW/18/106 FINANCIAL DEEP DIVE INTO NON PAY – FOLLOW UP REPORT
Steve Webster presented the report which provided an update on non pay overspends following the report previously presented to the Committee in
June 2018.
Members NOTED that 20 areas had been identified and included in the report which had significant non pay overspends. Members NOTED that
there were a number of complexities that would need to be worked through, particularly within Medicines Management.
Members NOTED that the projected year end spend on Non Pay was broadly in line with budget, with the exception of expenditure against
claims.
In relation to drugs expenditure, further work would be required to clarify the governance around some of the changes to drugs to determine whether
the changes had been appropriately scrutinised and had been considered as value for money.
Members NOTED that the phasing of budgets could be considered in some
areas, but not all areas and Steve Webster advised that Facilities already had a phased budget in place.
Keiron Montague advised that there were a number of areas which had a
high percentage of recurring problems and that there were similar issues
being experienced across a number of areas.
Agenda item 1.4
‘Unconfirmed’ Minutes of meeting held 20 September 2018
Page 11 of 11 Finance , Performance & Workforce Committee Meeting
25 October 2018
Members NOTED that a deep dive would be undertaken into the increase in expenditure against Medical Negligence and Personal Injury Claims.
Ruth Treharne suggested that Committee Members might wish to consider whether the financial deep dive reports coming forward were the most
appropriate, particularly in light of the issues being identified in the Directorate Reviews being undertaken by Internal Audit.
Members RESOLVED to:
• NOTE the report and that further work would be undertaken to analyse the position,
• ADVISE the Board that the Committee were now assured of the position.
FPW/18/107 EFFICIENCY, PRODUCTIVITY & VALUE BOARD ACTION NOTES
Members RECEIVED and NOTED the action notes from the Efficiency, Productivity & Value Board meeting held on 2 July 2018.
FPW/18/108 FORWARD LOOK FOR 2018/19
Members RECEIVED and NOTED the Forward Look for 2018/19. Mel Jehu
AGREED to review outside of the meeting.
FPW/18/109 COMMITTEE REFERRALS
There were no Committee referrals made.
FPW/18/110 ANY OTHER BUSINESS
There was none.
FPW/18/095 DATE OF THE NEXT MEETING
The next meeting of the Finance, Performance & Workforce Committee was
scheduled to be held on Thursday 20 September 2018 at 1pm, in Ynysmeurig House, Navigation Park, Abercynon.
Signed ………………………………………………. Mel Jehu, Independent Member
Date …………………………………………………..
1.5 Action Log
1 1.5 Action Log FPW 25 October 2018 v2 GR.docx
AGENDA ITEM 1.5
Action log Page 1 of 3
Finance, Performance and Workforce Committee Meeting 25 October 2018
FINANCE, PERFORMANCE & WORKFORCE COMMITTEE ACTION LOG UPDATE FOR 25 OCTOBER 2018
MEETING
DATE
SUBJECT KEY ACTIONS/DECISIONS RESPONSIBLE
OFFICER
COMPLETED/
updated
26/05/16 & 27/04/17 &
28/9/2017 21/6/2018
Interventions Not Normally
Undertaken (INNU)
To receive an update on Interventions Not Normally Undertaken (INNU).
Progress report to be presented to a future meeting.
Director of Public Health
October 2018 On agenda
26/01/17&
25/5/2017& 30/11/2017
Follow up
outpatient appointments
not booked
Report on progress to reduce the numbers in
the top 9 areas to be received.
John Palmer Due October 2018
Now January 2019
Added to Forward Look
25/5/2017 Workforce
Dashboard
Proposal to be presented to the September
meeting on how alignment and triangulation between the Performance, Workforce and
Finance Dashboards could be developed further.
Ruth Treharne/
Jo Davies/ Mark Thomas
Deep dive approach
being undertaken within
the Medicine Directorate
prior to full roll out
Agreed to defer
item until further notice
30/11/2017
19/7/2018
Finance Update Further consideration to be given to the format
and style of the Finance report moving forward following review undertaken by Wales Audit
Office on best practice reporting.
Executive summary to be reviewed & strengthened to identify the key issues and the
work being undertaken to address the issues in order to bridge the financial deficits
Steve Webster/
Mark Thomas
Completed .
AGENDA ITEM 1.5
Action log Page 2 of 3
Finance, Performance and Workforce Committee Meeting 25 October 2018
MEETING DATE
SUBJECT KEY ACTIONS/DECISIONS RESPONSIBLE OFFICER
COMPLETED/ updated
30/11/2017
19/7/2018
Pathology
Financial Deep Dive
Consideration to be given to the development
of a Service Level Agreement (SLA) Schedule moving forward.
John Palmer Early 2019
24/05/2018 Workforce
Report
Trends in relation to turnover rates to be
included in future iterations of the report.
Joanna Davies Completed
24/05/2018 Performance
Dashboard
Report on Cancer breaches to be presented to
a future meeting.
Kamal Asaad October 2018 –
On agenda – linked to Urology
Performance report
A report (topic to be confirmed) on one of the projects the Health Board was working on to
improve performance. Committee members AGREED to receive a
Deep Dive report into Urology at a future meeting.
Ruth Treharne October 2018 On agenda
21/6/2018 Non Pay
Overspends
Further update report to be presented to the
Committee at the September meeting.
Steve Webster Completed
Update report to be presented to the September Finance, Performance & Workforce
Committee.
John Palmer Completed
21/6/2018 Demand &
Capacity
Ophthalmology
Progress report to be presented to a future
meeting of the Committee.
John Palmer Due November
2018 Added to forward look
21/6/2018 CAMHS
performance report
CAMHS performance report being presented to
October meeting to include an update on Primary Care CAMHS
Alan Lawrie October 2018
On agenda
AGENDA ITEM 1.5
Action log Page 3 of 3
Finance, Performance and Workforce Committee Meeting 25 October 2018
MEETING DATE
SUBJECT KEY ACTIONS/DECISIONS RESPONSIBLE OFFICER
COMPLETED/ updated
20/9/2018 Month 5 Finance
Update
Financial deep dive reports to be presented to
a future meeting on Medical Staffing and Claims Expenditure
Steve Webster To be confirmed
20/9/2018 Performance
Dashboard
Cover report to be refined so that key issues
and headlines are included at the front of the report
Ruth Treharne In progress
20/9/2018 Performance
Dashboard
Trajectory to be developed which shows
predicted improvement for FUNB
John Palmer In progress
2.1 To receive a quarterly update report on CAMHS Performance
1 2.1 CAMHS update FPW 25 Oct 18 GR.doc
Update on CAMHS performance Page 1 of 12 Finance, Performance & Workforce Committee
25 October 2018
AGENDA ITEM 2.1
25th October 2018
Finance, Performance & Workforce Committee Report
UPDATE ON CAMHS PERFORMANCE
Executive Lead: Director of Primary Care, Community and Mental Health
Author: Directorate Manager, CYP and CAMHS
Contact Details for further information: Craige Wilson, Assistant Director of
Primary Care, Community and Mental Health – [email protected]
Purpose of the Finance, Performance & Workforce Committee Report
The purpose of this report is to provide the Finance, Performance & Workforce
Committee with a summary of current performance across Children and Adolescent Mental Health Services (CAMHS).
Governance
Link to
Health Board
Strategic Objective(s)
The Board’s overarching role is to ensure its strategic
objectives, and the related organisational objectives outlined
within the 3 Year Integrated Medium Term Plan 2018-2021, are being progressed. Aligned with the ‘Quadruple Aim’
described within ‘A Healthier Wales’ (Welsh Government, June 2018) these objectives are:
• To improve quality, safety and patient experience • To protect and improve population health
• To ensure that the services provided are accessible and sustainable into the future
• To provide strong governance and assurance • To ensure good value based care and treatment for our
patients in line with the resources made available to the Health Board.
This report aims to support the objectives above.
Supporting evidence
Engagement – Who has been involved in this work?
The data and information contained within the dashboard originates from a
variety of sources which have a number of engagement processes associated with them. This performance information is discussed with commissioners
(Abertawe Bro Morgannwg and Cardiff and Vale University Health Boards) and internally through performance meetings and clinical business meetings.
Update on CAMHS performance Page 2 of 12 Finance, Performance & Workforce Committee
25 October 2018
Finance, Performance & Workforce Committee Resolution To:
APPROVE ENDORSE DISCUSS NOTE √
Recommendation The Finance, Performance & Workforce Committee is
asked to: • NOTE the content of this update report, the current
CAMHS performance and the actions being taken to improve this across Specialist CAMHS, Primary
CAMHS and Neurodevelopmental services (ND)
Summarise the Impact of the Finance, Performance & Workforce
Committee Report
Equality and
diversity
There are no directly related Equality and Diversity
implications as a result of this report.
Legal implications A number of indicators monitor progress in relation to legislation, such as the Mental Health Measure.
Population Health NA
Quality, Safety &
Patient Experience
The performance data included in this paper relate
directly to the quality, safety and patient experience for CAMHS
Resources This report makes reference to various resource requirements and the current status in terms of
progressing bids for these
Risks and Assurance Within the Integrated Performance Dashboard, actions are listed where performance is not compliant with
national or local targets.
Health and Care
Standards
The 22 Health & Care Standards for NHS Wales are
mapped into the 7 Quality Themes: Staying Healthy; Safe Care; Effective Care; Dignified
Care; Timely Care; Individual Care; Staff & Resources http://www.wales.nhs.uk/sitesplus/documents/1064/
24729_Health%20Standards%20Framework_2015_E
1.pdf The work reported in this summary and related
annexes take into account many of the related quality themes.
Workforce This paper identifies where there are additional workforce requirements within CAMHS
Freedom of
information status
Open
Update on CAMHS performance Page 3 of 12 Finance, Performance & Workforce Committee
25 October 2018
UPDATE ON CAMHS PERFORMANCE
1. SITUATION / PURPOSE OF REPORT
The purpose of this report is to provide the Finance, Performance & Workforce Committee with a summary of current performance across Children and
Adolescent Mental Health Services (CAMHS).
2. BACKGROUND / INTRODUCTION
Cwm Taf UHB manages the CAMHS services on a Network basis across Cwm
Taf, Abertawe Bro Morgannwg UHB (ABMU) and Cardiff & Vale UHB (C&VUHB). Within Cwm Taf, for performance monitoring purposes, this includes Primary
CAMHS (SCAMHS), Specialist CAMHS (SCAMHS) and Neurodevelopmental (ND) services. Within ABMU this includes PCAMHS and SCAMHS and within C&VUHB
this includes SCAMHS only. This paper provides an update on current performance within these areas.
3. ASSESSMENT / GOVERNANCE AND RISK ISSUES
3.1 Specialist CAMHS
As described above, SCAMHS services are managed by Cwm Taf UHB on behalf
of Cwm Taf, ABMU and C&V Health Boards. The target measures compliance against the percentage of patients on the waiting list waiting <28 days (target
= 80%). The reported waiting times for each UHB at the end of September 2018 are shown below:
Specialist CAMHS ABMU C&V CT Total
Total Waiting List 161 167 176 504
Waiting 0-3 weeks 104 80 62 246 Waiting 4+ Weeks 57 87 116 260
% <4 weeks 64.5% 47.9% 35.2% 48.8% Longest Waiter 11 12 16 16
This data clearly demonstrates that the 80% target is not currently being met in any of the areas, however the situation is improving and the position at 16
October 2018 is as follows:
• ABMU 72% (average wait 2.9 weeks)
• C&V 54.5% (average wait 4.3 weeks) • Cwm Taf 47.5% (average wait 5.2 weeks)
The improvement in the position is as a result of a number of factors, including
tight performance management and the delivery of waiting list initiative clinics, providing additional capacity to core services.
Update on CAMHS performance Page 4 of 12 Finance, Performance & Workforce Committee
25 October 2018
It is recognised that this ad-hoc provision of additional capacity does not
provide long term sustainability and following the introduction of Choice and Partnership Approach (CAPA) and the improved data availability that this has
supported, the service has now been able to undertake detailed demand and capacity analysis for each of the areas.
Discussions are now ongoing with commissioners regarding the resource needs
in ABMU and C&V; resources will be sought within Cwm Taf for the additional
staff required to deliver a balanced and sustainable service going forward (approximately 3 Whole Time Equivalent (WTE) staff). This is outlined in further
detail later in this section of the paper.
As the following graph demonstrates, the total patients waiting for SCAMHS across the Network has reduced significantly, from a total of 793 patients
waiting in October 2017 to 507 at the end of September 2018, a reduction of 36%. Similarly, the longest wait has reduced from 30 weeks to 16 weeks;
approximately a 50% reduction. It is disappointing that the position has deteriorated since May 2018, however with WLI clinics now running again in all
areas it is anticipated that this will begin to improve again. A daily performance tracker is now in place to monitor progress and fortnightly performance
meetings are held with the locality teams.
Choice and Partnership Approach (CAPA)-
As referenced above and as per previous updates, the CAPA model has been fully implemented in SCAMHS across all 3 localities (Cwm Taf, C&V and ABMU).
As has been demonstrated by the overall improvement in waiting times, this has supported improved performance including reduced waiting times and
reduced total caseloads. The CAPA approach has also provided greater clarity regarding demand and capacity for both new and follow up patients and
therefore provides enhanced knowledge to inform service planning.
Update on CAMHS performance Page 5 of 12 Finance, Performance & Workforce Committee
25 October 2018
As the following charts demonstrate, total caseloads have reduced significantly,
through a combination of the implementation of CAPA and a focus on discharge plus improved file audit.
Demand and Capacity Analysis
As referred to previously, detailed demand and capacity work has been
undertaken across all of the SCAMHS Network services and this has demonstrated a need for the following additional staff to provide a sustainable
service: ABMU 1.4 WTE
Bridgend 1 WTE
Neath 0 WTE Swansea 0.4 WTE
C&V 2 WTE
Cwm Taf 3.3 WTE
In light of the above, discussions have been held with commissioners from C&V
and ABMU Health Boards identifying the service need and requesting that any underspends in year be re-directed into additional capacity to off-set this. This
principle has been agreed by ABMU and as a result the Waiting List Initiative (WLI) have been running continuously in Swansea and since August in
Bridgend. Discussions will continue with ABMU through the monthly commissioning meetings, regarding the requirement for additional recurrent
funding for future years.
C&V are yet to approve the use of underspend against the Service Level
Agreement (SLA) for WLI, however given the ongoing capacity shortfall the decision has been taken to proceed and WLI activity has therefore re-
commenced during October. The service will repatriate back to C&V management from April 2019, and whilst the capacity gap has been highlighted
in discussions any decisions around future funding will be considered by the C&V UHB.
Update on CAMHS performance Page 6 of 12 Finance, Performance & Workforce Committee
25 October 2018
The Cwm Taf capacity gap was highlighted to Welsh Government (WG) in a
paper submitted in September 2018 with a request for the resources required to deliver the 80% target in year. This paper set out the scale of the capacity
gap, including the current backlog, and the resource request as follows.
The demand and capacity assumptions to achieve 80% target at year end are as estimated as follows:
Demand
Backlog 156 New demand 356 (6 months x 55.4 referrals)
Total 512
Capacity
Activity (at current rate) 181 RoTT (15%) 27
Total 208
Gap Demand-capacity 304
Proposal Additional new capacity
Additional staff (1 x B7 + 2 x B6 for 6 months) 78 WLI (8.6 per week for 26 weeks) 186*
RoTT (15%) 40 Total 304
*It must be highlighted that these patients will also require follow up and so for 70% of every new patient seen, provision for 7 follow up appointments in WLI
must also be made. The total clinics required is therefore 490 which is equivalent to 18.8 WLI clinics per week for 26 weeks (calculated on the basis of
3 hours per new appointment, 1 hour per follow up appointment, 3 hours clinical time per WLI session to allow the remainder for admin).
The risks in terms of delivery of the above are as follows
• It may not be possible to recruit additional staff, either through NHS recruitment or agency
• There are currently small numbers of staff willing to deliver WLI, therefore it will require a significant increase to deliver this volume of
activity plus the associated follow up work to ensure that core service is not impacted
• There would need to be a plan to manage the cohort of follow up
patients, that would be generated by this work going into 2019/20 • Clinic space would need to be identified to accommodate all of the
additional staff/ clinics.
Update on CAMHS performance Page 7 of 12 Finance, Performance & Workforce Committee
25 October 2018
Cost
Proposal Cost per staff/ clinic Total cost 2018/19
1 x B7 £32,780 per staff (assume agency) 32,790
2 x B6 £28,590 per staff (assume agency) 57,180
490 WLI
clinics
£540 per session average (assume 50%
medics, 50% B7)
£264,600
Total £353,570
A further discussion with Welsh Government (WG) officers on 15 October, to discuss this proposal, was positive however similar information for C&V and
ABMU was requested by WG before a final response is given; this will be provided by 19 October.
This was an extremely ambitious proposal and a month has passed since the
proposal was submitted, therefore the time to deliver is further reduced. In the meantime, WLI clinics have commenced in order to provide some additional
capacity, however uptake is more limited than had been hoped and so this is not delivering at the rate required.
The delivery of WLI activity is dependent on the availability of staff to deliver
additional sessions. Unfortunately many have opted not to participate in this,
particularly since this is the third consecutive year when this has been requested and staff are expressing fatigue from ongoing requirements above
their contracted time. Without the recurrent investment in additional staff as per the above proposal, and the ability to recruit the staff required, the WLI is
anticipated to provide a limited improvement in the position; achieving the 80% target by year end will prove challenging.
It is however anticipated that ABMU will meet the 80% target by the end of
October or November, the challenge will be maintaining this position. Retention of staff across the Network is problematic and any loss of the staff in the period
prior to end of March could adversely impact on the position.
Detailed WLI plans are now being developed for C&V in light of the potential of additional funding from WG and there is a commitment from staff to undertake
WLI at least until Christmas. This should result in the C&V position improving to
around 70% by the end of December but maintaining this position and any further improved in the position will again be dependent on the commitment of
staff to undertake WLIs in the 2019.
3.2 Primary CAMHS
Primary CAMHS has two targets relating to waiting times, the first measures the proportion of new patients seen each month that receive their initial
assessment within 28 days of referral. The second measures the proportion of patients that commence an intervention that start this within 28 days of their
assessment. The target for both measures is 80% compliance.
Update on CAMHS performance Page 8 of 12 Finance, Performance & Workforce Committee
25 October 2018
The September position was as follows:
Health Board % assessment within
28 days
% intervention within
28 days
ABMU 21% 92%
Cwm Taf 15% 100%
The above demonstrates that the services are not currently providing patients
with their initial assessment within 28 days of referral, however once patients do enter the service they receive their intervention quickly and within the target
timeframe.
This is seen as a key quality and safety indicator within the service and is significantly ahead of some other HB areas in Wales, where the focus appears
to be very much on the new patient waiting times. It should be noted that due to the way that this target is measured e.g. the proportion of patients that are
seen rather than a measure of the total waiting list, until the total waiting list is
below 28 days then compliance will remain low; assuming patients are being booked in turn.
The waiting lists over time for each area, in terms of total waiting and total
waiting >28 days are as follows:
Cwm Taf
As the above demonstrates, there has overall been a significant reduction in the
total number of patients waiting for a primary CAMHS assessment and the longest wait since a peak was identified in 2017.
Update on CAMHS performance Page 9 of 12 Finance, Performance & Workforce Committee
25 October 2018
This improvement was achieved through a combination of validation, improved
booking processes and investment in WLI. It is disappointing that the position has since deteriorated, largely due to the team stopping WLI clinics, the cohort
of follow up patients built up from the WLI, and sickness within the team (noting that there are just 4 members of staff in the team).
A bid for additional staff has been included in the recent bids for
transformation/ Psychological Therapies and WG have responded to say that
they are willing to review requirements for in year funding but will make a decision on recurrent funding following the Delivery Unit review which is
planned for December, as part of an all-Wales PCAMHS review.
PCAMHS was included in the paper referenced above that was sent to WG in September 2018. This again provided a summary of the current position, a
proposal to meet the target in year, the risks associated and the cost.
The demand and capacity assumptions to achieve 80% target at year end are as follows:
Demand
Backlog 168 New demand 216 (6 months x 36 referrals)
Total 384
Capacity Activity (at current rate) 126
RoTT (15%) 19
Total 145
Gap Demand-capacity 239
Proposals for additional capacity-
2 x additional B6 staff members (6 months) 120
WLI (4.5 per week for 26 weeks) 88* RoTT 31
Total 239
*It must be noted that these patients will also require follow up and so for every new patient seen, provision for 3 follow up appointments in WLI must
also be made. The total clinics required is therefore 147 which is equivalent to 5.6 WLI clinics per week for 26 weeks (calculated on the basis of 2 hours per
new appointment, 1 hour per follow up appointment, 3 hours clinical time per WLI session to allow the remainder for admin).
Update on CAMHS performance Page 10 of 12 Finance, Performance & Workforce Committee
25 October 2018
The risks in terms of delivery of the above are as follows
• It may not be possible to recruit additional staff, either through NHS recruitment or agency
• The current staff are reluctant to undertake WLI, the additional WLI activity would therefore potentially be dependent on encouraging them to
re-start this or on the new staff once recruited • There would need to be a plan to manage the cohort of follow up patients
that would be generated by this work going into 2019/20
• Clinic space would need to be identified to accommodate all of the additional staff/ clinics
Cost
Proposal Cost Total cost 2018/19
2 x B6 staff (assume
agency)
£28,590 per staff £57,180
197 WLI clinics £307.5 £45,203
Total £102,383
Again, it must be noted that the risk, in terms of delivery, is significant. Given
that this was an extremely ambitious proposal when submitted and a month has since passed therefore the time to deliver is further reduced. In the
meantime, WLI clinics have commenced in order to provide some additional capacity, however uptake is very limited due to the small number of staff in the
team and fatigue with the ongoing requirement for this. The service is also seeking to recruit additional staff on a fixed term basis until the WG funding is
approved recurrently however this is expected to be challenging due to the
shortage of CAMHS staff that are available. Requests for agency staff through on contract agencies, have not identified any suitable candidates and the
Directorate has not yet received approval to recruit staff from off contract agencies. Additional staff will be essential in order for the position to begin to
improve again.
Update on CAMHS performance Page 11 of 12 Finance, Performance & Workforce Committee
25 October 2018
ABMU PCAMHS
As the above chart demonstrates, there has been a significant improvement in
terms of total patients waiting and longest wait within ABMU. This has been achieved largely as a result of the ICF investment within ABMU for 3 additional
PCAMHS staff, working in liaison with Local Authorities and also providing additional clinical capacity. These posts are ICF funded and so cannot be
guaranteed recurrently, however the benefits of these posts are clear from the data above. Going forward it will be important to monitor the impact that
enhanced liaison work has in terms of referral rates. It can be observed in the above chart that there was a deterioration in the position from April to July
2018 and this was due to sickness and vacancies within the team but now that these have been filled, the position is again improving. Should this continue it
would be anticipated that the target could be achieved by year end.
3.3 Neurodevelopment service
The target for Neurodevelopment (ND) services is for 80% of patients waiting for ASD and ADHD assessment to commence this within 26 weeks. The
following is the reported position at the end of September.
Neurodevelopmental CT
Total Waiting List 435 Waiting 0-11 weeks 105
Waiting 12-17 weeks 70 Waiting 18-25 weeks 80
Waiting 26-35 weeks 130 Waiting 36-51 weeks 50
Waiting 52+ weeks 0 % <26 weeks 58.6%
Update on CAMHS performance Page 12 of 12 Finance, Performance & Workforce Committee
25 October 2018
The ND service has been under significant pressure since it was established and
this continues, as a result the service is not currently meeting the 80% target for all patients to begin assessment within 26 weeks of referral. In recognition
of this, WLI activity has been reintroduced in order to support an improvement in the position, although uptake has been relatively limited. In addition to this,
the Community Paediatric service is currently seeking approval to replace vacant Consultant sessions plus a retiring staff member with 2 new posts, both
of which would include additional sessions for ND in order to support this
position.
When the ND service was established the resources allocated were significantly lower than had been requested and it was therefore agreed that the service
should be implemented in 2 phases, with the initial phase to establish the service and the second phase to expand this to meet the demand. Submissions
have been made via the Integrated Medium Term Plan (IMTP) for the resources required to implement phase 2 however this has not yet been approved. The
requirement for this investment is supported by a demand and capacity analysis of the service which demonstrates a capacity gap for 115 new patients
per year plus the associated follow up work, requiring 2 additional clinical staff immediately to sustain the service. This resource will be sought via the IMTP
process for 2019/22.
As with other CAMHS services, uptake of the current WLI has been relatively
low, however this additional capacity is anticipated to prevent the position from deteriorating further and may support a small improvement in the position.
Again, however, recurrent investment in additional staff is required in order to deliver and sustain performance against the waiting list target for ND.
4. RECOMMENDATION
The Finance, Performance & Workforce Committee is asked to:
• NOTE the content of this update report, the current CAMHS performance and the actions being taken to improve this across Specialist CAMHS,
Primary CAMHS and Neurodevelopmental services (ND).
Freedom of
information status
Open
2.2 To receive an updte report on the Deep Dive undertaken in Facilities
1 2.2 Update Report on Facilities Deep Dive - FPW 25 Oct 2018 V2 GR.doc
Facilities Performance Update Page 1 of 20 Finance, Performance and Workforce Committee
25 October 2018
AGENDA ITEM 2.2
25 October 2018
Finance, Performance and Workforce Committee Report
UPDATE REPORT ON FACILITIES DEEP DIVE
Executive Lead: Chief Operating Officer
Author: Assistant Director of Facilities
Contact Details for further information: Russell Hoare 01685 728688
or email [email protected]
Purpose of the Finance, Performance and Workforce Committee
Report
The purpose of the report is to provide the Finance, Performance and
Workforce Committee with an update on the deep dive carried out by the Facilities team into its performance.
Governance
Link to Health
Board Strategic Objective(s)
The Board’s overarching role is to ensure its strategic
objectives, and the related organisational objectives outlined within the 3 Year Integrated Medium Term
Plan 2018-2021, are being progressed. Aligned with the ‘Quadruple Aim’ described within ‘A Healthier
Wales’ (Welsh Government, June 2018) these objectives are:
• To improve quality, safety and patient experience. • To protect and improve population health.
• To ensure that the services provided are accessible and sustainable into the future.
• To provide strong governance and assurance. • To ensure good value based care and treatment for
our patients in line with the resources made
available to the Health Board. This report focuses on all of the above objectives.
Supporting evidence
See appendices
Engagement – Who has been involved in this work?
The operational team and directorate has worked together with their
Finance, Procurement and WF&OD Business Partners to undertake the deep dive into Facilities performance and address any issues identified and
to develop the actions in this paper.
Facilities Performance Update Page 2 of 20 Finance, Performance and Workforce Committee
25 October 2018
Finance, Performance and Workforce Committee Resolution to:
APPROVE ENDORSE DISCUSS √ NOTE √
Recommendation The Finance, Performance and Workforce Committee is asked to:
• DISCUSS and NOTE the content of the report.
Summarise the Impact of the Finance, Performance and Workforce
Committee Report
Equality and diversity
No implications have been highlighted from an equality and diversity perspective
Legal implications No known legal implications
Population Health There are no known population health implications
Quality, Safety &
Patient Experience
The performance of the Facilities Unit can impact on
the patient experience if quality and safety of services is not maintained. Facilities governance and
compliance arrangements are monitored through multidisciplinary groups:
• Housekeeping • Catering and Nutrition
• Environmental Management –ISO 1`4001:15 • Security and Violence and Aggression
Management
• Facilities Integrated Programme IMTP/CRES Board • Facilities Operational, Governance and
Performance Board • Medical Equipment and Devices
• Bridgend Facilities Transition Board
Resources There are no further resource issues than those
identified within the plan
Risks and Assurance Risks and Assurances are captured within Governance score cards and reported through to the
Corporate Risk Committee
Health and Care
Standards
The Board has a duty to ensure that the Standards
for Health Services in Wales are being embedded across services and this report relates to the
following standards: 2.1 - Environment, Risk, Safety and Security
▪ ISO 14001:15 – Standard 2015
▪ Corporate Health Standard ‘Platinum’ level 2.4 - Infection Prevention and Control (IPC) and
Decontamination - Laundry – EN 14065 2.5 - Nutrition and Hydration
2.9 - Medical devices, Equipment and Diagnostic Systems - ISO 9001;15 Quality Standard
Workforce There are no further resource issues than those identified within the plan
Freedom of
information status
Open
Facilities Performance Update Page 3 of 20 Finance, Performance and Workforce Committee
25 October 2018
UPDATE ON FACILITIES PERFORMANCE DEEP DIVE
1. SITUATION / PURPOSE OF REPORT
The purpose of the report is to provide the Finance, Performance and Workforce Committee with an update on the deep dive carried out by the Facilities team
into its performance.
The report has concentrated on the following key metrics: • Workforce
• Finance
• Cash Releasing Efficiency Scheme (CRES) • Quality, Risk and Standards
The report presents the financial year 2018-19 Month 5 position for the
Directorate and also provides key performance data for this calendar year with regard to CRES, workforce transactional management, quality and standards.
To frame the deep dive report comparisons have been made to performance
against the same period FY 2017-18 and also includes the latest benchmarking data from the EFPMS FY16-17 data report and Facilities CRES performance over
the last 5 years.
2. BACKGROUND / INTRODUCTION
The Facilities Directorate consists of 8 key service departments:
• Catering and Central Production Unit (CPU),
• Housekeeping, • Porter Services, Security and Car Parking,
• General Offices, Residences and Switchboard,
• Environmental, Waste and Grounds and Gardens, • Fleet Transport & Non-Emergency Patient Transport (NEPT),
• Laundry Processing Unit, • Clinical Engineering,
The Senior management team comprises of:
• 1 x Assistant Director of Facilities (ADF),
• 1 x Head of Facilities (vacant), • 4 x senior site and service managers,
• 1 x Facilities business manager, • 1 x Governance and compliance manager
Total Facilities Staff Establishment:
WTE = 754.17 Heads = 940
Facilities Performance Update Page 4 of 20 Finance, Performance and Workforce Committee
25 October 2018
3. ASSESSMENT / GOVERNANCE AND RISK ISSUES
3.1 WORKFORCE TRANSACTIONAL PERFORMANCE
Facilities Key Performance Indicators (KPI’s)
Workforce KPIs
Previous %
(August 17)
Month Actual %
(August 18) Run Rate
PDR % (85%) 68.89% 85.18% ↑
Sickness % (4.5%) 8.05% 6.26% ↓
LTS % 6.71% 5.26% ↓ STS% 1.34% 1.01% ↓
Core Skills % 46.9% 73.1% ↑
Datix/ Incidents 11 10 ↓
Personal Injury claims 2 2 ↔
Investigations 2 4 ↑
Grievances 1 4 ↑
Capability/Competency 0 0 ↔
Disciplinary pending 2 3 ↑
Disciplinary dismissals 0 1 ↑
Suspensions 1 0 ↓
Sickness Absence
A review of the proportion of sickness each year classified as Short term Sickness (STS) and Long Term Sickness (LTS) illustrates that the proportion
classified as LTS is growing year on year. This information is provided in the table below:
Time Period LTS STS
2015/2016 71.77% 28.23%
2016/2017 78.55% 21.45%
2017/2018 80.53% 19.47%
This suggests that appropriate sickness management processes are in place to manage sickness as a higher proportion of sickness each year is made up of
more serious sickness cases.
The LTS percentage and STS percentage over a rolling 12 months from August 2017 to August 2018 is included in table 1 below:
Facilities Performance Update Page 5 of 20 Finance, Performance and Workforce Committee
25 October 2018
Table 1 - LTS percentage and STS percentage over a rolling 12 months from
August 2017 to August 2018
STS Deep Dive
The Directorate has completed two deep dive analysis exercises in recent months to better understand sickness trends and patterns and to ensure
sickness management is effective.
Workforce business partners were involved in the deep dive analysis and continue to work with managers to ensure the correct management of sickness.
The Sickness deep dive reports are included at Appendix 1 for information.
Performance Development Review (PDR)
The current PDR compliance rate is now 85.18% as at 1 September 2018.
The average compliance rate over a rolling 12 months from August 2017 to
August 2018 is included in table 2 below:
Facilities Performance Update Page 6 of 20 Finance, Performance and Workforce Committee
25 October 2018
Table 2 – Average PDR Compliance Rate August 2017-August 2018
A plan has been prepared for the directorate that identifies the number of staff
who require a PDR and the month that staff with a current PDR will require a review. This plan can be used my managers to:
• Ensure all reviews are completed so that overall compliance does not drop,
• Schedule staff requiring a PDR to improve overall compliance rates, • Target service areas that are currently rated red for compliance
Core Skills Training
The current core skills compliance rate has continued to improve each month
and it is 73.1% as at 1st September 2018.
A training plan has been developed to ensure that all staff within Facilities have the training they require, this training is delivered in various formats including
classroom style training days, E-Learning, small presentations and information leaflets. The average compliance rate over a rolling 12 months from August
2017 to August 2018 is included in the table below:
Facilities Performance Update Page 7 of 20 Finance, Performance and Workforce Committee
25 October 2018
Table 3 – Average Core Skills Training Compliance August 2017-August 2018
40.0
50.0
60.0
70.0
80.0
Directorate % for all level 1 CSTF Competencies
Investigations/Disciplinary/Suspensions
• 6 Investigations ongoing.
Grievance
• 3 grievances ongoing relating to the changes to services in line with CRES scheme.
3.2 FINANCIAL PERFORMANCE ASSESSMENT
Whole Time Equivalent (WTE) Run Rate
The WTE run rate highlights the impact of the implementation of the FY
2017/18 CRES schemes and also the turbulence associated with the current porter services scheme in FY 17/18, the mitigation carried out to help reduce
Facilities Performance Update Page 8 of 20 Finance, Performance and Workforce Committee
25 October 2018
this and a high level of vacancies being processed in the first quarter of FY
2018/19. Some monthly variability also occurs due to the number of weeks overtime paid in individual months, for example months 3 and 4 in 2018/19
had four weeks of overtime payments, whereas months 2 and 5 had five weeks
of overtime payments.
Budget The month 5 position for Facilities is a cumulative variance (adverse) against
budget of £0.393m. This is forecast to be £0.918m at month 12 with a recurrent position of £0.818m which is detailed in the table below.
Description
Annual
Budget
Month 5 Forecast Variance
Budget Actual Variance 2018/19 Recurren
t
£000's £000's £000's £000's £000's £000's
Pay 16,963 7,126 7,177 50 218 276
Non-pay 7,147 2,798 2,762 (36) 12 -
CRES (871) (366) - 366 674 542
Income and
Trading 1,746 737 750 13 14 -
Grand Total 24,985 10,295 10,688 393 918 818
The main items which make up the over spend are shown in the following table and are explained further below.
Description
Month 5
Variance
Outturn
2017/18
Forecast Variance
2018/19 Recurrent
£000's £000's £000's £000's
Porter services 56 365 276 276
Housekeeping PCH 35 0 49 0
CPU (21) 75 (21) 0
Laundry 47 4 47 0
Undelivered CRES 366 609 674 542
Porter Services In order for savings to be realised, the revised appropriate manning rota needs
to be implemented. Following the staff engagement and consultation phases, staff supported by their trade union representatives have raised a grievance
against the revised rota. We are now in the process of hearing the grievance and we are awaiting the outcome report. To reduce the overtime spend on the
existing rota 6 WTE fixed term staff are now being recruited whilst workforce Organisational Change (OCP) and Grievance policy processes are being taken
forward. Further detail on this CRES scheme is provided in the report and at Appendix 5.
Housekeeping – PCH.
There are ongoing levels of long term sickness which is in excess of the
operational flexible ability to redeploy staff to cover this issue. Therefore,
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25 October 2018
additional hours (not at overtime rates) are being allocated to cover this. Some
additional temporary staff are being employed to ensure that premium overtime is not necessary, whilst the sickness issues are addressed.
CPU As reported at the April FP&W committee, in 2017/18 there were significant
increases in the cost of provisions and consumables which manifested in a £75,000 adverse position for the CPU. Considerable work was undertaken with
procurement business partners to reduce costs by sourcing alternative providers and to alter menu provision which has resulted in the improvement of
the CPU financial position that is currently showing a £21,000 underspend. This area continues to be a risk due to increases in provisions costs and will continue
to be closely monitored.
Laundry The laundry has experienced lower income levels due to lower customer activity
levels at ABMU sites. ABMU has advised that general activity levels at Princess of Wales (POW) have been lower to August and also the hot weather has had a
negative effect on demand for additional layers. ABMU advised that this is likely to return to historical levels from September. There has at the same time been
a period of high levels of sickness and it was necessary to work overtime to
cover this and which has now reduced.
CRES Savings Plan Progress
The 2018/19 CRES target is £1.177m (4.5%) and the current CRES forecast
delivery totals, as at month 5, are: • 2018/19 – in year £0.503m: full year £0.635m
• 2019/20 – in year £0.421m: full year £0.773m
The in-year CRES forecast has gradually increased during the year which is illustrated in the following chart and the Facilities team continue to seek savings
opportunities not on plan the aim being to reduce the gap.
Since the financial year
2013/14, the Facilities Directorate has always taken on a challenge and has delivered a combination of service transactional and transforming recurrent
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25 October 2018
savings totalling £4.314m. The detail of the annual delivery can be seen in
Appendix 2 and is summarised in the following graph.
In March 2016, the facilities team commissioned an external consultancy, to conduct a benchmarking review of the Cwm Taf Facilities costs against UK
benchmarks both public and private sector. The report analysed each of the service areas against a number of known NHS and industry standard key
performance indicators. The report assessed twelve areas of operational delivery namely:
• Administration, General Office & Helpdesk, • Facilities Operational Management,
• Security, • Linen,
• Catering - Patient Feeding, • Catering – Restaurant/Barista,
• Catering - Central Production Unit (CPU),
• Housekeeping, • Porter Services,
• Grounds & Gardens, • Waste,
• Transport.
The report identified the following areas of opportunity for further work and in support of Integrated Medium Term Plan (IMTP) potential savings financial year
2017-18: • Facilities Operational Management,
• Security, • Catering - Patient Feeding,
• Catering – Restaurant/Barista, • Catering - Central Production Unit (CPU),
• Housekeeping,
• Porter services,
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25 October 2018
• Grounds & Gardens,
• Transport.
Facilities has taken forward and delivered on the following schemes associated
with this report in financial year 2017-18: • Facilities Operational Management,
• Security services redesign, • Catering - Patient Feeding redesign,
• Housekeeping services redesigns.
The following table shows the status and forecast of the current CRES schemes:
Code Status In year Recurrent In year Recurrent
£000's £000's £000's £000's
Fac 01 CPU outsourcing Appraisal On-going 100 250
Fac 03 Non pay suppliers products volume and price Near completion 120 150
Fac 03a Non pay - VAT Delivered 150 150
Fac 04
Grounds and Gardens Service - Outsourcing
Appraisal On-going 60 150
Fac 05
Restaurants - new service model (capital
investment required) On-going 48 80
Fac 06 YGT Valley Life Service Redesign Phase 1 Delivered 54 54
Fac 06a YGT Valley Life Service Redesign Phase 2 Delivered 26 39
Fac 06b YGT Valley Life Service Redesign Non pay Delivered 38 50
Fac 07
Dewi Sant Health Park Barista (capital
investment required) On-going 5 8
Fac 08 Internal Transport Community/Pathology review On-going 6 58
Fac 10 Unscheduled Transport Spot Purchasing On-going 18 30
Fac 11 CPU Bonus On-going 81 90
Fac 12 General office rationalisation On-going 15 60
Fac 13
NHS Wales Laundry production unit service
review - Memorandum item 2020/21 delivery
Fac 14 Porter services On-going 113 135
Fac 15 Switchboard (New staff rota - centralisation) Near completion 53 100
Fac 16 Salary sacrifice personal lease cars Delivered 5 -
Fac 17
Laundry chemical container deposit
reimbursement (prior years) Delivered 30 -
Fac 18 Electricity Maximum Capacity Delivered 4 4
503 635 421 773
2019/202018/19
Forecast
Scheme Title
Facilities Bench Marking The results of the most recent annual benchmarking exercise that compares the
services provided by the Facilities Directorate at an all Wales level are detailed in Appendix 3. This illustrates that the Directorate are either near the all
Wales averages or are making progress towards those benchmarks.
CRES Project Management Arrangements
The CRES schemes involve a more innovative period of transformational change which requires careful balancing of strategic development and operational
delivery.
The redesign of some key services is at the centre of this planning period and the directorate acknowledge not only the importance of the leadership skills of
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25 October 2018
its management teams but also the support of our workforce and stakeholders
in making our strategic plans become an operational reality.
In order to deliver such a challenging transformational change programme
robust project management arrangements are in place.
3.3 QUALITY, RISK & STANDARDS PERFORMANCE ASSESSMENT
Quality KPIs
Service and Target
Actual %
(Quarter 2
17/18)
Actual %
(Quarter 2
18/19) Run Rate
Patient catering
satisfaction (90%) 95% 97% ↑
Restaurant
satisfaction (85%) 71% 68% ↓
Barista satisfaction
(85%) 88% 86% ↓
Cleanliness
satisfaction (85%) 93% 94% ↑
Patient Porter
Services satisfaction KPI’s In development as part of service redesign
Health and Care Standards KPIs
Health and Care
Standards KPI
Previous
Month Actual
% (Aug 17)
Month
Actual %
(Aug 18) Run Rate
EHO (9x5 = 45Pts) 44 44 ↔
CPU STS 100% 100% ↔
National Standards of Cleanliness
High Risk Areas
(95%) 96 95 ↓
Significant Risk Areas
(85%) 90 91 ↑
Low Risk Areas (75%) 91 78 ↓
ISO 14001:15 –All HB
Sites 100% 100% ↔
Clinical Engineering
ISO 9001:15 quality
standard external BSI
audit 100% 100% ↔
Waste Management Waste Performance Report (Appendix 4) Laundry
Decontamination BS
EN 14065
In development
Porter Services KPIs In development as part of service redesign
Facilities Governance and Compliance
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25 October 2018
Governance arrangements
• The directorate has an organisational chart in place that was included in the IMTP.
• There is a communication plan and a clear line of communication from
CBM to the Facilities Operations and Governance Group. • There is a Team operational exception report for each service area which
is presented by the Service Leads at the Operational Group meeting. The report includes Workforce KPI scores, Service Quality KPI's, establishment
figures, and updates and actions from previous meetings. • Governance issues such as compliance scorecards, health and safety,
policies and documents for review were discussed in all multi-disciplinary service groups.
• The Governance and Compliance Manager maintains a register of legal compliance for the Environmental Management System and will cross
reference this to the aspects and impacts register. New legislation that is relevant to the department is recorded and shared with the relevant
staff. • The directorate subscribes to the Environmental Legislations Update
Service and Coroner Facilities Management and the Governance and Compliance Manager routinely checks the Health & Safety Executive
(HSE) Website.
• The directorate has compliance scorecards in most service areas and evidence is provided annually to ensure compliance with all legislative
and regulatory requirements. The scorecards are managed by the Governance and Compliance manager who also holds regular meetings
with service managers to update the scorecards. • Legislative requirements for each service within the directorate have been
outlined in the IMTP. This is how the Service Leads are made aware of their responsibilities.
• The Governance and Compliance Manager checks that relevant legislation has been referenced in new and updated policies.
• The directorate has a good working relationship with its business partners and
• Facilities has recently been the subject of an internal audit by the NHS Wales Shared Services Partnership’s (NWSSP’s) audit and assurance
services. The audit was in two parts; (1) Compliance and (2)
Management Arrangements – Porter Services. We have met with the auditors and the report has been finalised. Facilities have provided a
response to the report’s recommendations and are carrying out the actions required and both reports will now be submitted to the audit
committee.
Planning The IMTP was developed in line with the timetable as set out in the framework
and covered all the key areas / priorities that were identified in the current local planning framework.
The relevant staff attended the formal IMTP engagement session held in October 2017 and the directorate was proactive in seeking views of
stakeholders and utilising the support of the business partners. Recognition was
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25 October 2018
given to the directorate for this approach in their IMTP feedback. There is a
policy and procedures plan in place that links to the compliance scorecards to monitor policy reviews. There is a Facilities work plan in place that captures
IMTP, CRES, strategic and service operational programmes of work. A copy of
the current plan is detailed at Appendix 6.
Risk Management The Facilities management have been reviewing its risk management process.
The following progress has been made to improve the risk management arrangements within the Facilities Department:
• The Facilities Risk Register has been reviewed and updated and as a result 9 risks that were found to have been mitigated have been
removed, • Each risk has now being reviewed and scored based on four essential
Facilities elements; Financial, Health & Safety, Business Service Delivery & Continuity and Statutory & Mandatory Compliance,
• The Facilities Risk Register has now been added as a formal agenda item in the Facilities Operational and Governance Group to ensure proactive
monitoring of the risks is being undertaken, • Work has commenced, in collaboration with the Datix risk team, to
improve the risk reporting format for the department, including the
development of KPIs, analysis of risks against claims, scrutiny of risk assessments and reducing the amount of risks not being closed.
Risk Register
There are currently 3 high risks, 20 moderate risks and 12 low risks on the risk register that are being managed.
Service Standards & Quality
Cleanliness
The health board is currently achieving the required standard for a clean environment in accordance with the national standards for cleaning in NHS
Wales.
Catering – EHO
The health board is currently achieving compliance with catering environmental health and food safety standard. 8 x very good (5 star rating) and 1 x good (4
star rating) assessment score.
Patient Quality Satisfaction and Experience feedback provided by the Facilities App survey is positive and encouraging.
Central Production Unit (CPU) Green and Kasab Facilities management consultants are currently carrying out
a deep dive review of the Catering Central Production Unit (CPU). This follows
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25 October 2018
earlier internal work carried out by the Facilities team and a CBM report which
made preliminary reference to potential savings at the CPU. The deep dive is now necessary to establish what opportunities exist to improve efficiency,
productivity and best value for the health board. In addition to take into
consideration the pending Bridgend Boundary Change and the fact that patient meals at the Bridgend sites are provided by a recognised commercial ready
meal supplier and not ABMU CPU.
The output required of this review is a fully-developed optimal service model for the CPU, which can be considered for adoption by the Health Board, it will
include: • An analysis of the options for the CPU business including the potential to
outsource the service to a third party inpatient meal provider. All meals provided by a third party provider would need to be fully compliant with
the requirements of the All Wales • An assessment of the Estate condition, compliance with the All Wales
nutrition and catering standards for food and fluid for hospital inpatients, environmental health food safety, and STS food processors and suppliers
to the public sector standards and code of practice. • The options appraisal would also need to consider the impact of the
expansion of the Health Board to include Bridgend and the inclusion of
further hospitals and its catering requirements to see whether this provides the existing CPU with a critical mass.
• The deep dive work is being supported by business partners and the Facilities Catering and CPU Management team. An option appraisal
report is scheduled for completion next month and first draft will be provided for CBM in December 2018.
Porter Service Redesign and Modernisation
Since 2016 the Porter Services have been the subject of an in depth service redesign implementation. In the last 5 years the facilities team has taken
forward a number of challenging service redesign and CRES schemes involving large groups of staff, however this one has been the most complex and
challenging change project for management, staff and business partners to date.
This change project is being implemented based on a number of factors not least of which is bringing considerable savings for CTUHB along with service
and working practice modernisation for the benefits stakeholders and our patients. This work also involves improvements in porter career development,
training, staff supervision, operational command and control and tactical response in support of bed management and clinical services and introducing
technology into the work place. The aim being to provide service delivery flexibility and effective support to acute site incident management and all
hospital clinical and security related tasks to the benefit of the organisation and our patients.
A consistent dedicated and determined approach by Facilities management and business partners has been adopted to the redesign of porter services, whilst
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25 October 2018
recognising and being sensitive to staff concerns that change is not always
acceptable to all staff.
Further details about this redesign scheme, the risks, benefits and the
challenges that Facilities and its business partners have been working to
overcome to achieve the objective are summarised at Appendix 5.
ISO 14001:2015 Standard Following an external surveillance audit carried out in July 2018, Cwm Taf UHB
has retained ISO 14001:15 certification for all its healthcare sites.
In preparation for the boundary change in April 2019, a gap analysis is being conducted to identify the ISO 14001:15 position for the Bridgend region. This
standard is currently managed by the Abertawe Bro Morgannwg UHB (ABMU) Estates department therefore will be subject of transition transfer / Service
Level Agreement (SLA). Once completed an action plan will developed to ensure the same high standards achieved by CTUHB are retained.
Waste Management
The health board is currently achieving its waste management targets across all waste streams and meets health and care and environmental management
standards. Details of the Facilities Waste management performance which
includes cost and tonnage over the last 5 years can be found at Appendix 4.
Clinical Engineering Following a recent Clinical Engineering external BSI audit. The health board is
currently achieving the quality standard ISO 9001:15 required.
There is a requirement for the majority of patient facing nursing staff to receive medical gas training. Depending on nursing staff responsibility, requirements
are between 1,500 to 3,000 staff requiring the training. This is a significant training challenge for the department and the one member of staff who also
provides medical device training. A Training needs analysis is being carried out. A bid to fund an additional trainer has been submitted. This risk and
requirement has been reported in the Facilities IMTP plan as a discretionary investment requirement.
There is an increasing requirement for Bariatric Beds and Equipment these bed systems have recently been rented. A bid for funding has been approved to
purchase and reduce rental requirements to mitigate the financial and service risks.
There is an increasing demand within community/localities setting for beds at
home for discharging patients. It is likely that further purchases will required from the replacement bed budget to accommodate demand and avoid rentals.
Purchase of a further ten at home beds is in progress and awaiting delivery.
Business managers in the Primary Care & Mental Health Directorate have been asked to provide a business case to clearly identify future at home bed demand
so that supply and cost can be forecast, included in the Facilities IMTP the aim
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25 October 2018
being to avoid high rental cost and to ensure we maintain service delivery for
the future.
The Facilities forward work plan includes service deep dive work to be carried
out within bed management services. This may require support from external service related management consultants.
Currently bed management services is provided from a combination of internal
and external (contract) bed management and bed maintenance services and spread across three Directorates within Cwm Taf UHB. The deep dive is now
necessary to establish what opportunities exist to improve efficiency, evaluate bed product requirement and suitability, and ensure quality of service for the
patient, productivity and best value for the health board. In addition to take into consideration the pending Bridgend Boundary Change and what bed
management and maintenance arrangements are in place.
Grounds and Gardens Services The Facilities forward work plan includes service deep dive work which is
currently being carried out within the Grounds and Gardens services. This service deep dive is included in the CRES plan and follows earlier internal work
carried out by the Facilities team and a CBM report which made preliminary
reference to potential savings.
Currently Grounds and Gardens services which also provides a small service delivery element (mainly the smaller primary care and locality sites) of gritting
and snow clearance in support of the UHB winter adverse weather plan.
The services are provided from a combination of internal and external (contract) maintenance services. The in-house service is considerably
stretched to meet the demand of the Estate which has increased in size and geographical scope and there has been very little investment in equipment over
the last 8 years.
The deep dive is now necessary to establish what opportunities exist to improve efficiency, evaluate services, equipment requirements and suitability, and
ensure quality of service delivery, productivity and best value for the health
board. In addition, to take into consideration the pending Bridgend Boundary Change and what grounds, gardens, gritting and snow clearance service
maintenance arrangements are in place.
The deep dive work is being supported by business partners and the Facilities management team. An options appraisal report is scheduled for completion in
December and the first draft will be provided to CBM in January 2019.
Other Facilities Key Areas of Work
Facilities Investment in Technology
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25 October 2018
We are currently scoping similar service delivery and transactional management
systems as an investment in technology for Porter and Housekeeping services as there are benefits to bringing in management information systems to the
Facilities services environment. We have met with the system provider to
discuss the benefits further and scope system costs. A Facilities investment in technology paper will then be drafted for CBM and included in the Facilities
IMTP and the project is included in the Facilities work plan 2018-20.
Staff Residences PCH Since the last FP&W report we have met with Tim Burns and Rosie Cavill Capital
/Estates and accommodation options were discussed and identified. It was agreed that the options needed to be drafted into an options appraisal paper for
decisions to be made on the future direction of the residential accommodation at PCH. Early indications are that capital investment even for the minimum
accommodation requirement is around £1.5m with no return on investment as minimum accommodation is funded for F1’s. Public service partner or private
investment appears to be the option that may need to be considered.
Estates/Capital colleagues have now commissioned an architect to provide costs for bringing the residential accommodation up to a good standard and we
expect to receive this shortly.
These costs will be reviewed and evaluated for their cost effectiveness
compared against a complete re-build option which may include a public service partner or a private investment option.
All Wales Laundry Processing Units Review
Work is continuing on an outline business case (OBC) for laundry services. A Risk workshop was held on the 6 September 2018 and a benefits and/or dis-
benefits associated with centralised management arrangements in relation to the All Wales Laundry review was held on the 2 October 2018. These workshops
will further support the information provided to date in refining the OBC. A follow up project group meeting will be arranged to share the OBC as planned.
The Cwm Taf Laundry manager has been tasked with undertaking a Cwm Taf
Laundry gap against the BS EN 14065/WHDM standard, Estates condition
assessment, identify productivity and efficiency improvements and consider future business opportunities. A report on progress with this work and the
findings of the gap analysis against the standard will be provided to CBM.
All Wales NHS Catering IT system Consultants have been engaged by Shared Services to review the benefits and
requirements of an all-Wales catering IT solution. CTUHB were highlighted in the report for best practice in catering and food waste management. The All-
Wales group continues to meet regularly and a representative from CTUHB attends the meetings.
An internal review of the costs and benefits of the IT solution is currently being completed, and a paper will be presented at the October CBM for discussion.
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25 October 2018
There are a number of benefits to introducing the Catering IT system, these
include: • Reduced food waste,
• Reduced cost associated with waste,
• Easier ordering for patients, • Need for paper menus eliminated,
• Joined up system from production to meal service, • System can be extended to include modules for IT management of
other services e.g. housekeeping and porter services
Non-Emergency Patient Transport (NEPT) - On the Day Discharge and Transfer Service
One of the Health Boards key priorities is to ensure that a robust service model is in place to facilitate and aid the efficient flow of patients through its Hospitals
and reduce the impact on the number of beds used and associated costs involved.
As part of developing this new service model the Health Board has recently
reviewed and improved patient flow through its two main District General Hospitals (DGH’s) at Prince Charles Hospital (PCH) and the Royal Glamorgan
Hospital (RGH).
The success of this initiative has seen an increase in ‘on-the-day’ demand for
patients requiring either a discharge home or transfer to other health care facilities and the Health Board is seeking to provide an additional Discharge and
Transfer Vehicle to complement the existing two vehicles in operation (provided by the Welsh Ambulance Service NHS Trust) and thereby completing the new
service model.
A detailed service specification has been developed which is currently subject to a competitive tendering exercise.
Once this exercise has been completed the findings will be compared and
contrasted against our own in-house costs and assessed for their relative merits.
PON Transport Model (Paediatrics, Obstetrics and Neonatal Redesign Programme)
The Facilities team have been asked to develop a dedicated transport service to support the work associated with the implementation of the South Wales
Programme in relation to the redesign of services for Paediatrics, Obstetrics and Neonatal.
Again, a detailed service specification has been developed with key stake
holders within the organisation which will shortly be going out to tender. Once completed the findings will be compared and contrasted against our own in-
house costs and assessed for their relative merits.
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25 October 2018
Bridgend Boundary Change The Facilities Transition Board was set up in July 18, reporting to Transition
Programme Board. To date 13 out of 27 work streams have been completed.
Service transfer proposals are being developed for all services and will be shared with the Transition Programme Board for consideration at the next
meeting scheduled for November 2018. The service areas that have a critical path for service continuity from April 1 2019 are:
• Clinical Engineering, • Switchboard,
• Waste management, • Transport management,
• Grounds and gardens, • Gritting and Snow,
• ISO 14001:2015
Conclusion
The Facilities Directorate acknowledge that further work is needed to improve the current financial position and to deliver on its IMTP and CRES plans.
The Directorate team are committed to ensuring financial sustainability. We maintain a positive attitude and appetite for seeking opportunity and doing
things differently and supporting our staff, whilst maintaining a good reputation for high quality and standards of service delivery in support of clinical services
and operations.
4. RECOMMENDATION
The Finance, Performance and Workforce Committee is asked to:
• NOTE and DISCUSS the content of the report.
Freedom of information status
Open
2.2.1 Appendix 1 Sickness deep dive report FPW 25 Oct 2018 GR
1 2.2.1 Appendix 1 Sickness deep dive report FPW 25 Oct 2018 GR.docx
Facilities Directorate
Short-term Sickness Deep Dive
June 2018
Compiled by Hayley Davey Sara Minahan
2.2
Appendix 1
Page | 1
Facilities Directorate
Short-term Sickness Deep Dive – June 2018
Introduction
Further to CBM requirements a short-term sickness (STS) deep dive
has been carried out for the Facilities Directorate.
The purpose of this review is to look at short-term sickness, from April 2017 to date, to establish the main causes of absence; to
explore actions or initiatives to potentially reduce the amount of short-term sickness absences by implementing pro-active
management processes across the directorate.
The facilities’ teams have worked hard alongside the workforce
business partners, to improve sickness management practices within the directorate. This hard work can be clearly seen in the table
below which shows STS falling across the directorate suggesting management practices are improving.
The table below shows the percentage of sickness categorised as
Long Term sickness (LTS) and STS out of the total sickness absence.
Time Period LTS STS
2015/2016 71.77% 28.23%
2016/2017 78.55% 21.45%
2017/2018 80.53% 19.47%
The data suggests that appropriate management of STS is in place as the proportion of overall sickness is falling year on year.
There are approximately 135 staff responsible for sickness
management within the directorate. Current records show that a total of 22 line managers/team leaders/supervisors have received
refresher training in managing sickness absence, within the last twelve months.
Findings
According to the Electronic Staff Record (ESR), the total number of short-term sickness cases, from 01/04/17 – 31/05/18 is 973.
Page | 2
The top ten main reasons for short-term sickness are listed below, along with the number of instances:
Reason for Absence Instances
Gastrointestinal problems 172
Cold, Cough, Flu - Influenza 167
Back problems & other musculoskeletal 75
Anxiety/Stress/Depression/Other
psychiatric illness
65
Chest & Respiratory problems 53
Ear, nose, throat 34
Genitourinary & gynaecological disorders 29
Injury, fracture 24
Headache/migraine 20
Unknown causes/not specified 14
Suggested areas for review from CBM were back and musculoskeletal (MSK) problems and anxiety/stress/depression, to
identify if moving and handling training had been completed for staff with back problems/MSK sickness, and if stress risk assessments had
been completed for work-related stress absences.
Back Problems & other musculoskeletal
• Total number of cases: 75 • Number of files randomly selected for checking: 46
• Number of cases work related: 5 • Number of staff compliant at time of sickness: 28
• Number of staff not compliant: 18
Eighteen staff (39%) were not compliant at the time of sickness.
None had received training after returning to work and still require training in moving and handling.
It is worth noting that 30 of the 46 staff files audited (65%) were
aged 50+ and in physically active roles.
Anxiety/Stress/Depression/Other psychiatric illness
• Total number of cases: 65 • Number of files randomly selected for checking: 38
• Number of cases work related: 5 (possibly 6 as there is one not stated)
• Number of risk assessments completed (for work related
stress): 0
Page | 3
There were five definite work-related instances (13%) (possibly six as there is paperwork missing and/or not stated) but none were
stated as such on ESR. There were differences between the self-certificates/RTW documents and GP certificates, namely the RTW
documents stating “work-related stress” and the GP certificates stating “stress”. Also, none of the work-related absences had stress
risk assessments on file.
It is worth noting that 11 of the staff files audited (29%) were for bereavement of a family member. Given this high number of cases
it may be worthwhile to have a sub category on ESR for bereavement as this will remove these and prevent the distorted
view currently presented.
Sickness Management – Third/Formal Final Stage
The Third/Formal sickness hearing process was considered for effectiveness and consistency.
9 Third/ formals have been undertaken in Facilities during the year
April 2017- March 2018, with 4 further Third/ Formals taking place from April 2018 to July 2018.
The number has felt to be considerably more because on numerous
occasions meetings have had to be rescheduled due to the unavailability of member of the management team or Unions,
especially when notified of their attendance at a late stage.
In all case considered within facilities to date the decision has been
to set a further review period, during which if the individual triggered and was absent would return to the final stage for consideration.
This is comparable with the outcomes seen within the other
Directorates which the Scheduled Care HR Team support.
The reason for these decisions have been due to a range of factors including, underlying conditions which are resolved or where further
support can be provided to improve future attendance, significant personal/domestic circumstances which have contributed to ill health
but are now resolved, Occupational Health advice which is advising of a positive prognosis.
The other area which impacts upon management decisions are the
quality of the paperwork which is submitted as a summary of the
absence management case and the level of consideration which has been given to support or actions which can be taken which has been
considered at earlier stages.
Page | 4
At the current time, there are no feedback mechanisms that enable
the outcome of a 3rd formal hearing to be shared with the line manager and HR advisor so that lessons can be learnt.
Given the number of 3rd formal cases, it is important to improve the
quality of the manager’s report to a hearing and to ensure consistency of both reporting and outcome across the directorate. A
formal Sickness Consultancy meeting will be established to implement these improvements and attempt to change the culture of
sickness management across Facilities. This meeting will be held bi-monthly and include membership from:
• Facilities managers with responsibility for presenting
managers reports,
• HR advisors who support the managers, • HR Business partners,
• Senior Facilities managers who hear the 3rd formal sickness hearing
These meetings will also provide opportunity for the discussion of
Long Term Sickness cases and ensure consistency of management and support offered to staff.
Summary
All data checked and collated for back/MSK absences suggests that
65% of staff were aged 50+, with physically active roles. Also, 61% were moving and handling compliant at the time of sickness.
Absences related to anxiety/stress/depression indicate that 13% were work-related but none had been risk-assessed by line
managers. Also, 29% of these cases were due to bereavement.
Over the course of the audit numerous anomalies were identified:
• Several departments using the wrong return to work (RTW) paperwork,
• Some return to work documents, e.g. self-certificates, RTW forms, were missing and/or had not been signed by the absent
staff member, • There were several instances in different departments where:
a) Sickness absence was recorded on the wrong staff member’s record,
b) The reason for absence was inputted on ESR incorrectly,
c) The dates of absence were different on the RTW paperwork to those on ESR,
Page | 5
d) Self-certificates and RTW paperwork stated that absence was work-related stress but GP certificates stated only
“stress”, • ESR statistics show that one department had ten staff with
“unknown causes/not specified”, which should only be used in exceptional circumstances. However, these files were not
audited as they did not appear under back/MSK or stress/anxiety/depression headings.
These anomalies suggest that further sickness management training
is required for all managers, supervisors and team leaders who have responsibilities for sickness absence management.
Page | 6
Facilities Directorate
Short-term Sickness, Further Analysis September 2018
Compiled by Hayley Davey
Page | 7
Facilities Directorate
Short-term Sickness Analysis – September 2018
Introduction
Further to CBM requirements a short-term sickness deep dive was carried out in July/August 2018 (for the period of April 2013 to May
2018) for the Facilities Directorate.
Following submission of the report to the CBM group in August, a further investigation was requested surrounding the current increase
of short term sickness in comparison with the previous five years’ data.
The line graph below displays all short-term sickness (STS) and long-term sickness (LTS) for full time equivalent (FTE) staff for the
last five years.
The chart below shows the number of sickness instances in relation to the top five reasons for sickness, for each financial year.
*N.B. 2018 includes figures from 01/04/17 - 31/08/18.
0.00%
1.00%
2.00%
3.00%
4.00%
5.00%
6.00%
7.00%
8.00%
20
13
/ 0
4
20
13
/ 0
6
20
13
/ 0
8
20
13
/ 1
0
20
13
/ 1
2
20
14
/ 0
2
20
14
/ 0
4
20
14
/ 0
6
20
14
/ 0
8
20
14
/ 1
0
20
14
/ 1
2
20
15
/ 0
2
20
15
/ 0
4
20
15
/ 0
6
20
15
/ 0
8
20
15
/ 1
0
20
15
/ 1
2
20
16
/ 0
2
20
16
/ 0
4
20
16
/ 0
6
20
16
/ 0
8
20
16
/ 1
0
20
16
/ 1
2
20
17
/ 0
2
20
17
/ 0
4
20
17
/ 0
6
20
17
/ 0
8
20
17
/ 1
0
20
17
/ 1
2
20
18
/ 0
2
20
18
/ 0
4
20
18
/ 0
6
20
18
/ 0
8
Sick
nes
s %
Year/Quarter
FTE % STS & LTS 2013 - 2018
Long Term Absence FTE % Short Term Absence FTE %
Page | 8
This data indicates that the highest sickness rates are consistently
for gastrointestinal problems and cold/cough/flu.
Further data was retrieved from ESR and feature in the following pages.
Findings
The chart below states the number of STS instances for the top five
reasons, per quarter, each year.
There are high numbers for cold/cough/flu in quarters 3 & 4 each
year but this is to be expected during the winter months. Likewise,
there is an increase in the chest/respiratory area for the same period.
26
57
8264
5241
2846 52
6544
32
59
122140
111 119 123
1739
61 60 5334
76
165
191 197
168
113
0
50
100
150
200
250
2013 2014 2015 2016 2017 2018
No
. of
Inst
ance
s
Financial Year *
S10Anxiety/stress/depression/other psychiatricillnessesS12 Othermusculoskeletalproblems
S13 Cold, Cough, Flu -Influenza
S15 Chest &respiratory problems
S25 Gastrointestinalproblems
Page | 9
However, the figures for gastrointestinal problems are fairly consistent for every quarter, with all figures ranging from 213 to 252
instances.
Duration of Short Term Sickness (STS)
For each of the top five reasons for sickness, from April 2013 to August 2018, the highest rate of absence appears to be within the
self-certification period of 1 – 7 days at 75%. Below is a summary of the percentage rate of short-term sickness, for each sickness
reason, occurring from 1 – 7 days:
Sickness Reason Duration 1 – 7 days (%)
Gastrointestinal problems 89%
Cold/Cough/Flu - Influenza 80%
Chest/Respiratory problems 63%
Other Musculoskeletal problems 59%
Anxiety/Stress/Depression 42%
Further analysis indicates that, for four out of the top five sickness
reasons, Monday has the highest rate for the first day of absence as summarised:
Sickness Reason Monday - 1st Day of Absence (%)
Cold/Cough/Flu - Influenza 28%
Chest/Respiratory Problems 27%
Other Musculoskeletal Problems 24%
Gastrointestinal Problems 21%
N.B. for Anxiety/Stress/Depression the percentage for reporting sickness on a Monday is 18%. The highest (for a Wednesday) is
19%.
ESR Sickness Sub-Categories
It was noted that many of the sickness absences reported on ESR were not input under sub-headings for each category, e.g. under the
anxiety/stress/depression heading a number of options are available
to select, such as anxiety, stress, etc. but the majority (74%) were left blank.
Page | 10
The following chart displays data, from 01 April 2013 to 31 August 2018, for sickness due to ‘other known causes – not elsewhere
classified’ and ‘unknown causes/not specified’:
Sickness for period 2017/2018 to date
When comparing this year’s data to the same period last year, i.e. April – August, the table below shows that ‘back problems’ now
feature in the top five in place of ‘chest & respiratory problems’.
30
176
3548
5 7 14 19 16 17 8 11
020406080
100120140160180200
S98
Oth
er k
no
wn
cau
ses
- n
ot
else
wh
ere
cla
ssif
ied
S99
Un
kno
wn
cau
ses
/ N
ot
spec
ifie
d
S98
Oth
er k
no
wn
cau
ses
- n
ot
else
wh
ere
cla
ssif
ied
S99
Un
kno
wn
cau
ses
/ N
ot
spec
ifie
d
S98
Oth
er k
no
wn
cau
ses
- n
ot
else
wh
ere
cla
ssif
ied
S99
Un
kno
wn
cau
ses
/ N
ot
spec
ifie
d
S99
Un
kno
wn
cau
ses
/ N
ot
spec
ifie
d
S98
Oth
er k
no
wn
cau
ses
- n
ot
else
wh
ere
cla
ssif
ied
S99
Un
kno
wn
cau
ses
/ N
ot
spec
ifie
d
S98
Oth
er k
no
wn
cau
ses
- n
ot
else
wh
ere
cla
ssif
ied
S99
Un
kno
wn
cau
ses
/ N
ot
spec
ifie
d
S98
Oth
er k
no
wn
cau
ses
- n
ot
else
wh
ere
cla
ssif
ied
2013 2014 2015 2016 2017 2018
No
. of
Inst
ance
s
Sickness due to unknown causes & known causes not classifedApril 2013 - August 2018
Page | 11
Gastrointestinal problems has the highest number of instances in every
month and the number more than doubles from June to July 2018. The rate then falls during August but still remains higher than usual compared
to the months prior to summer 2018.
After consulting the infection control team it was confirmed that were no ward closures relating to gastrointestinal/diarrhoea and
vomiting within the health board, during July and August 2018. There was one bay restricted in Prince Charles Hospital (PCH) for two
days in August but no staff were affected, according to the Infection Prevention Control (IPC) team.
Summary
The additional data collated indicates that:
• Gastrointestinal problems is the main cause of short-term sickness within Facilities at 37%, followed by cough/cold/flu at
27%, over a five-year period,
• Since 01 April 2017 to 31 August 2018, gastrointestinal-related absence is the highest of all short-term sickness at 24%,
followed by cough/cold/flu at 21%.
3
7 7
11
35
68
10
3
67
911
24
7 7
11
23
45
13
13
67
11
34 4 4
14
24
5
23
2 2
6
12
1 1
4
7
17
0
5
10
15
20
25
S11
Bac
k P
rob
lem
s
S12
Oth
er m
usc
ulo
skel
etal
pro
ble
ms
S13
Co
ld, C
ou
gh, F
lu -
Infl
ue
nza
S25
Gas
tro
inte
stin
al p
rob
lem
s
S12
Oth
er m
usc
ulo
skel
etal
pro
ble
ms
S11
Bac
k P
rob
lem
s
S10
An
xiet
y/st
ress
/de
pre
ssio
n/o
the
r…
S13
Co
ld, C
ou
gh, F
lu -
Infl
ue
nza
S25
Gas
tro
inte
stin
al p
rob
lem
s
S11
Bac
k P
rob
lem
s
S13
Co
ld, C
ou
gh, F
lu -
Infl
ue
nza
S10
An
xiet
y/st
ress
/de
pre
ssio
n/o
the
r…
S12
Oth
er m
usc
ulo
skel
etal
pro
ble
ms
S25
Gas
tro
inte
stin
al p
rob
lem
s
S11
Bac
k P
rob
lem
s
S12
Oth
er m
usc
ulo
skel
etal
pro
ble
ms
S13
Co
ld, C
ou
gh, F
lu -
Infl
ue
nza
S10
An
xiet
y/st
ress
/de
pre
ssio
n/o
the
r…
S25
Gas
tro
inte
stin
al p
rob
lem
s
S11
Bac
k P
rob
lem
s
S13
Co
ld, C
ou
gh, F
lu -
Infl
ue
nza
S10
An
xiet
y/st
ress
/de
pre
ssio
n/o
the
r…
S12
Oth
er m
usc
ulo
skel
etal
pro
ble
ms
S25
Gas
tro
inte
stin
al p
rob
lem
s
S11
Bac
k P
rob
lem
s
S13
Co
ld, C
ou
gh, F
lu -
Infl
ue
nza
S10
An
xiet
y/st
ress
/de
pre
ssio
n/o
the
r…
S12
Oth
er m
usc
ulo
skel
etal
pro
ble
ms
S25
Gas
tro
inte
stin
al p
rob
lem
s
S13
Co
ld, C
ou
gh, F
lu -
Infl
ue
nza
S12
Oth
er m
usc
ulo
skel
etal
pro
ble
ms
S11
Bac
k P
rob
lem
s
S10
An
xiet
y/st
ress
/de
pre
ssio
n/o
the
r…
S25
Gas
tro
inte
stin
al p
rob
lem
s
S10
An
xiet
y/st
ress
/de
pre
ssio
n/o
the
r…
S12
Oth
er m
usc
ulo
skel
etal
pro
ble
ms
S11
Bac
k P
rob
lem
s
S25
Gas
tro
inte
stin
al p
rob
lem
s
S11
Bac
k P
rob
lem
s
S13
Co
ld, C
ou
gh, F
lu -
Infl
ue
nza
S10
An
xiet
y/st
ress
/de
pre
ssio
n/o
the
r…
S25
Gas
tro
inte
stin
al p
rob
lem
s
S13
Co
ld, C
ou
gh, F
lu -
Infl
ue
nza
S11
Bac
k P
rob
lem
s
S12
Oth
er m
usc
ulo
skel
etal
pro
ble
ms
S10
An
xiet
y/st
ress
/de
pre
ssio
n/o
the
r…
S25
Gas
tro
inte
stin
al p
rob
lem
s
2017 2018 2017 2018 2017 2018 2017 2018 2017 2018
Apr May Jun Jul Aug
No
. of
Inst
ance
s
Top 5 Sickness reasons & instances April - August 2017 & April -August 2018
Page | 12
Also, gastrointestinal-related sickness more than doubled between June and July 2018. According to the IPC team, there
were no ward closures relating to gastrointestinal/diarrhoea & vomiting during this period, apart from a two-day bay closure
in PCH in August and no staff were affected,
• The highest rate of sickness occurs between 1 & 7 days (the self-certification period), for four out of the top five sickness
reasons, which accounts for 75% of all short-term sickness (over a five-year period),
• Monday is the most common day for reporting the first day of
sickness, (for four out of the top five sickness reasons) over the last five years,
• Over the previous five years, the majority of short-term sickness absence (69%) inputted on ESR does not appear
under a sub-category/heading. Ensuring this is done will provide a more accurate view when analysing sickness
absence.
Also, sickness for reasons not specified should only be used in exceptional circumstances. Where reasons are not clear at the
beginning of a sickness period ESR should be updated accordingly once the causes are known or when the staff
member returns to work.
2.2.2 Appendix 2 Five year CRES History FPW 25 Oct 2018 GR
1 2.2.2 Appendix 2 Five year CRES History FPW 25 Oct 2018 GR.docx
2.2.2 Appendix 2
FACILITIES HISTORIC CRES DELIVERY
A summary of the annual Cash Releasing Efficiency Savings (CRES) delivery
and associated targets for the period from 2013/14 to 2017/18 inclusive is
shown in the following diagram. The detail of the CRES delivery is presented
in the Tables that follow.
2013-14 Financial Performance Savings Achieved
2013/14 In
Year
Recurrent
delivery
£000's £000's
FYE Savings 199 199
Introduction of Hot vending at Royal Glamorgan Restaurant 11 11
Introduction of Hot vending at Royal Ysbyty Cwm Rhondda
Restaurant 15 15
Introduction of Hot vending at Dewi Sant Hospital Restaurant 14 14
Introduction of Hot vending at YCC Hospital Restaurant 8 8
Reduction in Portering staff through natural wastage 25 25
Capped reduction in Facilities Expenses 6 6
Reduction in sickness levels to reduce sickness related overtime 35 35
Non Emergency Patient Transport 40 40
Reduction in Housekeeping Materials to Benchmark Acute South 23 23
Reduction in Housekeeping Materials to Benchmark Acute North 10 10
Total 386 386
2.2.2 Appendix 2
2014-15 Financial Performance Savings Achieved
2014/15 In
Year
Recurrent
delivery
£000's £000's
Clinical Engineering Consumables 24 22
Fuel Cards 17 24
Patient feeding 334 319
Restaurant services B 55 37
Waste management 26 46
Workforce plan 347 486
VER Oct 14 30 120
EBME Structure 10 40
Cross cutting
CPU call off orders - AW contract compliance - non pay cross
cutting 46 50
AW fruit and veg contract 37 83
Gritting contract 6 12
Service redesign - Dewi Sant 162 541
Balance to FYE 13/14 Savings 12 12
Terms and conditions changes 7 16
Total 1,113 1,808
2015-16 Financial Performance Savings Achieved
2015/16 In
Year
Recurrent
delivery
£000's £000's
Restaurant services B 230 230
Waste management 19 19
CPU de-gear 50 230
Merge YCC Coffee Shop and restaurant 0 25
Patient feeding 25 25
Over time reduction 150 100
PCH Coffee Shop (7) 18
Laundry - items per bed 80 60
Cross Cutting
Non Pay 141 141
Total 688 848
2016-17 Financial Performance Savings Achieved
2016/17 In
Year
Recurrent
delivery
£000's £000's
RGH Restaurant (profit) 18 18
Kier Hardie Coffee Shop (profit) 5 5
YCR Restaurant (profit) 21 21
Patient feeding 40 40
CPU - Hywel Dda 18 18
Porter / Security 40 96
Laundry Transport 50 50
Grounds & Gardens outsourcing 14 14
Lease Car Salary Sacrifice 7 0
Total 214 262
2.2.2 Appendix 2
2017-18 Financial Performance Savings Achieved
2017/18 In
Year
Recurrent
Delivery
£000's £000's
Housekeeping 104 360
Portering - Porter / Security 83 272
Management and administration 59 59
Coffee beans and coffee cups 15 15
Paper towels 6 80
Laundry price increase 12 12
Catering - price increase, meal changes etc. 100 135
Salary sacrifice 5 0
Laundry 70 76
Total 454 1,009
2.2.3 Appendix 3 Benchmarking report FPW 25 Oct 2018 GR
1 2.2.3 Appendix 3 Benchmarking report FPW 25 Oct 2018 GR.docx
2.2.3 Appendix 3
FACILITIES BENCHMARKING REPORT
The most recent annual benchmarking exercise that compares the services provided by the
Facilities Directorate at an all Wales level was undertaken for the 2016/17 financial year.
The results of this are presented below together with adjusted values for the Cwm Taf
services where savings have been delivered subsequent to 2016/17, pending the
publication of the 2017/18 benchmarking results.
2.2.3 Appendix 3
2.2.4 Appendix 4 Waste performance Report FPW 25 Oct 2018 GR
1 2.2.4 Appendix 4 Waste performance Report FPW 25 Oct 2018 GR.docx
2.2.4 Appendix 4
Waste Cost & Tonnage Trends 2012/13 – 2017/18
The following is an analysis of waste cost and tonnage trends for the UHB
for financial years 2012/13 to 2017/18.
Summary
• Cost and tonnage trends are shown in the graphs below.
• In summary these show:
Cost
➢ The Landfill costs over the period show a downward trend, ➢ Non- burn (infectious) waste has shown a downward cost trend, being
combination of improved segregation and revised contract prices for
collection and disposal, ➢ Offensive Hygiene (Tiger) waste costs has have mirrored the general
increase in tonnage over the period and similarly reflects the decrease
in tonnage in 201/18 (See comment below on tonnage), ➢ Recovery/Recycling waste costs has increased in line with an increase
in tonnage, ➢ High Temperature (incineration) waste costs have remained flat over
the period.
Tonnage
➢ Landfill tonnage has shown a downward trend. Which reflects improved recycling and cyclic fluctuations in annual tonnages,
➢ Non- burn (infectious) waste has also shown a downward trend, ➢ Offensive Hygiene (Tiger) waste has shown an upward trend over the
period 2012/13 – 2016/17. The reduced tonnage in 2017/18 is due in part to in patient changes at YGT, which tiger waste percentages of
90%, ➢ Recovery/Recycling has shown an upward trend, ➢ High Temperature (incineration) waste has remained flat.
Cost Trends 2012/13 – 2017/18
Tonnage Trends 2012/13 – 2017/18
0.00
200.00
400.00
600.00
800.00
1000.00
1200.00
1400.00
2012-13 2013-14 2014-15 2015-16 2016-17 2017-18
Waste Tonnage TrendIncineration
Land Fill
Infectious
Tiger
Recovery/Recycling
£0
£50,000
£100,000
£150,000
£200,000
£250,000
£300,000
£350,000
2012-13 2013-14 2014-15 2015-16 2016-17 2017-18
Waste Cost Trend Incineration
Land Fill
Infectious
Tiger
Recovery/Recycling
2.2.5 Appendix 5 Porter service redesign FPW 25 Oct 2018 GR
1 2.2.5 Appendix 5 Porter service redesign FPW 25 Oct 2018 GR.docx
2.2.5 Appendix 5
Porter Service Redesign and Modernisation Summary
There has been considerable push back over the service and rota change from some of the porter services staff and supported by
trade unions who have often been instrumental in delaying process despite workforce business partner’s intervention. Some of this is
understandable because the service has not been reviewed in depth for many years and the changes impact on staff overtime pay and
their local customer practice working terms and conditions.
The delays in implementing the redesign and new rota have
resulting in additional cost and the continued use of the old rota that has already been identified and confirmed as not cost effective
and non-compliant. The problem has been that the existing old
rotas across all HB Sites are supporting the new service redesign model which is designed and in FY 2018/19 was budgeted for the
new rota.
The Porter Services re-design will support the correct management
of an efficient rota system across porter services at all sites which
includes migration to e-rostering.
The pushback has resulted in a number of staff matters being
worked through with workforce staff.
Following staff engagement and consultation, we are currently at stage 2 of grievance at Royal Glamorgan Hospital (RGH) and Prince
Charles Hospital (PCH). We are working this through with the staff and staff side colleagues and we are effectively supported by the
Workforce & Organisational Development (WF&OD) business partners in this process. This support going forward also involves
addressing dignity at work and I-care issues through training and
PULSE sessions which have been already requested for this group of staff.
A consistent dedicated and determined approach by Facilities management and business partners has been adopted to the
redesign of porter services, whilst recognising and being sensitive to
staff concerns that change is not always acceptable to all staff.
The following key risks and benefits are associated with this service redesign scheme.
Service Risks
• Lack of supervision, command and control, performance management and accountability of contract security staff,
• No command and control or supervision of pool porter staff at
night at RGH,
• At RGH dispatch and supervision is provided by 2 x porters but not 24/7. At PCH this is effectively achieved 24/7 by 1 x porter
supervisor,
• Standards and quality of services along with operating procedures, transactional management procedures, rotas and
service delivery were found to be different on each site,
• Shortfalls were identified in productivity and efficiency at RGH
the main reason being that all porters were operated from a central pool and there were no porters assigned and dedicated
to key high activity areas of the hospital e.g. x-ray, MRI, A&E in direct a support of clinical services. At PCH this service
arrangement has been provided for many years,
• At RGH 2 x pool porters and a nurse are required to carry out patient bed transfers, at PCH with the exception of bariatric
patients it is 1x pool porter and 1 x nurse,
• Communication linkage with site bed management and porter services at RGH in response to site incidents, patient flow
activity and security was found to be limited, with any
communication being restricted to telephone. At PCH bed management and porter services also have open channel radio
communication so that command and control, information can be shared and a rapid tactical response to alarms and incidents
can be provided.
Benefits
The key benefits to the organisation and porter services staff of redesigning the existing porter services role are as follows:
• Clearly defined roles and Porter Services policy and standard
operating procedures, • Cost savings and financial sustainability,
• Improved transactional and service delivery performance
management of rota and service delivery activity using KPI’s,
• Improved control of services over an out sourced security contractor,
• Improved accountability and quality of service providing a more flexible and responsive service for the organisation and
our patients, • Accurate recording of Porter Services data and service
delivery performance, • Access to Porter services using client self-serve approach and
dedicated porters at key hot spot locations e.g. A&E and X-ray/MRI departments,
• Provides clear communication links and support to internal clinical and external emergency services accessing the
hospital during normal and out of hours.
Command, Control and Responsive Porter Services
• Improved command and control of security service resulting
in service delivery based on flexibility, daily risk and requirements,
• Improvement in supervision of staff engaged on porter services and security related duties,
• Improved site communication, • Investment in technology,
• Additional training and career opportunities for porter services staff,
• Part of a multi-role for porter services staff improving career progression, role diversity and service flexibility,
• More direct control of the hospital Estate 24/7, • Auditable incident and activity reporting providing an accurate
record of incidents over 24 hour and 7 days a week using site
Facilities control centre Porter/Security BMS system.
Flexible workforce
• More flexibility in the allocation of duties and approach to day to day service delivery and risk,
• Revised and comprehensive job descriptions, • Duty shift roles and rotas designed around lean flexibility
and the requirement to provide hospital porter, waste management, security and site traffic management, mail
delivery and collection and transport.
Porter Services IT Management Systems
The existing portertrac management system is used to monitor daily
porter task activity. However the system is nearly 20 years old,
has not been invested in, is challenging to navigate and is not
currently used as an end user self-serve system.
Extracting meaningful and effective reports requires labour intensive system interrogation and does not always provide
accurate data as it is heavily reliant on accurate input from the
porter services duty dispatcher.
The Facilities team is currently developing a Facilities Management (FM) service technology plan which aims to further expand and
improve on 24/7 service delivery and staff transactional management using a software management system as an
investment in technology for Facilities core services e.g. Porters, housekeeping and catering.
For example, to date the Facilities management teams in hospitals
have relied upon pen and paper data collection and out of date IT systems. Communication is achieved by telephones between the
porter lodge and wards. In contrast, within the private FM sector
investment has been made and IT systems have been operational for many years.
There is a need to invest in FM management software solutions
which will bring benefits to the Facilities services environment, the clinical services and the patients it supports. A Facilities investment
in technology paper is currently being drafted and will be submitted at CBM and included in the Facilities IMTP.
It is acknowledged that there is an immediate requirement for
moving forward through negotiations with staff and staff side and support from WF&OD to implement the new rota to reduce cost and
realise the final element of the savings associated with this Facilities CRES and service redesign scheme. Despite the push back and
challenges with this scheme, the Facilities management team with
support from WF&OD business partners are committed and doing everything they can within the Organisational Change Process
(OCP) process to progress the scheme to completion
2.2.6 Appendix 6 Facilities work plan 18-20 FPW 25 Oct 2018 GR
1 2.2.6 Appendix 6 Facilities work plan 18-20 FPW 25 Oct 2018 GR.xlsx
FACILITIES BUSINESS WORKPLAN FY 2018-20
Line Facilities Work Stream Linked Process TaskPriority
RAGStatus
2018 2019 2020Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20
1 NHS Wales Laundry production unit service review - Memorandum item Compliance & Savings 32 Cwm Taf Laundry Review Compliance & Opportunity 23 Governance and Compliance/Risk Register Review Compliance 14 All Wales Catering Management System Review Efficiency, Compliance & Savings 25 Cwm Taf/Bridgend Catering Management System Benefits Appraisal Efficiency, Compliance & Savings 16 Facilities ICT Systems Services Modernisation Plan Compliance and Efficiency 27 RGH CCTV Upgrade Review Compliance & Security 38 Policies and Procedures Plan Review Compliance 29 Porter Services Procedures & Training Review in Support of HTA Audit Compliance 110 Staff Core Skills Compliance Training Plan Workforce Compliance 111 Staff Skills Level 2 & 3 Training Plan Workforce Compliance 112 PDR Staff Development Plan Workforce Compliance 113 Multi Skilled Staff Development Initiative Workforce, Efficiency & Savings 314 Porter Services Patient Satisfaction and Experience Quality Initiative Quality & Standards 215 Bridgend Facilities Services Transformation 2019 Quality, Standards, Finance 216 Pathology Transport Services & Standards Review - Option Appraisal Quality, Standards, Finance 217 Facilities Customer Helpdesk Systems and Operations Review Support and Customer Services 218 Adverse Weather Plan Review 2018 Contingency 119 IMTP 2019-20 including Bridgend Facilities Services Business Planning 120 UHB Business mileage cap - Memorandum item across organisation initiative Planning and Finance 321 Capital and Non Capital Asset Replacement Plan Planning and Finance 122 Facilities Site Management - Support Control Centre Development Site Command & Control Support 323 Bridgend Facilities Services Transition Organisational Change 124 Transport Paediatric Retrieval Service Options Appriasal Review Organisational Change, Finance 125 Bed Management Review - Acute and Community/Localities Efficiency, Finance, Quality, Standards 226 PCH Staff Residences Estate - Joint Review (with Capital/Estates) Compliance, Quality, Finance 327 CPU Deep Dive - Outsourcing/Investment Appraisal CRES Plan FY 2019-20 128 Non pay suppliers products volume and price CRES Plan FY 2018-19 129 Non pay - VAT Recovery Deep Dive CRES Plan FY 2018-19 130 Grounds and Gardens Service Deep Dive - Outsourcing /Investment Appraisal CRES Plan FY 2019-20 231 Restaurants - new service model (capital investment required) CRES Plan FY 2019-20 232 YGT Valley Life Service Redesign Phase 1 CRES Plan FY 2018-19 133 YGT Valley Life Service Redesign Phase 2 CRES Plan FY 2018-19 134 YGT Valley Life Service Redesign Non pay CRES Plan FY 2018-19 135 Dewi Sant Health Park Barista (capital investment required) CRES Plan FY 2019-20 236 Internal Transport Pathology Community Service CRES Plan FY 2019-20 237 Internal Transport Shuttle bus review CRES Plan FY 2018-19 138 Unscheduled NEPT Transport Spot Purchasing CRES Plan FY 2018-19 139 CPU Bonus CRES Plan FY 2018-19 140 General office rationalisation CRES Plan FY 2019-20 241 Postal Services Review CRES Plan FY 2018-19 142 Porter services redesign and modernisation CRES Plan FY 2018-19 143 Switchboard (New staff rota - centralisation) CRES Plan FY 2018-19 1
2.3 To receive a quarterly update report on the organisational risks assigned to the Committee
1 2.3 Org Risk Register, FPW 25 Oct 2018 GR.doc
Organisational Risk Register Page 1 of 19 Finance, Performance & Workforce Committee
25 October 2018
AGENDA ITEM 2.3
25 October 2018
Finance, Performance and Workforce Committee Report
ORGANISATIONAL RISK REGISTER
Executive Lead: Board Secretary / Director of Corporate Services and Governance
Author: Interim Board Secretary
Contact Details for further information: Gwenan Roberts, 01443 744818 or email [email protected]
Purpose of the of the Finance, Performance and Workforce
Committee Report
The purpose of this report is for the Finance, Performance and Workforce
Committee to receive, review and discuss the organisational risk register and consider whether the recorded risks are appropriately assigned. This
Organisational Risk Register was last considered by the Executive Board and by the Quality Safety and Risk Committee in September 2018 and has
been updated to reflect related discussions.
Governance
Link to Health
Board Strategic Objective(s)
The Board’s overarching role is to ensure its strategic
objectives, and the related organisational objectives outlined within the 3 Year Integrated Medium Term Plan
2018-2021, are being progressed. Aligned with the ‘Quadruple Aim’ described within ‘A Healthier Wales’
(Welsh Government, June 2018) these objectives are:
• To improve quality, safety and patient experience • To protect and improve population health
• To ensure that the services provided are accessible and sustainable into the future
• To provide strong governance and assurance • To ensure good value based care and treatment
for our patients in line with the resources made available to the Health Board.
This report focuses mainly on providing strong governance and assurance.
Supporting evidence
• The content of this report is informed by the
University Health Board’s (UHB) Risk Management Strategy.
Engagement – Who has been involved in this work?
The information contained within this report has been developed following
engagement with senior staff and Executive Directors.
Organisational Risk Register Page 2 of 19 Finance, Performance & Workforce Committee
25 October 2018
Finance, Performance and Workforce Committee Resolution to:
APPROVE ENDORSE √ DISCUSS √ NOTE √
Recommendation The Finance, Performance and Workforce
Committee is asked to: • DISCUSS and NOTE the update provided
within this report and the risks assigned to the Board and its Committees and,
• ENDORSE the updated risk register and the assignment of risks.
Summarise the Impact of the Finance, Performance and Workforce Committee Report
Equality and
diversity
There are no identified equality & diversity implications.
Legal implications It is essential that the Board has robust arrangements in place to assess, capture and
mitigate risks faced by the organisation, as failure to do so could have legal implications for
the UHB.
Population Health No specific impact.
Quality, Safety & Patient Experience
Ensuring the organisation has robust risk management arrangements in place that ensure
organisational risks are captured, assessed and mitigating actions are taken, is a key requisite to
ensuring the quality, safety & experience of patients receiving care and staff working in the
UHB. Resources The risks outlined within this report have
resource implications which are being addressed
by the respective Executive Director leads and taken into consideration as part of the Board’s
IMTP processes. Risks and Assurance This report and the organisational risk register is
an integral element of the Board’s risk and assurance arrangements. It should be no ted
that this work continues to develop.
Health & Care Standards
The 22 Health & Care Standards for NHS Wales are mapped into the 7 Quality Themes but within
a Governance Framework. This report focuses mainly on Governance & Accountability but also
spans many of the 7 quality themes. Workforce Failure to capture, assess and mitigate risks can
impact adversely on the workforce.
Freedom of Information
status
Open
Organisational Risk Register Page 3 of 19 Finance, Performance & Workforce Committee
25 October 2018
ORGANISATIONAL RISK REGISTER
1. SITUATION / PURPOSE OF REPORT
The purpose of this report is for the Finance, Performance and Workforce
Committee to receive, review and discuss the organisational risk register
and consider whether the recorded risks are appropriately assigned. This Organisational Risk Register was last considered by the Executive Board
and by the Quality Safety and Risk Committee in September 2018 and has been updated to reflect related discussions. Changes made since are
identified in RED font. There are six risks for the Committee to consider.
2. BACKGROUND / INTRODUCTION
The organisational Risk Register summarises the key ‘live’ extreme risks facing the Health Board and the actions being taken to mitigate them. The
Health Board manages risk through i t s Directorate structures and in
close alignment with the Board’s ‘approved’ Assurance Framework. The Assurance Framework reports into the Audit Committee for periodical
review, monitoring and scrutiny and also features (at least annually) on the agenda of the Board.
It is also important to NOTE that the Executives, as risk owners, are
appropriately sighted and involved in the development of the organisational risk register, providing updates, including reports on
mitigating actions. The organisational risk register is reviewed and where appropriate updated on a bi-monthly basis with input from the Executive
lead as required.
All organisational risks have a lead Executive Director and the risk assigned to either the Board, or as appropriate, a Committee of the Board
to ensure appropriate review, scrutiny and where relevant updating. Each Director is responsible for the ownership of the risk(s) and the reporting of
the actions in place to manage/control and/or mitigate the risks.
The organisational Risk Register is reported quarterly to the Executive
Board and routinely to the Quality, Safety & Risk Committee of the Board, for information and where appropriate, scrutiny of any assigned risks.
Whilst this cover report summarizes the detail, the supporting appendices provide more detail.
Improvement continues to be made with directorates and localities
routinely completing integrated risk reporting templates that are used for exception reporting.
3. ASSESSMENT OF GOVERNANCE AND RISK ISSUES
Following discussion at the Executive Board and Quality, Safety & Risk Committee in September, the following changes to the register were agreed:
Organisational Risk Register Page 4 of 19 Finance, Performance & Workforce Committee
25 October 2018
Updates to the Organisational Risk Register:
Action Status
The risk in relation to Board Member changes be
removed
Completed
That the risk in relation to Nasogastric Tube insertion would not be added to the register.
Noted
A further review and assessment of the risk in relation
to Funded Nursing Care would be undertaken after
discussion at Board in March 2018. This has now been concluded and agreed with Mrs L Williams, former
Director of Nursing, Midwifery & Patient Services.
Noted
That the narrative in relation to unscheduled care associated risks was strengthened,
To be discussed with
Executive Team
That a foot note be added to explain the trend / controls
section.
To be
discussed with Executive
Team
That risk 39, failure to provide adequate capacity to
ensure safe and secure storage of patient records, be reassessed, as the records hub would reportedly reach
full capacity in December 2018.
Narrative
amended
That risk 11, failure to achieve financial balance on a
recurring basis, be more appropiately worded by the Director of Finance.
To be
discussed with the Director of
Finance
That an overarching risk be assessed and added to the register in relation to implementation of the Paeds, Obs
& Neonates service change, reflecting also the issues associated with communication and engagement.
Risk 13 updated to
reflect communication
issues. Overarching
riks narrative to be discussed
with Executive Team
That the impending implications of the Welsh Language
Standards and their implementation, be assessed and added to the register.
Added to
register
That the 8 hour target should read 12 hour targets
Completed
Organisational Risk Register Page 5 of 19 Finance, Performance & Workforce Committee
25 October 2018
New Risks The following risks have been added to the register:
• The Bridgend Boundary change, • The Human Tissue Authority (HTA) inspection and related report findings
has been assessed and added to the Register and monitoring of related progress with actions assigned to the Quality, Safety & Risk Committee,
as agreed by the Board in its July 2018 meeting • Maternity, Obstetrics and gynaecology – Maternity Services
Overall analysis
The organisational risk register currently includes 33 Extreme / High risks
which are categorised into the following groupings:
Categories / Risk Rating
Extreme (rated 15 -25)
High (rated 8-12)
Business objectives / projects 5 4
Impact on Safety 9 1
Statutory duty / inspections 8 2
Finance (including claims) 1 1
Workforce / Organisational
Development / Staff Competence
1 0
Service Business Interruptions 0 1
Total Risks 24 (+1)* 9 (-1)**
*(+1) = New Risk 43 has been added,
** (-1) = Risk 039 rotation of board members has been removed.
NB - new risk 43 has yet to be risk assessed for a matrix score and not included in the above table
High / Extreme Risks (Rating 20 and above)
In considering the robustness of a developing organisational risk register,
Board Members need to consider whether the top recorded risks are those that Members of the Board can relate to and indeed evidence that they are
informing the work of the Board and its Committees in delivering its related Strategy.
The top risks outlined within the Organisation’s risk register are:
• Failure to recruit sufficient numbers of medical & dental staff
and its related impact on rotas and finance going forward (also aligned with South Wales Programme outcome),
• Reduction in medical staff training posts,
• Failure to recruit sufficient numbers of registered nursing
staff,
• Increasing dependency on agency staff to cover registered nursing and medical staff gaps,
• Deprivation of Liberties Safeguards (DoLS) mainly associated
Organisational Risk Register Page 6 of 19 Finance, Performance & Workforce Committee
25 October 2018
with the volume / backlog of related assessments, • Fire Safety compliance and ongoing issues with Prince Charles
Hospital (PCH) site (Ground & First Floor),
• Lack of control and capacity to accommodate all hospital follow up outpatient appointments,
• Failure to ensure delivery of a viable balanced/break even 3
year integrated medium term plan, • Achieving financial break even on a recurring basis,
• Human Tissue Authority (HTA) report,
• Bridgend Boundary Change, • Health Records Storage,
• Welsh Language Standards Compliance.
Of the categorised risks, these have been broken down under one of our
existing Strategic Objectives:
• There are currently 24 extreme (increased by 4) and 9 high (reduced by 1) risk, assigned to the Board and its various Committees
• The majority of assessed risks are linked with workforce shortages and
their related impact, which includes GP shortages and Primary Care
Sustainability.
Organisational Risk Register Page 7 of 19 University Health Board Meeting
27 September 2018
Risk Register Category – Business Objectives / Projects (9 risks)
Strategic
Objective
Risk
Reference
Description of risk
identified
Initial
Score
Current
Score
Trend Controls Last
Reviewed
Scrutiny
Committee
Setting the
Direction and
Performance
and
Operational
Efficiency
028
Failure to ensure delivery of a viable
balanced/break even 3 year
integrated medium term plan.
20
(was 16)
20
September
2018
Health Board
015
Reputational damage & potential legal
challenge on the decision making on
Funded Nursing Care (FNC). 16 12
September
2018 Health Board
029
Failure to invest in and develop
Primary Care Services, across RCT
and Merthyr Tydfil but particularly in
the Rhondda Valleys.
16 16
September
2018 Primary & Community
Care
036 Primary Care Workforce - Recruitment
and sustainability 16 16
September
2018 Primary & Community
Care
030
Failure to continue to provide and
sustain GP Out of Hours Services as
currently configured.
16 16
September
2018 Primary & Community
Care
002 Failure to achieve Referral to
Treatment targets. 12 12
(was 20)
September
2018 Finance, Performance
& Workforce
003
Failure to achieve the 4 and 12 hour
emergency (A&E) waiting times
targets. 12 16
September
2018 Finance, Performance &
Workforce
013 Implementation of South Wales
Programme outcomes.
12 12 September
2018 Health Board
023
Failure to meet the timescale relating
to issuing concerns (complaints)
responses to patients and/or carers.
16 12
September
2018 Quality, Safety & Risk
The Trend column indicates whether the risk overall (from when first assessed), is increasing (), reducing () or unchanged ().
The Controls column indicates whether assessed controls overall are improved (), reduced () or unchanged () from when first
assessed. Regardless of whether the risks rating has changed.
Organisational Risk Register Page 8 of 19 University Health Board Meeting
27 September 2018
Risk Register Category - Impact on Safety (10 risks)
Strategic
Objective
Risk
Reference
Description of risk identified Initial
Score
Current
Score
Trend Controls Last
Reviewed
Scrutiny
Committee
To improve
quality,
safety
and patient
experience.
007
Failure to recruit sufficient medical &
dental staff. 25 20
September
2018
Quality, Safety &
Risk
034
Increasing dependency on Agency Staff
cover in Medical and Nursing areas,
which has the potential to impact on
continuity of care and patient safety and
is actually impacting on the UHB
financial position.
20 20 September
2018
Quality, Safety &
Risk
035 Failure to recruit sufficient registered
nursing staff. 20 20 September
2018 Quality, Safety
& Risk
008
Reduction in medical training posts
within various specialties & capacity to
meet workload demands.
20
20
September
2018
Quality, Safety &
Risk
027
Lack of control and capacity to
accommodate all hospital follow up
outpatient appointments.
20
20
(was 16)
September
2018
Finance,
Performance &
Workforce
032 Sustainability of a safe & effective
Ophthalmology Service.
20
16
September
2018 Quality, Safety
& Risk
005
Failure to sustain services as currently
configured to meet cancer targets.
20 16
September
2018
Finance,
Performance &
Workforce
033
Failure to sustain Child & Adolescent
Mental Health Services across the
Network
16 16
September
2018 Quality, Safety &
Risk
037
Ensuring the development, approval and
implementation of a Strategy for IM&T,
that is clinically led and supports staff in
care delivery
12 12
September
2018
Health Board
Organisational Risk Register Page 9 of 19 University Health Board Meeting
27 September 2018
038
Inconsistent approach and arrangements
in place for the management and
monitoring of patients requiring
anticoagulation management within Cwm
Taf UHB.
16 16
September
2018 Primary &
Community Care
(043)
New
Possible Under Reporting of Clinical
Incidents in Maternity Services - - N/A
September
2018
Quality, Safety &
Risk
Risk Register Category – Statutory Duty / Inspections (10)
Strategic
Objective
Risk
Reference
Description of risk
identified
Initial
Score
Current
Score
Trend Controls Last
Reviewed
Scrutiny
Committee
Statutory
Compliance 017 Failure to meet Fire Safety Standards
on ground and first floor PCH. 20 20
September
2018 Quality, Safety &
Risk
021
Failure to ensure all Staff obtain
competency/ compliance with
mandatory training requirements. 16 20
September
2018 Quality, Safety &
Risk
025 Failure to meet Fire Safety
Standards across the UHB. 16 16
September
2018 Quality, Safety &
Risk
018
Failure to achieve statutory and
mandatory planned preventative
maintenance (PPM) programme. 15 15
September
2018 Quality, Safety &
Risk
031
Failure to appropriately apply
Deprivation of Liberties Safeguards
(DoLS) legislation following the West
Cheshire court judgement.
16
(was 12)
12
September
2018 Quality, Safety &
Risk
016 Failure to comply fully with the
arrangements for managing Asbestos 16 12
September
2018 Quality, Safety &
Risk
Organisational Risk Register Page 10 of 19 University Health Board Meeting
27 September 2018
039
(New)
Failure to ensure sufficient storage
capacity (or alternative solutions) are in
place to safely store and secure patient
records.
N/A 16 N/A N/A
September
2018 Quality, Safety &
Risk
040
(New)
Failure to fully comply with all the
requirements of the Welsh Language
Standards, as they apply to the
University Health Board.
N/A 15 N/A N/A
September
2018 Quality, Safety &
Risk
041
(New)
Failure to fully meet all the licensing
requirements of the Human Tissue
Authority in relation to Mortuary &
Services for the Deceased.
N/A 16
N/A
N/A
September
2018 Quality, Safety &
Risk
042
(New)
Failure to ensure successful
implementation of the Welsh
Governments decision to realign the
Health Boundary, as it applies to the
resident population of the Bridgend
County Borough.
N/A 15 N/A N/A
September
2018 Health Board
(Joint Transition
Board)
Risk Register Category – Finance / Including Claims (2)
Strategic
Objective
Risk
Reference
Description of risk
identified
Initial
Score
Current
Score
Trend Controls Last
Reviewed
Scrutiny
Committee
Financial
Viability 011
Failure to achieve financial balance
on a recurring basis and mitigate
reliance on in year non recurring
funding slippage.
15 20
September
2018 Health Board
012
Failure to Deliver Major &
Discretionary Capital programmes 12 12
September
2018 Capital
Programme
Board
Organisational Risk Register Page 11 of 19 University Health Board Meeting
27 September 2018
Risk Register Category – Workforce / Organisational Development / Staff Competency (1)
Strategic
Objective
Risk
Reference
Description of risk
identified
Initial
Score
Current
Score
Trend Controls Last
Reviewe
dd
Scrutiny
Committee
Workforce
Sustainability/
OD and
Innovation
019
Failure to achieve the Management of
Absence target. 15 12
September
2018
Finance,
Performance
& Workforce
Risk Register Category – Service / Business Interruption (1)
Strategic
Objective
Risk
Reference
Description of risk
identified
Initial
Score
Current
Score
Trend Controls Last Reviewed Scrutiny
Committee
Business
Continuity
006
Failure to appropriately manage
Discharge Delays from Hospitals 12
12
(Was 16)
September
2018
Finance,
Performance
& Workforce
Organisational Risk Register Page 12 of 19 University Health Board Meeting
27 September 2018
Quality, safety and patient experience
The Health Board’s risk management arrangements are in place to ensure risks
are assessed and mitigating actions taken to improve the quality, safety and
experience of patients and where appropriate escalation arrangements are in place to inform the Board via its key sub-committees.
Use of resources
There is a significant risk to the service if robust risk based assessment
arrangements are not in place. Good governance arrangements, including effective risk management help to ensure the effective use of resources. It is
important to note that routinely as part of the Internal Audit and Assurance Annual Plan, 3 clinical and 1 corporate directorate undergo a governance review
each year, which includes a review of its risk management arrangements. This
is in addition to the organizational related audit reviews.
Compliance with Legislation There may be an adverse effect on the organization if arrangements are not in
place to manage and mitigate risks.
Performance
Assessment and monitoring of risks within the Health Board is undertaken within Directorates/Localities/Departments. The extreme / high organizational
risks will be monitored by the Executive Team / Board and be reviewed and scrutinized by the Board and/or its Committees.
As a general rule the organisational risk register will be routinely reviewed by
the Quality, Safety & Risk Committee and elements discussed at the Integrated
Governance Committee, although all Committees of the Board have a role to play in ensuring risks assigned to a Board Committee are considered as part of
its work. Risk management arrangements will also be a key element of internal audit work and key risks will help to inform the annual internal audit plan.
4. RECOMMENDATION
The Finance Performance and Workforce Committee is asked to:
• DISCUSS and NOTE the update provided within this report and the risks assigned to the Board and its Committees, and
• ENDORSE the updated risk register and the assignment of risks.
Freedom of
Information
Open
Organisational Risk Register Page 13 of 19 Finance Performance & Workforce Committee
25 October 2018
HEALTH BOARD ORGANISATIONAL RISK REGISTER SUMMARY OF ASSESSED RISKS (OVERALL TREND) – SEPTEMBER 2018
Imp
act/
Co
nse
qu
ence
5 042 Bridgend Boundary change
017 Failure to meet Fire Safety Standards on Ground & First Floor Prince Charles Hospital ↔
031 Failure to appropriately apply DOLS legislation following West Cheshire court judgement
011 Failure to achieve financial balance 007 Failure to recruit Medical & Dental Staff ↔
4
002 Failure to achieve RTT 037 Ensuring the development, approval and implementation of a Strategy for Digital Health, that is clinically led and supports staff in care delivery ↔ 016 Management of asbestos 012 Failure to deliver major and discretionary capital programmes ↔ 006 Discharge delays from acute hospitals ↔ 013 South Wales Plan outcomes ↔ 023 Deterioration in the timescale relating to issuing concerns (complaints) responses to patients and or carers
032 Sustainability of safe & effective Ophthalmology Services
005 Failure to sustain services as currently configured to meet cancer targets
033 Sustaining CAMH Services ↔
029 Failure to Invest in and develop Primary Care Services, particularly in Rhondda ↔
036 Primary Care workforce – recruitment & sustainability ↔
038 inconsistent approach and arrangements in place for the management and monitoring of patients requiring anticoagulation management within CTUHB ↔
025 Failure to meet Fire Safety standards across the UHB ↔ 015 Reputational damage & potential legal challenge (FNC) 030 Continuing to provide GP Out of Hours Services as currently configured 021 Staff competency – compliance with statutory/mandatory training 041 Human Tissue Act compliance mortuary / deceased services
028 Producing Viable balanced 3 year IMTP
034 Increasing dependency on agency staffing (medical & nursing) finance impact↔
035 Failure to recruit registered nursing staff ↔
008 Reduction in medical training posts within various specialities & capacity to meet workload 003 Failure to achieve 4 & 8 hour Emergency access targets.
027 Lack of control & capacity to accommodate Follow Up Outpatients 039 Ensuring Sufficient Health Records Storage
3 019 Failure to achieve the management of absence target
018 Failure to achieve statutory and mandatory planned preventative maintenance programme ↔
040 Compliance with Welsh Language Standards
2
1
C x L
1 2 3 4 5
Likelihood
Organisational Risk Register Page 14 of 19 Finance Performance & Workforce Committee
25 October 2018
Objective: Setting the Direction & Performance & Operational Delivery
Director Lead: Chief Operating Officer
Assuring Committee: Finance, Performance & Workforce
Risk: Failure to achieve Referral to Treatment Times (RTT) Date last reviewed: September 2018
Risk Rating
0
5
10
15
20
25
Jan
-17
Ap
r-1
7
Jul-
17
Oct
-17
Jan
-18
Ap
r-1
8
Jul-
18
Risk Score
Target Score
Rationale for current score:
(consequence x
likelihood):
Initial: 5 x 4 = 20
Current: 4 x 3 = 12
Target: 4 x 2 = 8
The current score reflects year end out turn and the significant
progress made during 2016-18 to address the large volume of
patients awaiting planned treatment.
Rationale for target score:
Effective D&C Plans with improved efficiency in flow, length of stay
and assessment, and some improvement in theatre performance
informs the target score of 8.
Level of Control
=70%
Date added to risk
register
April 2013
Controls (What are we currently doing about the risk?) Mitigating actions (What more should we do?)
• Directorate Demand & Capacity Plans in place (and being further
developed) with regular RTT meetings in place
• Ongoing Flow Programme to address capacity issues
• Improved capacity for Day Surgery and 23:59 case load
• Monthly and Quarterly monitoring of trajectories, routinely discussed
within CBMs
• Routine reporting into Finance, Performance & Workforce Committee
• Surgical Assessment facilities now available on both District General
Hospital sites.
Action Lead Deadline
Continue delivery of the controls in place Ops
Directors
Ongoing
Ensure winter plans to address and respond
to surge in demand are effective and
support continued delivery of RTT
Ops
Directors
Quarter
3 & 4
Develop, implement and monitor
Directorate Demand & Capacity Plans
Ops
Directors
Ongoing
quarterly
Assurances
(How do we know if the things we are doing are having an impact?)
Gaps in assurance
(What additional assurances should we seek?)
Waiting list reductions; better response times from departments / compliance
figures will improve.
Currently off trajectory and improvement actions being taken to
bring performance back in line. F,P&W monitoring progress.
Current Risk Rating
Additional Comments
Ref No.
002
Current Risk Rating : 4 x 3 = 12
The plan last year (and this), was to sustain RTT
position and deliver against the target without (or with
limited) external outsourcing. However, this has not
been possible and additional outsourcing utilised.
Organisational Risk Register Page 15 of 19 Finance Performance & Workforce Committee
25 October 2018
Objective: Setting the Direction & Performance & Operational Delivery
Director Lead: Chief Operating Officer
Assuring Committee: Finance, Performance & Workforce
Risk: Failure to achieve the 4, 8 and 12 hour emergency (A&E) waiting times
targets.
Date last reviewed: September 2018
Risk Rating
0
5
10
15
20
25
Jan
-17
Ap
r-1
7
Jul-
17
Oct
-17
Jan
-18
Ap
r-1
8
Jul-
18
Risk Score
TargetScore
Rationale for current score:
(consequence x
likelihood):
Initial: 4 x 5 = 20
Current: 4 x 4 = 16
Target: 4 x 3 = 12
Whilst the target is not being achieved, the current score reflects an
improved position with almost 90% delivery against 4 hour
performance, which needs to be sustained.
Level of Control
=70%
Rationale for target score:
To meet the emergency access targets set by Welsh Government is
dependent on the patient flow and therefore a target of 12 is
challenging for the unscheduled care service (USC). Date added to risk
register
April 2013
Controls (What are we currently doing about the risk?) Mitigating actions (What more should we do?)
Meeting some targets consistently; however, not all of the time.
Need to strengthen minors streams at both DGH sites to sustain improved
delivery of performance against the 4, 8 and 12 hour targets. Also variable
practice across both A&E departments. Additional minors physical capacity at
RGH has impacted positively and more recently improved performance
approaching 90% against the 4 hour target, with reduced 12 hour wait
breaches.
Action Lead Deadline
1) Clear discharge planning processes in place. COO Ongoing
2) Improvements in the patient flow and
investments to support seasonal planning.
Dep
COO
Ongoing
3) Stay Well At Home (SW@H) Service
introduced and evaluated (6 month).
Dep
COO
January
2018
4) SW@H 2 developments being progressed COO Ongoing
Assurances
(How do we know if the things we are doing are having an impact?)
Gaps in assurance
(What additional assurances should we seek?)
Monthly reporting of 4, 8 and 12 hour performance within the Integrated
Performance Dashboard. Trend overall is one of improvement currently.
None identified although reliant on the recruitment and retention of
appropriate workforce and general improvement in flow across USC.
Current Risk Rating
Additional Comments
Ref No.
003
Current Risk Rating : 4 x 4 = 16
Recruitment and retention of staff essential; closure of
beds in the operational environment challenging when
the numbers of patients continues to rise.
Organisational Risk Register Page 16 of 19 Finance Performance & Workforce Committee
25 October 2018
Objective: To improve quality, safety and patient experience
Director Lead: Chief Operating Officer
Assuring Committee: Finance, Performance & Workforce
Risk: Lack of control and capacity to accommodate all hospital follow up
outpatient appointments
Date last reviewed: September 2018
Risk Rating
0
5
10
15
20
25
Jan
-17
Ap
r-1
7
Jul-
17
Oct
-17
Jan
-18
Ap
r-1
8
Jul-
18
Risk Score
TargetScore
Rationale for current score:
Follow up appointments not booked increasing; concern raised by
Board Members, discussed at Audit Committee, Finance Performance
& Workforce Committee and Quality, Safety and Risk Committee.
Improvement actions not reducing the large numbers of patients
awaiting follow up clinic review.
(consequence x
likelihood):
Initial: 5 x 4 = 20
Current:5 x 4 = 20
Target: 4 x 3 = 12
Level of Control
=60%
Rationale for target score:
Agreed actions approved by Executive Board, being implemented
and routine monitoring in place, which is being aligned with
Integrated Performance Dashboard. Date added to the
risk register
November 2014
Controls (What are we currently doing about the risk?) Mitigating actions (What more should we do?)
• Continued monitoring of progress at Quality Delivery Meetings with WG.
Initial progress with reductions in some specialities but need to change the
current operating model, with actions to address the validated position to
be progressed at pace across directorates.
• Note this matter considered regularly at meetings of the Finance,
Performance & Workforce Committee, where concerns relating to progress
and pace of progress were noted and escalated to the Executive.
• Further revised actions agreed along with follow up of progress and related
monitoring at F, P & W.
• Exploring patient safety implications for some categories of follow ups not
booked for consideration by the Executive Board and at Q,S&R Committee
where further audit related action is being undertaken.
• Recently considered at December 2017 IG Committee.
Action Lead Deadline
1) Scoping exercise undertaken –small
investment agreed, will require more
COO /
DPC&MH
Ongoing
2) Actions by speciality agreed, the
outcome from which will help capacity and
demand planning.
COO /
DPC&MH
Ongoing
3) Service redesign proposals developed by
speciality, to be implemented linked to D&C
Plans.
COO /
DPC&MH
In
Progress
4) Action plans with agreed timescales
established and linked to D&C plans with
regular monitoring of progress but capacity
not sufficient.
COO /
DPC&MH
Ongoing
Assurances
(How do we know if the things we are doing are having an impact?)
Gaps in assurance
(What additional assurances should we seek?)
Some initial progress made. Still further work needed to address and reduce
volume. Further WAO review did not provide assurance of progress.
Need to better understand any safety implications for follow ups not
booked and patients waiting past clinic review dates.
Current Risk Rating Additional Comments Ref No.
027 Current Risk Rating : 5 x 4 = 20
Note Report on actions taken and proposed presented to
Executive Board (September 2018). Additional
investment needed to address backlog at pace. D&C
plans not sufficient – not enough capacity
Organisational Risk Register Page 17 of 19 Finance Performance & Workforce Committee
25 October 2018
Objective: To improve quality, safety and patient experience
Director Lead: Chief Operating Officer
Assuring Committee: Finance, Performance & Workforce
Risk: Failure to sustain services as currently configured to meet cancer
targets
Date last reviewed: September 2018
Risk Rating
0
5
10
15
20
25
Risk Score
Target Score
Rationale for current score:
(consequence x
likelihood):
Initial: 5 x 4 = 20
Current: 4 x 4 = 16
Target: 4 x 3 = 12
An overall reducing trend in current risk assessed score. Whilst
target not consistently being met, general improvement trajectory
which needs to be sustained.
Level of Control
=70%
Rationale for target score:
Target score reflects the challenge this area of work present the
Board and where small numbers of patients impact on the potential
to breach target. Date added to the
risk register
April 2014
Controls (What are we currently doing about the risk?) Mitigating actions (What more should we do?)
• Tight management processes to manage each individual case on the
unscheduled care (USC) Pathway.
• Initiatives to protect surgical capacity to support USC pathways have been
put in place in RGH and PCH to protect core activity.
• Prioritised pathway in place to fast track USC patients.
• Ongoing comprehensive demand and capacity analysis with directorates to
maximise efficiencies.
• Overall Cancer target performance plateau at around 90% with ongoing
monitoring of related actions in place at F,P&W Committee.
• Small numbers of patients breaching which is impacting on sustained
delivery of the 31 and 62 day target.
Action Lead Deadline
Introduction of revised models for rapid
diagnostic review / assessment in cancer
pathways being introduced.
COO /
DPC&MH
Med Dir
In
Progress
(Nov17)
Continue close monitoring of each patient
on the USC pathways to ensure rapid flow
of patients through the pathway.
COO /
DPC&MH
Med Dir
Ongoing
Some speciality challenges remain in Lung
and Urology - Action plans in place, along
with monitoring.
COO /
Med Dir
Ongoing
Assurances
(How do we know if the things we are doing are having an impact?)
Gaps in assurance (What additional assurances should we
seek?)
General improvement (sustained) trajectory. Need to continue improvement
actions and close monitoring. Early diagnosis pathway launched and impact
being closely monitored.
The need to deliver sustained performance.
Current Risk Rating Additional Comments Ref No.
005 Current Risk Rating : 4 x 4 = 16
Will need to monitor the effectiveness and impact of the
early cancer diagnosis pathway and single cancer
pathway, whilst maintaining review of current service
delivery / performance.
Organisational Risk Register Page 18 of 19 Finance Performance & Workforce Committee
25 October 2018
Objective: Workforce Sustainability/Organisational Development and
Innovation
Director Lead: Director of Workforce & OD
Assuring Committee: Finance, Performance & Workforce
Risk: Failure to achieve the Management of Absence target Date last reviewed: September 2018
Risk Rating
0
5
10
15
20
25
Risk Score
Target Score
Rationale for current score:
(consequence x
likelihood):
Initial: 5 x 4 = 20
Current: 4 x 3 = 12
Target: 4 x 2 = 8
Overall there is a small improvement in trend across the UHB and the
overall risk score aligns to the improvement trajectory and
strengthened controls in place.
Level of Control
=80%
Rationale for target score:
Failure to achieve the Management of Absence target (although
greater risk is the impact absence is having on patient safety / care,
workforce and associated cover costs) Target is 5% Date added to risk
register
April 2012
Controls (What are we currently doing about the risk?) Mitigating actions (What more should we do?)
The Workforce Team, through the business partner model are continuing to
work proactively with Directorates to manage and reduce sickness absence
rates. Regular training is also provided by the Team, including;
• Identification of hot spot areas and deep dives undertaken;
• Improving the processes around access and timeliness of Occ Health
support (Joint consultant appointment with neighbouring Health Board);
• Sickness audits in place and routinely discussed at CBMs;
• Improving availability via ESR of real time data;
• Presentation (including deep dives) on position and actions made to
Executive Board, WIPF and Finance, Performance & Workforce Committee;
• All Wales Sickness Policy adopted and being applied across the UHB.
Action Lead Deadline
Maintain existing controls and ensure
consistent application by Line Managers of
the All Wales Policy / Procedures.
JD
All
Directors
Ongoing
with
monitoring
Regular review and assessment of sickness
management to take place routinely at
CBMs.
JD
All
Directors
Ongoing
with
monitoring
Continue the business partner model to
support directorates to proactively manage
sickness absence.
JD
Ongoing
Assurances
(How do we know if the things we are doing are having an impact?)
Gaps in assurance
(What additional assurances should we seek?)
Some small reductions in overall sickness levels achieved. Need to continue
to monitor improvement and sustain actions.
Need to maintain improvement actions and continue to reinforce the
role of line management in consistently applying the Policy /
Procedure.
Current Risk Rating
Additional Comments
Ref No.
019
Current Risk Rating : 5 x 3 = 12
Organisational Risk Register Page 19 of 19 Finance Performance & Workforce Committee
25 October 2018
Objective: Business Continuity
Director Lead: Chief Operating Officer
Assuring Committee: Finance, Performance & Workforce
Risk: Failure to appropriately manage Discharge Delays from Hospitals Date last reviewed: September 2018
Risk Rating
0
5
10
15
20
25
Risk Score
Target Score
Rationale for current score:
(consequence x
likelihood):
Initial: 5 x 4 = 20
Current: 4 x 3 = 12
Target: 4 x 3 =12
The current score reflects the overall improvement in reductions in
DTOCs with a number of related initiatives established to reduce, in
partnership with Local Authority colleagues.
Level of Control
=70%
Rationale for target score:
The target score reflects the requirement to reduce the numbers of
patients delayed, whilst the impact can be significant for patients
whose discharge is delayed, for them individually and for those
awaiting admission.
Date added to the
risk register
April 2013
Controls (What are we currently doing about the risk?) Mitigating actions (What more should we do?)
• Grouping of complex discharges; Implementation of Anticipated Date of
Discharge (ADD), significant improvements following focus on flow work.
• Working with Local Authority partners within the consortium to develop a
partnership response.
• General staff awareness being raised with regards the court ruling and its
related impact.
• New UHB Deprivation of Liberties Safeguarding (DoLS) team set up and
strengthened to support assessment and discharge. Prioritisation process
in place for DoLs applications and training for all disciplines.
• Internal Audit report on DoLS to Audit Committee (April 2016) provides
limited assurance in relation to the backlog in assessment required. Action
Plan in place to address and recent additional investment to help address
some of the actions and mitigate the risks provided.
Action Lead Deadline
Ensure robust monitoring arrangements are
maintained and actions in place to mitigate
flow barriers and escalate impact on flow
COO /
DPC&MH
Ongoing
Ensure the DoLS action plan is delivered
(monitoring is via Audit Committee)
Nurse
Director
Complete
Maintain Flow improvement work and
ensure all enablers (including planned
benefits) to reduce dependency on hospital
and appropriately support patients in their
own communities are realised.
COO /
DPC&MH
Ongoing
Assurances
(How do we know if the things we are doing are having an impact?)
Gaps in assurance
(What additional assurances should we seek?)
The overall reduced trend in numbers, provides assurance that the
improvement actions are having a positive effect.
As there is seasonal volatility in DTOCs, important still to monitor our
position routinely. In relation to DoLS actions important to monitor
progress with Limited Assurance & WAO Report at Audit Committee.
Current Risk Rating
Additional Comments
Ref No.
006
Current Risk Rating : 4 x 3 = 12
Maintain monitoring and joint working with Partners
2.4 To receive a Clinical Deep Dive into Urology
1 2.4 Clinical Deep Dive Urology Paper FPW 25 Oct 2018 GR.doc
Urology Service Update Page 1 of 14 Finance, Performance & Workforce Committee
25 October 2018
AGENDA ITEM 2.4
25 OCTOBER 2018
Finance, Performance & Workforce Committee Report
UROLOGY SERVICE DEEP DIVE RELATING TO CANCER BREACHES
Executive Lead: Chief Operating Officer, John Palmer
Author: Assistant Director of Surgery, Deb Lewis
Contact Details for further information: Deb Lewis, Assistant Director of
Surgery – [email protected]
Purpose of the Finance, Performance & Workforce Committee Report
The purpose of this report is to provide the Finance, Performance & Workforce (FPW) Committee with a Deep Dive update on the Urology service provision at
Cwm Taf UHB, focussing on the achievement of the Welsh Government’s
Cancer Waiting Time Targets.
Governance
Link to Health Board
Strategic Objective(s)
The Board’s overarching role is to ensure its strategic objectives, and the related organisational objectives outlined
within the 3 Year Integrated Medium Term Plan 2018-2021, are being progressed. Aligned with the ‘Quadruple Aim’
described within ‘A Healthier Wales’ (Welsh Government, June 2018) these objectives are:
• To improve quality, safety and patient experience. • To protect and improve population health.
• To ensure that the services provided are accessible and sustainable into the future.
• To provide strong governance and assurance.
• To ensure good value based care and treatment for our patients in line with the resources made available to the
Health Board. This report focuses on all of the above objectives.
Supporting evidence
N/A
Engagement – Who has been involved in this work?
The data and information contained within the dashboard originates from a variety of sources which have a number of engagement processes associated
with them.
Urology Service Update Page 2 of 14 Finance, Performance & Workforce Committee
25 October 2018
Finance, Performance & Workforce Committee Resolution (insert √) To;
APPROVE ENDORSE DISCUSS √ NOTE √
Recommendation The Finance, Performance & Workforce Committee is asked to:
• DISCUSS and NOTE the Urology Service Deep Dive and the associated performance actions
to support the achievement of cancer targets.
Summarise the Impact of the Finance, Performance & Workforce
Committee Report
Equality and
diversity
There are no directly related Equality and
Diversity implications as a result of this report.
Legal implications None.
Population Health A number of indicators monitor progress in relation to Population Health and the impact of
cancer diagnosis and treatment upon it.
Quality, Safety & Patient Experience
A number of indicators monitor progress in relation to Quality, Safety and Patient
Experience.
Resources There are no directly related resource
implications as a result of this report.
Risks and Assurance The Urology Service Update lists where performance is not compliant with national or
local targets.
Health and Care
Standards
The 22 Health & Care Standards for NHS Wales
are mapped into the 7 Quality Themes: Staying Healthy; Safe Care; Effective Care;
Dignified Care; Timely Care; Individual Care;
Staff & Resources http://www.wales.nhs.uk/sitesplus/documents/1
064/24729_Health%20Standards%20Framework_2015_E1.pdf
The work reported in this summary and related appendices take into account many of the related
quality themes.
Workforce A number of indicators monitor progress in
relation to Workforce.
Freedom of information status
Open.
Urology Service Update Page 3 of 14 Finance, Performance & Workforce Committee
25 October 2018
UROLOGY SERVICE DEEP DIVE RELATING TO CANCER BREACHES
1. SITUATION / PURPOSE OF REPORT
The purpose of this report is to provide the Finance, Performance & Workforce
(FPW) Committee with a Deep Dive update on the Urology service provision at Cwm Taf UHB, focussing on the achievement of the Welsh Government’s Cancer
Waiting Time Targets.
2. BACKGROUND / INTRODUCTION
The Finance, Performance and Workforce Committee has received a number of
reports providing updates on urology as part of performance reporting in the
normal course of FPW business over recent months. In particular, a decline in urology performance was identified at the July FPW meeting and Members
requested that a report be brought back to the Committee outlining initial improvement activities that had been completed. This report provides an
update on progress across a number of key quality and performance targets, specifically:
• the ability to achieve compliance with the 31 and 62 day Cancer
Targets and progress towards the implementation of the Single Cancer Pathway
• Sustained delivery of the Referral to Treatment (RTT) 36 week target; and
• Service delivery issues affected by the reconfiguration of services other than Urology.
3. ASSESSMENT / GOVERNANCE AND RISK ISSUES
3.1 Service Profile
The Urology service sits within the portfolio of the Assistant Director of Surgery and within the Directorate of Surgery that covers Urology, General Surgery and
Trauma & Orthopaedics. The department provides services across our two District General Hospital’s (DGHs) (outpatient clinics, diagnostics and inpatient
and daycase surgery), and on three community hospital sites (outpatient clinics only). The following services are provided:
• Core urology
• Percutaneous and laparascopic surgery • Andrology, including a tertiary level service; and
• Oncology.
3.2 Workforce
The service remains challenged by its current workforce profile, particularly in
relation to the medical workforce. The profile of the workforce is outlined below.
Urology Service Update Page 4 of 14 Finance, Performance & Workforce Committee
25 October 2018
Table 1 – Current workforce model
Staff
Group
Establishment Vacancies
Consultants
• 5 WTE Consultants covering:
Core Urology Percutaneous and
Laparoscopic Surgery
Andrology Oncology.
• 2 WTE
vacancies currently
covered by
locum Consultants.
Middle
Grades
• 2 WTE Registrars
• (2 training ST and 1 specialty doctor)
• 1 WTE SHO (CT2)
• 1 x CT2 from
August (locum is now covering
this post)
Juniors • 1 WTE F1
Nursing • 1 WTE ANP
• 3 WTE NP • 1 WTE SCP
• 1 WTE Urology team assistant
Admin Support
• 4.5 WTE band 4 • 1.5 WTE band 3
• 0.6 WTE band 2
• 1.9 WTE band 4
The main area of concern relating to the medical workforce is its long term
reliance upon locum consultants; although the service is currently relatively stable with three permanent and two long-term locum consultants in situ. This
provision is at a relatively high cost and outside of the current allocated medical staff budget. A recent recruitment drive to attempt to put in place a
substantive workforce structure attracted interest from some potentially appointable medical staff, however, unfortunately all of the potential applicants
withdrew their applications prior to interview. Informal feedback from the candidates on the reasons for withdrawing applications included:
• Concerns around the provision of a 1:5 consultant rota across two (and
after April 2019 potentially three) hospital sites • Lack of a robust middle grade tier rota; and
• Concern about the pending integration with Princess of Wales (POW)
Hospital, given the fragility of its urology service.
Work is progressing through the Transition programme clinical work streams to provide more clarity on the future service, with the aim of providing a
compelling vision of the service that will secure further substantive consultants to join our current team (which is generally acknowledged as containing
outstanding individuals).
Urology Service Update Page 5 of 14 Finance, Performance & Workforce Committee
25 October 2018
3.3 Performance
The service currently delivers services that feature in the target reports for both
Referral to Treatment (RTT) and Cancer Waiting Times.
Referral to Treatment (RTT)
As can be seen from the table below, the service delivered the zero breach position required at the end of the financial year. This was for the second year
in a row and is expected to also be delivered for 2018/19.
Table 2 – RTT Performance Apr 2017 – Aug 2018
RTT Performance 2017/18
Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18
Breached 15 32 38 39 56 54 40 54 61 51 19 0
RTT Performance 2018/19
Apr 18 May 18 Jun 18 Jul 18 Aug 18
Breached 16 19 46 43 51
The demand and capacity plans developed for the service are balanced overall.
However, due to the small consultant numbers, the sub-specialty element of the service continues to pose a significant month on month challenge, even
though patient numbers are also relatively small.
The capacity available within the service is impacted considerably by high suspected cancer demand. This is the case for outpatient, diagnostic and
surgical capacity. In addition, the sub-specialism in Andrology has further impact due to the relatively high levels of out of area referrals into the service.
Work is ongoing with Commissioning colleagues to ensure that any tertiary elements of the service are appropriately monitored and that tariffs are
proportionate to the impact on the service.
Cancer 62 day Target
The graph below outlines the Health Board’s overall performance against the 62
day cancer target. The further detail relates specifically to Urology.
As can be seen and is reflected to the Committee on a monthy basis, the Health Board performance against the 62 day target since January 2017 has fluctuated
between 81% and 94%. The average number of monthly breaches has been 8 (range 3 to 14).
Urology Service Update Page 6 of 14 Finance, Performance & Workforce Committee
25 October 2018
Graph 1 – Urgent Suspected Cancer (USC) Monthly Performance
The same graph below shows the performance in Urology only where performance ranges between 30% and 80% with average breaches of 5.2
(range 2 to 10).
Graph 2 – Urology monthly performance
As already noted above, there remains a high demand on the service for patients referred with symptoms that are suspicious for urological cancers.
Urology Service Update Page 7 of 14 Finance, Performance & Workforce Committee
25 October 2018
Although the number of patients receiving a positive cancer diagnosis remains consistent with an average of 14 per month via USC and 17 per month Non-
Urgent Suspected Cancer (NUSC), the volume of patients referred into the
service with cancer symptoms is showing an upward trend since January 2017. Our internal referral data shows the average referred into the service from Jan-
2017 to September 2018 is 1,037 per month, with a range between 916 and 1,221 (as shown in Graph 3 below). This gives an overall detection rate for
cancer referrals of between 2.4% and 4.7%, the lowest detection rate of all tumour sites.
3.4 Performance improvement
Although performance against the 62 day Cancer Target across Wales is
problematic within Urology, the Health Board acknowledges that performance in Cwm Taf UHB over the last 12 months has been a particular issue. This was
raised appropriately via the Finance Performance and Workforce Committee and an improvement plan has been put in place.
That improvement plan focused on the two main pathways within the Urology Cancer service; Haematuria (bladder cancer) and Prostate.
Within both pathways the primary cause of breaches within the Health Board
was delays for diagnostic investigation and the subsequent reporting of results:
• Flexible cystoscopy • CT
• MRI • TRUS biopsy
• Histology.
Graph 3 – Urology Urgent Suspected Cancer (USC) referrals
900
950
1000
1050
1100
1150
1200
1250
Urology Suspected Cancer Referrals
Urology Service Update Page 8 of 14 Finance, Performance & Workforce Committee
25 October 2018
One of the main elements of the Directorate’s plan to improve the patient
pathway within Urology was the development of the Treatment Centre at the
Royal Glamorgan Hospital (RGH). This facility houses the Urology clinical team with dedicated diagnostic rooms to facilitate the one-stop pathways within a
single unit. The implementation of this facility has been challenging, and it became fully functional in October 2018.
Haematuria
In March 2018 the Health Board implemented a six month pilot of a one-stop
haematuria pathway, which is included at Appendix 1 for information. The service had previously implemented what was originially considered to be a
“one-stop” pathway but this included only the initial USS and flexible cystoscopy. Patients continued to experience further delays for CT scans. In
addition, the new one-stop service includes:
• A designated Ultrasound machine within the one stop haematuria clinic
• All patients with visible haematuria requiring a CT scan will have this following their flexible cystoscopy (on the same day); and
• If a renal tumour or invasive bladder cancer is detected on USS, it is intended the necessary staging investigation are carried out on the same
day.
The implementation of this pathway required considerable collaborative working between the urology and radiology departments. The six month pilot has now
completed and although a formal report is yet to be produced, initial findings are positive in that:
• Of the active patients referred post July 2018, there are no breaches on this
pathway, with 45 days being the current longest wait and this patient has surgery booked imminently; and
• The average wait for these patients to get to clinic was 12 days.
Prostate
The pathway for suspected and confirmed prostate cancer patients has
historically been problematic, which is replicated across both NHS Wales and NHS England. Within Cwm Taf UHB, the pre-diagnosis pathway is delivered
locally but for patients with a positive diagnosis the surgical treatment is delivered within the tertiary unit at the University Hospital of Wales. Both sides
of this pathway have had inherently long delays for patients. In addition, the nationally agreed pathway has seen changes in recommended clinical practices,
which has posed further challenges.
The Health Board has had a one-stop prostate pathway in place since 2016. However, due to fluctutations in capacity, particularly for the radiology
elements of the pathway, it has struggled to be delivered consistently within
the 62 day target.
Urology Service Update Page 9 of 14 Finance, Performance & Workforce Committee
25 October 2018
Over the last 4 years the number of confirmed prostate cancers has remained relatively constant, however the number of trans-rectal ultrasound (TRUS)
guided biopsies undertaken has increased by 37% (443 in 2011/2012 to 609 in
2015/2016). The National Institute for Health and Care Excellence (NICE) recommendations for repeat biopsies on active surveillance patients; the
lowering of age related Prostate-Specific Antigen (PSA) reference ranges; and requirement for repeat biopsies when an abnormality is identified on MRI scan,
have all contributed to a substantial increase in prostate biopsy numbers.
The original prostate pathway required patients to undergo a standard TRUS biopsy prior to MRI (undertaken in separate outpatient appointments).
Depending on the MRI results, some patients are then required a repeat (targeted) biopsy.
In March 2018, a revised pathway was developed, with first phase
implementation in July 2018. The pilot pathway realised centralisation of the Royal Glamorgan Hospital (RGH) Prostate pathway into the Treatment Centre
with all patients deemed clinically suitable for a one-stop process, receiving
their consultation, counselling, and both MRI and TRUS biopsy at the same visit. There are some patients who, due mainly to medication regimes, are not
able to have investigations on the same day as their consultation and they are treated via a 2-stop pathway.
It was anticipated that patients referred in from 1 July 2018 onwards would
follow the designated pathway which is included at Appendix 2 for information. However, this proved difficult to achieve due to summer annual leave and
although the pathway improved from this point, it is only for patients referred from 1 September 2018 onwards that we are seeing the overall
improvements anticipated. It should be noted however that there are still patients in the system who were referred before 1st July 2018 which may
breach the pathway once treated.
The most recent review of the prostate pathway is showing:
• There are currently 26 active urgent suspected cancer (USC) patients who
were referred in prior to July 2018. Currently 24 of these look likely to breach the 62 day path pre-validation. The average wait to date is 97 days
with the longest wait at 170 days
• There are 11 active USC patients who were referred in during July 2018. Unfortunately six of these are likely to be considered breaches pre
validation. The average wait to date is 51 days with the longest 84 days. This was prior to any change in capacity
• There are 129 active USC patients who were referred in from August 2018
onwards. There are no patients who are likely to breach to date. The longest wait to date is 60 days. This is a significant improvement on the pre August
position
Urology Service Update Page 10 of 14 Finance, Performance & Workforce Committee
25 October 2018
• Although the average wait for OSPBC improved to 14 days maximum it has plateaued at around 22 days maximum since early September. (This figure
also includes a number of patients who previously would have attended two
stops.) This compares to the average wait of 35 days and the maximum wait of 45 days pre August 2018.
• The largest impact on pathway improvement, however is the reduction in
patients who had to attend for separate TRUS and biopsy (BX) and MRI. These patients made up over 50% of the breach numbers we have seen in
2018. There are now significantly less patients missing a one stop service due to capacity, which has reduced the delays in pathways.
The table below illustrates the anticipated net result of these issues and
improvements:
Forecast for next 3 months
September 18 October 18 November 18
USC Best Case
82% USC Best Case
88% USC Best Case
90%
No Treated
60 No Treated
60 No Treated
60
No
Breaches
11 No
Breaches
7 No
Breaches
6
USC
worst Case
80% USC
worst Case
85% USC
Worst Case
87%
No
Treated
60 No
Treated
60 No
Treated
60
No
Breaches
12 No
Breaches
9 No
Breaches
8
NUSC
estimate
98% NUSC
estimate
98% NUSC
estimate
98%
As noted, the main issues that will impact on performance are:
• We are still managing Urological patients and reporting patient breaches
through to their treatment pathways, which were delayed at diagnostics between March and June
• We are expecting a drop in performance in September’s reporting as we continue to clear the backlog of those patients delayed at the front end
earlier in the year • The position regarding USC patients commencing their pathway from August
2018, shows a significant improvement in performance and expected breach
numbers going forward • There are no main issues identified in other tumour sites, aside from a
general issue in radiology capacity with timely CT reporting. A cancer pathway coordinator is also shortly to be appointed in radiology to improve
the timeliness of appointments and reporting of patients on cancer pathways.
Urology Service Update Page 11 of 14 Finance, Performance & Workforce Committee
25 October 2018
The following actions are being taken to mitigate the impact of the above:
• Enhanced scrutiny for the whole Urological pathway by the Urological cancer pathway coordinator, who has worked with the urological Clinical Nurse
Specialist (CNS) to manage the pathways and escalate these patients on a daily basis
• Increased capacity for the two main Urological pathways from 1st July onwards; this will be reflected in those patients being treated from
September onwards • Continous monitoring of one stop diagnostic capacity to ensure delays are
not recurring at the front end of the pathway.
It should also be noted that the pathways being implemented within Cwm Taf UHB are considered to be best practice across NHS Wales and England. A
recent national Single Cancer Pathway workshop focussed on Urology pathways and we were able to show that we were among the first to have implemented
them successfully. The challenge is to sustain delivery in an area of increasing
demand and with consistently challenging workforce issues.
It should also be noted that the pathway improvements implemented ensure that patients can be referred for tertiary treatment in a timely manner.
Unfortunately once a patient is referred to the tertiary unit we relinquish an element of control on the pathway and there remains a risk that patients will
breach the pathway. The cancer service team continue to work closely with colleagues in tertiary centres to highlight patients at risk of breaching and to
develop innovative treatment pathways acorss the full spectrum of the service.
3.5 Resources
In addition to the physical pathway changes implemented in these two pilots, non-recurrent investment has also been made into a cancer pathway co-
ordinator. This is a crucial resource requirement if we are to sustain and
further improve these clinical pathways. As the initial funding was non-recurrent, there is a need for a band 4/5 cancer pathway co-ordinator role to be
appointed on a substantive basis and this will therefore be included in the Integrated Medium Term Plan (IMTP) for 2019/20.
3.6 Future Changes
As has been noted previously, Health Boards are now required to report against
Welsh Government’s new Cancer target; the Single Cancer Pathway. Under this target all patients with symptoms suspicious of cancer will be expected to
receive a first definitive treatment within 62 days of the suspicion being noted. The majority of Urology patients diagnosed with cancer are reported under the
current 31 day target, which poses a further challenge for the diagnostic elements of the service. However, the Welsh Cancer Network is working closely
with Health Boards to identify demand and capacity needs for implementation
of the Single Cancer Pathway (SCP) and we continue to be at the forefront of this work.
Urology Service Update Page 12 of 14 Finance, Performance & Workforce Committee
25 October 2018
4. RECOMMENDATION
The Finance, Performance & Workforce Committee is asked to:
• DISCUSS and NOTE the Urology Service Deep Dive and the associated
performance actions to support the achievement of cancer targets.
Freedom of information status
Open
Urology Service Update Page 13 of 14 Finance, Performance & Workforce Committee
25 October 2018
APPENDIX 1
Urology Service Update Page 14 of 14 Finance, Performance & Workforce Committee
25 October 2018
APPENDIX 2
2.5 Update report on cancer breaches- FPW 25 Oct 2018
1 2.5 Update report on cancer breaches- FPW 25 Oct 2018 GR.doc
Update Report Cancer Breaches Page 1 of 4 Finance, Performance and Workforce Committee
25 October 2018
AGENDA ITEM 2.5
25 October 2018
Finance, Performance and Workforce Committee Report
UPDATE ON CANCER PERFORMANCE
Executive Lead: Kamal Asaad, Medical Director / Balan Palaniappan, Lead Cancer Clinician
Author: Wayne Jenkins, Lead Cancer Manager
Contact Details for further information: Wayne Jenkins, Lead Cancer
Manager [email protected]
Purpose of the Finance, Performance and Workforce Committee
Report
The purpose of the report is to provide the Finance, Performance and
Workforce Committee with an update on the latest performance for Urgent Suspected Cancer (USC) and Non Urgent Suspected Cancer (NUSC)
cancer targets which are a tier 1 priority for Health Boards.
Governance
Link to Health Board Strategic
Objective(s)
The Board’s overarching role is to ensure its strategic objectives, and the related organisational objectives
outlined within the 3 Year Integrated Medium Term Plan 2018-2021, are being progressed. Aligned with
the ‘Quadruple Aim’ described within ‘A Healthier Wales’ (Welsh Government, June 2018) these
objectives are: • To improve quality, safety and patient experience.
• To protect and improve population health. • To ensure that the services provided are accessible
and sustainable into the future. • To provide strong governance and assurance.
• To ensure good value based care and treatment for
our patients in line with the resources made available to the Health Board.
This report focuses on all of the above objectives.
Supporting
evidence
Welsh Government Referral to Treatment (RTT) Times
management rules.
Engagement – Who has been involved in this work?
-
Update Report Cancer Breaches Page 2 of 4 Finance, Performance and Workforce Committee
25 October 2018
Finance, Performance and Workforce Committee Resolution to:
APPROVE ENDORSE DISCUSS NOTE √
Recommendation The Finance, Performance and Workforce Committee is asked to:
• NOTE the report and the issues raised in
the achievement and sustainability of the target delivery.
Summarise the Impact of the Finance, Performance and Workforce Committee Report
Equality and
diversity
No implications have been highlighted from an
equality and diversity perspective
Legal implications No known legal implications
Population Health There are no known population health
implications
Quality, Safety &
Patient Experience
Urgent Suspected Cancer (USC) and Non Urgent
Suspected Cancer (NUSC) cancer targets are a tier 1 priority for Health Boards.
Resources There are no further resource issues
Risks and Assurance The attached reports outline any issues of risk
and assurance for the Committee.
Health and Care Standards
The 22 Health & Care Standards for NHS Wales are mapped into the 7 Quality Themes:
Staying Healthy Safe Care
Effective Care Dignified Care
Timely Care Individual Care
Staff & Resources
http://www.wales.nhs.uk/sitesplus/documents/1064/24729_Health%20Standards%20Framework
_2015_E1.pdf
Workforce n/a
Freedom of
information status
Open
Update Report Cancer Breaches Page 3 of 4 Finance, Performance and Workforce Committee
25 October 2018
UPDATE ON CANCER PERFORMANCE
1. SITUATION / PURPOSE OF REPORT
The purpose of the report is to provide the Finance, Performance and Workforce Committee with an update on the latest performance for Urgent Suspected
Cancer (USC) and Non Urgent Suspected Cancer (NUSC) cancer targets which are a tier 1 priority for Health Boards.
2. BACKGROUND / INTRODUCTION
There are two cancer targets:
• 31 days to treatment for 98% of patients not referred in as USC, • 62 days to treatment for 95% of patients referred in as USC. (A local
delivery target of 90% has been agreed with Welsh Government due to
the low treatment numbers within Cwm Taf UHB)
A number of Cwm Taf residents receive the treatment part of their pathways at tertiary centres at Cardiff and Vale UHB and Velindre. If Cwm Taf refers a case
within half of the pathway then the delivery responsibility passes to the treating centre. Otherwise responsibility remains with the originating health board. (We
reflect this as ‘True Performance’ in the table below.)
The Health Board has managed to deliver the NUSC target on a sustained basis over time.
The table below shows the performance against both targets for the last 3
months.
Month NUSC True Performance
USC True Performance
Target 98% 90%
August 2018 100% 86.25%
July 2018 100% 86.25%
June 2018 100% 88%
The latest report prepared for Welsh Government is attached at Appendix 1
for information.
The report highlights that the main challenge facing the Health Board in achieving and sustaining the USC target is with Urological Cancers. The report
clarifies the actions taken to address the issues raised.
Update Report Cancer Breaches Page 4 of 4 Finance, Performance and Workforce Committee
25 October 2018
3. ASSESSMENT / GOVERNANCE AND RISK ISSUES
This report provides an assurance that the Health Board has effective processes in place to manage and monitor performance across a range of indicators and
key issues, in particular where there are current organisational challenges.
4. RECOMMENDATION
The Finance, Performance and Workforce Committee is asked to:
• NOTE the report and the issues raised in the achievement and
sustainability of the target delivery.
Freedom of
information status
Open
2.5.1 Appendix 1 - Monthly Cancer Performance Report Aug 18wj
1 2.5.1 Appendix 1 - Monthly Cancer Performance Report FPW 25 Oct 2018 GR.docx
1
2.5.1 Appendix 1
Monthly Cancer Performance Report – Cwm Taf
August 2018
Main reasons cancer targets not met this month and actions taken to mitigate harm
Non Urgent Suspected Cancer (NUSC) – 97% achieved with 4
breaches. 2 breaches were Urological, treated at Cardiff and Vale UHB and had date of decision to treat (DoDT) and the whole wait at
Cardiff and Vale. 2 breaches were Upper Gastrointestinal treated at Velindre and had DoDT and whole wait there. Cwm Taf true
performance is 100%.
Urgent Suspected Cancer (USC) – 85% achieved with 12 breaches, although 1 breach (Lung) was referred on within 31 days,
therefore Cwm Taf true performance is over 86%.
Urology accounted for 9 of the USC breaches, which reflects the
recent challenges reported over the last few months in this tumour site. We have addressed the main issue, which is capacity for One
Stop Prostate Biopsy Clinic and one stop haematuria clinic this will be reflected in improved performance from October onwards as
patients reach the main diagnostic events earlier in the pathway.
Forecast for next 3 months
September 18 October 18 November 18
USC Best
Case
82% USC Best
Case
88% USC Best
Case
90%
No
Treated
60 No
Treated
60 No
Treated
60
No
Breaches
11 No
Breaches
7 No
Breaches
6
USC worst
Case
80% USC worst
Case
85% USC Worst
Case
87%
No
Treated
60 No
Treated
60 No
Treated
60
No Breaches
12 No Breaches
9 No Breaches
8
NUSC estimate
98% NUSC estimate
98% NUSC estimate
98%
Reasons for not achieving target in next 3 months
Issues and challenges
We are still managing Urological patients and reporting patient breaches through to their treatment pathways, which were delayed
at diagnostics between March and June.
2
We are expecting a drop in performance in September’s reporting
as we continue to clear the backlog of those patients delayed at the front end earlier in the year.
The position regarding USC patients commencing their pathway
from August 2018, shows a significant improvement in performance and expected breach numbers going forward.
There are no main issues identified in other tumour sites, aside from a general issue in radiology capacity with timely CT reporting.
A cancer pathway coordinator is also shortly to be appointed in radiology to improve the timeliness of appointments and reporting
of patients on cancer pathways.
Actions to be taken in next few months to improve performance
We have implemented enhanced scrutiny for the whole Urological
pathway by putting in place a Urological cancer pathway coordinator, who has worked with the urological CNS to manage
the pathways and escalate these patients on a daily basis.
We have put in place increased capacity for the two main Urological pathways from 1st July onwards and this will be reflected in those
patients being treated from September onwards.
We are continuing to monitor one stop diagnostic capacity and ensure delays are not reoccurring at the front end of the pathway.
Number of cancelled cancer operations due to emergency
pressures or other for this month (please detail whether they have since been rescheduled and the reason for the
cancellation)
None
2.6 INNU update report FPW 25 Oct 2018 GR
1 2.6 INNU update report FPW 25 Oct 2018 GR.docx
Interventions Not Normally Undertaken (INNU) update
Page 1 of 11 Finance, Performance & Workforce Committee
25 October 2018
AGENDA ITEM 2.6
October 2018
Finance, Performance & Workforce Committee Report
INTERVENTIONS NOT NORMALLY UNDERTAKEN (INNU) UPDATE
Executive Lead: Director of Public Health
Authors: Consultant in Public Health
Contact Details for further information: Kimberley Cann [email protected] Cwm Taf Local Public Health Team
Purpose of the Finance, Performance & Workforce Committee Report
The purpose of this report is to inform the Finance, Performance and Workforce Committee as to the progress of the Interventions Not Normally
Undertaken (INNU) workstream within the Value-Based Healthcare cross-
cutting theme.
Governance
Link to Health
Board Strategic Objective(s)
The Board’s overarching role is to ensure its Strategy
outlined within ‘Cwm Taf Cares’ 3 Year Integrated Medium Term Plan 2015-2018 and the related
organisational objectives aligned with the Institute of Healthcare Improvement's (IHI) ‘Triple Aim’ are being
progressed, these in summary are: • To improve quality, safety and patient experience.
• To protect and improve population health. • To ensure that the services provided are accessible
and sustainable into the future.
• To provide strong governance and assurance. • To ensure good value based care and treatment for
our patients in line with the resources made available to the Health Board.
This report focuses on all of the above objectives.
Supporting
evidence
Identified within the report
Engagement – Who has been involved in this work?
Local Public Health Team
Interventions Not Normally Undertaken (INNU) update
Page 2 of 11 Finance, Performance & Workforce Committee
25 October 2018
Finance, Performance & Workforce Committee Resolution To:
APPROVE ENDORSE √ DISCUSS NOTE √
Recommendation The Finance, Performance & Workforce Committee is asked to:
• NOTE the proposed process for ensuring policy accuracy, compliance, and identifying and
realising and cost-savings, and • ENDORSE the implementation of this process
by Directorates and incorporation into Integrated Medium Term Plans (IMTPs).
Summarise the Impact of the Finance, Performance & Workforce Committee Report
Equality and
diversity
A population wide approach for those meeting the
criteria for INNU is employed.
Legal implications None
Population Health Cwm Taf University Health Board (CTUHB) has a
policy which sets out INNU procedures which are
available within the Health Board and the criteria which must be met for the procedure to take
place. There are 30 INNUs in total available where appropriate for the population of CTUHB.
Quality, Safety & Patient Experience
INNUs are procedures which are not normally undertaken because: (i) there is currently
insufficient evidence of clinical and/or cost-effectiveness; (ii) the intervention has not been
reviewed by the National Institute for Healthcare and Clinical Effectiveness (NICE) or the All Wales
Medicines Strategy Group (AWMSG); and/or (iii)
it is considered to be of relatively low priority for NHS resources.
Resources This work has formed part of the Value-Based Healthcare cross-cutting theme.
Risks and Assurance The undertaking of INNUs has consequences for
individual’s health, as well as healthcare resource and opportunity costs.
Health and Care Standards
Health and Care Standards (2015) 1.1 Health promotion, protection and
improvement 3.1 Safe and clinically effective care
Workforce Health Board funding has supported staff resource
to undertake this work.
Freedom of Information Status
Open
Interventions Not Normally Undertaken (INNU) update
Page 3 of 11 Finance, Performance & Workforce Committee
25 October 2018
INTERVENTIONS NOT NORMALLY UNDERTAKEN (INNU) UPDATE
1. SITUATION / PURPOSE OF REPORT
The purpose of this report is to inform the Finance, Performance and Workforce Committee as to the progress of the Interventions Not Normally Undertaken
(INNU) work stream within the Value-Based Healthcare cross-cutting theme.
2. BACKGROUND / INTRODUCTION
INNUs are procedures which are not normally undertaken because: (i) there is currently insufficient evidence of clinical and/or cost-
effectiveness; (ii) (ii) the intervention has not been reviewed by the National Institute
for Healthcare and Clinical Effectiveness (NICE) or the All Wales
Medicines Strategy Group (AWMSG); and/or (iii) it is considered to be of relatively low priority for NHS resources.
Cwm Taf University Health Board (CTUHB) has a policy which sets out these INNU
procedures and the criteria which must be met for the procedure to take place.
Recent work has suggested that there may be cost-savings available from ensuring that these procedures are only performed in line with policy criteria. It
has also highlighted that there is an ongoing need to ensure accurate coding and monitoring of activity levels to provide accurate estimates for comparisons at a
local and national level, ensuring the guidance is kept up to date with latest evidence, and engaging with clinicians to enable them to stay informed and
supported when adhering to the policy.
3. ASSESSMENT / GOVERNANCE AND RISK ISSUES
Status summary (October 2018) The Local Public Health Team (LPHT) within CTUHB have developed a clear,
replicable process by which Directorates can ensure policy accuracy, compliance, and identify and realise and cost-savings. It is recommended that this process is
incorporated into the Integrated Medium Term Plan (IMTP). It has been tested
with two INNUs (grommets and tonsillectomy) to date and found to be effective but may vary between INNUs.
This process is set out for the relevant Directorates with INNUs in Appendix 1.
The LPHT will provide ongoing support to the Directorates to help implement the process and adapt to their individual needs, including identifying ongoing plans
to reduce activity (where appropriate), and ongoing monitoring of activity.
4. RECOMMENDATION
The Finance, Performance & Workforce Committee is asked to: • NOTE the proposed process for ensuring policy accuracy, compliance, and
identifying and realising and cost-savings, and • ENDORSE the implementation of this process by Directorates and
incorporation into Integrated Medium Term Plans (IMTPs).
Freedom of
Information Status
Open
Interventions Not Normally Undertaken (INNU) update
Page 4 of 11 Finance, Performance & Workforce Committee
25 October 2018
Appendix 1: Report for Directorates on implementation of the INNU process
Interventions Not Normally Undertaken (INNU):
Establishing a process for ensuring INNU policy accuracy, compliance and identifying and realising cost-savings
October 2018
Contents
1. Purpose of this paper ................................................................... 4 2. Background ................................................................................ 4
3. Aims and objectives ..................................................................... 5 4. Proposed methodology ................................................................. 6
5. Potential benefits to the Directorate ............................................... 7
Purpose of this paper
This papers sets out a process by which Directorates can ensure policy accuracy, compliance, and identify and realise and cost-savings relating to Interventions
Not Normally Undertaken (INNUs).
Background
INNUs are procedures which are not normally undertaken because: (i) there is currently insufficient evidence of clinical and/or cost-effectiveness; (ii) the
intervention has not been reviewed by the National Institute for Healthcare and Clinical Effectiveness (NICE) or the All Wales Medicines Strategy Group
(AWMSG); and/or (iii) it is considered to be of relatively low priority for NHS resources. Cwm Taf University Health Board (CTUHB) has a policy which sets out
these INNU procedures and the criteria which must be met for the procedure to
take place.
Recent work has suggested that there may be cost-savings available from ensuring that these procedures are only performed in line with policy criteria. It
has also highlighted that there an ongoing need to ensure accurate coding and monitoring of activity levels to provide accurate estimates for comparisons at a
local and national level, ensuring the guidance is kept up to date with latest evidence, and engaging with clinicians to enable them to stay informed and
supported when adhering to the policy.
The Local Public Health Team (LPHT) within CTUHB have developed a clear, replicable process by which Directorates can ensure policy accuracy, compliance,
and identify and realise and cost-savings. It is recommended that this process is incorporated into the IMTP. It has been tested with two INNUs (grommets and
tonsillectomy) to date and found to be effective but may vary between INNUs.
Interventions Not Normally Undertaken (INNU) update
Page 5 of 11 Finance, Performance & Workforce Committee
25 October 2018
The LPHT can provide ongoing support to the Directorates to help implement the process and adapt to their individual needs, including identifying ongoing plans
to reduce activity (where appropriate), and ongoing monitoring of activity.
Aims and objectives
Aim: to ensure ongoing INNU policy accuracy and compliance, identifying and realising cost-savings to the Directorate where available
The table below shows the INNUs which occur within your Directorate:
Area INNU
Surgery & Urology
1. Treatment for erectile dysfunction 2. Scar revision
3. Female breast enlargement (augmentation mammoplasty)
4. Breast prosthesis removal or replacement 5. Breast lift (mastopexy)
6. Botulinum toxin 7. Correction of nipple inversion
8. Haemorrhoidectomy 9. Circumcision
10. Varicose veins (asymptomatic and mild/moderate cases)
11. Vascular skin lesions
12. Other skin conditions (benign) – removal of
Trauma &
Orthopaedics
13. Hallux valgus (bunion) surgery
14. Ganglia – surgical removal
Obstetrics &
Gynaecology
15. Elective caesarean section
16. Reversal of sterilisation (male and female)
Area INNU
Head & Neck 1. Correction of prominent ears (pinnaplasty) 2. Face or brow lift (rhytidectomy)
3. Rhinoplasty 4. Laser therapy for myopia
5. Blepharoplasty 6. Xanthelasma palpebrum (fatty deposits on the eyelids)
7. Soft palate implants for obstructive sleep apnoea 8. Apicetomy
9. Wisdom teeth 10. Orthodontic treatment
Area INNU
Therapies 1. Skin hypo-pigmentation
Area INNU
Unclassified 1. Fibromyalgia in adults
Interventions Not Normally Undertaken (INNU) update
Page 6 of 11 Finance, Performance & Workforce Committee
25 October 2018
The objectives of this work are to: a. Provide a mechanism to support clinicians in identifying whether a
procedure should take place and provide reasoning for not undertaking
a procedure on an individual basis b. Identify and realise any cost-savings from reductions in procedures
which do not fit policy criteria c. Identify and amend any errors in the coding or definitions in the
current policy, to support accurate estimates of local activity and national comparisons
d. Keep the INNU policy up-to-date to reflect current procedure guidance and coding practice
e. Ensure clinical engagement to inform any needed changes to policy and to raise awareness of policy criteria
f. To support ongoing monitoring of INNU activity.
Proposed methodology
Figures 1-3 show an overview of the proposed process. The order of the steps
within each stage is not prescriptive but should be flexible to take advantage of availability of the range on individuals who can contribute to this process. Full
details of the implementation of this process for the two piloted INNUs and the resulting recommendations on the most effective approach are available from the
LPHT who can advise Directorates on each stage.
It is recommended that where possible the process is undertaken for groups of similar INNUs (e.g. requiring input from the same clinical team) conjointly to
save time and duplication of work.
Figure 1: Establish current situation
Interventions Not Normally Undertaken (INNU) update
Page 7 of 11 Finance, Performance & Workforce Committee
25 October 2018
Figure 2: Identify any action required
Figure 3: Embed compliance with policy and monitoring of activity
Potential benefits to the Directorate
Undertaking this process will provide Directorates with ongoing oversight of
policy adherence by: (i) ensuring activity levels are interpreted consistently over time; (ii) providing a baseline for comparison and expected activity levels; and
(iii) ensuring clinical agreement over the criteria for undertaking the intervention.
The use of run charts can be used to highlight activity levels which are outside of those expected due to change fluctuations. Which can then prompt further
exploration through audit of patient notes and clinical engagement.
Interventions Not Normally Undertaken (INNU) update
Page 8 of 11 Finance, Performance & Workforce Committee
25 October 2018
Until policy accuracy and compliance (in particular around coding and interpretation of codes) is ensured via stages 1-2, it is difficult to estimate
potential cost-savings related to individual INNUs as activity estimate can vary
widely. The process was piloted on tonsillectomy and the findings are shown below. Currently reported activity levels for the INNUs in this Directorate are also
shown below and estimate a total of 1,445/293/0 excess procedures.
Key findings for tonsillectomy Outcome
Coding agreed F34.1>5, F34.7>9
Data interpretation
caveats agreed
Filter by diagnosis code: J03, J35-36
All diagnosis fields should be searched (not just primary)
Filter by procedure code: F34.1>5,
F34.7>9
Only need to search primary procedure field
Current annual activity
level
(April 2017 – March
2018)
165 FCEs per 100,000 population (494 in total)1
Comparators HDUHB: 68.2 per 100,000 population (262)
C&VUHB: 84.5 per 100,000 population (417)
ABUHB: 75.9 per 100,000 population (446)
ABMUHB: 105.3 per 100,000 population (560)
BCUHB: 88.3 per 100,000 population (615)
Figures not available for PTUHB
HB peer comparator rate (excluding HDUHB & PTUHB): 97.1
FCEs per 100,000 population (507 in total)2,3
Year-on-year variation for CTUHB was not outside of expected
random fluctuations (statistical process control)
Current costing
estimate
Fully absorbed cost per procedure (including overheads):
£1,598
Fully absorbed cost for 498 procedures: £789,412
Direct releasable cost saving opportunity per procedure: £538
Potential number of FCEs saved if peer rate applied: 204
Potential cost savings if peer rate applied: £109,752
New guidance identified Royal College of Surgeons (2016). Commissioning Guide:
Tonsillectomy. NICE accredited evidence.
Recommended changes
to policy
Policy to refer to ‘Tonsillectomy for recurrent tonsillitis and its
complications (adult and child)‘ in future (instead of
‘Tonsillectomy (adult and child)’)
No policy criteria changes
No coding changes
Estimated impact on
activity levels
None4
Estimated impact on
costing estimate
None4
Scoping audit of patient
notes findings
It is not well documented in patient notes how the policy
criteria are met to enable accurate audit
Recommendations Further exploration of whether outsourcing of tonsillectomy is
conducted by other Health Boards and incorporation into peer
comparisons
Feedback on these findings to clinicians at the ENT audit
session to: (i) further raise awareness of policy criteria; (ii)
agree how reductions in activity can be achieved; and (iii)
improve reporting of how policy criteria are met in patient
notes. Ongoing monitoring of activity.
Interventions Not Normally Undertaken (INNU) update
Page 9 of 11 Finance, Performance & Workforce Committee
25 October 2018
1. Based on mid-year population estimate for 2017 by Stats Wales (BCUHB: 696,284; PTUHB: 132,515; HDUHB: 384,239; ABMUHB: 531,858; CTUHB:
299,080; ABUHB: 587,743; C&VUHB: 493,446)
2. It has not been explored whether any outsourcing is undertaken within the other Health Boards
3. Sensitivity analysis: assuming HDUHB is not under-reporting, the peer value is 466.
4. Please note that whilst there is no change in activity and cost, there is improvement on data interpretation which may make figures appear different to
previous reports.
The table below shows the estimated activity for INNUs within your Directorate, comparisons against other Health Boards, and potential cost-savings. It is
important to note that until coding and interpretation of activity is agreed for these INNUs these estimates may not be accurate.
Interventions Not Normally Undertaken (INNU) update
Page 10 of 11 Finance, Performance & Workforce Committee
25 October 2018
Area INNU Coding Rate per
100,000 (activity)
(Apr 17 – Mar 18)*
Peer com-parator rate per
100,000 (activity)**
Excess activity (expec-
ted) [tbc]
Surgery & Urology
Treatment for erectile dysfunction
N29.1 1.0 (3) 0.8 (23) 1 (2)
Scar revision S06.5 or
S06.9; S23.1>4
122.0 (365) 37.8
(1,131)
252
(113)
Female breast enlargement (augmentation mammoplasty)
B30.1; B31.2 0 (0) 1.6 (23) 0 (5)
Breast prosthesis removal or replacement
B30.- 7.4 (22) 1.4 (33) 18 (4)
Breast lift (mastopexy) B31.3 1.3 (4) 0.5 (24) 2 (2)
Botulinum toxin X85.1 1.7 (5) 2.8 (85) 0 (8)
Correction of nipple inversion
B35.6 0 (0) 0 (0) 0 (0)
Haemorrhoidectomy H51.1>3;
H51.8>9; H52.1>4;
H52.8>9
26.7 (80) 4.8 (144) 66 (14)
Circumcision N30.3 53.2 (159) 7.7 (230) 136 (23)
Varicose veins (asymptomatic and
mild/moderate cases)
L84.1>6; L84.8>9
L85.1>3; L85.8>9 L86.1>2; L86.8>9 L87.1>9; L88.1>3 L88.8>9
66.5 (199) 5.1 (153) 184 (15)
Vascular skin lesions I99 (ICD-10) 2.0 (6) 0.2 (10) 5 (1)
Other skin conditions (benign) – removal of
S04.1>3; S04.8 S05.1>5;
S05.8>9
S06.1>5; S06.8>9 S09.1>5; S09.8>9 S10.1>5; S10.8>9 S11.1>5;
S11.9>9
133.7 (400) 43.4 (1298) 270 (130)
Trauma & Ortho-paedics
Hallux valgus (bunion) surgery
W79.1 1.7 (5) 1.6 (49) 0 (5)
Ganglia – surgical removal T59.1>4; T59.8>9
T60.0>4-; T60.8>9
13.7 (41) 2.3 (68) 34 (7)
Obstetri
cs & Gynae-
cology
Elective caesarean section R17.1, 17.2,
17.8, 17.9
178.2 (533) 20.2 (604) 473 (60)
Reversal of sterilisation (male and female)
N18.1; Q29.1>2 Q29.8>9; Q37.1 Q37.8>9;
0.3 (1) 0 (0) 1 (0)
Total 1,445
*Based on primary procedure only; **Based on only those Health Boards for
which figures are reported.
Interventions Not Normally Undertaken (INNU) update
Page 11 of 11 Finance, Performance & Workforce Committee
25 October 2018
Area INNU Coding Rate per
100,000
(activity)
(Apr 17 –
Mar 18)*
Peer com-
parator
rate per
100,000
(activity)**
Excess
activity
(expec-
ted)
[tbc]
Head &
Neck
Correction of prominent
ears (pinnaplasty)
D03.3 5.0 (15) 0.6 (16) 13 (2)
Face or brow lift
(rhytidectomy)
S01.- 1.7 (5) 1.6 (33) 0 (5)
Rhinoplasty E02.1>9;
E07.1>3;
E07.8>9
24.4 (73) 1.5 (46) 69 (4)
Laser therapy for
myopia
C46.1 0 (0) 0 (0) 0 (0)
Blepharoplasty C12.1>6;
C12.8>9
C13.1>4;
C13.8>9
C15.1>5;
C15.8>9
49.8 (149) 10.9 (327) 116
(33)
Xanthelasma palpebrum
(fatty deposits on the
eyelids)
C12.1>3 7.0 (21) 5.0 (149) 6 (15)
Soft palate implants for
obstructive sleep
apnoea
F32.8 0.3 (1) 0 (0) 1 (0)
Apicetomy F12.1 0 (0) 0.8 (8) 0 (2)
Wisdom teeth F09.3 32.8 (98) 3.3 (99) 88 (10)
Orthodontic treatment F14.1>3;
F14.8 >9
F15.1>4;
F15.9
0.7 (2) 1.1 (21) 0 (3)
Total 293
*Based on primary procedure only; **Based on only those Health Boards for
which figures are reported.
Area INNU Coding Rate per
100,000
(activity)
(Apr 17 –
Mar 18)*
Peer com-
parator
rate per
100,000
(activity)**
Excess
activity
(expec-
ted)
Therapies Skin hypo-
pigmentation
L81.9 (ICD
10)
0 (0) 0 (0) 0 (0)
Total 0
*Based on primary procedure only; **Based on only those Health Boards for which figures are reported.
Area INNU Coding Rate per
100,000
(activity)
(Apr 17 –
Mar 18)*
Peer com-
parator
rate per
100,000
(activity)**
Excess
activity
(expec-
ted)
Un-
classified
Fibromyalgia in adults M7909
(ICD10)
0 (0) 0 (0) 0 (0)
Total 0
*Based on primary procedure only; **Based on only those Health Boards for
which figures are reported.
3.1 To review the Forward Look for 2018/19
1 3.1 Forward Look FPW 25 October 2018 GR.doc
Agenda item 3.1
Forward Look FP&W
Page 1 of 1 Finance, Performance & Workforce Committee Meeting 25 October 2018
Finance, Performance and Workforce Committee: Forward Look 2018/19
25 October 2018 1.00pm – YMH
• To receive a quarterly update on CAMHS Performance – to include Primary Care CAMHS Alan Lawrie
• To receive an update on the Deep Dive undertaken in Facilities John Palmer
• To receive a quarterly update on the organisational risks assigned to the Committee Robert Williams
• To receive a Clinical Deep Dive into Urology John Palmer
• To receive an update report on Cancer Breaches Kamal Asaad
• To receive an update report on Interventions Not Normally Undertaken (INNU) Nov 2018 Kelechi Nnoaham
22 November 2018 1.00pm – YMH
• Finance Dashboard Steve Webster
• Performance Dashboard Ruth Treharne
• Workforce Dashboard Jo Davies
• To receive an update on Demand & Capacity Planning – Ophthalmology John Palmer
24 January 2019 1.00pm – YMH
• Finance Dashboard
• Performance Dashboard
• Workforce Dashboard
• To receive an update on Follow Up Outpatients Not Booked (now January 2019) John Palmer
2018/19 • Detailed update on Delayed Transfers of Care – Operational Director (s)
• Committee Assigned Organisational Risks Quarterly Update - to be added to Forward Look for January 2019. • Annual Report for 2017/2018 – to include Annual Self-Assessment and Updated Terms of Reference –October
2018 • To receive an update on Frequent Attenders – to be confirmed
NB - No meeting will be held
in August or December. Urgent items will be
accommodated as required and the Forward Look is
subject to change. Quarterly items
• CAMHS Performance
Annual review of the Terms of Reference in line with the Standing Orders – each October
Principles • Anything that has improved for 3 months consecutively will be placed on the Agenda
(Good news) for Info • Anything that has declined for 3 months consecutively will be placed on the Agenda
(Improvement Plan) • Any area where we have a Delivery Unit intervention will be reviewed at every
meeting until intervention is withdrawn