nhs wales bundle _public_… · bundel of health board - public on 23 june 2016 1 opening business...

Bundel of Health Board - Public on 23 June 2016

1 OPENING BUSINESS & EFFECTIVE GOVERNANCE

1.1 16/108 Chair's Introductory Remarks

1.2 16/109 Apologies for Absence

1.3 16/110 Declarations of Interest

1.4 16/111 Draft Minutes of the Health Board Meeting held on 19.5.16 for Accuracy, Matters Arising and Review of Actions

16_111.2 Summary Action Plan Public_ live v58 10.6.16.doc

16_111.1 Minutes Board 19.5.16 Public v0.03 draft.doc

2 ITEMS FOR CONSENT

2.1 16/112 Summary of In Committee Board business to be reported in public

16_112 Items in committee reported in public.docx

2.2 16/113 Documents Signed Under Seal – Update

16_113 Documents signed under Seal June 16 Board.doc.docx

2.3 16/114 Welsh Language Services Annual Monitoring Report 2015-2016

16_114 BCUHB Welsh Language Services Annual Monitoring Report 2015-2016.doc

2.4 16/115 Committee and Advisory Groups Chairs’ Reports

16_115.1 F&P Chairs Report 26.4.16.pdf

16_115.2 Chair's Assurance Report RaTS 16.5.16 V1.0.pdf

16_115.3 LPF Advisory Group Chairs' Report 11.4.16 v1.0.pdf

16_115.4 Chair's Assurance Report Audit 31.5.16 V1.0.pdf

16_115.5 Chair's Assurance Report QSE 10.5.16 V1.0.pdf

3 FOR DISCUSSION

3.1 16/116 Special Measures Improvement Framework – Task & Finish Group Chair’s Assurance Report 2.6.16

16_116 Chair's Assurance Report SMIF T&F 2.6.16.doc

3.2 16/117 Integrated Quality & Performance Report

16_117 IQPR revised.pdf

3.3 16/118 Finance Report – Month 1

16_118 Finance Report Month 1- Final 16th May 2016.docx

4 CLOSING BUSINESS

4.1 16/119 Date of Next Meeting - 21.7.16, Venue Cymru, Llandudno

Ka109599

Typewritten text

10.00am, Catrin Finch Centre, Glyndwr University, Wrexham

1.4 16/111 Draft Minutes of the Health Board Meeting held on 19.5.16 for Accuracy, Matters Arising and Review of Actions

1 16_111.2 Summary Action Plan Public_ live v58 10.6.16.doc

1 Summary Action Plan – Health Board – arising from meetings held in public

HEALTH BOARD SUMMARY ACTION LOG – ARISING FROM MEETINGS HELD IN PUBLIC

Lead Executive / Member

Minute Reference and Action Agreed Original Timescale Set

Update Action to be closed

17.3.16:

C Wright 16/54.5 – provide a briefing note on the Welsh language Team capacity, following publication of the operational plan

29.4.16

31.5.16 A briefing note was circulated on 6.6.16 Closed

21.4.16:

A Thomas 16/68 – arrange for All Wales Blood Service monitoring report to be submitted to QSE Committee, outlining whether any of the risks originally identified have come to fruition (after the service has been running for 6 months)

1.12.16 Raised at the AWBS stakeholder meeting – will report back to QSE in December 2016. Added to QSE cycle of business.

Closed

JM Jones 16/70.2.3 – Use the Engagement Strategy approved 21.4.16 as a model document to develop a Staff Engagement Strategy

29.7.16 Further discussion has taken place at the Committee Business Management Group and it has been agreed that the draft strategy will be taken to SPPH in July prior to Board in August. Capita have been appointed to assist with the development of the strategy.

JM Jones 16/71.2.7 – add total numbers to the core mandatory training compliance chart in the IQPR

6.6.16 The Workforce & OD team has collated the data and the Performance team will have put in place arrangements for this to be routinely included in the IQPR from July/August

M Olsen 16/71.2.7 – provide a briefing on readmissions

23.6.16 Will be submitted to the QSE Committee. Added to QSE cycle of business

Closed

19.5.16:

M Walker 16/85.2 – arrange for a timetable to be produced setting out when R&D opportunities for clinical research

23.6.16 Dr Walker has requested the information – in hand.

2 Summary Action Plan – Health Board – arising from meetings held in public

facility/strategy will be brought back to the Board via the Committee structure

V Morris 16/88.1 – circulate Prof B Duerden’s report to Board members

23.5.16 Circulated 20.5.16 Closed

G Lang 16/90.5 – complete further work on the performance monitoring/public facing aspects of the Operational Plan

23.6.16 Performance monitoring of items not covered by the Integrated Quality & Performance Report to be reported to the Strategy, Partnerships & Population Health Committee in July. Public facing document currently being drafted.

C Wright 16/91 – arrange for special measures pages on website to give prominence to End of Phase 1 Report

23.6.16 Completed – added to website page: http://www.wales.nhs.uk/sitesplus/861/page/81806

Closed

G Lewis-Parry

16/91 – update Special Measures End of phase 1 Report and arrange submission to Welsh Government

20.5.16 Updated document submitted 20.5.16 Closed

P Higson / G Doherty

16/92.2 – review the governance aspects of the SSWB/WFG Acts

23.6.16 Dr Higson will be leading a programme of work jointly with the Chief Executive of Conwy Local Authority to review partnership governance.

Closed

JM Jones 16/94 – re-circulate the recent report on sickness absence

23.6.16 Re-circulated 25.5.16 Closed

B Cuthel 16/95 – provide further information on the actions to be taken to develop a separate learning disabilities strategy

23.6.16 The development of the strategy has involved a wide range of stakeholders including staff from Learning Disabilities . Whilst the overarching strategy will be underpinned by a common set of priorities, these will be reflected differently in the new models of care for the different client groups within Mental Health and Learning Disabilities across the life cycle. It is anticipated that the strategic review will deliver clear priorities for each client group across health and Social Care and this will include the range of services for children and adults with learning disabilities. There is a well- developed Regional partnership for children and adults with Learning Disabilities which will play a key role in informing these priorities.

Closed

V58 10.6.16

2 16_111.1 Minutes Board 19.5.16 Public v0.03 draft.doc

Minutes Health Board 19.5.16 V0.03 draft Public session GLP PH comments 1

Betsi Cadwaladr University Health Board (BCUHB)

DRAFT Minutes of the Board Meeting held on 19.5.16

in Neuadd Reichel, Bangor

In Attendance: Mrs L Jones Translator, staff, observers and members of the public.

Head of Corporate Affairs, Office of the Board Secretary

Present:

Dr P Higson (PH) Chairman

Cllr C Carlisle Mr J Cunliffe Ms B Cuthel (BC) Ms J Dean

Independent Member Independent Member Interim Director of Primary, Community & Mental Health Strategy Independent Member

Mr G Doherty (GD) Cllr P Edwards Mr R Favager

Chief Executive Associate Board Member - Chair, Stakeholder Reference Group Executive Director of Finance

Cllr B Feeley Mrs M Hanson

Independent Member Vice-Chair

Mr JM Jones (JMJ) Mr G Lang (GL) Mrs G Lewis-Parry

Executive Director of Workforce & Organisational Development Executive Director of Strategy Board Secretary

Ms L Meadows Independent Member

Mrs V Morris (VM) Ms M Olsen

Interim Executive Director of Nursing, Therapies & Health Sciences Chief Operating Officer

Prof M Rees Mrs B Russell-Williams Mr C Stradling Ms N Stubbins

Associate Board Member - Chair, Healthcare Professionals Forum Independent Member Independent Member Associate Member ~ Local Authority (part meeting)

Mr A Thomas Assistant Director ~ Therapies and Health Science (part meeting)

Dr M Walker (MW) Mr C Wright (CW)

Interim Medical Director Director of Corporate Services

Agenda Item

Action

16/81 Chairman’s Introductory Remarks Dr Higson opened the meeting and welcomed those present, in particular Mrs Russell-Williams following her recent illness. Mrs Russell-Williams was pleased to report that she had received excellent care at Ysbyty Gwynedd. Dr Higson also reminded those present of the events taking place to celebrate Equalities Week, such as running up the rainbow flag at each main hospital site.

16/82 Apologies for absence


Apologies were received from Mrs MW Jones, Prof J Rycroft-Malone and Mr A Jones.

16/83 Declarations of Interest There were no new declarations of interest.

16/84 Draft minutes of the Health Board meeting held on 21.4.16 16/84.1 Accuracy The minutes were approved as a correct record. 16/84.2 Matters arising and review of actions The action plan was reviewed and updated accordingly. Ms Olsen noted that the readmissions briefing referred to under item 71.2.7 would be submitted as a paper to the Quality, Safety & Experience Committee.

16/85 Presentation: Research & Development (R&D) 16/85.1 Dr Nefyn Williams and Dr Lynne Grundy attended to give this presentation, covering the reasons for conducting research, the current position, funding, key areas of research, ambitions and challenges. They concluded by stating that they were seeking commitment to R&D from the Board, a visible dedicated clinical research facility and also strengthened links to Bangor University. Board members questioned Dr Williams and Dr Grundy and commented on a range of topics. These included the impact of reducing referral and treatment delays, R&D links to prudent healthcare, the need to share examples of good practice particularly in primary care research, raising the profile of R&D in North Wales, income generation resulting from R&D, national work regarding introducing an academic element into clinical jobs, promoting multidisciplinary research, the specification for the proposed clinical research facility and the potential for management research and joint projects with Local Authorities. 16/85.2 Dr Higson stated that the new R&D Strategy referred to would need to come to the Board via the Strategy, Partnerships & Population Health Committee in due course. Mr Doherty acknowledged the importance of training staff in R&D and innovation, although he added that there were challenges relating to the request for space to house a clinical research facility. He explained that the costs and benefits of a dedicated facility would need to be considered alongside other requests for additional space for different purposes across the organisation. He concluded that the Board was committed to R&D and would welcome exploration of the opportunities for a clinical research facility. Dr Higson stated that a timetable setting out when the R&D Strategy would be brought back to the Board and how it would integrate with other strategies was required. Dr Williams and Dr Grundy were thanked for attending and they left the meeting.

MW

16/86 Update of the Mental Health Act 1983 as amended by the Mental Health Act 2007 Register (All Wales) Section 12(2) Approved Doctors and Approved Clinicians (Wales) Directions 2008


16/86.1 Section 12(2) Approved Doctors This item was ratified. 16/86.2 Approved Clinicians This item was ratified.

16/87 Standing Orders amendments Mrs Lewis-Parry presented this agenda item. The amendments listed were ratified, with the exception of the third entry (Table A, 11u) which it was agreed should have listed the Director of Workforce & Organisational Development as having delegated and operational responsibility for the Voluntary Early Release Scheme, but with the Director of Finance responsible operationally for sign-off of the financial viability aspect. It was noted that further changes would be made in due course to reflect the evolving organisational structure.

16/88 Update on the Prevention & Control of Infections 16/88.1 Mrs Morris presented this agenda item. She explained that Prof B Duerden’s latest report would be submitted to the July Board meeting, following scrutiny by the Quality, Safety & Experience (QSE) Committee in June. Dr Higson commented that this seemed to be a long timeframe and he was keen to get the report into the public domain. Mr Doherty responded that he would expect the improvement actions identified in the report to be well underway by the time it was presented to the Board. It was agreed that, in the interim, the report would be circulated to Board members for information. 16/88.2 Cllr Feeley expressed disappointment regarding the continuing over-prescription of antibiotics referred to in the update. Dr Higson responded that the key issue was what the Board needed to do to get to where it wanted to be. Cllr Carlisle expressed concerns relating to mandatory training, which she observed had not shown sufficient improvement. Mrs Morris agreed that mandatory training was an issue of concern that required significant improvement. To this end, steps were being taken to support individual access to computers so that e-learning could be undertaken. 16/88.3 Mrs Hanson stated that the update presented should be viewed in its proper context. She pointed out that infection prevention and control was not simply about MRSA and similar infections, as it also involved wider population issues such as responding to the ebola virus. Some actions that needed to be taken were outwith the Health Board’s gift. She concluded that the Health Board only had a small team to deal with such issues, however the situation was set to improve as there were plans to fill the gaps in capacity over the next few months. She suggested that the QSE Committee should receive regular reports on the prevention and control of infection. Following discussion, the update was noted.

VM VM

16/89 Committee and Advisory Group Chairs’ Assurance Reports 16/89.1 Finance & Performance Sub-Committee 23.2.16


This report was noted. Cllr Carlisle queried where discussions regarding minor injury units were taking place. Ms Olsen confirmed that this was part of planning for the future. In response to Cllr Feeley, Mr Favager stated that budget holders had been given a deadline of 20.1.16 to sign off accountability agreements. 16/89.2 Finance & Performance Committee (extraordinary) 8.3.16 This report was noted. 16/89.3 Finance & Performance Committee 22.3.16 This report was noted. 16/89.4 Audit Committee 15.3.16 This report was noted. In response to Mr Stradling, who drew attention to the risks and concerns section of his report, Mrs Hanson stated that the Special Measures Improvement Framework Task & Finish Group had recently discussed the issue of ensuring completion of all actions from historic governance Audit reports. Committee Leads had been asked to work with Executives to confirm that all loops had been closed. 16/89.5 Charitable Funds Committee 14.3.16 This report was noted. 16/89.6 Quality, Safety & Experience (QSE) Committee 8.3.16 This report was noted. 16/89.7 QSE Committee 12.4.16 This report was noted. 16/89.8 Remuneration & Terms of Service (extraordinary meetings) 3.3.16 and 7.4.16 This report was noted. 16/89.9 Healthcare Professionals Forum 22.1.16 This report was noted. 16/89.10 Local Partnership Forum 10.12.15 This report was noted. 16/89.11 Stakeholder Reference Group 7.3.16 This report was noted. In response to Cllr Feeley who queried whether the groups connected to the SRG were the right ones and whether there were sufficient numbers, Cllr Edwards stated that he and Mr Wright were currently reviewing the membership. An


issue with Local Authority attendance remained, however progress was being made.

16/90 Annual Operational Plan - summary of key deliverables 2016/17 16/90.1 Mr Lang presented this agenda item. He explained the background to the submission of the final draft of the full Plan to Welsh Government and subsequent circulation of the document to Board members. It was felt that a summary document would be helpful to focus on the key areas of health improvement and inequality, resilience in primary care and community services, with a clear focus on quality and safety. Evidence of improvement was necessary and the summary of key deliverables needed to capture the main actions and milestones. Mr Doherty added that the summary document was required as the main Plan was such a large document. He stated that clarity was required on unscheduled care as that pathway represented the biggest challenge. 16/90.2 Dr Higson stated that there was a process for keeping track of progress in 2016/17. The Executive would use the long version of the Plan and would report quarterly through the Committee structure. Cllr Edwards suggested adding the 11 improvement areas to the spreadsheet at the back of the document. Mr Lang explained that the indicators were taken from Welsh Government core data sets, however he agreed to review the chart and consider distilling the information and show it in a slightly different way. In response to Mrs Meadows, Mr Doherty explained that elements of the Social Services & Wellbeing Act and Future Generations Act were covered in the main Plan. Mrs Hanson stated that the essence of the document should be turned into a separate document that the population could use for holding the Health Board to account. She added that the document needed to explain to members of the public what difference the Plan would make to their health and that of their families. In addition, it needed to set out ways of measuring improvements. Mrs Hanson emphasised that this transparency would be an important step in regaining public trust. She also stated that jargon should be avoided, as should any language that potentially stigmatises particular groups of patients. Dr Higson concurred that there was a need to translate both documents into a narrative for the public, containing statements such as ‘the Board will...’ 16/90.3 Mrs Russell-Williams pointed out that there was a key role for groups and communities in delivering new services and it was important to involve them. The third sector was also key to delivering services differently, however she was not sure that the Plan documents gave adequate detail on how the challenges would be met, although she welcomed the commitment to being clear on progress to the public. Dr Higson stated that the Health Board did not as yet have a longer term strategic plan or objectives. However, high level goals had been agreed and these were sufficient for the time being in order to develop the strategic vision. Mr Doherty stated that the Health Board would need to move towards 3, 5 and 10 year planning cycles, but the current document covered just the current year. Cllr Feeley commended the holistic approach set out in the document. Dr Higson stated that he believed the current document to be a good summary. 16/90.4 Mr Cunliffe expressed concerns that the document was aspirational in nature rather than a plan for delivery with identified outcomes and outputs for which the Executive could be held to account. Dr Higson agreed that clear metrics and commitments were needed. Mr Doherty reminded the Board that there were over 100 project initiation documents sitting beneath the Plan, each with quantifiable success


measures. Dr Higson queried how information could be meaningfully distilled for use for assurance purposes, and Ms Olsen responded that the Integrated Quality & Performance Report reflected this and was scrutinised by Committees and the Board. Discussion ensued on the commitment of Divisions to the Plan and its deliverables, divisional annual reports, lack of visibility of additional investment in staff engagement and organisational development, the follow-up appointments backlog, timelines for the development of the clinical services strategy and the need to have connectivity between service strategies in recognition of the fact that individuals can have both physical and mental health problems. Mr Doherty confirmed that there was a timetable in place for developing the clinical strategy. There was also a plan in place for an organisational development strategy, though this would require an options appraisal on additional investment. 16/90.5 Prof Rees commented that the 7 domains referred to in the document felt right. He called for messages to staff to be more positive. Mr Doherty responded that there were many positive examples that could be quoted in relation to staff engagement. Mr JM Jones reminded Board colleagues of the recent development session where there had been recognition of areas doing well on staff engagement, but there remained a question as to whether more pace was needed behind this work. Dr Higson summarised that his impression was that the Board was eager for the Plan to be taken forward. He believed that having the Plan and summary document was a significant step forward, enabling the organisation to focus and progress with an agreed set of commitments. He thanked all those involved in producing the Plan documents. The summary of key deliverables 2016/17 was approved, subject to more work being done on the performance monitoring and a public facing document, as discussed.

GL

16/91 Special Measures Improvement Framework – End of Phase 1 Report Mr Doherty presented this agenda item. He described the background to the report and highlighted its content. He explained that the Task & Finish Group was collating the evidence to underpin the progress reports. Mrs Hanson added that the Group had met the previous day to determine priorities for phases 2 and 3 and also to discuss the evidence base and the possibility commissioning support for this aspect of the work. The beginning of the next Board development session would be used to discuss the approach being taken by the Task & Finish Group. Dr Higson stressed that all improvements achieved must be sustainable. Cllr Edwards commented that the report represented a milestone, as it demonstrated to the public that the Health Board had embraced special measures. It was agreed that the report would be given prominence on the special measures pages of the Health Board’s website. Following discussion, the report was approved for submission to Welsh Government, subject to an update to page 11 to reflect the fact that the Operational Plan key deliverables had now been approved.

CW GLP

16/92 External partnership governance - Social Services & Wellbeing (Wales) Act 2014 and Wellbeing of Future Generations (Wales) Act 2015 16/92.1 Mrs J Charles was in attendance for this item. Mrs Lewis-Parry introduced the paper and explained that Board briefings were being scheduled to ensure that Board members were fully conversant with their responsibilities under the Acts. She also described the Regional Partnership Board and the intention to formalise its associated governance arrangements. Mrs Charles explained the content of the paper relating to the Wellbeing of Future Generations in more detail, noting that there was commitment to the


new legislation across Wales, but implementation would be challenging. She highlighted the legally binding common purpose, the sustainability principle at its heart, preparation for Public Service Boards and the model set out in the International Framework: Good Governance in the Public Sector. Cllr Feeley gave an update on an all Wales workshop she had attended regarding the Regional Partnership Board, where it was noted that pooling of budgets would require the breaking down of barriers. Mrs Hanson added that issues of subsidiarity and ‘sovereignty’ would need to be explored with other public bodies. Ms Olsen reported that membership had been discussed at a recent Partnership Board meeting and it was felt that public health was missing, therefore the suggestion was to include three Health Board members rather than two. Mr Lang commented that the complexity of North Wales had been evident at a recent national meeting. He added that there was a need to agree tangible deliverables. 16/92.2 Dr Higson stated that he agreed with the need for a Health Board nomination for a public health member to the Regional Partnership Board. He added that the governance around the Partnership Board and Regional Leadership Board required more clarity and a ‘de-cluttering’ exercise. Mrs Lewis-Parry explained that the chart provided in Appendix 1 was the first cut at setting out these reporting arrangements. Dr Higson stated that the Health Board would need to better understand where the new arrangements fit with its own governance. Following discussion, it was agreed that there was strong support and commitment to making the new arrangements work, however further work was required on the governance aspects and therefore authority was delegated to Dr Higson and Mr Doherty to work together on this in liaison with the Regional Leadership Board. Mr Thomas and Ms Stubbins left the meeting.

PH/GD

16/93 Finance Report Month 12 16/93.1 Mr Favager presented this agenda item. He explained the end of year position and the accounts process. The financial year had closed with a deficit of £19.5 million, just below the forecast. There had been a £26.6 million deficit in the previous financial year, which amounted to a cumulative deficit of £46 million. This meant that unless the Health Board could deliver a £46 million surplus at the end of the next financial year, it would fail in its statutory duty to break even over a three year period. Mr Favager reported that the Health Board had remained within its capital resource limit and had achieved 93.4% compliance with the Public Sector Payment Policy. The accounts had been submitted to the Wales Audit Office and the auditing was underway prior to consideration by the Audit Committee on 31.5.16. 16/93.2 Mr Favager stated that he did not anticipate any change to the outturn position, other than a few minor presentational issues in the remuneration report. He explained that, in respect of charitable funds accounts, the Wales Audit Office was unable to conduct their audit until September 2016, after which the accounts would need to be submitted to the Charities Commission by January 2017. Prof Rees queried the locum overspend. Ms Dean updated on the scrutiny that had taken place at the Finance & Performance Committee. She noted that £31 million of savings had been achieved, but £11 million of this was non-recurrent. She added that medical agency costs were increasing as were unscheduled care costs. The fragility of the care home situation was also cause for concern. Following discussion, it was agreed to approve the recommendations set out in the paper presented, including delegation of authority to approve the accounts and Annual Governance Statement to the Audit Committee.


16/94 Integrated Quality & Performance Report (IQPR) Ms Olsen presented this agenda item, noting that the relevant elements had undergone prior scrutiny by the Finance & Performance and Quality, Safety & Experience Committees. She described the new service improvement methodology to be employed within the organisation. Board members were asked to give Ms Olsen notice should they require more in-depth information on particular aspects of the IQPR. Prof Rees stated that he would like additional information on sickness absence and work related stress. Mr Jones agreed to re-circulate the recent report previously shared with Board members. Mrs Hanson observed that media reports suggested that performance in the Health Board was deteriorating, however the IQPR suggested that it was the highest performing Health Board in Wales in many areas. Mrs Russell-Williams stressed the need to draw more attention to successes such as national awards. It was noted that understanding the IQPR would be covered during a forthcoming Board development session. Following discussion, the report was noted.

JMJ

16/95 Development of an Integrated Mental Health Strategy for North Wales Ms Cuthel presented this agenda item. She described the key elements involved in developing the strategy, including the cultural shift to include the third sector as equal partners, governance arrangements, the need to commission a strategic partner and the need to increase pace. Board members commended the approach being taken and it was agreed that further information should be provided on the actions to be taken to develop a separate learning disabilities strategy. Following discussion, the recommendations listed in the paper were approved.

BC

16/96 Corporate Risk Register 16/96.1 Mrs Lewis-Parry presented this agenda item. She explained that the Committees had been scrutinising in detail the risks allocated to them. She explained that information on when the target risk was likely to be achieved would be added in and other layout and format changes were underway under the guidance of the Audit Committee and Mrs Ann Lloyd. She added that an additional risk regarding Safeguarding had been escalated to Executives since the current update paper had been written. The new risk would however be added to the version of the register published on the website once finalised. 16/96.2 In response to Ms Dean, Ms Olsen explained that Health & Safety Executive feedback and steps take to reduce risks had meant that the Health & Safety risk discussed in February 2016 no longer required escalation to the corporate register. It would be managed at an operational level. Mrs Hanson, referring to the primary care strategy risk, queried whether the actions quoted were sufficient and she believed that the implementation elements should be allocated to the Quality, Safety & Experience Committee. Mr Stradling commented that the infection prevention & control risk could be more optimistic. In response to Cllr Edwards, Mrs Morris explained that the continuing healthcare (CHC) risk had a likelihood of ‘5’ due to the fragility of the nursing home sector as a whole. Cllr Edwards also raised the issue of Deprivation of Liberty Safeguards (DoLS) in connection with the CHC and care home risk and it was noted that the Mental Health Act Committee would review this.


16/96.3 It was noted that the capital risk might be de-escalated following review by the Audit Committee. Consideration would need to be given to disaggregating the informatics and organisational development risks. Dr Higson raised the issue of connectivity with the Operational Plan and asked if it would be possible to cross-reference risks back to the plan. In response to Cllr Feeley, Ms Olsen recommended awaiting risk registers from the Area Teams before deciding whether partnership working and partnership governance should be escalated to the corporate risk register. Following discussion, it was agreed to approve the risk register on the understanding that its component parts were to be reviewed by the relevant nominated committee.

16/97 Emergency Ambulance Services Committee (EASC) 26.1.16 and summary of key matters 22.3.16 Noted for information.

16/98 Welsh Health Specialised Services Committee minutes 26.1.16 and summary of key matters 22.3.16 Noted for information.

16/99 NHS Wales Shared Services Partnership Committee Assurance Report and summary of key matters 17.3.16 Noted for information.

16/100 Date of next meeting 23.6.16, Wrexham.

2.1 16/112 Summary of In Committee Board business to be reported in public

1 16_112 Items in committee reported in public.docx

Board Paper 23.6.16 Item 16/112

To improve health and provide excellent care

Title: Summary of In Committee Board business to be reported in public.

Author: Mrs L Jones, Head of Corporate Affairs

Responsible Director:

Mrs G Lewis-Parry, Board Secretary

Public or In Committee

Public

Strategic Goals (Indicate how the subject matter of this paper supports the achievement of BCUHB’s strategic goals –tick all that apply)

1. Improve health and wellbeing for all and reduce health

inequalities

√

2. Work in partnership to design and deliver more care

closer to home

3. Improve the safety and outcomes of care to match the

NHS’ best

4. Respect individuals and maintain dignity in care

5. Listen to and learn from the experiences of individuals

6. Use resources wisely, transforming services through

innovation and research

√

7. Support, train and develop our staff to excel. √

Approval / Scrutiny Route

The issues listed below were considered by the Board at its private in committee meeting of 19.5.16.

Purpose: Standing Order 6.5.3 requires the Board to formally report any decisions taken in private session to the next meeting of the Board in public session.

Significant issues and risks

Issues with commercially sensitive content were considered as follows: - Single tender waivers (STW): Chairs action in respect of one STW noted and confirmation of the Chief Executive’s authority to extend a contract in respect of a second STW. - Replacement of legacy telephony systems: the full business case was approved. - Welsh Health Specialised Services Committee confidential minutes 26.1.16 and summary of key matters 22.3.16.

Equality Impact Assessment

No equality impact assessment is considered necessary for this paper.

Recommendation/ Action required by the Board

The Board is asked to note this paper.

Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board

2.2 16/113 Documents Signed Under Seal – Update

1 16_113 Documents signed under Seal June 16 Board.doc.docx

1

Board Paper 23.6.16 Item 16/113


Title: Documents Signed Under Seal: Update 18.9.15 – 26.5.16

Author: Mrs Liz Jones, Head of Corporate Affairs


Mrs Grace Lewis-Parry, Board Secretary


Public

Strategic Goals (Indicate how the subject matter of this paper supports the achievement of BCUHB’s strategic goals –tick all that apply)


inequalities


closer to home


NHS’ best





7. Support, train and develop our staff to excel.


This paper has been reviewed by the Executive Team.

Purpose: To comply with Standing Order 8.1.1, which requires a report of all documents signed under seal to be presented to the Board for noting at least bi-annually.


None.


Not considered necessary for a paper of this nature.

Recommendation/ Action required by the Board

The Board is asked to note the update presented.


2

The Health Board is requested to note the following documents signed under seal during the period 18.9.15-26.5.16

16.10.15 Deed of settlement

11.11.15 Bryn y Neuadd farm business tenancy

11.11.15 Sale of part of HM Stanley Hospital

11.11.15 Engrossment lease for Caia Park Primary Care Resource Centre

11.11.15 Endoscope decontamination unit, Wrexham – building contract

11.11.15 Refurbishment of bedrooms, Heddfan Unit, Wrexham

17.2.16 Bus stop relocation, Ysbyty Gwynedd

17.2.16 Midwife led unit, Ysbyty Gwynedd

17.2.16 Hergest Unit seclusion suite

17.2.16 Discharge lounge, Ysbyty Gwynedd

17.2.16 Renal Unit, Ysbyty Gwynedd

17.2.16 Paediatric Assessment, Ysbyty Gwynedd

17.2.16 New lift at Ysbyty Alltwen

17.2.16 Primary Care Centre and Medical Ward, Tywyn Hospital

7.3.16 Deed variation: Primary Health Care Centre at Colwyn Bay

7.4.16 Lease relating to GP surgery at Tywyn Community Hospital

11.4.16 Sub-contractor collateral warranty (Alltwen lift)

21.4.16 Transfer of former Prince Charles Road Clinic to Caia Park Community Council

21.4.16 Transfer of Llangollen Community Hospital to Grwp Cynefin Cyf.

11.5.16 Sale of Buckley Health Centre to Grwp Cynefin

2.3 16/114 Welsh Language Services Annual Monitoring Report 2015-2016

1 16_114 BCUHB Welsh Language Services Annual Monitoring Report 2015-2016.doc

Board Paper

23.6.16

Item 16/114


Title: Welsh Language Services Annual Monitoring Report 2015-2016

Author: Mrs Eleri Hughes-Jones, Welsh Language Services Manager

Responsible

Director:

Mr Chris Wright, Director of Corporate Services

Public or In

Committee

Public

Strategic Goals (Indicate how the subject matter of this paper supports the achievement

of BCUHB’s strategic goals –tick all that apply)


inequalities


closer to home


NHS’ best






Approval /

Scrutiny Route

This report has been subject to prior scrutiny by the Welsh Language

Strategic Forum and the Strategy, Partnerships and Population Health

Committee. Final approval of the Annual Monitoring Report is reserved

for the Board.

Purpose: The Welsh Language Services Annual Monitoring Report for 2015-2016

provides the Board with an overview of delivery against key

performance indicators.

This report is presented for approval by the Board prior to submission to

Welsh Language Services Annual Monitoring Report 2015-2016 Page 1

the Welsh Language Commissioner.

Significant issues

and risks

This report demonstrates the Health Board’s compliance with its Welsh

Language Scheme under the Welsh Language Act 1993 and details

progress made and initiatives implemented during the last reporting

year.

The report also acknowledges and addresses the required actions and

resource implications of the delivery of the Welsh Language Standards

that will be made applicable to Health Boards under the Welsh

Language Measure (Wales) 2011.

There are inherent risks that services will not be delivered bilingually

which will lead to non compliance with the Welsh Language Standards.

These risks are being managed and mitigated as part of detailed

implementation arrangements to ensure there is no detrimental impact

on the quality and safety of services.

Equality Impact

Assessment

No equality impact assessment is considered necessary for this paper.

Recommendation/

Action required by

the Board

The Board is asked to approve this report.


Welsh Language Services

Annual Monitoring Report

2015 - 2016


Content Page Executive Summary 2 Foreword 3 Welsh Language Standards 4 More than just words 5 Primary Care Services 6 Achievements and Awards 7 Performance Indicators Data 9

Policy Impact Assessment 9

Services Provided by Others 11

Workforce Planning 12

Training to Improve Welsh Language Skills 17

Recruitment 20

Language Awareness Training 22

Website 23

Welsh Language Services Provided 24

Complaints 26

Next Steps and Forward Vision 28


Executive Summary

This report addresses the statutory duty of Betsi Cadwaladr University Health Board to provide an annual report to the Welsh Language Commissioner on compliance with its Welsh Language Scheme. The Health Board continues to make progress in implementing its Welsh Language Scheme and in providing services bilingually, and in establishing processes to facilitate the implementation of the Welsh Language Standards under the Welsh Language (Wales) Measure 2011. The report reflects the format and content included in the guidance produced by the Welsh Language Commissioner and details compliance within the eleven domains outlined in the Health Board’s Welsh Language Scheme; New policies and initiatives, Services provided by others, Face to face contact with the public, Information Technology, Recruitment, Language Skills, Training to improve Welsh language skills, Language awareness training, Complaints, Publicity and Workforce planning. It gives an overview of general progress including areas of good practice and areas for development. The report also takes account of the feedback received from the Welsh Language Commissioner following submission of the 2014-2015 Annual Monitoring Report. This report reflects work undertaken to develop a Bilingual Skills Strategy, implementation of ‘More than just words’ and the “Active Offer”, as well as further developments with primary care contractors. Plans and processes are in place to ensure that progress can be monitored in preparation for the Welsh Language Standards. Further areas of good practice and service improvements have been included throughout this report.

19 May 2016


Foreword This report reflects the Health Board’s performance against key legislative requirements and obligations under the Welsh Language Act 1993. The report also focuses on Welsh Government’s Strategic Framework for Welsh Language Services in Health, Social Services and Social Care, ‘More than just words’. The 2011 Census showed there were 204,406 Welsh speakers in the Betsi Cadwaladr University Health Board’s region (all ages), amounting to a total of 30.8 per cent of the whole population of North Wales. The Health Board’s Welsh Language Team is responsible for monitoring delivery of the Welsh Language Scheme across North Wales, and the provision of a high quality Welsh language translation service across all areas.

Number of staff within the Welsh Language Team

1 x Welsh Language Services Manager (1 WTE) 2 x Welsh Language Officers (1.8 WTE) 4 x Translators (4 WTE)

Number of staff within the organisation

18,592

Population in catchment area

676,000

Demographics of Welsh speaking population within each county served by the Health Board

County % of Welsh speakers

Number of Welsh speakers

Gwynedd 65.4% 77,000

Anglesey 57.2% 38,568

Conwy 27.4% 30,600

Denbighshire 24.6% 22,236

Flintshire 13.2% 19,343

Wrexham 12.9% 16,659

A significant proportion of the population of North Wales speak Welsh as a first language. Evidence based research has identified that a substantial number of patients prefer to speak Welsh when accessing health services, and delivering care to patients in their preferred language of choice can improve quality and safety.

The vision of the Health Board is to provide a service that satisfies the needs of Welsh speakers and their families or carers, by ensuring that they are able to receive services in their own language.


Welsh Language Standards

It is anticipated that the Health Board will become subject to the Welsh Language Standards under the Welsh Language (Wales) Measure 2011 in 2016. There will be four specific areas of compliance:

i. Service Delivery Standards – focusing on promoting or facilitating the use of Welsh in activities associated with service delivery

ii. Policy Making Standards – ensuring that public bodies give full consideration to the way developing and/or implementing specific policies will impact on the availability and accessibility of Welsh-medium services

iii. Operational Standards – focusing on promoting and facilitating the use of Welsh within internal administrative arrangements.

iv. Record Keeping Standards – ensuring that public bodies keep detailed records relating to any actions or developments with regards to Welsh language service provision

The Health Board has been proactive in preparing and addressing future requirements with the Standards. Work has already been undertaken to establish the current position with bilingual service provision and to identify potential gaps to ensure that activities can be targetted at specific areas. Implementation and Delivery The Health Board will drive implementation through three delivery dimensions that will allow planning, engagement and monitoring on an organisation wide level: Workstreams have been identified aligning to the NHS Outcomes Framework, focusing on behavioural change, strategic intervention and monitoring performance. In delivering, the Health Board will build on its current provision by focusing on

Behavioural Change in the form of Training, Corporate Identity and Communicating Key Messages

Strategic Intervention in the form of Workforce Planning, Service Delivery and incorporating requirements into ICT Systems

Securing Performance in the form of Frontline Provision, Governance and Identifying Good Practice


service delivery, workforce planning, mainstreaming requirements into ICT Systems, as well as securing robust channels of communication to provide awareness and support on an organisation wide level. A high level Project Management Group has been established with senior leads across services, who will address key challenges and associated risks and drive and co-ordinate the process of implementation within the Health Board. Ownership of the standards across all service areas will be essential. Key Challenges There will be challenges gloing forward, and these include potential additional costs, clinical recruitment and embedding the requirements in service planning and delivery. An initial standards mapping exercise has identified a substantial increase in terms of document and simultaneous translation requirements and the need to develop and deliver bilingual internal operating procedures. These challenges and proposed solutions are currently being further explored.

‘More than just words’

The Welsh Government’s 2012 Strategic Framework for Welsh Language Services in Health, Social Services and Social Care ‘More than just words’ is a three year framework for strengthening Welsh language services to improve the quality of care, maintain professional standards, meet the language need of users and comply with legal and statutory requirements. The “Active Offer” principle is fundamental to the successful delivery of the framework as a means for organisations to accept responsibilty of offering patients services in the language of their choice, rather than the service user having to specifically request a Welsh language service. The Strategic Objectives set within the framework require the implementation of systematic approaches to service planning and delivery based on the “Active Offer”. They require a strengthening of the capability of the workforce to provide Welsh language services, an increase in language awareness among staff; the creation of leaders who will foster a supportive ethos within the organisation; the development of targeted learning programmes; and the guidance of national strategies, policies and leadership.

The Health Board’s position at the end of Year three demonstrates progress against all objectives, notably the collation of data with regard to the language skills element of the Electronic Staff Record (ESR).

Other progress includes the development of an Older People’s Mental Health project to map current provision and capacity to deliver the “Active Offer” within dementia services. The Health Board has also seen progress in its


obligation to increase staff confidence to speak Welsh at work. This has been delivered through the provision of varying levels of Welsh language courses and resources offered, as well as targeted promotional activities such as ‘Diwrnod S’mae’. We have aquired and promoted ‘Learning Welsh’ lanyards for staff, with the aim of encouraging staff to converse with patients in their mother tongue. One of the key actions required during Year three was to ensure effective provision of service for Welsh speaking patients by mainstreaming the ‘Active Offer’ into dementia services. This has been proactively addressed within dementia and stroke services, identifying Welsh speaking patients and staff, and planning services so that Welsh speaking clinical staff and allied health professionals are paired with Welsh speaking patients. Additional progress against key targets is further detailed in this report.

Primary Care Services

Work has been undertaken during the reporting year to further develop the relationship between primary care providers and the Health Board in terms of Welsh language provision. It should be noted that primary care providers are independent, self employed contractors and therefore not bound by the Health Board’s Welsh language requirements. Proactive work has been undertaken to develop a number of initatives to meet the needs of service users. A report was presented to the Board in March 2016 detailing progress against the recommendations made in the Welsh Language Commissioner’s Inquiry into the Welsh Language in Primary Care ‘My Language, My Health’, with areas of good practice noted and highlighted. Link to Primary Care Report - Item 1 Following a concern raised in 2014 regarding the provision of bilingual prescriptions, a project has been developed collaboratively between Bangor University and the Health Board to provide cautionary instructions on prescribed medicines, for the first time, in Welsh. This innovative provision, endorsed by the Chief Pharmaceutical Officer for Wales, will ensure that bilingual labels on prescription medicines will be made available to patients. A team comprising language specialists and pharmacists has made the first step by translating 30 cautionary instructions given to patients on prescription medicines. These will now become available to all pharmacies and doctors, increasing the amount of health support provided in Welsh within the NHS in Wales. The labels are available in the online edition of the British National Formulary, the standard pharmaceutical reference text used by prescribers, nurses and pharmacists within the NHS, and will become available in the next printed edition. A working partnership has been established with Bron Derw Medical Centre in Bangor, with the Practice Manager actively working with the Health Board’s Welsh Language Team to provide bilingual correspondence to its patients. The Centre makes full use of the Health Board’s Translation Team to ensure letters, information


and pamphlets are provided bilingually. The Centre has also undertaken a data cleanse project to update patients’ medical records, asking patients to update their language details. Forms were provided to patients in the surgery to encourage them to note their spoken language and preferred language of care. Posters were also displayed at reception to inform them that a Welsh language service was available, whilst ensuring visibility was given to the Welsh language in the form of the Welsh Language Commissioner’s ‘Working Welsh’ resources. Work has also been undertaken with the Centre to develop a bilingual website to improve accessibility for patients in their first language.

Achievements and Awards

The Health Board received eight awards at last year’s Welsh Language in Healthcare Awards. Derwen, the Integrated Team for Disabled Children won the award for ‘Work done with priority groups’ for the creation of, ‘May I join you?’, a bilingual booklet to support parents in developing their children’s needs. In the ‘Working in Partnership Category’ the Gyda’n Gilydd Team, bringing together Gwynedd Council’s Early Years Unit, the Health Board, Barnados and Citizens Advice was awarded for providing a wide range of preventative services bilingually to families in Gwynedd. Denbighshire’s Single Point of Access provision between Denbighshire County Council and the Health Board, including British Red Cross were also successful in the same cateogry for developing an integrated model of community services for preventative and rehabilitation work for adults. The Health Board also received two awards in the ‘Technology and the Welsh Language’ category for a fully Bilingual Appointment Reminder Service and The North Wales Cancer network Patient Forum for an online bilingual cancer information resource. Three members of staff were awarded Welsh Leaners of the Year titles for learning Welsh to an exeptional standard. Services to Bilingual Healthcare also continue to be celebrated as part of the Health Board’s Staff Achievement Awards. This year’s winners included North Wales Clinical School for providing training to increase the capability of the workforce to provide bilingual care. Other winners also included Derwen and the Ysbyty Gwynedd Orthodontic Team for the provision of bilingual British Orthodontic Society patient information leaflets.


Winners in the Welsh Language in Healthcare Awards

2015

Gareth Hutchinson, Community Pharmacy Technician, joint winner in the category for

‘Learner of the Year – Under 2 years’

Laura Owens, Dietician at Ysbyty Gwynedd – joint winner in the category for Learner of the

Year - Under 2 years

Amy de Cunha Prys, Staff Nurse in Tegid Ward, Ysbyty Gwynedd - winner in the category for Learner of the Year - Over 2 years

Informatics Team, Appointment Reminders Service in the ‘Technology and the Welsh Language’ Category

Derwen, ‘May I Join you’ bilingual communication pack for children with communication problems in the category for ‘Work done with people with learning difficulties including

speech and language therapy’


Performance Indicators Data

The Welsh Language Commissioner has requested quantative and qualatative data on key performance indicators relating to the Health Board’s Welsh Language Scheme requirements as detailed below.

Policy Impact Assesment

Number and percentage of policies (including those that were reviewed or revised) where consideration was given to the effects the policy would have on the use of the Welsh language

All new policies and initiatives produced by the Health Board are subject to an Equality Impact Assessment, which includes language impact assessment. 111 policies were produced or revised during 2015/16, of which 100 per cent have been scrutinized for language impact assessment. Of these, four policies (3.6 per cent) made specific reference to the Welsh language, where the policy would have an effect on the use of the Welsh Language as part of the organisations’ service delivery. Policies which did not include reference to the Welsh language ranged from clinical policies (e.g. Infection Surveillance policy, Decontamination of Endoscopes Protocol), Finance policies (e.g. Income and Debt Recovery Procedure and Petty Cash Procedure) to Healthcare record policies (e.g. Locating Casenotes out of core hours, Binding of Acute Casenotes Procedure) and Medical Devices Policies (e.g. Decontamination of Medical Devices Procedure, Single Use Medical Devices Procedure), where the policy, as part of the robust impact assessments, had been identified that it would not have an effect on a patient’s ability to receive services through the medium of Welsh.

2015 / 2016 Data:

In total there are 269 policies and procedures, of which 100 per cent have

been assessed, with 26 of these (9.6 per cent) including references to the use

of the Welsh language.

2014 / 2015 Data: 40 new policies were produced, of which 100 per cent were considered for Welsh language effect. No Welsh language references were required in those policies.


Example of an assessment deemed to have an impact on the use of the Welsh language and details of how the policy was amended as a result

The Health Board’s policy impact assessment procedures allow for the consideration of how certain policies will affect service provision. One example is the Health Board’s ‘Consent to Examination or Treatment Policy’ which includes specific reference to the Welsh language in the body of the policy:

“Provision for patients whose first language is Welsh 4.6 The Health Board is committed to ensuring that patients whose first language is Welsh receive the information they need and are able to communicate appropriately with healthcare staff. In order to safeguard the consent process and when seeking written consent, a healthcare professional who is fluent in Welsh should be sought from within the healthcare team in the first instance. If this is not possible and in an emergency then Language Line should be contacted.

The policy also refers to the fact that the Health Board has purchased Eido INFOrm4U Patient Information documents which are available bilingually. This allows the Health Board to provide a comprehensive bilingual service in terms of providing both face to face and written information bilingually. This policy not only ensures better bilingual care for the patients, it also addresses complex and crucial issues in relation to patient safety and informed consent to treatment. The Patients Visitors Protocol for the Tŷ Llywelyn Medium Secure Unit also makes specific reference to the Welsh Language. The policy addresses complex issues in relation to both patients and families and their care, thus ensuring a bilingual service in exceptional and difficult circumstances:

“If the Supervisor feels it is appropriate the visit may be terminated at any time. An explanation should be given to the visitor and if they are not happy with the explanation given, should be made aware of the Complaints Procedure. N.B. consideration should be given to making such explanations in Welsh or English and the visitor(s) preference sought.”

Furthermore, to ensure operational delivery and recording of preference, the Visitors Approval Form in Appendix 1 of the Protocol includes a question about Visitor’s Preferred Language: Welsh / English.

Patients Visitors Protocol - Tŷ Llywelyn Medium Secure Unit.pdf


Services Provided By Others Number and percentage of third party agreements monitored to ensure

they comply with the relevant requirements of the Welsh Language Scheme

2015 / 2016 Data: Number: 40 contract reviews Percentage: 51 per cent of all contracts issued by the Health Board

2014 / 2015 Data: Number: 30 contract reviews Percentage: 43 per cent of all contracts issued by the Health Board

Example of monitoring work undertaken to assess whether or not a third party agreement complied with the relevant requirements of the Welsh Language Scheme and details of any action taken as a result of the monitoring work

Welsh language compliance is included as part of the legal / statutory requirements within the final contract review and service contract checklist. However, processes have recently been established to strengthen and clarify Welsh language requirements within contractual agreements. Whilst the majority of care is provided directly by the Health Board, care is also commissioned from a wide range of NHS and independent healthcare providers. It is imperative that Welsh language requirements are taken into account during the commissioning process. As a commissioner of care, there is a responsibility to ensure that external providers are formally contracted to deliver care in line with the Health Board’s expectations, with specific reference to Welsh language needs. In order to ensure the robustness of contractual performance management, a Contracts Review and Governance Group has been established to oversee a robust assurance process, supporting Area, Secondary Care, Children’s and Mental Health teams (the commissioners), Finance, Planning and Performance departments to take a multidisciplinary approach to support overall contract management arrangements. The Welsh Language Team will work as part of this multidisciplinary approach to performance management working in conjunction with Finance, Quality and Performance teams. Welsh language outcome measures have been identified with specification and monitoring controls to ensure an integrated approach to the delivery of bilingual care. A robust checklist has also been developed to ensure adherence to all aspects of performance issues and Welsh Language Scheme requirements. Contractors will be


required to ensure the delivery of bilingual correspondence, telephone communication, signage, producing bilingual information, publicity and activities as well as staffing requirements before contracts are issued, i.e. in ‘Pre-placement agreements’. During the course of the contract, monitoring controls will be established and performed via quarterly contract review meetings, spot visit checks as well as patient feedback.

Workforce Planning

An update on progress made to adopt/implement the organisation’s Welsh language/bilingual skills strategy

The Bilingual Skills Strategy is designed to enable effective workforce planning and the recruitment of staff to ensure the delivery of bilingual services through the medium of Welsh and English, according to individual choice and the needs of the population in the area. The vision is to provide a service that satisfies the needs of Welsh speakers and their families or carers, by ensuring that they were able to receive services in their own language through the care process. To deliver this, the Bilingual Skills Strategy has four key workstream areas to ensure that appropriate Welsh language skills are available within the workforce to deliver a bilingual service:

Identifying Patient’s Language Choice An urgent assessment was required by the community mental health team for a 53 year old woman, living on a farm in a very rural area. The Duty Officer would usually make such an assessment, but because the family spoke Welsh, the Duty Officer (who could not speak Welsh) requested for two Welsh speaking Occupational Therapists to attend to make the initial assessment. The patient was very unwell and classed as high risk and was to be admitted to the mental health unit in Ysbyty Glan Clwyd. The paramedics were informed that the patient was a Welsh speaker and was not comfortable communicating in English. The Welsh speaking paramedic sat with her in the back of the ambulance to reassure and care for her. The unit was also informed of her language needs and a Welsh speaking nurse was present on arrival to greet the patient and to help with the admission assessment. The Approved Mental Health Practitioner and a doctor attended the unit to make this assessment, and the Welsh speaking Occupational Therapist (who conducted the initial assessment) was also asked to attend to act as a translator. The Practitioner and doctor were sensitive throughout and apologized for not being able to speak Welsh but stated that they were happy for her to answer any questions in Welsh. Following a two week stay in hospital she was discharged to the care of the community mental health team, and her language needs prioritized. A Welsh speaking Care Manager was assigned to support her and her family. Community Mental Health Team


Audit of current workforce Welsh language skills

Assessment of the Welsh/bilingual service needs

Identifying skills gaps

Workforce planning and recruitment During the reporting year, progress has been made in terms of auditing the Welsh language skills of the workforce (figures are presented in performace indicators section). Monitoring processes have also been established in the form of a reporting template that will allow the Health Board to scrutinze vacancy bulletins on a weekly basis to identify any shortfalls in terms of bilingual requiremernts within the recruitment process. The Bilingual Skills Implementation Group, chaired by the Assistant Director of Workforce and Organisational Development, has also been focusing on reviewing the Welsh Language Operational Standards. This has allowed the Helath Board to mainstream future requirements into the Bilingual Skills Strategy ensuring overall incorporation and inclusion. To allow for adequate training provision to upskill the workforce, the Health Board has included Welsh language training as part of its Study Leave Policy to ensure it is a key element of personal development. This will ensure that training is offered to both clinical and administrative staff to support the implemention of the Welsh Language Service Delivery Standards. The strategy has been ratified by the Health Board’s Strategy, Partnership and Population Health Committee, chaired by the Health Board’s Vice Chair. Link to Bilingual Skills Strategy - Item 2 Progress has been made in auditing Welsh language skills, service needs assessment, creative ways of working, staff development and strategic recruitment. Information provided below reflects the work undertaken during the reporting year.

Update on Welsh Language skills audit (data cleansing) of employee records: Individual e-mails containing a list of non-compliant staff (staff with no Welsh Language skills levels recorded in their ESR record) were sent to line managers throughout October and November 2015 requesting them to update ESR with the employee’s individual Welsh Language skills levels. Managers were given three options for updating employee ESR records:

Employee or manager to update ESR using ESR Self Service

Manager to submit WL return for mass update

Employee to complete and submit individual WL skills questionnaires


Progress to date with regards to the cleansing of records is as follows:

2014 / 2015 Data: 62.1% of the entire workforce had recorded their Welsh language skills on ESR. Further work is required to improve the quality of the Welsh language data held. Given the scale of the data cleansing undertaken to date and efforts made to cleanse outstanding records, service areas which have yet to respond will be escalated to senior management to ensure full compliance.

1 Nov

2012

1 Apr

2013

1 Oct

2013

1 Nov

2014

1 Jan

2015

1 Aug

2015

16 Oct

2015

3 Nov

2015

13 Nov

2015

08

Apr

2016

Assignment Count

16,551

16,494

16,456

16,930

17,081

17,164

17,140

17,143

17,175

18,592

No. Achieved

867

1,000

6,081

6,590

6,780

8,064

10,380

10,641

11,183

12,874

Compliance %

5.24%

6.06%

36.95%

38.92%

39.69%

46.98%

60.56%

62.07%

65.11%

69.2%


Number and percentage of employees whose Welsh language skills have been assessed (data was unavailable during 2014 / 2015):

Number Percentage

Across the organisation 12,874 69.2%

Per priority group

- Children and young people 935 78.92%

- Older People 17 39.53%

- People with Learning disabilities and Mental Health

1177 68.9%

- Dementia services Not known – difficult to identify from WOD reports

- Stroke services 11 (but may not be accurate as difficult to identify from WOD reports

Speech and language therapy services 126 97.7%

Number and percentage of employees who have Welsh language skills, per skill level (data was unavailable during 2014 / 2015):

Across the organisation

Count of Employee Number

Individual Proficiency Level Total %

0 - No Skills / Dim Sgiliau 5222 28.1

1 - Entry/ Mynediad 1951 10.5

2 - Foundation / Sylfaen 1076 5.8

3 - Intermediate / Canolradd 1142 6.1

4 - Higher / Uwch 1545 8.3

5 - Proficiency / Hyfedredd 1936 10.4

Blank 5718 30.8

Grand Total 18592 100

Children and young people







4 - Higher / Uwch 111 8.5

5 - Proficiency / Hyfedredd Blank

150 376

11.5 28.6



Older people








2 27

4.7 62.8

Grand Total 43 100

People with learning disabilities and mental health services







4 - Higher / Uwch 161 9,5


173 530

10.1 31


Speech and language therapy services.








5 - Proficiency / Hyfedredd Blanks

18 3

13.9 2.3

Grand Total 129 100

The system is currently unable to provide a breakdown for dementia and stroke services. However, the Health Board is pro-actively targeting stroke and dementia services with a new initiative to identify patients’ preferred language of care at ward level.


Training to Improve Welsh Language Skills

Number and percentage of the organisation’s workforce that received training to improve their Welsh skills to a specific qualification level

BCUHB provided funding to allow 62 of its staff to attend Wlpan courses during 2015-16, with priority given to front line staff working with vulnerable groups on a day to day basis. Welsh for Adults: North Wales (which is based within Bangor University) provides a range of Wlpan courses – for beginners, individuals with some Welsh-medium skills, and more experienced learners – at locations throughout North Wales. The Health Board has secured a working partnership with Bangor University for both daytime and evening lessons for staff to allow the greatest possible number of individuals to attend. As described earler, as part of the Study Leave Policy, Welsh language training is now being considered as all other study leave requirements, demonstrating the Health Board’s commitment to improving the Welsh language skills of its staff. Further information is detailed below with regard to specific qualification levels achieved:

Identifying Patient’s First Language on Wards Welsh language provision is a crucial part of the care of dementia patients, who often revert back to their mother tongue as the condition progresses. In order to ensure the best possible services for dementia patients, an initative has been developed on Ward Glaslyn in Ysbyty Gwynedd to include the ‘Speaking Welsh’ emblem magnets on patient white boards on the ward so that staff are able to identify Welsh speaking patients. This allows the ward to plan its workforce so that Welsh speaking staff are paired with Welsh speaking patients. This ‘opt in’ system has also ensured that large ‘Speaking Welsh’ magnets are displayed above a patient’s bed. This has also ensured wider planning, allowing physiotherapists, pharmacists and the wider clinical workforce to plan their care when attending the ward. Following the success of this pilot, it has been rolled out with stroke patients on Ward Prysor, and will continue to be further rolled out.


Wlpan Courses provided by Welsh for Adults: North Wales

September – December 2015

Type of course

Number of BCUHB staff that received funding to attend

Number of different courses attended by BCUHB funded staff

Entry Level (i.e. Beginner)

35 16

Foundation Level

18 10

Intermediate Level

7 5

Advanced Level

2 2

Total

62 33

2015 / 2016 Data: Number of the organisation’s workforce that received training to improve their Welsh skills to a specific qualification: 62 This total equates to 0.37 per cent of the Health Board’s current workforce.

2014 / 2015 Data: Number of the organisation’s workforce that received training to improve their Welsh skills to a specific qualification: 70 This total equated to 0.3 per cent of the Health Board’s workforce at that time

The Health Board has also provided funding to enable certain priority areas to engage the services of an external Welsh language tutor during 2015-16, allowing a further 50 members of the Health Board’s workforce to improve their Welsh skills. A tutor from Welsh for Adults: North Wales was engaged to assist the Wrexham Central Community Mental Health Team with their Conversational Welsh Group. This group – which convenes once a week – provides opportunities for staff members (and for learners especially) to speak Welsh in an informal and relaxed atmosphere whilst continuing to offer guidance and support in an encouraging environment. Such regular opportunities to practice linguistic skills will ensure that more members of the Wrexham Central Community Mental Health Team will gain confidence to enable them to use Welsh in more formal situations. The same external tutor was also engaged to provide a short series of basic Welsh lessons for 30 members of staff from the Pharmacy Department at Wrexham Maelor Hospital,


with arrangements in place to further extend training offered due to the positive response received. To ensure all staff are supported to learn or improve their ability to speak Welsh, internally produced resources, focused on key areas such as frequent communication with Welsh speakers, whether face to face or by telephone are key aspects of the Health Board’s training programme.

Along with providing funding to allow staff to improve their Welsh skills by attending formal lessons, the Health Board has also developed a language course that staff can follow and complete in their own time and at their own pace (i.e. Welsh courses that are not delivered through tutor-led face-to-face sessions). The ‘Welsh in the Workplace – Level 1’ course CD has been designed for individuals who have no previous experience of speaking Welsh and is offered to all staff in the Health Board. The course primarily focuses on developing a vocabulary of words and phrases which specifically relate to the healthcare sector. This year, a follow on course ‘Welsh in the Workplace – Level 2’ CD has been produced which allows staff to build upon skills already gained. Further training support is offered to the workforce in the form of useful resources that allow staff to develop their basic linguistic skills informally, without having to attend formal Welsh lessons or committing to complete a full course. ‘Gair i Glaf’ is an English-Welsh phrasebook that has been designed for health care professionals and contains phrases and vocabulary relevant to a number of areas within health

Mr Phillip Moore, ENT

surgeon at Ysbyty Gwynedd

has learned Welsh to an

exceptionally high standard,

often conducting clinics

through the medium of Welsh.

At this year’s ‘Rhoi’r Iaith ar

Waith’ Conference in Bangor

University, Mr Moore gave a

presentation, speaking of the

support received from the

Health Board in further

progressing with his learning,

as well as highlighting the

importance of speaking Welsh

with patients.


care (along with some guidance about how to pronounce letters and words when speaking Welsh). A clinically based phonetic Welsh phrases card is also offered to staff to assist in using basic Welsh phrases with patients on a day to day basis. To secure support not only for clinical staff, but also within the Health Board’s corporate and administrative areas, a ‘Bilingual Greetings’ card has been produced to inform staff of the protocol on answering the telephone bilingually, offering relevant phrases, all written both grammatically and phonetically, for the user’s convenience. All resources have been offered through various promotional events and within the Health Board’s internal information distribution channels.

2015 / 2016 Data: Number of bilingual greeting cards and Welsh phrases cards distributed: Approximately 1,200 Number of Level 1 and 2 CDs distributed: Approximately 500

2014 / 2015 Data:

Number of resources distributed: Approximately 900 Number of Level 1 CDs distributed (Level 2 CD had not been produced at that time): Approximately 185

Recruitment

Number and percentage of new and vacant posts advertised with the requirement that:

2015 / 2016 Data:

- Welsh language skills are essential - 62 (2%) - Welsh language skills are desirable - 3042 (98%) - Welsh language skills not required - 0


Link to Breakdown of Recruitment Data - Item 3

2014 / 2015 Data:

- Welsh language skills were essential - 28 (1.2%)

Data for posts where Welsh language skills were desirable or not required was not requested for the report

Example of an assessment which shows how a decision was taken to advertise the post :

- Welsh Language skills are essential; - Welsh language skills are desirable; - Welsh language skills are not required.

The Workforce and Organisational Development Team have added Welsh language skills requirements assessment to the Health Board’s position request form. This assists managers to determine whether posts should be advertised as Welsh Essential or Welsh Desirable. The tool ensures that recruiting managers follow set formulae, looking at language needs of the population, current skill mix and skills gap within the team. This allows services to ensure that individuals with the required level of Welsh language ability are recruited to ensure a comprehensive bilingual service is available. Follow link to an example of an assessment undertaken that determined Welsh language skills were essential for a post: Link to WL Skills Assessment - Engagement Officer - Item 4 Follow link to an example of an assessment undertaken that determined Welsh language skills were desirable for a post: Link to WL Skills Assessment - Dietician - Item 5 All posts advertised require either Welsh language as an essential skill or Welsh language as a desirable skill.

Of those posts advertised with an essential requirement, the number and percentage of posts filled by individuals who met the requirement - Of the 62 posts advertised as Welsh essential, 35 Welsh speaking

candidates were appointed (56 per cent). - 5 adverts had multiple appointees therefore the 35 candidates were

appointed to 29 advertised posts


- The remaining 33 posts advertised were either closed with no appointees, the appointee withdrew the application, the post was withdrawn or the post was re-advertised as Welsh desirable

Language Awareness Training

Number and percentage of the organisation’s new staff (i.e. new since 1 April 2015) that received Welsh language awareness training

The Health Board’s newly formed Orientation Programme incorporates Welsh language awareness, including legislative requirements and the “Active Offer” principle. 2015 / 2016 Data: Number: 859 newly appointed staff have received Welsh language awareness training This total equates to 100 per cent of the Health Board’s new starters.

2014 / 2015 Data: Number: 1099 newly appointed staff received Welsh language awareness training This total equated to 100 per cent of the Health Board’s new starters.

Welsh language awareness training is also offered across the organisation to individual services and areas, including volunteers. 25 newly qualified doctors attended Welsh language awareness sessions as a part of their induction training at the Medical Institute in Wrexham and in Ysbyty Gwynedd, with two sessions provided to 200 nursing students across the Health Board. A total of 18 newly recruited Spanish nurses also attended similar training sessions, specifically arranged as part of their induction to the Health Board. The Health Board secured a Welsh language interactive awareness session during the annual Health Care Support Workers’ Conference at Venue Cymru, with approximately 100 attendees.

Number and percentage of the organisation’s entire workforce that has received Welsh language awareness training since the training was introduced


Since the establishment of Betsi Cadwaladr University Health Board, apart from the organisation’s newly appointed staff as noted above, 5,073 of the organisation’s entire workforce have received Welsh language awareness training.

Number of the organisation’s entire workforce that has received Welsh language awareness training since the training was introduced: 6075 This total equates to 32 per cent of the Health Board’s current workforce.

Website

Percentage of the organisation’s website that is available in Welsh

An update on progress made to improve/ increase the Welsh language provision of the website

Information relating to the process used to ensure that existing content, updates and new content, complies with the relevant requirements of the Welsh language scheme (if the process has changed since the 2014-15 report)

100% of the Health Board’s is available in Welsh. There is no need for the user to look for the information in Welsh, it is offered proactively and includes over 1000 pages. The website:

- offers users language choice proactively from the start of their visit; - provides a clear language choice on each page; - Welsh and English pages are of equal quality; and - offers a search function that works in Welsh and English;

Users can search in Welsh or English and the results are returned in the present interface language used at the time. The search results do not inform the user if there are additional results available in the other language. The website interface is exactly the same in both languages. The layout is of the same quality, is as clear for example in relation to colour, size, font and text format. The Health Board has produced guidelines on publishing bilingual web pages (Cascade Users Handy Hints - Bilingual Pages). During training sessions, standard requirements are highlighted in relation to format, naming files and documents bilingually, using images and consistency. The Health Board’s Communication Team is responsible for loading, editing and reviewing content on the Health Board’s website but due to the organisation’s


substantial size, the task of editing the website has been delegated to a core of some 20 devolved website editors from various departments. Each editor receives training on how to manage the website’s Content Management System (provided by NHS Wales Informatics Service). Ensuring understanding of the guidelines on publishing bilingual web pages is an essential component of this training. The editors receive directions not to publish revised or new content on the website until it is available in Welsh and English, in order to ensure the consistency of pages in both languages. When text is available to the editors in one language (English usually) they must arrange for it to be translated into the other language. A process has been established whereby a devolved web editor sends a request to the Health Board’s Translation Service to prepare the text in the other language (further comments on the translation process are provided on the next page). The translated text is returned to the devolved editor for placing it on the new page and then the corresponding Welsh and English pages are simultaneously published on the website. All of these robust processes ensure the Health Board fully complies with its Welsh Language Scheme and ensures a fully bilingual website is provided.

Welsh Language Services Provided

Information about methods used to promote the organisation’s Welsh language services and evidence of any subsequent increase in the public’s use of the services

The Health Board is committed to ensuring that awareness is raised of all its Welsh medium provision and publicity is used to promote the organisation’s Welsh language services.

The Health Board’s S4C documentary, ‘Ward Plant’, drew attention to the range of Welsh language services provided to vulnerable groups, predominaantly children and young people. Members of the ENT Team demonstrated commitment to improving communication, initiating a cultural awareness of the importance of speaking Welsh when caring for children.


Information is regularly provided on the Health Board’s weekly noticeboard round-up which is circulated to all staff. In the last reporting year, examples of promoting the organisation’s Welsh language services included informing staff of the requirements under the Health Board’s Welsh Language Scheme to provide all internally produced information for the public bilingually. In this respect, details of the services provided by the Health Board’s Translation Team were provided and circulated organisation-wide. The organisation has delivered campaigns to draw staff attention to ‘More than just words’, the “Active Offer” and the importance of providing services bilingually in general.

The national ‘Diwrnod Su’mae’ in October was met with great enthusiasm as members of the Welsh Language Team held a display event outside the dining areas of all three main hospital sites. This also afforded the opportunity for staff discussion, distribution of ‘Cymraeg’ resources such as lanyards and badges, and provision of advice regarding the Health Board’s Welsh

Language Scheme and its obligations. Information stalls were also held across the Health Board to celebrate St David’s Day and to raise awareness of the Standards and the “Active Offer”. These campaigns are also valuable in that they raise awareness amongst the public of services that are provided bilingually, such as the Pharmacy’s Bilingual Medicines Helpline.

The Health Board, in its endeavours to internally promote, encourage and support the Welsh language amongst staff, has gone above and beyond its current Welsh Language Scheme requirements in ensuring bilingual key messages and correspondence from the Chief Executive and the Chairman. The Chief Executive has developed a weekly round up to inform staff of his daily activities and deliver a personal message to staff. This assists in creating a bilingual environment, fostering an ethos of leadership and demonstrating top-down commitment in Welsh language provision.

Information about methods used to assess the quality of the organisation’s Welsh language services by assessing the experience of service users (such as surveys, mystery shopper etc)

The North Wales Community Health Council (CHC) independently monitors the provision and delivery of health services in North Wales and conducted a year-long Welsh language monitoring exercise following on from their findings in their previous surveys of the Health Board’s Welsh-medium services. The survey encompassed unannounced visits to all of North Wales’ District General and community hospitals (a total of 27 locations) and a mystery shopper exercise (which was conducted via telephone), whilst the contents of the Health Board’s website, social media pages and press releases were also regularly monitored.


Furthermore, documentation received by the CHC from the Health Board (including correspondence and papers relating to specific meetings) were also reviewed, in order to verify their compliance with the requirements noted in the Welsh Language Scheme. Whilst particular attention was given to signage, the hospital visits also allowed the CHC to monitor other aspects of the Health Board’s bilingual provision, including the availability of Welsh-medium posters and leaflets, and the extent and quality of the bilingual service provided verbally by frontline staff at main receptions. Improvements were identified in terms of bilingual signage, as well as further progress reported in the provision of bilingual greetings by staff at all sites. The monitoring exercise also highlighted some concerns in certain areas in relation to temporary signage and this is being addressed at local level and at an organisation wide level through regular reminders and site visits. Regular walkabout inspections are now held at hospitals throughout North Wales allowing the Welsh Language Team to remind staff about the availability of a range of useful resources to swiftly resolve any issues. The Health Board’s ‘Temporary Signs Database’ on the Welsh Language Section of the intranet site has recently been expanded, facilitating compliance with the Health Board’s Welsh Language Scheme.

Further insight into the quality of the Health Board’s Welsh-medium services was also provided through the publication of ‘A new measure; a new mind-set: The Welsh Language Commissioner’s Assurance Report for 2014–15’ in October 2015. The contents of the Assurance Report were primarily based on the results of a number of mystery shopper surveys. Useful information was received about the quality of the Welsh-medium service provided by reception staff at six BCUHB sites and at switchboards. The exercise gathered positive results in terms of bilingual telephone services and reception areas in Ysbyty Gwynedd, Ysbyty Penrhos Stanley, Ysbyty Alltwen, Denbigh Infirmary and Ysbyty Llandudno. Specific reference to the Health Board’s main public website as an example of best practice noting that the Welsh-medium content is as easy to use as its English language service and this is celebrated as part of the Commissioner’s final report. Link to Welsh Language Commissioner Assurance Report - Item 6

Complaints

Number of complaints received about the implementation of the Welsh Language Scheme

The Health Board received 14 complaints relating to the implementation of its Welsh Language Scheme during 2015-16. (The Health Board received 18 complaints relating to the implementation of its Welsh Language Scheme during 2014-15). The main themes and lessons learned are highlighted below.


Welsh-medium telephone services These complaints covered a wide range of issues – from the failure to provide Welsh-language versions of certain forms, to the provision of S4C for inpatients, to the shortcomings in relation to Welsh-medium telephone services. However, further investigation revealed that the Health Board’s provision of Welsh-medium telephone services referred to isolated incidents, which were all unavoidable, caused by temporary staffing issues (i.e. each of the reported shortcomings was caused by a short-term leave of absence of Welsh-speaking staff at a certain location). This does not therefore reflect the general quality of the Health Board’s Welsh-medium telephone service provision. However, in order to further develop and sustain our ability to provide comprehensive Welsh medium provision, the Health Board recently published a Bilingual Skills Strategy, detailing how teams and departments can maximize their ability to provide Welsh-medium services through strategic recruitment, creative ways of working and workforce planning to make the most of their staff’s linguistic skills. Thus, it is envisaged that the implementation of the new Bilingual Skills Strategy will contribute towards ensuring that such shortcomings are addressed and planned for in advance, eliminating the possibility of any reoccurrence. Primary Care Three of the fourteen complaints received by the Health Board during 2015-16 were about issues which related to services provided by independent primary care contractors. Whilst clause 1.5 of the BCUHB Welsh Language Scheme states that the ‘Health Board will continue to build on the relationship and contacts established by previous Local Health Boards with primary care, by working closely with the contractors and their staff, and will continually encourage and support them in the delivery of a bilingual service to the people of North Wales’, the same passage also emphasizes that ‘Primary Care Contractors (i.e. General Practitioners, Dentists, Pharmacists and Opticians) are independent, self employed contractors and are not employees of the Health Board’. In this respect, as independent contractors, they are not obliged to comply with the Health Board’s Welsh Language Scheme. However, these concerns were fully addressed with the Welsh Language Team offering support and encouragement in the form of resources, awareness sessions as well as the services of its Translation Team. The Health Board has established relationships with key contractors within its limited resource and capacity and will continue to expand its support. The Welsh Language Commissioner’s Investigation and Report into the Health Board’s provision of Cognitive Assessments through the medium of Welsh

The Health Board was subject to an investigation by the Welsh Language Commissioner during 2015-16 relating to an alleged failure to provide a child with a Welsh-medium Cognitive Assessment. The Commissioner’s investigation considered


eight specific clauses within the Health Board’s Welsh Language Scheme, and concluded that the Health Board had acted in accordance with six of them. Whilst the investigation concluded that the Health Board had breached the other two clauses in question by failing to provide a Welsh-medium Cognitive Assessment, the report explained that these contraventions occurred because ‘it was not possible for the Health Board alone to arrange for the standardization of the assessment’ with a formal understanding that in the absence of a nationally standardized Welsh language translation of the Wechsler Intelligence Scales for Children – it was ‘inevitable’ that the Health Board would fail to comply fully with its Welsh Language Scheme in relation to providing Cognitive Assessments. This point of view is confirmed by the report’s only recommendation to draw the attention of relevant partners, including the Welsh Government, to the absence of Welsh language tools or assessments which hinder their ability to treat the Welsh and English languages on a basis of equality in the conduct of public business. Discussions have already taken place with other organisations, including Bangor University, Welsh Government and the Welsh Language Commissioner and the Health Board will continue to provide specialist knowledge from within the service area to advise and facilitate further collaboration with all involved.

Next Steps and Forward Vision Betsi Cadwaladr University Health Board is confident that it will meet its obligations to the public through the implementation of the Welsh Language Scheme over the remaining term of the Scheme. The Health Board has continued in its endeavours to foster a sense of ownership and responsibility of the Welsh Language Scheme amongst its workforce. The Welsh Language Team will continue with their efforts to raise language awareness within services directed towards the four vulnerable groups, and to improve bilingual service provision. Work will also progress with nominated senior leads across all service areas, including West, Central and East areas, Secondary Care, Mental Health, Estates and Procurement to implement improvement plans within the structures. As noted in the main body of the report, the Health Board is fully aware of its challenges and operational pressures during the next reporting year. However, its vision to provide a service that satisfies the needs of Welsh speakers and their families or carers will not be compromised. The Health Board has undertaken a population needs assessment in order to plan its services in accordance and will focus on four key areas during the next reporting year:


The Welsh Language Standards will drive the implementation of service delivery through key dimensions, notably Behavioural Change, Strategic Intervention and Performance and Delivery. This will allow planning, engagement and monitoring on an organisation wide level. We look forward to further developing the working relationship with the Welsh Language Commissioner during the unfolding of the implementation of the Welsh Language Standards that will replace the Welsh Language Schemes. The Bilingual Skills Strategy will be further progressed to ensure implementation across the Health Board, enabling service planning to ensure a sufficient amount of Welsh speakers to deliver services to its Welsh speaking population. ‘More than just words’ and the “Active Offer” will be incorporated into Welsh language service and communication plans to raise awareness at all levels through social and interactive engagement with staff and the public. A pan North Wales ‘More than just words’ Forum has been established with local authorities and other key organisations to ensure an integrated approach to Welsh language planning. Primary Care services will also form a key element of the Health Board’s agenda by continuing to build upon relationships already established with Primary Care contractors, focusing on the Welsh Language Commissioner’s recommendations in her report ‘My Language, My Health’. Welsh language requirements will be mainstreamed into local cluster plans and leads will be identified within the Area Teams to work with the clusters to identify needs, implement imminent achievable actions and roll out existing good practice The Health Board will continue to work with key partners and stakeholders in taking forward Welsh language requirements and encouraging the use of the Welsh language across healthcare provision within the Betsi Cadwaladr University Health Board area. 23.6.16

2.4 16/115 Committee and Advisory Groups Chairs’ Reports

1 16_115.1 F&P Chairs Report 26.4.16.pdf

Date of Meeting 23.6.16

Item 16/115.1To improve health and provide excellent care

Committee Chair’s Report

Name ofCommittee:

Finance & Performance

Meeting date: 26.4.16

Name of Chair: Ms Jenie Dean, Independent Member

ResponsibleDirector:

Mr Russell Favager, Executive Director of Finance

Summary of keyrisks and otheritems discussed:(Minutes areavailable viaSecretariat)

1. Provide summary of discussion of each relevant risk on theCorporate Risk Register:

Financial The finance report for month 12 was discussed. The year

ended with a deficit of £19.5m which is slightly below the£19.7m deficit forecasted but £5m more than the originalbudget set.

The Board did not achieve its savings target of £42.5mhowever £34m of savings were delivered which in cash termsin relation to the other Health Boards is a good achievement.Of this, £11m of savings has been gained through nonrecurring measures which adds to the underlying deficitposition.

For the year ahead, so far savings plans have been producedfor different schemes amounting to £23m of the required£30m.

Access and Delivery Discussion of domains assigned to the Committee within the

IQPR focussing on RTT, Cancer, Stroke, ED performanceand GP out of hours. In relation to RTT, at the end of Marchthere were 643 over 52 week waiters (against a WelshGovernment expectation of zero) and 3,666 over 36 weekwaiters (against the expectation of 3,142). The team arenow working to deliver 3142 over 36 week waiters by theend of quarter 1.

Estates & Environment/ Capital Systems

The month 12 capital programme report was discussed.

The discretionary capital programme was discussed andapproved. Recommendations for bids against Welshgovernment additional discretionary capital were supported.

Informatics The replacement of legacy telephone systems was

endorsed for board approval, noting the robust procurementexercise that had been undertaken.

Continuing Health Care A report with recommendations for a new structure for

Continuing Health Care fees over the next 12 monthsincluding issues such as funded nursing care (FNC), CHCcare homes and domiciliary care was discussed in detail. Allrecommendations were endorsed noting that decisions maygive rise to questions and challenges. The Committee weremindful of the fragility and challenges within the care homeand domiciliary care sector in reaching a decision to supportthe recommendations.

2. Provide summary of other business discussed:

External Contracts Update – April 2016 Staff Seasonal Flu Vaccination Summary Report Winter

2015/16 Organisational Change 2015/16 Progress

Key assurancesprovided at thismeeting:

Year end financial forecast achieved.

Capital resource limit achieved with all the resourcesallocated expended by year end.

Significant progress in regularising external contracts hasbeen made with improved scrutiny around quality andsafety. In addition the requirements of the Welsh LanguageAct are written into the contracts and a Welsh languagecoordinator is part of the Contracting Group.

GP Out of Hours performance was praised in the JETmeeting in relation to performance against the 20 and 60minutes target at the same time as a large increase in thenumber of calls.

Cat A Ambulance performance good only missing the targetfor one week through the Winter

Performance and accountability reviews are taking place ona monthly basis. The quarter 3 work has been completedand a one day event is taking place on Friday 13th May torecognise the work completed during the last year.

Key risks andconcerns:

Medical Agency usage is of concern; costs are increasingwith little sign these will change in the short term.

Unscheduled care costs have not been contained within thewinter pressures funding indicating the degree of the stressin the system around emergency activity.

Final forecast year end cost pressure resulting from externalcontracts including WHSSC is £9.3m.

There is a particular need to review orthopaedic waitingtimes and how this can be managed going forward workingwith Welsh Government.

Staff uptake of flu vaccine was low in Secondary Care andMental Health. The uptake rate was also low in nursing,ancillary staff and healthcare support workers therefore acontingency plan is required in these areas. The 2016/17 fluplan will be submitted to the Executive Team in June and tothe Committee in July 2016.

Issues to bereferred to anotherSub-Committee

None

Matters requiringescalation to theBoard:

Board to be aware of issues around Continuing Health Carefunding.

Planned businessfor the nextmeeting:

A range of regular reports including Finance, Capital, Workforceand IQPR plus

Intermediate Care Fund Funding 2016/17 Performance Plan and Proposed Integrated Quality

& Performance Reporting Arrangements Update on PADR and Mandatory Training Relocation Expenses Policy Committee Annual Report Shared Services Partnership Committee Assurance Report.

Date of nextmeeting:

24.05.16.

Disclosure:Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health Board

2 16_115.2 Chair's Assurance Report RaTS 16.5.16 V1.0.pdf

Board Meeting 23.6.16



Name ofCommittee:

Remuneration & Terms of Service Committee


Name of Chair: Dr Peter Higson


Mr Martin Jones, Executive Director of Workforce & OrganisationalDevelopment

Summary of keyrisks and otheritems discussed:

The workforce related risks on the Corporate Risk Register areformally monitored by the Strategy Planning & Partnerships SubCommittee. No additional risks were identified for escalation.

Public Session:

The Committee received papers on: The NHS contract and leavers which detailed provisions for the

rotation of staff, options for individuals leaving the organisation,current data on leavers and displaced staff across BCUHB andthe range of supporting policies and procedures.

The Committee endorsed: Its annual report for 2015-16, for submission to the Health

Board A paper outlining proposals in relation to relocation expense

allowances of overseas recruitment of both temporary, fixed-term and substantive medical staff

A protocol for determining salaries of interim appointments atexecutive and other senior level posts to cover a vacant role forwhich is an establishment within the BCUHB structures

Proposals to increase hourly rates paid to substantive medicalstaff undertaking additional duties – internal locums

In Committee Session:

The Committee received an update on agreed salaries forrecent substantive Executive appointments details of JESPoutcomes for other senior posts.

The Committee considered a range of applications made underthe Voluntary Early Release Scheme.

The Committee were provided with a copy of the deed ofsettlement on the mutually agreed separation with the formerChief Executive.


None to report


Reputational and potentially regulatory risks were highlighted withinthe papers considered.

Issues to bereferred to anotherCommittee

The Committee agreed that the Audit Committee be asked toapprove the final version of the Remuneration and Staff Report aspart of the accountability and financial statements report.

As part of the NHS Contract and Leavers paper, further informationin displaced staff was requested for the Finance & PerformanceCommittee.


None


Range of standard items plus: Update on consultant sessions, job planning, private practice; Policy for provision of pay flexibility for executives taking on

significant additional responsibilities; Options for use of VERS monies.


18.7.16

Note – an extraordinary in committee meeting was also held on the19.5.16 to consider an application for pay flexibility.

Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health BoardV1.0

3 16_115.3 LPF Advisory Group Chairs' Report 11.4.16 v1.0.pdf

Board meeting 23.6.16


Advisory Group Chair’s Report

Name of AdvisoryGroup:

Local Partnership Forum


Name of Chair: Mr Martin Jones / Mrs J Hughes / Mrs J Tomlinson(Rotational)


Mr Martin Jones, Executive Director Workforce and OrganisationalDevelopment

Summary of keyitems discussed:

Presentations were received on the Mental Health (MH) Strategyand Primary Care Strategy. Trade Union representatives wereinvited to feed into the MH commissioning process beingdeveloped and consider TU representation within the new primarycare model and engagement with clusters.

An update on progress with healthcare provision for HMP Berwynwas received.

The implications of the introduction of Welsh Language Standardswere outlined across the organisation, including employmentpractice areas supported by Trade Union representatives.

Following a request by Trade Union representatives, progress withBCUHB’s Health and Safety Management structure was outlined.Concern was raised over provision within Area Teams andclarity sought on how Violence and Aggression was supported.

Continued concern on the lack of progress with Job Evaluation wasnoted, including availability of management trained job matchersfor scheduled panel meetings.

Following concerns raised on the findings of the Health andWellbeing pulse survey, further information on BCU’s approach towork related stress would be addressed at a future meeting.

The draft LPF annual report 2015/16 was approved for submissionto the Board.

A presentation on the Proud of campaign was well received.

A Working Time Directive statutory rate of 12.07% across BCUfrom 1.4.16 was supported, subject to further work beingaddressed on inconsistencies and substantive employees workingon the bank.

Presentations on the Leadership Behaviours Framework and DraftWorkforce Engagement Strategy provided opportunities to feedinto the developments.

Key advice /feedback for theBoard:

The Chief Executive commended the work that had beenundertaken by staff during the busiest quarter of the year toachieve reductions in waiting times in certain areas. Heextended a big thank you to staff.


Recruitment and Retention Strategy;Whole Systems Strategy.


21.6.16.


V1.0

4 16_115.4 Chair's Assurance Report Audit 31.5.16 V1.0.pdf

1




Name ofCommittee:

Audit Committee


Name of Chair: Mr Ceri Stradling


Mrs Grace Lewis-Parry


1. Summary of discussion of each relevant risk on theCorporate Risk Register:

None.

2. Summary of other business discussed:

Agreed the updated Annual Report of the Audit Committee Approved the Audit Committee improvement plan arising

from the annual self-assessment. Approved recent amendments to the Standing Orders Endorsed the updated Governance Statement for Board

approval. Received the Internal Audit Annual Report and Audit Opinion Received the Annual Report of Post Payment Verification

work. Received the Annual Report of the Local Counter Fraud

service. Discussed the quarterly Financial Conformance Report. Discussed the Accountability Reports that support the

Financial Statements. Received the ISA 260 Report on the Financial Statements

from the External Auditors.


The Audit Committee complies with most aspects of goodpractice and has an action plan to address any improvementareas identified.

The Audit Committee has started the process of identifying,classifying and evaluating key sources of Board Assurance andthis will be further refined in 2016-17.

The Annual Governance Statement is a comprehensive

2

analysis of the position of the Board in 2015-16 reflecting theprogress made and the challenges facing the Board as it movesforward.

The Board can be assured that its primary care payments andsupporting arrangements are operating well.

The Board can be assured that the measures it employs, viathe local counter fraud service, to deter, prevent and detectfraud are effective.

Good assurance has been provided by both Internal andExternal Audit that the Board’s financial procedures andcontrols are operating as intended and that areas of risk arenow subject to regular scrutiny.

The Board’s Financial Statements for 2015-16 were preparedpromptly (by 29 April) and the WAO found they were to a highstandard and supported by comprehensive working papers. TheWAO were able to conclude that the accounting policies andestimates used were appropriate and disclosures unbiased, fairand clear. As a result it is the AGW’s intention to issue anunqualified audit report on the financial statements.


The Head of Internal Audit provided a Limited Audit Opinion for2015-16. The opinion was based on the limited assurance obtainedfrom audit work in the primary domain of corporate governance,risk management, regulatory compliance and capital and estatesmanagement.

Some recent reviews had contributed to this limited opinionnamely:

the declaration of gifts and hospitality below Board level; partnership governance over section 33 agreements; the Tywyn Hospital redevelopment project.


The Finance & Performance Committee should be aware of thefindings of the three audit reports referred to above when available.


None other than those referred to above.


Range of Standing Items plus:

BCUHB Response to Wales Audit Office Consultation on Well-Being of Future Generations

Annual Quality Statement Draft Organisational Annual Report 2015-16 Gifts and Hospitality / Declarations of Interest Annual Review Annual Clinical Audit Plan Final Internal Audit Reports (Business Conduct / Gifts &

3

Hospitality and Tywyn Capital) WAO Local Report Medical Equipment & Management

Response.


14.7.16.


V1.0

5 16_115.5 Chair's Assurance Report QSE 10.5.16 V1.0.pdf




Name ofCommittee:

Quality, Safety and Experience


Name of Chair: Mrs Marian Wyn Jones, Independent Member


Mrs Vicky Morris, Executive Director of Nursing, Midwifery,Therapies & Health Science.


Summary of discussion of each relevant risk on the Corporate RiskRegister:

CRR2 Infection PreventionAs part of consideration of the integrated quality performancereport, the Committee suggested that norovirus and numbers ofbed moves be included as local indicators.

CRR3 Continuing Health Care/Nursing HomesDiscussion around delayed transfers of care, resulting in decisionto seek paper from Area Directors for the Stakeholder ReferenceGroup regarding relationships with local authorities.

CRR4 Maternity ServicesFactors contributing to a deteriorating position with caesareansection rates would be picked up by the Interim Executive NurseDirector, and an exception report be provided.

CRR5 Patient ExperienceListening and learning report – noting rich data but a range ofvariation in patient feedback for Q3 2015/16. An increase innumber of complaints but high percentage of patients still ratedcare as good. Implementation of PALS, Patient advice and liaisonservice should help resolve some low level issues.

CRR13 Mental HealthAssurance paper deferred pending appointment of substantive MHDirector into role.

Summary of other business discussed:

Director of Quality Assurance’s Report – discussion aroundclinical audit, with concern expressed re dissemination ofclinical audit actions and recommendations. HIW reports intoindependent/private contractors/review of learning disabilities.Presentation on quality improvement objectives and suggestionthat the Healthcare Professionals Forum could provide achampion role.

Year end self-assessed position for health and care standardswas noted.

A short in-committee meeting was held at the end of themeeting to sight members on two issues which would besubject to public papers at the next meeting.


Progress with addressing and responding to Health & SafetyExecutive interventions

Receipt of internal audit report regarding the QualityImprovement Strategy which provided a level of moderateassurance.


Ongoing work required to improve links between Clinical AuditGroup, Clinical Effectiveness Group and Area Groups.Schedule of high priority audits to be presented to the QualityAssurance Executive.


The Chief Operating Officer was asked to raise at Executive Teamthe issue of Board level influence / direction of Area Quality &Safety Groups.


The endorsement of Policy MD18 “Being Open”, noting that theduty of candour should apply to all health professionals, not justdoctors and nurses.


Range of regular reports plus Putting things right annual report Ombudsman’s annual report Accessible healthcare standards Women’s service assurance report Mental Health assurance report Safeguarding activity Annual quality statement National complex care Mortality Infection prevention / Prof B Duerden’s report.


14.6.16.

Disclosure: Betsi Cadwaladr University Health Board is the operational name of Betsi Cadwaladr University Local Health BoardV1.0

3.1 16/116 Special Measures Improvement Framework – Task & Finish Group Chair’s Assurance Report 2.6.16

1 16_116 Chair's Assurance Report SMIF T&F 2.6.16.doc

Date of Health Board meeting: 23.6.16 Agenda item number


DRAFT Committee Chair’s Report

Name of Committee:

Special Measures Improvement Framework Task & Finish (SMIF T&F) Group


Name of Chair: Mrs Margaret Hanson, Health Board Vice-Chair


Mrs Grace Lewis-Parry

Summary of key risks and other items discussed:

Information requirements for the covering letter to accompany the submission of the End of Phase 1 Report to Welsh Government

Reporting arrangements to Board – SMIF T&F to submit monthly updates via Chair’s Assurance Reports

Embedding special measures in core business – Committee and Board coversheets to include an additional field requiring authors to identify to which element of special measures their paper applies

Progress against the Improvement Framework progress and action log relating to Phase 2.

Key assurances provided at this meeting:

Risks and timescales associated with the Special Measures Improvement Framework are being managed appropriately; overall, good progress has been made.

There is linkage between the expectations and deliverables in the Improvement Framework progress and action log and the Operational Plan

Each theme within the Improvement Framework is to be allocated to a specific Committee of the Board.

Key risks and concerns:

Sustaining a stable Board is of primary importance; the Board has made key new appointments but there are instability risks during this transitional phase

Scope, timescales and preparedness of the system/public are the key challenges relating to the whole system change

Staff engagement and culture change requires further development otherwise progress may be impeded

Additional resources will be required to support continued progress against the Improvement Framework

Mental health remains an area of risk, and there are also risks associated with HMP Berwyn.

Issues to be referred to another Committee

Themes will be allocated to Committees as follows, for additional scrutiny and monitoring purposes: Leadership – to be retained by the SMIF T&F Governance – to be retained by the SMIF T&F Strategic & Service Planning – Strategy, Partnerships & Population Health Committee Engagement – Quality, Safety & Experience Committee Mental Health Services – Quality, Safety & Experience Committee Maternity Services – Quality, Safety & Experience Committee Primary Care – Strategy, Partnerships & Population Health Committee.

Matters requiring escalation to the Board:

None.

Planned business for the next meeting:

Progress monitoring for Phase 2.

Date of next meeting:

7.7.16


Committee Chair’s Assurance Report Template V3.0 8.3.16

3.2 16/117 Integrated Quality & Performance Report

1 16_117 IQPR revised.pdf

1

Board Paper23.6.16

Item 16/117 To improve health and provide excellent care

Title: Integrated Quality & Performance ReportAuthor: Jill Newman, Director of Performance

Richard Gillett, Head of Business Intelligence & Performance AssuranceResponsibleDirector:

Morag Olsen, Chief Operating Officer

Public or InCommittee

Public

Strategic Goals

1. Improve health and wellbeing for all and reduce healthinequalities

2. Work in partnership to design and deliver more carecloser to home

3. Improve the safety and outcomes of care to match theNHS’ best



6. Use resources wisely, transforming services throughinnovation and research

7. Support, train and develop our staff to excel

Approval /Scrutiny Route

Four sections of the report have had prior scrutiny with the Finance &Performance Committee and three sections have had prior scrutiny bythe Quality, Safety and Experience Committee.

Purpose: This report provides the Board with a summary of key quality,performance, financial and workforce indicators.

Significant issuesand risks

The integrated quality and performance report for March 2016 includes: National Indicators aligned to the seven national performance

domains Locally agreed indicators aligned to the performance domains

Monthly updates against National Indicators

The national indicators for the domains demonstrate the followingchanges in direction of performance since last month’s report:

National Targets

Domain ImprovedPerformance

SustainedPerformance

Decline inPerformance

2

Staying Healthy 8 6 3

Safe Care 5 6 1

Effective Care 3 4 2

Dignified Care 1 0 1

Individual Care 1 1 3

Timely Care 6 1 9

Staffing and Resources 3 1 2

Total 27 19 21

Local Targets

Domain ImprovedPerformance

SustainedPerformance

Decline inPerformance

Staying Healthy 1 0 1

Safe Care 4 1 8

Effective Care 2 0 2

Dignified Care 2 0 1

Individual Care 2 1 2

Timely Care 8 0 2

Staffing and Resources 2 0 0

Total 21 2 16

Staying Healthy

Good progress has been made on reducing the numbers of babies whoare born with low birth weight, a key indicator for a healthy population.This improved to 6.1% in April 2016. It is expected that performance willimprove further this year. Further detail can be found on page 17.

Safe Care

3

Ward to Board measures, contained within the Ward Quality Auditsdeteriorated slightly by 1% to 87% this month. There has been adeterioration of theme scores in general wards, in particular inCommunity Hospitals, and an improvement in performance in MentalHealth and Learning Disabilities. There was a small improvement incompliance in general wards, but a reduced compliance in Mental Health

There we no new never events this month.

Performance against the complaints response target for 30 days, shownon page 27, has deteriorated this month to 19.3% and still remains shortof the target of 75%. Performance is managed locally and staffs areaiming to offer direct contact with complainants to improve responsetimes.

Effective Care

The continuing investigation into higher mortality at the Wrexham Maelorsite is reported, together with the actions being taken to investigatecauses of concern. A detailed investigation is expected to report in mid-2016. The report is on page 38.

Individual Care

Performance against the I Want Great Care pilot at Wrexham Maelorscore was 4.66 out of 5.00.

The number of non-mental health patients who were delayed transfers ofcare performance worsened again this month, however the overallnumber of bed days lost due to delays improved. The actions which arefocussed around nursing and residential care home beds were reviewed.The percentage of patients who leave Emergency Departments withoutbeing seen has deteriorated further at the Wrexham Maelor site.Further detail can be found on page 48.

For Mental Health services, we saw a decline in performance inassessment and treatment waiting times in April, Adult Mental Healthservices mentioned sickness absence levels for the decline inperformance. Ensuring that all service users have an agreed care planis a key indicator for the services, the continued performance gains showthat in April the service is only just short of the 90% target, see page 46of this report for further detail.

Dignified Care

Performance against the target to ensure we cancel fewer patient’sprocedures after they have been admitted continues to improve.However, cancellations prior to admission continues to show poorperformance (page 50).

4

Timely Care

Referral to Treatment showed a deterioration in performance from Marchto April (page 55). Therapy waiting times have achieved the target ofzero patients waiting at the end of April. Diagnostic services havesignificantly increased the volume of patients accessing tests this year,unfortunately at the end of April, the 8 week target was breached.Actions are being taken to increase the number of tests and scansperformed per month to support improvement in performance which isexpected to be evident in May and June 2016. Emergency Departmentperformance remains poor, with a modest improvement in April overMarch. Wrexham Maelor remains the poorest performer of our hospitals,with actions to improve the performance by focusing on low acuitypatients at Wrexham Maelor’s Emergency department (page 57). Thestroke measures have been refined this month to reflect the 2016/2017performance measures as set out in formal guidance from the WelshGovernment.

Our Staff & Resources

The financial position of the Health Board is reported, an adversevariance of 2.7% is shown at the end of Month 1. Further detail can befound in the finance report. The rolling 12 month sickness absence hasworsened slightly from last month; however our performance is the bestout of the 6 large health boards (page 67).

Referrals & Activity

New referrals at the Health Board, both from GPs and consultants, areincluded in the report in line with Ann Lloyd’s recommendations. Overallreferrals have increased by 11.4% compared to April last year, howeverthis variance is just for a single month of April. The previous April hadfewer referrals due to the Easter holiday period falling within it.

Quality & Effectiveness Measures

The indicators covering readmissions, complications and misadventuresare not included in this month’s report due to data processing issues atthe clinical benchmarking company used to produce the report. It isanticipated that correct figures will be available in time for the next fullreport.

Equality ImpactAssessment

The Health Board’s Performance Team are establishing a rollingprogramme to evaluate the impact of targets across the Equality &Diversity agenda.

Recommendation/Action requiredby the Board

The Board is asked to note the report.

5

Disclosure:Betsi Cadwaladr University Health Board is the operational name of Betsi CadwaladrUniversity Local Health Board

Integrated Quality & Performance Report 2016/17

Performance to the end of April 2016


Health Board

Title

Contents

Foreword

1.0 Executive Summaries

2.0 Overview and Areas of Escalation

2.1 Staying Healthy

2.2 Safe Care

2.3 Effective Care

2.4 Individual Care

2.5 Dignified Care

2.6 Timely Care

2.7 Our Staff & Resources

3.0 Referrals & Activity

Appendix A

Further information and links

Section Content

Contents

Performance Report April 2016

Page 2

Table of Contents

Table of Contents


Page 3

Title 1 New Serious Incidents 23 MHM Treatments (Part 1) 45 Sickness 67

Contents 2 Welsh Government Reportable

Incidents 24 MHM Care & Treatment Plans (Part 2) 46 Financial Balance 68

Table of Contents 3 New Never Events 25 MHM Re-Access (Part 3) 47 Outpatient DNA 69

Foreword 4 Patient Safety 26 ED Left Without Being Seen 48 Appraisals (Non Medical) 70

Status Guide 5 Complaints (1) – Special Measures 27 Dignified Care Summary 49 Mandatory Training 71

Executive Summary (Sunburst) 6 Complaints (2) SM 28 Inpatient Cancellations 50 Agency and Locum Spend 72

Achievements Staying Healthy 7 Coroner Reports 29 Outpatient Cancellations 51 Operating Theatres 73

Achievements Safe Care 8 ITU Delayed Transfers 30 Timely Care National Summary 52 Hospital Activity 74

Achievements Effective Care 9 Incidents 31 Timely Care Local Summary 53 Referrals 75

Achievements Individual Care 10 Caesarean Section – Special

Measures 32 GP Opening Times 54 Appendix A – Further Information 76

Achievements Dignified Care 11 Anti-Microbial Prescribing 33 Referral To Treatment 55

Achievements Timely Care 12 Ward Quality Audit 34 Diagnostic Waits 56

Achievements Staff Resources 13 Safe Staffing 35 ED Waits 57

Staying Healthy National Summary 14 Effective Care National Summary 36 ED Waits over 12 Hours 58

Staying Healthy Local Summary 15 Effective Care Local Summary 37 Ambulance Performance 59

Smoking Cessation 16 Mortality Measures 38 Urgent Suspected Cancer 60

Low Birth Weight – Special Measures 17 Data Quality 39 NHS Dental Access 61

Safe Care National Summary 18 Elective Average Length of Stay 40 Follow Up Waiting List 62

Safe Care Local Summary 19 Individual Care National Summary 41 Therapy Waiting Times 63

Healthcare Acquired Pressure Ulcers 20 Delayed Transfer of Care 42 Out Of Hours 64

C.difficile infections 21 Delayed Transfer of Care 43 Staff & Resources National Summary 65

Staph Aureus infections 22 MHM Assessments (Part 1) 44 Staff & Resources Local Summary 66

Title 1 New Serious Incidents 23 MHM Treatments (Part 1) 45 Sickness 67

Contents 2 Welsh Government Reportable

Incidents 24 MHM Care & Treatment Plans (Part 2) 46 Financial Balance 68

Table of Contents 3 New Never Events 25 MHM Re-Access (Part 3) 47 Outpatient DNA 69

Foreword 4 Patient Safety 26 ED Left Without Being Seen 48 Appraisals (Non Medical) 70

Status Guide 5 Complaints (1) – Special Measures 27 Dignified Care Summary 49 Mandatory Training 71

Executive Summary (Sunburst) 6 Complaints (2) SM 28 Inpatient Cancellations 50 Agency and Locum Spend 72

Achievements Staying Healthy 7 Coroner Reports 29 Outpatient Cancellations 51 Operating Theatres 73

Achievements Safe Care 8 ITU Delayed Transfers 30 Timely Care National Summary 52 Hospital Activity 74

Achievements Effective Care 9 Incidents 31 Timely Care Local Summary 53 Referrals 75

Achievements Individual Care 10 Caesarean Section – Special

Measures 32 GP Opening Times 54 Appendix A – Further Information 76

Achievements Dignified Care 11 Anti-Microbial Prescribing 33 Referral To Treatment 55

Achievements Timely Care 12 Ward Quality Audit 34 Diagnostic Waits 56

Achievements Staff Resources 13 Safe Staffing 35 ED Waits 57

Staying Healthy National Summary 14 Effective Care National Summary 36 ED Waits over 12 Hours 58

Staying Healthy Local Summary 15 Effective Care Local Summary 37 Ambulance Performance 59

Smoking Cessation 16 Mortality Measures 38 Urgent Suspected Cancer 60

Low Birth Weight – Special Measures 17 Data Quality 39 NHS Dental Access 61

Safe Care National Summary 18 Elective Average Length of Stay 40 Follow Up Waiting List 62

Safe Care Local Summary 19 Individual Care National Summary 41 Therapy Waiting Times 63

Healthcare Acquired Pressure Ulcers 20 Delayed Transfer of Care 42 Out Of Hours 64

C.difficile infections 21 Delayed Transfer of Care 43 Staff & Resources National Summary 65

Staph Aureus infections 22 MHM Assessments (Part 1) 44 Staff & Resources Local Summary 66

Foreword Seven Domains

We present performance to the Board using the frameworks against which

NHS Wales is measured. This report includes the indicators from the

seven domains of; Staying Healthy, Safe Care, Effective Care, Dignified

Care, Individual Care, Timely Care and Our Staff and Resources.

The first three domains of Staying Healthy, Safe Care, Effective Care are

scrutinised at the Quality, Safety & Experience committee.

From October 2015 the Individual Care domain has shared scrutiny, with

some indicators being scrutinised by the Quality, Safety & Experience

committee and the remaining indicators being scrutinised by the Finance

& Performance committee.

The final three domains of Dignified Care, Timely Care and Staffing &

Resources are scrutinised by the Finance and Performance Committee.

Introductory Reports & Exception reports

Each new local indicator has an introductory report that gives the context of the indicator. We include exception reports where

performance is either worse than the required standard or the Board require sight of the actions we are taking to maintain or

improve performance. After we have achieved an indicator for three consecutive months, it will be stood down from exception

reporting.

Foreword


Page 4

Status Guide and Legend Status On the following pages, we report the overall escalation status of the Health Board. We use the Welsh Government’s status levels. The status level of each indicator group is graded from zero to four, with four being of most concern.

Legend

This report uses trend arrows. They show if the position has become better or worse than the previous month. Where the arrow is coloured, green signifies that performance is better than where we planned to be this month, whereas red signals that we are worse than where we planned to be this month. ↑ The value is better than the previous month → The value is the same as the previous month ↓ The value is worse than the previous month

Level 0 – local delivery of all targets and / or within trajectory

Level 1 – failure to deliver achieve or deliver one target or deliverable

Level 2 – continued failure to achieve or maintain one or more key deliverables

Level 3 – continued failure to maintain an agreed improvement trajectory

Level 4 – continued failure to improve performance or failure to engage with the national process

Special

Measures

This escalation status applies at Health Board level. Five key areas are a focus of the intervention

by Welsh Government; Reconnecting with the public, Staff Engagement, Mental Health, Obstetric

Care, Out of Hours Care and Board Governance.

Cross-hatch

Cross-hatch background. Where the background is cross-hatched this figure is the provisional, unvalidated position.

No Target No target level or the trajectory has not been set. This is used for new indicators which we are introducing into the report. The relevant executive director has been asked to set the target level. -

Status Guide


Page 5

Summary of

performance

within theme

(Red/Green)

Domain

Theme

Legend

1 Executive Summary

Executive Summary (Sunburst)

Mo

rta

lity

Staying Healthy

SafeCare

EffectiveCare

Individual Care

DignifiedCare

Timely Care

Staff & Resources

Performance

Summary

Our Achievements Staying Healthy I am well informed & supported to manage my own physical and mental health

North Wales Cancer Treatment Centre and

Tenovus Cancer Care

Tenovus Cancer Care, in partnership with the

Health Board, has launched Chemotherapy

Education Sessions. These sessions are for new

patients who will be undergoing chemotherapy

treatment at the North Wales Cancer Treatment

Centre.

Patients are invited to the session at the

centre before to their first chemotherapy

treatment, along with a family member, friend or

carer. Hospital staff use their professional

judgement to determine who the session is

suitable for and tailor this decision on; the

distance the patient would need to travel to the

session, the complexity of that individual’s

particular treatment and the patient’s individual

circumstances

For some patients, a one to one information

session is more appropriate, but for the majority

of patients the group education session is best.

The session gives an insight into the treatment,

a chance to see the chemotherapy department,

meet some of the staff involved and ask any

questions. It includes a talk about chemotherapy

from a nurse and a talk from Tenovus Cancer

Care about the free cancer support services that

are on offer to patients. This includes a welfare

benefits advice service, counselling service and

nurse telephone support, accessible via a free

support line. The attendees are then given time

to chat to NHS and Tenovus Cancer Care staff,

before being shown around the department.

One benefit of the session to NHS staff is

that considerable time can be saved by

delivering information in a group setting. The

first session took place on 15th April 2016.

Sessions have taken place at a rate of 1 per

week (every Friday afternoon) over a period of 4

weeks to date. Over the 4 sessions, a total of 24

people (patients and supporters) have attended

the sessions.

86% of

respondents

said they

found the

session

extremely

useful

Achievements Staying Healthy

0

5

10

15

20

NoKnowledge

LimitedKnowledge

FairKnowledge

GoodKnowledge

Attendees' knowledge of chemotherapy treatment after

session


Page 7

Our Achievements - Safe Care I am protected from harm & protect myself from known harm

New infection prevention measures developed by Betsi nurse gets UK-wide launch

A new tool which will help surgical teams prevent infection has been launched following

pioneering work by a senior Betsi Cadwaladr University Health Board nurse. Glan Clwyd Hospital-

based Tracey Radcliffe has worked with the OneTogether Partnership over the last two years to

develop a self-assessment tool which encourages best practice among operating theatre staff. The

OneTogether infection prevention programme is a network of professional associations and

industry partners working together to improve patient outcomes.

Tracey worked with other leading professional organisations to develop the clinical tool, which

encourages surgical staff to assess their everyday work and the way they care for patients. The

two-year project was supported by theatres at Wrexham Maelor Hospital, which was one of 15

clinical pilot sites where the new self-assessment tool was put to the test.

The self-assessment tool helps theatre staff compare their work with NICE guidelines,

highlighting areas where they can improve their clinical practice. Tracey said: “There hasn’t been a

tool like this for surgical teams to use before, so hopefully it’ll prove to be a really valuable

resource for education, assessment and quality improvement. “It’ll be used by staff involved in

treating patients who need surgery to help assess their own standards and identify where

improvements can be made. We looked at all areas of practice that contribute to preventing

surgical site infection, for example education for patients in keeping themselves warm prior to

surgery and theatre staffs’ practices to keep them warm during surgery.

We worked on creating the tool and launched a pilot phase in April 2015 in hospitals across the

UK, including Wrexham Maelor. It ran for approximately three months, giving all sites capacity to

carry out the assessment needed.

The new toolkit was launched at the OneTogether Conference at Birmingham’s Think Tank

science museum, which brought together leading theatre practitioners and specialists in infection

prevention. Tracey is now working with fellow OneTogether partners to look at further ways of

promoting the spread and adoption of best practice in surgical site infection prevention, having

polled participants at the conference on areas they felt were a priority for improvement.

There hasn’t

been a tool like

this for surgical

teams to use

before, so

hopefully it’ll

prove to be a

really valuable

resource for

education,

assessment and

quality

improvement.

Achievements Safe Care

Tracey Roberts


Page 8

Improvement of Psychiatric Liaison

A psychiatric liaison team works in general

hospitals, for example in the emergency

department or in-patient wards. They provide

psychiatric assessment and treatment to those

patients who may be experiencing distress

whilst in hospital and provide a valuable

interface between mental and physical health.

The Psychiatric Liaison Accreditation Network

(PLAN) works with services to assure and

improve the quality of psychiatric liaison in

hospital settings.

PLAN engages staff and patients in a

comprehensive process of review, through

which good practice and high-quality care are

recognised and services are supported to

identify and address areas for improvement.

Accreditation assures staff, patients and carers,

commissioners and regulators of the quality of

the service being provided.

PLAN includes core areas common for all

teams, such as assessment and care planning,

but also recognises that some areas may be

outside a team’s remit. This means that a small

but well functioning team can still be accredited

in the domains that it is measured against.

PLAN provides year round support to help

accreditation members maximise opportunities

for learning and development. This support

includes the option of taking part in email

discussion groups, learning events and annual

conferences, as well as quality improvement

advice targeted at individual services

Why is PLAN accreditation So Valuable?

It provides formal recognition…

Accreditation assures patients, carers, frontline

staff, commissioners, managers and regulators

that the liaison service is of a good quality and

that staff are committed to improving care.

Meeting accreditation target helps meet other

priorities too, including national and government

drives. PLAN accreditation and quality

improvement activity is highly valued

Our Achievements - Effective Care I receive the right care & support as locally as possible & I contribute to making that care successful

PLAN engages

staff and patients in

a comprehensive

process of review,

through which good

practice and high-

quality care are

recognised and

services are

supported to

identify and

address areas for

improvement.

Staff Member

PLAN

Achievements Effective Care


Page 9

Our Achievements - Individual Care I am treated as an individual, with my own needs and responsibilities

Maternity Outpatient Assessment Unit

(MOAU) Womens Services

The MOAU’s were introduced with the aim of

improving service user experience and

increasing efficiency within the maternity units.

Previous to this model of service delivery

there were Antenatal Day Units in each of the

maternity units, operating a weekday service

mostly during office hours. The majority of

women requiring closer monitoring can be

managed as outpatients if an enhanced facility

exists, such as an assessment unit accessible

on a 24hr 7 day per week basis. The Obstetric

Units (Labour Wards) were often at capacity

as women were being admitted for

assessment and observation in the latent

phase of labour. Women requiring

assessment and observation during night time

hours would need to be admitted to the

antenatal ward as no facility existed to assess

them out of hours.

The first MOAU opened in Glan Clwyd

Maternity Unit in September 2014, followed by

the opening of an MOAU in Wrexham and

Bangor maternity units in April 2015. The

MOAU consists of an assessment unit

operating scheduled appointments during the

day, with a 24hr triage service alongside,

available to all pregnant women ensuring ease

of access and support, whilst also maintaining

capacity on the Obstetric Unit.

This new model of care enables all health

care professionals to consistently deliver a

high standard of outpatient antenatal

surveillance to women whose pregnancy

requires further monitoring. Health care

professionals refer to relevant national and

local guidelines as necessary when monitoring

and assessing maternal and fetal wellbeing

therefore providing consistent evidence based

care.

Majority of the

women who

attend an

MOAU return

home with an

identified plan

of care based

on their

individual risk

assessment Paula (Patient), 47, from

Kinmel Bay

Achievements Individual Care


Page 10

Our Achievements - Dignified Care I am treated with dignity & respect and treat others the same

Community Formulary:

Continence & Urology Products 2016

A Health Board Community Formulary for

Continence & Urology Products was launched

on the 12th April 2016.

The Formulary and related Product Order Form

have been developed for the Prudent Medicines

Management Continence Work Stream. The aim

is to standardise continence and urology

products that are available on prescription

across North Wales.

It will simplify the prescribing of these products,

promote best practice and ensure efficient use

of NHS resources. The purpose of the evidence-

based Continence Formulary is to provide a list

of urinary products that can be used for the

majority of patients and as an educational

resource.

To celebrate the launch a drop in session was

arranged at the Optic Centre, St Asaph.

The session was well attended by community

nurses as an opportunity to become familiar with

the Formulary products and discuss the

implementation process with members of the

Continence Team, Improvement Team,

Medicines Management and Company

Representatives. Real sense of

satisfaction

seeing how

happy the

nursing staff

were at the

launch that the

Formulary is

published. The

first of many

more goals to

come Adam El Lamie

Project Manager

Achievements Dignified Care


Page 11


Page 12

Reducing Outpatient Waiting Times

Outpatient services are on a transformational

journey, under the guidance of Simpler

Healthcare. We identified that there was a lack of

a proactive coordinated approach to managing

the outpatient waiting times, a need to remove

waste in the process, reduce the follow-up

backlog, DNA rates and hospital initiated

cancellations. This project aims to develop a

flexible service to meet needs, demands and

capacity as required. Planning cells are now

established on each site to support:

i) Cohesiveness and joined up working

ii) Horizon planning ‘no surprises’

iii) Reduction in non-notified clinic cancellations

due to improved communication

iv) Reduction in Non Value Add time spent

v) Understanding and root cause of the data

we get

vi) No blame culture.

Examples of success so far are:

• A Direct Booking pilot is about to be

introduced, linking with the Welsh

Government, because project work has shown

that this will significantly improve the current

process flow and improve the patient

experience.

• Validation processes for the follow up backlog

have been developed and roll out across

specialties is being planned

• In Gastroenterology new templates are to be

implemented from May that improve the

capacity of the clinics, one example of

success is below:

Medical Records Improvement

Medical records have completed an ambitious

programme of work to improve both the flow of

their work and the work environment. They are

about to implement a new electronic tracking

system in East that will significantly help in the

management of records. Through collaborating

with nursing staff in the urology clinics in

Wrexham they have released 100 hours a month

of nursing time previously spent in prepping case

notes before clinics.

Our Achievements - Timely Care I have access to services based on clinical need & am actively involved in decisions about my care

The approach

is proven to

work – the

challenge now

is to roll out the

lessons

learned in

order to make

a real

difference

Alison Ravenscroft

Project Lead

Achievements Timely Care

NHS Wales Honoured at Global Sepsis Awards

The Global Sepsis Alliance is an international non-profit organisation responsible for numerous

worldwide sepsis awareness initiatives – such as World Sepsis Day. NHS Wales’ contribution to

sepsis awareness and prevention was recognised in the “Governments and Healthcare

Authorities” category. 1000 Lives Improvement has long been supporting the prevention of sepsis

in NHS Wales through its Rapid Response to Acute Illness Learning Set (RRAILS) programme.

Through this work, Wales became the first country to adopt NEWS (National Early Warning

Score): with the life-saving intervention now an integral part of ward care in hospitals across the

nation.

Chris Hancock, 1000 Lives Improvement’s programme lead for the (RRAILS) said: “I am really

proud that NHS Wales has won the Global Sepsis Award recognising the outstanding work across

all health boards and trusts in improving treatment and reducing death from sepsis. Participants in

the 1000 Lives Wales Rapid Response to Acute Illness Learning Set (RRAILS) have made a huge

difference, working tirelessly and going above and beyond the expectations of their day to day

roles to improve safety for all people accessing healthcare in Wales.”

Our Achievements - Our Staff and Resources I can find information about how the NHS is open & transparent on its use of resources & I can make careful use of them

I am very humbled to

have been

nominated for this

prestigious award

and proud to accept

on behalf of our

trainees who are our

greatest asset. Their

enthusiasm and

drive for learning is

truly inspirational and

keeps me motivated

to do the best I can

to help them achieve

their potential.

Dr Harsha Reddy

Achievements Staff Resources


Page 13

2 Staying Healthy Overview – National Standards

Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current

PlanPrevious Current Month Trend

Welsh

Benchmark

Morag

Olsen

Unavailabl

e- 1,019 958 1,125 1,119 Nov-15 2nd

Morag

OlsenNo - 225 498 249 247 Nov-15 3rd

Andrew

JonesNo 75.0% 75.0% 75.0% 68.6% 68.6% Mar-16 1st

Andrew

JonesNo 75.0% 75.0% 75.0% 49.1% 49.1% Mar-16 2nd

Andrew

JonesNo 75.0% 75.0% 75.0% 43.3% 43.3% Mar-16 1st

Andrew

JonesNo 50.0% 50.0% 55.0% 43.6% 43.6% Mar-16 1st

Andrew

JonesNo 95.0% 95.0% 97.0% 96.7% 97.1% Q4-16/17 5th

Andrew

JonesNo 95.0% 95.0% 98.0% 98.0% 98.1% Q4-16/17 5th

Andrew

JonesNo 95.0% 95.0% 97.0% 97.2% 95.8% Q4-16/17 1st

Andrew

JonesNo 95.0% 95.0% 97.0% 97.2% 96.2% Q4-16/17 1st

Andrew

JonesNo 95.0% 95.0% 97.0% 96.9% 95.3% Q4-16/17 1st

Andrew

JonesYes 5.0% 5.0% 5.0% 3.8% 3.8% Jan-16 1st

Andrew

JonesYes 40.0% 40.0% 40.0% 31.9% 37.6% Jan-16 7th

Andrew

JonesNo 27.8% 27.0% 25.4% 27.8% 27.4% 2014/15 5th

Bernie

CuthelNo - 100% 100% 100% 100% Apr-16 1st

Bernie

CuthelNo - 45.0% 35.0% 34.8% 35.1% Apr-16 7th

Bernie

CuthelNo - 85.0% 78.0% 77.6% 80.2% Apr-16 3rd

% uptake of the influenza

vaccine in the following

groups:

% smokers treated by NHS smoking cessation CO-

validated as successful; year to date

% of reception class children (aged 4/5) classified as

overweight or obese

Hib MenC Booster age 2

% uptake of the childhood

vaccines up to the age of 4:

Pregnant women

Healthcare workers

5 in 1 age 1

Men C age 2

MMR1 age 2

% estimated smoking population treated by smoking

cessation services; year to date

PCV age 2

% of GP Practices that are set up to use My Health On-

Line (MHOL)

Of those practices set up to use MHOL, % who are

offering appointment bookings

Of those practices set up to use MHOL, % who are

offering repeat prescriptions

Staying Healthy

Number of emergency admissions for basket of 8

chronic conditions per 100,000 population

Number of emergency readmissions for basket of 8

chronic conditions per 100,000 population

Over 65s

Under 65s in at risk

groups

% uptake of the influenza

vaccine in the following

groups:

Chronic

Conditions

Flu

Vaccinations

Childhood

Immunisations

Smoking

CessationChild Health

M y Health

Online3 2

Staying

Healthy

Staying Healthy National

Summary


Page 14

2 Staying Healthy Overview – Local Standards

Healthy

Children1 1

Staying

Healthy

Morag

OlsenYes - 7.0% 7.0% 7.5% 6.1% Apr-16 -

Percentage of live singleton births with a birth weight of

less than 2500 grams

Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh

BenchmarkStaying Healthy

Morag

OlsenNo - 82.0% - 83.0% 81.1%

Autumn-

2015 -

Percentage of children in the Flying Start Programme

who have met or exceeded their developmental

Staying Healthy Local Summary


Page 15

Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh


Andrew

JonesYes 5.0% 5.0% 5.0% 3.8% 3.8% Jan-16 1st

% estimated smoking population treated by smoking

cessation services; year to date

2.1 Exception Report: Smoking Cessation

Andrew

JonesYes 40.0% 40.0% 40.0% 31.9% 37.6% Jan-16 7th

% smokers treated by NHS smoking cessation CO-

validated as successful; year to date

Smoking Cessation

Performance Context:

• 3.9 % of smokers treated in quarter 3 as per previous quarter

• 37.6% of smokers quit at 4 weeks (CO validated) compared to 35.3% in previous

quarter

• For Feb 2016 the percentage of treated smokers was 4.3%.

• Projected performance based on year to date remains at 3.8%

Key Actions for Improvement:

Maternal Smoking Specialist Cessation Services

• Business case approved by Executive Management Group; no funding identified to

date

Smoking Cessation Services Integrated Feasibility Pilot

• Phase 1: 2 Making Every Contact Count (MECC) courses delivered in Wrexham

and 2 planned for Rhyl.

• Phase 2: Funding secured to trial QuitManager in Rhyl

Quit for Them 6 month interim report identified (www.quit.wales):

• Facebook advertising reached over 450,00 people

• Website visited by over 10,000 people with many returning

• Campaign seen online more than two million times in 6 months; average person

seen a ‘quit’ message about 6-8 times

• Funding secured to target areas of high prevalence areas until August 2016

0%

1%

2%

3%

4%

5%

6%

% estimated smoking population treated by smoking cessation services; year to date

Actual Plan Target

0%

10%

20%

30%

40%

50%

% smokers treated by NHS smoking cessation CO-validated as successful; year

to date

Actual Plan Target


Page 16

Intelligence

Triangulated

Root Cause

UnderstoodAction Plan Set

Actions

Underway

Actions

Complete


Page 17

Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh


2.1 Exception Report: Low Birth Weight

Morag

OlsenYes - 7.0% 7.0% 7.5% 6.1% Apr-16 -

Percentage of live singleton births with a birth weight of

less than 2500 grams

Low Birth Weight – Special

Measures

Where we are

The national incident rate for live singleton babies with a birth weight below 2.5kg is 6.7%. In

accordance with Public Health Wales guidance we are now reporting all live singleton births

under 2.5kg rather than all births. The overall rate for April 2016 is within target at 6.1%, an

improvement on the previous month (7.5% in March). Central: 5.7% (9.4% in March); West:

6.3% (6.5% in March); East: 6.3% (6.6% in March)

What we are doing about it:

The highest incidence of babies born weighing less than 2.5kg has been recorded within the

Flying Start areas which reflect areas of deprivation in North Wales. Our work includes

interventions in the antenatal period:

• Smoking cessation programmes

• Gaining no more than the recommended weight in pregnancy programme

• Healthy eating and exercise initiatives and working with local authorities on projects that

reflect these specific programmes

• Introduction of the Gestational Related Optimal Weight (GROW) programme to detect babies

who are small for their gestational age during the antenatal period. The size for gestational

age is calculated from an early scan and based on factors such as maternal weight, height

and previous birth outcomes (birth weight of previous babies), all of which will be individual to

each case. Once babies are identified an intervention is then planned according to the

circumstances.

In addition to the above, we are working with Public Health leads to review the actions being

taken to address low birth weight and implement new initiatives and clinical programmes to

support this work. When we expect to be back on track

With particular focus on the above areas, we aim to maintain performance to remain within the

national target during 2016.

0%

2%

4%

6%

8%

10%

12%

Ap

r-15

Ju

n-1

5

Au

g-1

5

Oct-

15

Dec-1

5

Fe

b-1

6

Ap

r-16

Ju

n-1

6

Au

g-1

6

Oct-

16

Dec-1

6

Fe

b-1

7

Percentage of live singleton births with a birth weight of less than

2500 grams

Actual Plan Target

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

2.2 Safe Care Overview – National Standards

The Quality, Safety & Experience committee scrutinises the performance for the indicators above.

Where performance has not reached the required standard, we have included an exception report.

Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh

Benchmark

Vicky

MorrisYes 20 32 47 49 47 Apr-16 7th

Vicky

MorrisYes 0.0 28.0 36.6 52.7 49.2 Apr-16 6th

Vicky

MorrisYes 0.0 20.0 24.0 17.0 15.8 Apr-16 3rd

Mark

WalkerNo 100.0% 100.0% 100.0% 100.0% 100.0% Apr-16 7th

Mark

WalkerNo 100.0% 100.0% 100.0% 100.0% 100.0% Apr-16 1st

Mark

WalkerNo 100.0% 100.0% 100.0% 100.0% 100.0% Apr-16 1st

Mark

WalkerYes 100.0% 100.0% 95.0% 92.0% 96.6% Apr-16 1st

Vicky

MorrisYes 30

Not

submitted

Not

submitted36 64 Apr-16 -

Chris

WrightYes 0 0 0 0 0 Apr-16 1st

% compliance with Welsh Patient Safety - Safety

Solutions Wales Alerts (post Apr-14)

% compliance with Welsh Patient Safety - Safer Patients

Notices (post Apr-14)

Safe Care

Number of cases of S. Aureus Bacteraemia per 100,000

of the population

% compliance with English Patient Safety - Patient Safety

Alerts (prior Apr-14)

Number of healthcare acquired pressure ulcers in a

hospital setting

Number of cases of C.difficile per 100,000 of the

population

% compliance with English Patient Safety Alerts - rapid

response notices (prior Apr-14)

Number of incidents reportable to Welsh Government

Number of new never events

Never

Events

Pressure

UlcersC. difficile

Staph

Aureus

Patient

Safety

Responses

Serious

Incidents3 4Safe Care

Vicky

MorrisYes -

Not

submitted

Not

submitted4.8% 4.8% Feb-16 -

Vicky

MorrisYes -

Not

submitted

Not


Vicky

MorrisYes -

Not

submitted

Not


Cephalosporin items as a percentage of

total antibacterial items

Co-amoxiclav items as a percentage of


Quinolone items as a percentage of


Safe Care National Summary


Page 18

2.2 Safe Care Overview – Local Standards Complaints

Response

Hand

Hygiene

Safe

Staffing

Incident

Response

Coroner

Response

Ward Quality

AuditC-Section 4 4Safe Care

Chris

WrightYes - 0 0 1 0 Apr-16 -

Chris

WrightYes 0 0 0 0 1 Apr-16 -

Morag

OlsenYes 5.0%

Not

submitted

Not

submittedIncomplete Incomplete Apr-16 - -

Morag

OlsenYes 95.0%

Not

submitted

Not


% of Intensive Care discharges within 4 hours of patient

being ready

Total number of Regulation 28 responses issued and

not closed

Number of Regulation 28 responses overdue more than

56 days

The percentage of hours lost due to Intensive Care Unit

delayed transfers

Chris

WrightYes - 98% 85% 82% 97% Apr-16 -

Chris

WrightYes - 50.0% 75.0% 25.7% 19.3% Mar-16 -

Chris

WrightYes - 80.0% 90.0% 77.5% 71.8% Nov-15 -

Vicky

MorrisNo -

Not

submitted

Not

submitted88% 87% Apr-16 -

Vicky

MorrisNo 95.0% 95.0% 95.0% 95.5% 95.4% Apr-16 -

Vicky

MorrisYes 100.0% 95.0% 86.0% 83.0% 83.0% Apr-16 -

Vicky

MorrisYes 60% 60% 60% 58% 57% Apr-16 -

Vicky

MorrisYes - 24.9% 25.0% 25.3% 30.0% Apr-16 -

Vicky

MorrisYes -

Not

submitted

Not

submitted42.0% 44.0% Mar-16 -

Vicky

MorrisYes -

Not

submitted

Not

submitted73.0% 71.0% Oct-15 -

Vicky

MorrisYes 100% 50% 15% 37% 80% Apr-16 4th

Ward Staffing Levels Fill Rate (Medical & Surgical Acute)

Ward Staffing Skill Mix Ratio

Registered : Unregistered (Medical & Surgical Acute)

Maternity : Caesarean Section Rate

% of incidents closed within 30 days

% of incidents closed within 6 months

Of the serious incidents due for assurance within the

month, % which are assured in the agreed timescale.

% of complaints closed within 6 months

Ward Quality Audit

% of complaints acknowledged within 2 working days

% of complaints closed within 30 working days

Hand Hygiene Rates

Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh

BenchmarkSafe Care

Safe Care Local Summary


Page 19

2.2 Exception Report: Pressure Ulcers Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh

BenchmarkSafe Care

Vicky

MorrisYes 20 32 47 49 47 Apr-16 7th

Number of healthcare acquired pressure ulcers in a

hospital setting

Healthcare Acquired Pressure

Ulcers

Where we are

Recognised inconsistencies in reporting and categorisation reported in the

Welsh Wound Audit which was undertaken in October 2015. This encouraged

a Health Board wide commitment to accessing pressure ulcers prevention and

categorisation study days, complemented with clinical area specific Specialist

Tissue Viability support. Timely review, investigation and validation has provided

assurance of accuracy in reporting.

• Grade 4 – an increase of one reported case: deteriorated from a grade 3

despite all measures in place

• Numbers of Grade 3 indicate a decrease from 6 to 5 reported cases

compared with March 16

• Numbers of Grade 1 & 2 show an improvement from 35 to 34 cases against

March 16 Improved reporting and accuracy in classification has been demonstrated in the

decrease in the numbers of ‘Unstageable’ reported HAPU cases (unable to determine grade) - 7 cases reported

What are we doing about it

In recognising poor standards of pressure ulcer related documentation,

streamlining and reducing duplication is currently a main focus. The introduction

of newly formatted HAPU prevention and management nursing documentation

will ensure patients ‘at risk of’ and those who have developed HAPU receive

holistic, centred care, time appropriate assessments and reviews. Local

Multidisciplinary HAPU groups continue to monitor and investigate HAPU

development, exploring themes to ensure learning practices are in place.

When we expect to be back on track

Practices outlined above, with additional on-going Strategic scrutiny and

direction aims to achieve the national target in the 2nd quarter of 2016/17.

0

10

20

30

40

50

60

Number of healthcare acquired pressure ulcers in a hospital setting

Actual Plan Target


Page 20

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

2.2 Exception Report: C. difficile infections

Vicky

MorrisYes 0.0 28.0 36.6 52.7 49.2 Apr-16 6th

Number of cases of C.difficile per 100,000 of the

population

Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh

BenchmarkSafe Care

C.difficile infections


• Focus still remains on hand hygiene, isolation, antimicrobial prescribing and

cleanliness standards. Monthly monitoring and clear performance standard in

place for all 10 key standards.

• Antimicrobial Stewardship Group continues to drive forward a range of actions.

Cephalosporin use is reducing. Revised monthly audit tool to be launched shortly,

aiming to engage medical staff in audit of their antibiotic prescribing practices.

• Public Health Wales progressing recruitment to the vacant microbiologist posts.

Advert due to be placed by 13-05-2016.

• Focus wards and regular scrutiny meetings in place on all secondary care sites.

Enhanced focus on environmental issues and prescribing being taken forward.

Additional focus and site-specific action plan in place at Wrexham Maelor Hospital

to drive improvement.

• Professor Duerden has re-visited the Health Board in March 2016 to perform a re-

review of progress. His report is awaited.


We are aiming to achieve the target, maximum 16 cases per month, by October 2016.

0

10

20

30

40

50

60

70

80

90

Number of cases of C.difficile per 100,000 of the population

Actual Plan Target


Page 21

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

April 2016 Total

Wrexham Maelor

Hospital 5

Ysbyty Glan Clwyd 9

Ysbyty Gwynedd 3

BCUHB (incl GP cases) 28

2.2 Exception Report: S. aureus infections

Vicky

MorrisYes 0.0 20.0 24.0 17.0 15.8 Apr-16 3rd

Number of cases of S. Aureus Bacteraemia per 100,000

of the population

Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh

BenchmarkSafe Care

Staph Aureus infections


• Meticillin-Resistant Staphylococcus aureus (MRSA) universal screening of high-risk

groups as per Welsh government guidance in place. High compliance.

• Roll-out of screening to all patients on a risk assessment basis commenced

January 2016. Programme of education and awareness raising to be progressed to

ensure this is implemented consistently.

• Proactive decolonisation of patients with MRSA is linked into the screening

programme.

• Focus continues on care bundle compliance as part of 10 key standards approach,

with particular focus on peripheral cannulae and aseptic non-touch technique roll-

out. Support for work on care bundles requested from Public Health Wales 1000

Lives team.


We are aiming to achieve the target set, no more than 11 cases per month, from

October 2016 onwards. The chart below shows the cases, the chart to the upper right

shows the rate per 1000,000 population.

0

5

10

15

20

25

30

35

40

Number of cases of S. Aureus Bacteraemia per 100,000 of the population

Actual Plan Target


Page 22

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

March 2016 Total

MRSA bacteraemia 1

MSSA bacteraemia 10

Combined

S. aureus bacteraemia 11

2.2 Exception Report: WG Reportable Incidents Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh

BenchmarkSafe Care

Vicky

MorrisYes 30

Not

submitted

Not

submitted36 64 Apr-16 -Number of incidents reportable to Welsh Government

New Serious Incidents

0

10

20

30

40

50

60

70

Incidents Reported to Welsh Government

Reported Reported within 2 days Never Events

0

10

20

30

40

50

60

70

80

Welsh Government Closure Performance

Closure Forms Submitted

Submitted within time frame

Where we are

472 serious incidents (not including No Surprises) have been reported to Welsh

Government (WG) for the period April 2015 to April 2016. Of these 176 closure forms

have been submitted to WG and are awaiting confirmation from WG prior to final

closure. 292 cases remain open with the Health Board.

What we are we doing about it

Performance against 2 day reporting and closures within 60 working days is being

monitored by the local site/area weekly concerns meetings in each geographic area

and weekly information is provided by the Corporate Team to support this. These

groups have set local performance trajectories, and plans to deliver against each

case, identifying challenges and barriers. Each case is fully investigated and plans to

deliver improvement are developed. The local Quality and Safety Committees receive

the completed action plans and have the responsibility to ensure improvement is

delivered.

All serious incidents graded as major/catastrophic are reported to clinical executives

on a weekly basis and to the relevant lead nurse.

Of the 64 new cases reported in April 2016 the top 3 incident types reported to Welsh

Government were patient falls resulting in harm/death; Grade 3 or above hospital

acquired pressure ulcer and unexpected death. Work streams are established within

the Health Board to address the incident types/themes reported.


Page 23

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

2.2 Exception Report: Reportable Incidents Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh

BenchmarkSafe Care

Vicky

MorrisYes 100% 50% 15% 37% 80% Apr-16 4th

Of the serious incidents due for assurance within the

month, % which are assured in the agreed timescale.

Welsh Government Reportable

Incidents


For those incidents reported pre 1st April 2015 (20) a trajectory has been set to ensure

closure of all cases submitted to Welsh Government by the 30 April 2016 with the

exception of cases that are beyond the control of the Health Board such as POVA

investigations.

It is anticipated this will be achieved.

To aid focus on closure, weekly and monthly reports are prepared for the service/area

for those cases upcoming for closure in order to embed a pro-active approach in the

management and closure of WG reportable incidents.

Site specific dashboards have been developed on Datix to allow easy monitoring of

performance and tracking of cases.

Additional capacity to manage WG reports is being explored.

0%

20%

40%

60%

80%

100%

Of the serious incidents due for assurance within the month, % which are assured in

the agreed timescale.

Actual Plan Target


Page 24

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

2.2 Exception Report: Never Events Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh

BenchmarkSafe Care

Chris

WrightYes 0 0 0 0 0 Apr-16 1stNumber of new never events

New Never Events

Where we are

The Health Board has reported a total of 6 Never Events to Welsh Government since April 2015.

There are currently 3 Never Events open under investigation by the Health Board.


Never Events are fully investigated by the Health Board, with support from the delivery unit (DU) at Welsh Government to ensure

that robust investigations are undertaken and that actions are completed and lessons learnt and shared across the Health Board.

All Never Events are reported directly to Clinical Executives as soon as possible following the incident. The investigation is chaired

by a Director and supported by the Senior Investigation Managers.


• There are currently 3 Never Events within the Health Board that remain under investigation:

In relation to the fall, the final report has been signed off by the Director of Quality Assurance and the report has been sent to the

DU on the 6th May 2016. Action plan to be monitored for implementation and closure form to be completed.

• In relation to the misplaced naso/oro gastric tube incident, the draft report is being updated following DU support and guidance.

Report to be sent for approval to ensure action plan is robust and completed.

• In relation to the insulin incident, a meeting took place with the Investigation Team and DU on Monday 9th May to clarify the

action plan and the requirements needed to complete with DU guidance. Once complete, work through the agreed action plan

with a view to progress and close.

0

1

2

Number of new never events

Actual Plan Target


Page 25

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

Clinic / Health

Centre

Wrexham Maelor

Hospital - Acute

Ysbyty Eryri

Hospital Total

Falls from poorly restricted windows 0 0 1 1

Misplaced Naso or oro-gastric tubes 0 1 0 1

OD of Insulin due to abbreviations or

incorrect advice 1 0 0 1

Total 1 1 1 3

2.2 Exception Report: Safety Updates Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh

BenchmarkSafe Care

Mark

WalkerYes 100.0% 100.0% 95.0% 92.0% 96.6% Apr-16 1st

% compliance with Welsh Patient Safety - Safer Patients

Notices (post Apr-14)

Patient Safety

Where we are

All Patient Safety Notices due compliance within the month of April 2016 are complete.

However one Patient Safety Notice issued by the WG with compliance due in March 2016 remains open.

WG informed that, although the Health Board has an action plan to address outstanding control actions,

we are not compliant, and will remain so until such time as funding has been committed to appoint an

Emergency Department Pharmacist and Technician within each of the three acute hospitals.

This requirement has been identified in the Health Board’s operational plan for this year.

Current Medicines Reconciliation compliance has fallen to an average of 55% from 75-80% within 24 hours over the winter of 2015-

2016. The reason for this is most likely to be that with the winter pressures, unscheduled patients are admitted without first passing

through the medical or surgical admission wards. All patients undergoing planned surgery in YG and YM will have a pre-operative

assessment shortly before admission which will include medicines reconciliation with the inpatient medication administration chart

ready prepared. The three acute hospitals pharmacies have Standard Operating Procedures covering medicines reconciliation.

What we are doing about it

• Medicines reconciliation to be added to the Pharmacy & Medicines Management risk register.

• Appoint ED Pharmacist and Technician to each acute hospital once approved.

• The All Wales Chief Pharmacists Quality & Safety work stream are preparing an All Wales Medicines Reconciliation Policy, which

will require final approval by the All Wales Medicines Strategy Group. Expected date for completion is December 2016.

• Benchmark the Health Board’s position against other Health Board’s in Wales.


Confirmation of compliance to the WG in respect the Patient Safety Notice is subject to approval of the operational plan, and target

date set for recruitment of ED Pharmacists and Technicians.

-20%

0%

20%

40%

60%

80%

100%

% compliance with Welsh Patient Safety -Safer Patients Notices (post Apr-14)

Actual Plan Target


Page 26

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

2.2 Exception Report: Complaint Handling Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh

BenchmarkSafe Care

Chris

WrightYes - 98% 85% 82% 97% Apr-16 -

Chris

WrightYes - 50.0% 75.0% 25.7% 19.3% Mar-16 -

% of complaints acknowledged within 2 working days

% of complaints closed within 30 working days

14% 19% 21% 19%26% 21% 23% 27% 26% 19%

0%

25%

50%

75%

100%

Ju

n-1

5

Ju

l-1

5

Au

g-1

5

Se

p-1

5

Oct-

15

Nov-1

5

Dec-1

5

Ja

n-1

6

Fe

b-1

6

Ma

r-16

Ap

r-16

Ma

y-1

6

% of Complaints Closed within 30 working days

Performance Trajectory

Complaints (1) – Special

Measures

95% 97%91%

85%95% 94%

51%61%

89%82%

97% 93%

25%

50%

75%

100%

Ju

n-1

5

Ju

l-1

5

Au

g-1

5

Se

p-1

5

Oct-

15

Nov-1

5

Dec-1

5

Ja

n-1

6

Fe

b-1

6

Ma

r-16

Ap

r-16

Ma

y-1

6

% of Complaints Acknowledged within 2 working days


Where we are

645 formal concerns are open as at the time of writing this

report (3rd May). Of the 645 cases which are open 189 (29%)

have not breached the 30 day target. Of those remaining, 337

(52%) have not exceeding 6 months.

The trajectories for 2016/17 have been reset to provide

challenging yet achievable improvement. Local trajectories are

being developed to support maximum improvement across the

Health Board and performance will be reported during the year

on improvement.


Page 27

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

189 249

88 105 14

Not Overdue 1-3 monthsoverdue

3-6 monthsoverdue

6-12 monthsoverdue

12 months +overdue

Timeframes of open concerns

2.2 Exception Report: Complaint Handling Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh

BenchmarkSafe Care

Chris

WrightYes - 80.0% 90.0% 77.5% 71.8% Nov-15 -% of complaints closed within 6 months

Complaints (2) SM

79% 76% 77% 78% 77% 72%

0%

25%

50%

75%

100%

Ju

n-1

5

Ju

l-1

5

Au

g-1

5

Se

p-1

5

Oct-15

Nov-1

5

Dec-1

5

Ja

n-1

6

Fe

b-16

Ma

r-16

Ap

r-16

Ma

y-16

% of Complaints closed within 6 calendar months (inc 30 day responses)


Where we are

In April 2016, a total of 167 new formal concerns were

received by the Health Board. The regulations recognise

that some complaints cannot be resolved within 30 days.

For these cases, normally graded as 4/5, up to 6 months is

permitted. The number of cases closed within 6 months is

increasing and is above trajectory.


Performance against both 30 day and 6 month response

trajectories are being proactively managed and monitored

by the local weekly meetings and local trajectories are

established and plans for each case. The service are

aiming to routinely offer direct contact to complainants to

gain an early resolution to their satisfaction wherever

possible.

The learning from complaints is reported to the site or area

Quality & Safety Committees who are responsible for the

delivery of improvement and sharing of lessons learnt.

When do we expect to be back on track

Revised trajectories for 2016/17 have been proposed as

part of the Operational Annual Plan to be approved by the

Board in May 2016.


Page 28

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

55

32 28

16 8

Access,

Appo

intm

en

t,A

dm

issio

n,

Tra

nsfe

r,D

ischa

rge

Tre

atm

en

t,pro

ced

ure

Abusiv

e,

vio

len

t,dis

ruptive

or

self-h

arm

ing

be

havio

ur

Co

nsent,

Co

nfiden

tia

lity o

rC

om

mu

nic

ati

on

Clin

ical

assessm

ent

(in

ve

stiga

tio

ns, im

ag

es

an

d lab t

ests

)

Formal Concerns by Theme Top 5 -April 2016

2.2 Exception Report: Coroner Reports Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh

BenchmarkSafe Care

Chris

WrightYes - 0 0 1 0 Apr-16 -

Total number of Regulation 28 responses issued and

not closed

Coroner Reports

Where we are

The Health Board has received 11 Regulation 28 reports from the Coroners Office

between April 2015 and April 2016.

The report received last month has been closed, there are no regulation 28 reports

open at present.

This indicator will be stood down from exception reporting next month.


Of the 11 cases which have been closed, the majority of these were responded to

within the 56 day timeframe with detail reported to the Coroner of the actions taken by

the Health Board to address the issues raised and how these are being implemented

within the Health Board. Any delays to submissions were agreed with the Coroner.

2

0

1

0

1

0 0

2

4

0 0

1

00

1

2

3

4

5

Total number of Regulation 28 responses issued and not closed

Actual Plan Target


Page 29

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

2.2 Exception Report: Delays in Transfer from ITU Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh

BenchmarkSafe Care

Morag

OlsenYes 5.0%

Not

submitted

Not


Morag

OlsenYes 95.0%

Not

submitted

Not


% of Intensive Care discharges within 4 hours of patient

being ready

The percentage of hours lost due to Intensive Care Unit

delayed transfers

ITU Delayed Transfers

Where we are

The Health Board is not currently in a position to report its performance. The current

information excludes performance at Wrexham Maelor, due to a data clerk staffing

vacancy.


• The Health Board undertakes a daily review of delayed transfers of care. The

nurse in charge documents in daily bed meeting – for escalation if appropriate

action not sought.

• We are reviewing guidance for Clinical Site Managers for Critical Care discharges

to support well organised, safe and timely discharges to include prioritising when

demand exceeds priority


It is not expected that performance will improve, when Wrexham Maelor information

becomes available, it is expected that reported performance will show a deterioration.

0%

2%

4%

6%

8%

10%

12%

The percentage of hours lost due to Intensive Care Unit delayed transfers

Actual Plan Target

0%

20%

40%

60%

80%

100%

% of Intensive Care discharges within 4 hours of patient being ready

Actual Plan Target


Page 30

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

2.2 Exception Report: Incidents Closed Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh

BenchmarkSafe Care

Vicky

MorrisYes -

Not

submitted

Not


Vicky

MorrisYes -

Not

submitted

Not

submitted73.0% 71.0% Oct-15 -

% of incidents closed within 30 days

% of incidents closed within 6 months

Incidents

56% 56%54%

52% 51% 51%54% 54%

42%44%

0%

10%

20%

30%

40%

50%

60%

70%

80%

% Closed within 30 working days

Performance

Trajectory

78% 76%73% 73% 71%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

% Closed within 6 calendar months

Performance

Trajectory

Where we are

The organisation has reported a total of 31,553 incidents between April 2015 and April

2016. Of these 21,849 (69%) have been finally approved. Incidents graded as 1-3 are

the responsibility of the local management structures. Those graded 4 are coordinated

by the investigation team and those at grade 5 are investigated by the Corporate Area

Concerns teams.


• During April 2016 a total of 2506 incidents were reported via Datix. The top 3

incidents reported are slips, trips, falls and collisions; pressure sore / decubitus

ulcer and abuse etc. of staff by patients. There are organisational wide work

streams to address Falls and pressures areas and pressure sores. The Health

Board operates relevant policies and procedures to protect staff and offer relevant

training and require risk assessments as appropriate.

• Site Specific dashboards have been developed on Datix to allow easy monitoring of

performance and tracking of cases.

• Performance against both 30 day and 6 month response trajectories are being

monitored by local weekly meetings. The learning from incidents is reported to the

site/area Quality & Safety Committees which are responsible for the delivery of

improvement and sharing of lessons learnt.

• Reports are submitted to both Quality Assurance Executive and Quality Safety and

Experience meetings which detail themes and trends emerging.


The Hospital Management Team receive monthly reports on incidents reported and at

what stage of investigation they are at. Trajectories are being agreed for 2016/17 as

part of the operational plan.


Page 31

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

2.2 Exception Report: Caesarean Section Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh

BenchmarkSafe Care

Vicky

MorrisYes - 24.9% 25.0% 25.3% 30.0% Apr-16 -Maternity : Caesarean Section Rate

Caesarean Section – Special

Measures

Where we are

The national tolerance rate for caesarean sections (CS) in Wales is set at 25% (10%

elective / 15% emergency). Our overall rate for 2015 was 25.9%. Our performance in

April 2016 reflects a worsened position on the previous month and is above the

national target at 30.0%.


• Ysbyty Maelor Wrexham (WXM) – Whilst month to month variation it to be

expected, we are continuing to monitor the number of high risk women, in particular

high Body Mass Index and diabetes in pregnancy. A marked increase in the number

of elective sections due to a previous caesarean was noted this month.

• Ysbyty Glan Clwyd (YGC) – An increase in the number of elective sections due to

previous caesarean, and for breech delivery was noted. We are working on

increasing the number of patients going through vaginal birth after caesarean

section (VBAC) clinics, encouraging VBAC as default in the absence of

complicating factors.

• Ysbyty Gwynedd (YG) – A lower number of VBACs were noted this month with a

50% success rate, we are continuing to focus on this. We are taking part in the

national audit on malposition in the 2nd stage of labour and mode of delivery.

Resident consultants are teaching a range of rotational delivery methods in addition

to existing training.


Whilst month to month variation is to be expected, with the measures above

implemented in practice we would expect to be back on track over the next three

months. Overall responsibility for this sits with the Labour Ward Lead Consultant

Obstetricians in each area.

0%

5%

10%

15%

20%

25%

30%

35%

Maternity : Caesarean Section Rate

Actual Plan Target


Page 32

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

Variation per unit is

demonstrated in the table below:

East Apr-16 Mar-16

Emergency CS 12.84% 12.83%

Elective CS 13.30% 6.64%

Total 26.14% 19.47%

Central Apr-16 Mar-16



Total 32.91% 27.06%

West Apr-16 Mar-16



Total 31.01% 29.29%


Page 33

2.2 Exception Report: Antimicrobial Prescribing Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh

BenchmarkSafe Care

Vicky

MorrisYes -

Not

submitted

Not


Cephalosporin items as a percentage of


Vicky

MorrisYes -

Not

submitted

Not




Anti-Microbial Prescribing

0%

2%

4%

6%

8%

Ma

r-14

Ju

n-1

4

Se

p-1

4

Dec-1

4

Ma

r-15

Ju

n-1

5

Se

p-1

5

Dec-1

5

Cephalosporin items as a percentage of total antibacterial

items

Actual

Where we are: The local target for antimicrobials is a 10% reduction year on year. The national target for

cephalosporins and quinolones is to be in the lower prescribing quartile. Cephalosporins and quinolones are

included in the Health Board’s antimicrobial policies for specific indications

What are we doing about it: The Local Enhanced Service (LES) targets for 2016/2017 reflect those of

last year and are as follows.

1. Practices will support the establishment of accurate antibiotic prescribing histories for patients admitted to

hospital with C.difficile. All patients who have had C.difficile will have a code on their files to alert GP of

diagnosis and highlight the risk of relapse with further antibiotic use. Cephalosporins and quinolones are

associated with a high risk of C.difficile infection compared to other antibiotics.

2. Practices will review patients on long term antibiotics. This will include patients prescribed long term

antibiotics for recurrent urinary tract and respiratory infections.

3. Quarterly antibiotic prescribing data at practice and individual prescriber level will be provided to the

practice for evidence of improvement.

Practices will also continue to work at Cluster level with local medicines management teams on National

Prescribing Indicators which include the reduction in prescribing of cephalosporins, quinolones, and co-

amoxiclav as a percentage of total antibiotic prescribing, and also the total number of antibacterial items

prescribed measured by the All Wales Medicines Strategy Group.

Primary Care Specialist Antimicrobial Pharmacist Funding has been secured for a 1WTE post in the East

area. The post holder will, with the support of the Antimicrobial Stewardship Group assume responsibility for

developing and implementing strategies for good antibiotic stewardship in primary care, by optimising clinical

outcomes, minimising adverse reactions and errors and limiting the development of antimicrobial resistance

and healthcare acquired infections. A similar post would be beneficial in both the Central and East areas.

When we expect to be back on track We are expecting performance to continue to improve towards March

2017 target for both cephalosporins and quinolones. The total number of antimicrobial items prescribed in

February 2016 was less when compared to the same month last year.

0%

1%

2%

3%

Ma

r-14

Ju

n-1

4

Se

p-1

4

Dec-1

4

Ma

r-15

Ju

n-1

5

Se

p-1

5

Dec-1

5



Actual

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

2.2 Exception Report: Ward Quality Audits

Vicky

MorrisNo -

Not

submitted

Not

submitted88% 87% Apr-16 -Ward Quality Audit

Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh

BenchmarkSafe Care

Ward Quality Audit

Where we are: There has been an deterioration of theme scores in general wards, in

particular in Community Hospitals, and an improvement in performance in Mental

Health and Learning Disabilities. There was a small improvement in compliance in

general wards, but a reduced compliance in Mental Health.

Staying Healthy: Performance regarding integrated assessment continues to

improve, however remains the lowest performing theme, with performance of only

59% in having and documenting the “What Matters” conversation, an increase of 2%

from March 2016.

Staff and Resources: There has been no improvement in this theme, only 81% of

wards were displaying staffing levels, and 81% results of last month’s audit with

improvement actions. The number of wards achieving the minimum staffing levels

improved from 66% in Jan, 79% in Feb, 82% in March and 83% in April.

Effective Care: There has been no improvement in implementing pathways relating to

continence and urinary catheters, and continues to remain a low performing area.

Dignified Care: Performance in this theme is low due to failing to consistently

document evidence of pain assessment on admission/transfer, and care planning for

patients requiring regular analgesia, however patient feedback regarding pain

management is very satisfactory.

What are we doing about it: Training sessions will be available to all staff during

July at the three main hospitals in having the “What Matters” conversation. We need

to engage in ensuring a standardised approach documenting assessment and

management of pain.

When we expect to be back on track: We expect to see a continued improvement in

Effective Care as the continence training is spread further across clinical teams.

We also expect to see an improvement in integrated assessment as training is made

available to clinical staff.

40%

60%

80%

100%

Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16

Ward Quality Audit

Actual Plan Target


Page 34

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

General Wards

Theme Mar-16 Apr-16

Staying Healthy 66% 69%

Staff and Resources 83% 82%

Effective Care 86% 85%

Dignified Care 88% 85%

Safe Care 91% 88%

Timely Care 100% 100%

Total 87.5% 85.6%

Mental Health Wards

Theme Feb-16 Mar-16

Staff and Resources 88% 92%

Timely Care 84% 70%

Safe Care 91% 94%

Effective Care 93% 95%

Dignified Care 100% 97%

Individual Care 100% 100%

Total 91.7% 93.6%

2.2 Exception Report: Ward Staffing Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh

BenchmarkSafe Care

Vicky

MorrisYes 100.0% 95.0% 86.0% 83.0% 83.0% Apr-16 -Ward Staffing Levels Fill Rate (Medical & Surgical Acute)

Vicky

MorrisYes 60% 60% 60% 58% 57% Apr-16 -

Ward Staffing Skill Mix Ratio

Registered : Unregistered (Medical & Surgical Acute)

Safe Staffing

Where we are: The target for acute ward staffing is from the Chief Nursing Officer for

Wales guidelines for acute medical and surgical wards. The Health Board remains off

target due to the number of Registered Nurse (RN) vacancies.

What are we doing about it: Nurse staffing is assessed daily with staff redeployed

according to staffing gaps and clinical priority. Additional hours, overtime and bank &

agency are utilised as necessary. Bank fill rates for February 2016 are: Bank: RN

31%, HCSW 74%. Agency fill rate: RN 68%, HCSW 84% (NB: graphs are not a true

reflection of staffing as agency fill rates are excluded from the graphs) . A variety of

strategies are underway including attendance at job fairs, graduate and overseas

recruitment. Recruitment within the divisions is continuing alongside bank

recruitment. Scrutiny and monitoring of rosters continues to ensure the efficient

deployment of substantive staff. A secondary care staffing workshop occurred in May

2016 , with a number of actions agreed as a result which will be progressed over the

forthcoming months

When we expect to be back on track: This will be dependant on the success of

overseas recruitment, job fairs and continued local recruitment to substantive posts

0%

20%

40%

60%

80%

100%

Ward Staffing Levels Fill Rate (Medical & Surgical Acute)

Actual Plan Target

45%

50%

55%

60%

65%

70%

75%

Ward Staffing Skill Mix RatioRegistered : Unregistered (Medical &

Surgical Acute)

Actual Plan Target


Page 35

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

Roster

Filled %

Roster

Unfilled %

Registered

Skill Mix %

Unregistered

Skill Mix %

Total Acute Central Average 85% 15% 58% 42%

Total Acute East Average 80% 20% 57% 43%

Total Acute West Average 84% 16% 55% 45%

Total Acute BCU Average 83% 17% 57% 43%

2.3 Effective Care Overview – National Standards

The indicators above are monitored at the Quality, Safety & Experience committee.

An exception report is included for indicators which are not achieving the standard.

Crude

Mortality

Risk

Adjusted

M ortality

Clinical

Coding

Clinical

Research3 3

Effective

Care

Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh

Benchmark

Mark

WalkerYes - 1.6% 1.5% 1.8% 1.8% Mar-16 3rd

Mark

WalkerYes - 108 103 111 111 Nov-15 5th

Mark

WalkerYes 95.0% 95.0% 95.0% 86.6% 85.9% Dec-15 6th

Mark

WalkerYes 98.0% 98.0% 98.0% 94.6% 96.0%

12 mths to

Dec-15 5th

Mark

WalkerNo - 118 - 100 108 Q3-15/16 -

Mark

WalkerNo - 3,580 - 3,307 3,255 Q3-15/16 -

Mark

WalkerNo -

5%

increase - 9 9 Q3-15/16 -

Mark

WalkerNo - 87 - 60 83 Q3-15/16 -

Bernie

CuthelNo - 100.0% - 100.0% 100.0% Q2-15/16 1st

Effective Care

% valid principle diagnosis code 3 months after episode

end date - monthly

Crude Mortality - rolling 12 months

Risk Adjusted Mortality Index rolling 12 months (2014

RAMI is used from July onwards)


end date - rolling 12 months

Number of Health & Care Research Wales clinical

research portfolio studies (rolling 4 quarter sum)

Number of patients recruited into Health & Care

Research Wales clinical research portfolio studies

Number of commercially sponsored studies (rolling 4

quarter sum)

Number of patients recruited into commercially

sponsored studies (rolling 4 quarter sum)

% of GP locality cluster plans that have been agreed

Effective Care National

Summary


Page 36

2.3 Effective Care Overview – Local Standards

The Quality, Safety & Experience committee monitors the indicators above.

We have included an exception report for any area not achieving the standard.

Daycase

Elective

Length of

Stay

Non Elective

Length of Stay2 2

Effective

Care

Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh

BenchmarkEffective Care

Morag

OlsenYes - 80.0% 75.0% 78.3% 79.9% Dec-15 -

Morag

OlsenYes - 85.0% 80.0% 84.3% 86.9% Jan-16 -

Morag

OlsenYes -

Not

submitted

Not

submitted2.7 3.1 Apr-16 -

Morag

OlsenNo -

Not

submitted

Not

submitted9.9 10.4 Apr-16 -

Average Length of Stay (Elective Admissions)

Average Length of Stay (Emergency Admissions)

Efficiencies: % Procedures as Daycase

British Association of Day Surgery (BADS) basket of

procedures score

Effective Care Local Summary


Page 37

2.3 Exception Report: Risk Adjusted Mortality Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh


Mark

WalkerYes - 1.6% 1.5% 1.8% 1.8% Mar-16 3rd

Mark

WalkerYes - 108 103 111 111 Nov-15 5th


Risk Adjusted Mortality Index rolling 12 months (2014

RAMI is used from July onwards)

Mortality Measures

90

95

100

105

110

115

120

Risk Adjusted Mortality Index rolling 12 months (2014 RAMI is used from July

onwards)

Actual Plan Target

Where we are

The current position with respect to crude over a prolonged period is essentially stable,

and risk adjusted mortality unchanged over this period.


The Reducing Avoidable Mortality Committee (RAMC), led by the Executive Medical

and Nursing Directors is now established with a specific focus on improving the

outcomes in this exception report. Complimenting the creation of RAMC, Quality &

Safety Objectives have been defined and these have been submitted for consideration

by the Quality, Safety & Experience committee.

Retrospective Case Record Reviews continue on all sites, extending from the start of

this month to community hospitals. In addition, we are in the process of assessing an

IT system, which will ensure we derive maximum benefit. It is anticipated this will

improve the efficiency and effectiveness of the mortality case record review process.

Work continues on the Wrexham Mortality review and looking at deaths following

Myocardial Infarction. It is anticipated first drafts for the former will be available by end

of June, and for the latter end of July. For both there is some evidence the review is

having a positive effect, but further progress will rely on conclusions.


Not directly amenable to any direct influence, reductions in mortality will come as a

consequence to a number of interventions. Over the next year through the application

of recommendations from the above reviews, coupled with other areas of quality focus

by the direction of RAMC will lead to improvement.


Page 38

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

1.0%

1.2%

1.4%

1.6%

1.8%

2.0%


Actual Plan Target

2.3 Exception Report: Clinical Coding Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh


Mark

WalkerYes 95.0% 95.0% 95.0% 86.6% 85.9% Dec-15 6th

Mark

WalkerYes 98.0% 98.0% 98.0% 94.6% 96.0%

12 mths to

Dec-15 5th


end date - monthly


end date - rolling 12 months

Data Quality

Clinical Coding is the process of extracting standardised diagnosis and treatment data

from case notes once a patient has been discharged. The purpose of the current

targets are to enable useful data to be available in a timely manner.

Where we are

The Health Board is not meeting either of the 2 targets due to long term staffing

issues. However, performance is better than noted above. There is a discrepancy

between local and national figures. This is due to a long standing system issues

extracting data to be sent to National Wales Information Service.


The submission issue has been resolved, and should result in a significant

improvement next month. The department is near full complement of staff, but has a

number of new staff, whose training is long term. Agency staff will remain in place to

support the backlog. The department is continuing to reach the weekly target of 4,900

episodes that has been set internally.


We expect to be achieving 95% Coding Completeness within 3 Months by September

2016. However, the new 95% coded in 1 month target recently introduced will cause

significant issues in the medium term. Plans are being developed to support

achievement of the new, more stretching targets being introduced in 2016/17.

0%

20%

40%

60%

80%

100%

% valid principle diagnosis code 3 months after episode end date - monthly

Actual Plan Target

80%

85%

90%

95%

100%

% valid principle diagnosis code 3 months after episode end date - rolling 12 months

Actual Plan Target


Page 39

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

2.3 Exception Report: Average Length of Stay Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh


Morag

OlsenYes -

Not

submitted

Not

submitted2.7 3.1 Apr-16 -Average Length of Stay (Elective Admissions)

Elective Average Length of Stay

Where we are

We continue to perform well across all specialties including General Surgery, Urology,

Orthopaedics and Gynaecology. The ENT target of 0.9 has not been delivered by the

Health Board but performance improved slightly for March. General Surgery continues

to be a pressure point for Central and West hospital sites, however, the specialty was

better than target for March.


ENT continues to be reviewed by each site. A number of complex Head and Neck /ENT

cancer patients are being treated in the Centre, which is also contributing to longer

lengths of stay for some patients.


The service will focus on maintaining improved performance across all specialties, with

further analysis of Paediatric length of stay to be undertaken for ENT and progression of

post operative tracheotomy care pathway.

1.5

2.5

3.5

Average Length of Stay (Elective Admissions)

Actual Plan Target


Page 40

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

Specialty Target Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

General Surgery 3.8 4.15 4.1 3.93 3.63 4.68 3.64 3.87 4.46 4.02 3.27 3.59 3.3

Urology 2.9 2.26 2.77 2.03 2.75 2.51 2.42 2.44 3.06 2.65 2.55 2.44 2.32

Orthopaedics 4 3.45 3.45 3.71 3.78 3.61 3.46 3.15 3.34 3.4 2.13 3.24 3.51

ENT 0.9 1.9 1.38 1.79 1.68 1.17 1.54 1.5 1.45 1.32 0.93 1.13 0.98

Gynaecology 3 2.41 2.19 2.54 2.44 3.02 2.4 2.27 2.39 2.7 2.74 2.67 2.43

2.4 Individual Care Overview – National Standards

Where we have not achieved a target, we have included an exception report.

Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh

Benchmark

Morag

OlsenYes 80.0% 80.0% 80.0% 82.4% 75.7% Apr-16 4th

Morag

OlsenYes 80.0% 80.0% 80.0% 78.1% 64.5% Apr-16 5th

Morag

OlsenYes 90.0% 90.0% 86.0% 85.9% 87.7% Apr-16 7th

Morag

OlsenNo 100.0% 100.0% 100.0% 100.0% 100.0% Q4-16/17 1st

Morag

OlsenYes 100.0% 100.0% 100.0% 77.8% 76.9% Mar-16 3rd

Individual Care

% of assessment by the LPMHSS undertaken within 28

days of the date of referral

The percentage of therapeutic interventions started within

(up to and including) 28 days following an assessment

% of LHB residents (all ages) to have a valid CTP

completed at the end of each month

% of hospitals with arrangements to ensure advocacy

available to qualifying patients

Service users assessed under part 3 to be sent a copy of

the assessment in 10 working days

Local Standards

Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh

BenchmarkIndividual Care

I Want Great

Care0 0

Individual

Care

Mental

Health

Ass'ssment

M ental

Health

Treatment

M ental

Health Re-

Access

2 3Individual

Care

Morag

OlsenYes 2.70 2.50 2.80 2.68 2.84 Apr-16 2nd

Morag

OlsenYes 129.5 180.0 184.0 184.9 186.8 Apr-16 4th

Morag

OlsenYes - 2,089 2,089 1,759 1,754 Apr-16 -

Mental Health

Non Mental Health aged

>65

Delayed transfers of Care per

10,000 LHB population,

Rolling 12 months (all

providers)

The number of non-mental health bed days lost due to

delayed transfers of care in the month

Vicky

MorrisNo - 4.75 4.68 4.66 4.66 Apr-16 -"I Want Great Care" initiative

Morag

OlsenYes - 8.0% 9.8% 10.4% 8.6% Apr-16 5thPatients who leave ED without being seen

Individual Care National

Summary


Page 41

2.4 Exception Report: Delayed Transfer of Care Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh


Morag

OlsenYes 129.5 180.0 184.0 184.9 186.8 Apr-16 4th

Delayed transfer of care delivery per 10,000 LHB

population – non mental health (aged 75+)

Morag

OlsenYes - 2,089 2,089 1,759 1,754 Apr-16 -

The number of non-mental health bed days lost due to

delayed transfers of care in the month

Delayed Transfer of Care

Where we are

April saw a significant deterioration in the North Wales position with an increase in

total patients delayed from 121 in March to 151. Mental Health Delayed Transfers of

Care increased from 24 to 31 and the days lost increased from 3,409 to 4,549. Non

MH delays increased from 97 to 120 although the days lost reduced from 2,132 to

2,089. Small increases were seen in Conwy, Flintshire, and Wrexham. An increase of

18 was evident in Gwynedd which rose from 19 to 37. Mon and Denbighshire showed

no change.

There has been an increase in patients identified as delayed for assessment but the

predominant reason for delay is due to the lack of Nursing and Residential Care

availability.


Each Area and corresponding Acute site have reviewed the situation and developed

an Action plan which has been shared by Welsh Government. Discussions are

ongoing with Local Authorities as to how to support the Independent Sector. There is a

North Wales Strategic Commissioning Group which has been set up by Local

Authority. The Health Board is represented on it.


The Action plans will address the transactional system improvements in the short term

but the structural deficit in the Independent Sector provision will take some time to

resolve.

0

50

100

150

200

Delayed transfers of Care per 10,000 LHB population, Rolling 12 months (all

providers)

Actual Plan Target

0

500

1,000

1,500

2,000

2,500

The number of non-mental health bed days lost due to delayed transfers of care in the

month

Actual Plan Target


Page 42

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

2.4 Exception Report: Delayed Transfer of Care

Delayed Transfer of Care

Where we are

The individual monthly figures for March and April are 16 and 23 patients delayed

respectively. Current month and previous month are within expected normal ranges.


To improve performance, the Mental Health and Learning Disability team have:

• Appointed patient flow coordinator.

• Developed and rolled out bed management system.

• Undertakes daily bed meeting.

• Participates in whole system wide bed meeting.


A 10% improvement trajectory, based on the May 2016 census position has been

submitted to Welsh Government, showing clear improvement by the end of Q2.

Regular monitoring features as part of business as usual.

0.0

0.5

1.0

1.5

2.0

2.5

3.0

Delayed transfers of Care per 10,000 LHB population, Rolling 12 months (all

providers)

Actual Plan Target

Morag

OlsenYes 2.70 2.50 2.80 2.68 2.84 Apr-16 2nd

Delayed transfer of care delivery per 10,000 LHB

population – mental health (all ages)

Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh



Page 43

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete


Page 44

2.4 Exception Report: Mental Health Measure Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh


Morag

OlsenYes 80.0% 80.0% 80.0% 82.4% 75.7% Apr-16 4th

% of assessment by the LPMHSS undertaken within 28

days of the date of referral

MHM Assessments (Part 1)

Where we are

The target refers to the percentage of patients assessed in the month that were

assessed within 28 of the referral. Adult Mental Health (AMH) The Division’s

performance has dropped below the target this month. Some counties have expressed

high levels of sickness and vacancies as the cause. Child and Adolescent Mental Health

Services (CAMHS): As at the end of March 2016 there were 650 children and young

people waiting for a Mental Health Assessment (MHA). This has reduced to 608 as at

the end of April, 19% of which are under 28 days.


AMH: Individual counties have developed specific interventions address the shortfall,

These include:

• Running 1 day anxiety management courses, in addition to session based courses

• Arranging extra appointment slots

• Using the duty team to backfill some of the work

• Using bank / overtime to increase capacity

• Expediting vacancies

• Bidding for additional staffing

• Re-introduction of weekly performance reporting

• Introduce local exception reporting process to identify team plans for performance

improvement, which will inform the Divisional Exception report from May 2016

onwards.

CAMHS: The actions to support delivery are the same actions the CAMHS team have

highlighted in the Mental Health Measure (Part 1) – Treatments slide.


CAMHS expect all teams to have met the targets by January 2017, this is subject to no

significant increases in demand. The AMH team expects to be back on track by June

2016.

0%

20%

40%

60%

80%

100%

% of assessment by the LPMHSS undertaken within 28 days of the date of

referral

Actual Plan Target

0

20

40

60

80

100

Oct

ob

er

No

vem

be

r

De

cem

ber

Jan

uar

y

Feb

ruar

y

Mar

ch

Ap

ril

Part 1 Assessment Performance

BCU

Adult

CAMHS

ExpectedImprovement

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete


Page 45

2.4 Exception Report: Mental Health Measure Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh


Morag

OlsenYes 80.0% 80.0% 80.0% 78.1% 64.5% Apr-16 5th

The percentage of therapeutic interventions started within

(up to and including) 28 days following an assessment

MHM Treatments (Part 1)

Where we are

Child and Adolescent Mental Health Services (CAMHS):

At the end of March 2016 there were 211 children and young people waiting for

therapy after receiving a full mental health assessment. This has reduced to 140 as at

the end of April, 40% of which are under 28 days.

The Adult Mental Health (AMH) division’s performance has dropped below the target

this month with some counties expressing high levels of sickness and vacancies as

the cause.


CAMHS: All teams have produced trajectories and action plans to deliver the targets.

Actions include:

• Recruitment of Child Psychotherapist across the teams and Family Therapist for

each area

• Staff doing additional hours

• Use of agency staff

• Use of private providers – tender exercise recently signed off with three private

providers awarded contracts

AMH: The actions to support delivery are the same actions the team has highlighted

in the Mental Health Measure (Part 1) – Assessments slide.


CAMHS expect all teams to have met the targets by January 2017, this is subject to

no significant increases in demand. The AMH team expects to be back on track by

June 2016.

0%

20%

40%

60%

80%

100%

Oct-

15

Nov-1

5

Dec-1

5

Ja

n-1

6

Fe

b-1

6

Ma

r-16

Ap

r-16

Ma

y-1

6

Ju

n-1

6

Ju

l-1

6

Au

g-1

6

Se

p-1

6

Oct-

16

Nov-1

6

Dec-1

6

Ja

n-1

7

Fe

b-1

7

Ma

r-17

The percentage of therapeutic interventions started within (up to and including) 28 days

following an assessment by LPMHSS.

Actual Plan Target

0%

20%

40%

60%

80%

100%

Apr-

16

Ma

y-1

6

Jun-1

6

Jul-1

6

Aug-1

6

Sep-1

6

Oct-

16

No

v-1

6

De

c-1

6

Jan-1

7

Feb

-17

Ma

r-1

7

CAMHS Therapy - % waiting under 28 days

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

2.4 Exception Report: Mental Health Measures Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh


Morag

OlsenYes 90.0% 90.0% 86.0% 85.9% 87.7% Apr-16 7th

% of LHB residents (all ages) to have a valid CTP

completed at the end of each month

MHM Care & Treatment Plans

(Part 2)

Where we are

Adult Mental Health continue to progress towards the 90% target.


• Weekly monitoring of team performance .

• Weekly communication to individual practitioners regarding their non-compliant

cases.

• Feedback to Team, County, Locality managers, who are the accountable managers

for the delivery of the measure standards.

• Presentation of data and discussion regarding improvement at monthly divisional

Meetings.

• Teams without ongoing improvement have been required to define additional

actions to comply and are receiving additional support from the Mental Health

Measure Team.

• Clarified with the Information Department regarding those services included in

organizationally reported performance.

• Introduce local exception reporting process to identify team plans for performance

improvement, which will inform the Divisional Exception report from May 2016

onwards.


We expect to be back on track by June 2016.

0%

20%

40%

60%

80%

100%

% of LHB residents (all ages) to have a valid CTP completed at the end of each

month

Actual Plan Target


Page 46

0

20

40

60

80

100

Part 2, MHM, Performance Improvement

(Adult Mental Health Only)

MonthlyPerformance

Target

AnticipatedPerformance

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

2.4 Exception Report: Mental Health Measures Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh


Morag

OlsenYes 100.0% 100.0% 100.0% 77.8% 76.9% Mar-16 3rd

Service users assessed under part 3 to be sent a copy of

the assessment in 10 working days

MHM Re-Access (Part 3)

Where we are

The two month in arrears reporting schedule agreed has given the division the

opportunity to fully complete the Part 3 process for those patient receiving

assessments in the latter half of the month. The organisation has up to 10 days

following the assessment to send the outcome to the patient, however in previous

months the data for the exception reporting process has been required prior to this

time.

Assessments completed in March (13),

Compliant assessments (10), Non-compliant assessments (3) = 77%


Over the last few months there appears to be a growing number of patients who have

requested a part three assessment, but don’t turn up for their appointments. Our

current system of data collection did not differentiate between an assessment where

the service user was not provided with a copy of the assessment or they did not

attend.

The Division has re-iterated the importance of sending copies of assessments in a

timely manner, to all teams and the information collection processes have been

modified.


We are expecting to be back on track by the end of June 2016

0%

20%

40%

60%

80%

100%

120%

Service users assessed under part 3 to be sent a copy of the assessment in 10

working days

Actual Plan Target


Page 47

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

2.4 Exception Report: Left Without Being Seen

Morag

OlsenYes - 8.0% 9.8% 10.4% 8.6% Apr-16 5thPatients who leave ED without being seen

Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh


0%

2%

4%

6%

8%

10%

12%

Patients who leave ED without being seen

Actual Plan Target

ED Left Without Being Seen

Where are we

April has seen an improving position across North Wales with the most significant

improvement in Wrexham with a 4% reduction in patients who have left the

Emergency Department (ED) without being seen.


The Survey planned for April has been delayed due to difficulties in agreeing the

appropriate questions to be asked and the right people to ask the questions with the

Patient Experience Team. A final planning meeting is taking place on May 17th. The

Survey will take place by the end of May 2016.

Following the survey an action plan will be developed and actions attributed and

followed up by the Unscheduled Care Performance group in Wrexham

An improvement trajectory against the 4 hour ED target has been agreed with the

Executives for the next three months. Improvement in compliance with the 4 hour

target is expected to also see an aligned reduction in the number of patients who have

left without being seen. The less time people are waiting in ED, the less likely they are

to leave without being seen.


It is not expected that the performance will improve to the target level before June

2016.


Page 48

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

Hospital Site Mar-16 Apr-16

Ysbyty Gwynedd 4.2% 4.0%

Ysbyty Glan Clwyd 6.6% 5.8%

Wrexham Maelor Hospital 19.1% 15.1%

Health Board 10.4% 8.6%

2.5 Dignified Care Overview – National Standards

The Finance and Performance committee scrutinises performance within this domain.

Where we have not achieved the target, we have included an exception report.

Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh

Benchmark

Morag

Olsen

Not

Available100.0% 95.0% 100.0% 46.5% 39.4% Mar-16 6th

Vicky

MorrisNo -

Not

submitted

Not

submitted88% 95% 2015 -

Dignified Care

% procedures postponed more than once, had

procedure <=14 days/earliest convenience

Fundamentals of Care Audit Score

Dignified

Care

Postponed

Procedures

Fundamenta

ls of Care3 3

Dignified

Care

Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh

BenchmarkDignified Care

Dignified Care Overview – Local Standards

Morag

OlsenYes -

Not

submitted

Not

submitted3.8% 3.7% Jan-16 -

Morag

OlsenYes -

Not

submitted

Not


Morag

OlsenYes -

Not

submitted

Not

submitted10.6% 10.8% Apr-16 -

Efficiencies: Patient admitted but procedure not carried

out

Total Cancellations for Consultant and Nurse Led

Outpatient appointments

Total Cancellations Inpatient (Clinical and Non-Clinical)

Dignified

Care

Inpatient

Cancellat ions

Outpatient

Cancellat ions4 4

Dignified

Care

Dignified Care Summary


Page 49

2.5 Exception Report: Cancellations Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh


Morag

OlsenYes -

Not

submitted

Not

submitted12.7% 11.6% Mar-16 -Total Cancellations Inpatient (Clinical and Non-Clinical)

Morag

OlsenYes -

Not

submitted

Not

submitted3.8% 3.7% Jan-16 -

Efficiencies: Patient admitted but procedure not carried

out

Inpatient Cancellations

Where we are

The Health Board currently monitors patients admitted but where the procedure is not

carried out (Chart 1) and Inpatient cancellations each month(Chart 2). The inpatient

cancellations are reported in the following categories:

i) Hospital postponements (Clinical)

ii) Hospital postponements (Non-clinical)

iii) Patient postponements.

The Health Board performance since March 2015 is outlined on Chart 2.

In March there has been a small improvement in the performance of hospital

postponements compared to the previous month.


Work continues on each site with Alturos to support improved scheduling of theatre

sessions and individual theatre lists. Pilots with individual consultants in different

specialties commenced on each site.

• Roll out of text reminder service for inpatients and daycases to more specialties

based upon current Did Not Attend rate

• Weekly validation of all clinical and non-clinical cancellations undertaken on each

site with clinical teams

• Day case ward in Ysbyty Gwynedd staffed after 10pm on an ad hoc basis to reduce

cancellation rate of patients only requiring overnight stay

• Focus on ensuring that first patient of the day on theatre list starts on time even

during heightened unscheduled care pressures.


We expect to be back on track by October 2016


Page 50

0%

1%

2%

3%

4%

5%

6%

Efficiencies: Patient admitted but procedure not carried out

Actual Plan Target

0%

2%

4%

6%

8%

10%

12%

14%

Total Cancellations Inpatient (Clinical and Non-Clinical)

Actual Plan Target

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

2.5 Exception Report: Outpatient Cancellations Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh


Morag

OlsenYes -

Not

submitted

Not

submitted10.6% 10.8% Apr-16 -

Total Cancellations for Consultant and Nurse Led

Outpatient appointments

Outpatient Cancellations

Where we are

The Health Board is working towards achieving a target of less than 5% hospital

initiated cancellations. The performance in March was 10.9% and the Chart

highlights the performance on a monthly basis since April 2015 for appointments

(combined new and review).


• A rapid improvement event on Outpatient clinic templates and clinical booking took

place week commencing 9th November 2015. The implementation of actions from

this event are being monitored at both local and Health Board wide mission

controls. A follow up visioning event also took place in April 2016 and an agreed

action was to focus upon outpatient cancellation data and reporting. Project

initiation document outlines requirement to reduce hospital initiated cancellations

by 50%.

• A direct booking process has been agreed in April 2016 and the plan for

implementation across the Health Board has been agreed and consulted upon

with primary care.

• Continued escalation of any cancelled outpatient sessions outside the required

notice period.

• Monitoring of trends and developing mitigating actions taking place at weekly

outpatient planning cells on each site.

• Monthly outpatient planning cell chaired by Director of Secondary care.


We expect to be back on track by October 2016

0%

2%

4%

6%

8%

10%

12%

14%

Total Cancellations for Consultant and Nurse Led Outpatient appointments

Actual Plan Target


Page 51

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

2.6 Timely Care Overview – National Standards

* England, Dec-15. Please note: 18 week target not 26 weeks and different methodology used for ‘stop clocks’.

** England, Jan-16.

GP AccessReferral to

Treatment

Diagnostic

Waits

Emergency

Department

Ambulance

ResponsesCancer Dental Stroke 3 4Timely Care

Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh

Benchmark

UK

Benchmark

Bernie

CuthelYes - 98.5%

Not

Submitted98.2% 95.5% Q3-15/16 7th -

Bernie

CuthelYes - 89.5%

Not

Submitted88.5% 89.2% Q3-15/16 6th -

Morag

OlsenYes 95.0% 88.0% 88.0% 87.8% 86.8% Apr-16 5th 91.8% *

Morag

OlsenYes 0 3,142 3,142 3,666 4,140 Apr-16 7th -

Morag

OlsenYes 100.0% 100.0% 95.0% 99.9% 98.7% Apr-16 3rd -

Morag

OlsenYes 95.0% 90.0% 76.0% 72.9% 74.8% Apr-16 6th 83.0% **

Morag

OlsenYes 0 0 1,170 1,254 1,133 Apr-16 7th 158 **

Morag

OlsenNo 65.0% 65.0% 65.0% 69.8% 66.0% Apr-16 2nd -

Morag

OlsenYes 0 0 1,150 1,251 981 Apr-16 6th -

Morag

OlsenNo 98.0% 98.0% 97.0% 98.2% 98.0% Apr-16 1st 96.9%

Morag

OlsenYes 95.0% 95.0% 89.0% 91.1% 88.0% Apr-16 1st 81.0%

Bernie

CuthelYes 54.7% 50.0% 50.3% 50.0% 50.1% Mar-16 6th -

Morag

OlsenNo - 60.0% 45.0% 48.3% 45.1% Apr-16 1st -

Morag

OlsenNo - 95.0% 94.0% 94.5% 93.1% Apr-16 5th -

Morag

OlsenNo - 85.0% 80.0% 96.7% 97.1% Apr-16 1st -

Morag

OlsenNo - 100.0% 98.0% 100.0% 100.0% Apr-16 1st -

Percentage of the health board population regularly

accessing NHS primary dental care

Percentage of patients who have a direct admission to an

acute stroke unit within 4 hours

Percentage of patients who receive a CT scan within 12

hours

Percentage of patients who have been assessed by a

stroke nurse within 24 hours

Percentage of patients who have received a formal

swallow assessment in 72 hours

Timely Care

open during daily core hours or within1

hour of daily core hours

% GP practices

% of patients newly diagnosed with cancer not via the

USC pathway, definitively treated within 31 days of

% of patients referred via the USC pathway definitively

treated within 62 days of referral

The percentage of patients waiting less than 26 weeks

for treatment

offering appts between 17:00 and 18:30

at least two days a week

Number of 36 week breaches- all specialties

% of new patients spend no longer than 4 hours in A&E

(inc Minor Injury Units)

Number of patients spending 12 hours or more in A&E

% of Cat A Ambulance responses within 8 minutes

Number of ambulance handovers over one hour

% of patient waiting less than 8 weeks for diagnostics

Timely Care National Summary


Page 52

2.6 Timely Care Overview – Local Standards

Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh

BenchmarkTimely Care

Where we have not achieved a target, we have included and exception report.

Morag

Olsen

Not

Available- 55,697 59,890 60,271 59,951 Apr-16 6th

Morag

Olsen

Not

Available- 5,997 6,836 4,966 4,493 Apr-16 -

Morag

Olsen

Not

Available- 6,854 8,532 6,260 6,612 Apr-16 -

Morag

Olsen

Not

Available- 33,229 34,907 26,835 26,521 Apr-16 -

Morag

OlsenYes 0 0 0 3 0 Apr-16 -

Morag

OlsenYes 98.0% 85.0% 80.0% 65.9% 82.6% Apr-16 -

Morag

OlsenYes 98.0% 90.0% 84.0% 68.4% 89.4% Apr-16 -

Morag

OlsenNo 75.0% 95.0%

Not

Submitted90.8% 92.9% Jan-16 2ndAdmission on day of surgery

Out of Hours : Urgents triaged/assessed within 20

minutes

Out of Hours : Non-urgents triaged/assessed within 60

minutes

All patients overdue on the Follow Up Waiting List

Follow Up Waiting List (25-50% overdue)


Follow Up Waiting List (Over 100% overdue)

Therapies Waits Over 14 weeks

Follow up

Access

Therapies

Access

Out of

Hours

Access

4 4Timely Care

Morag

OlsenNo - 12.0% 10.0% 9.9% 7.8% Apr-16 -

Morag

OlsenNo - 100.0% 80.0% 72.7% 88.9% Apr-16 -

The percentage of all strokes thrombolysed

The percentage of all eligible patients thrombolysed

Timely Care Local Summary


Page 53

2.6 Exception Report: GP Opening Times Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh


Bernie

CuthelYes - 98.5%

Not

Submitted98.2% 95.5% Q3-15/16 7th

Bernie

CuthelYes - 89.5%

Not

Submitted88.5% 89.2% Q3-15/16 6th

open during daily core hours or within1

hour of daily core hours

% GP practices

offering appts between 17:00 and 18:30

at least two days a week

GP Opening Times

Where we are

The current rise in achievement is due to the total number of practices reducing to 111

from 112 from the 1st of April as 2 practices in Arfon, Gwynedd have merged. The

routine surgery times have not changed. Please note that the appointments measured

are routine appointments only.


• The pressure on practices to maintain levels of access at a time of significant

recruitment and retention difficulties, and of increasing workload continues to be a

major concern.

• The access arrangements for all GP surgeries are reviewed quarterly. The return

has been refined to facilitate the identification of individual practice changes which

are being discussed with the practices concerned. In addition to this, Primary Care

Support Unit (PCSU) staff raise access at meetings with practices, as a part of

quality assurance visits, and in response to queries from patients or where

concerns are highlighted from other sources.

• PCSU continues to work with the North Wales Local Medical Committee to

encourage practices to consider ways of improving access to meet the needs of

their populations.


We will be reviewing the current GMS Access standards and working with clusters to

encourage a review of access on a cluster basis to achieve improvements during

2016/17.

80%

85%

90%

95%

100%

Q3

-14/1

5

Q4

-15/1

6

Q1

-15/1

6

Q2

-15/1

6

Q3

-15/1

6

% of practices offering appts between 17:00 and 18:30 at least two days a week

Actual Plan Target

50%

60%

70%

80%

90%

100%

% of practices open during daily core hours or within1 hour of daily core hours

Actual Plan Target


Page 54

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete


Page 55

2.6 Exception Report: Referral To Treatment Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh


Morag

OlsenYes 0 3,142 3,142 3,666 4,140 Apr-16 7thNumber of 36 week breaches- all specialties

Morag

OlsenYes 95.0% 88.0% 88.0% 87.8% 86.8% Apr-16 5th

The percentage of patients waiting less than 26 weeks

for treatment

Referral To Treatment

Where we are

The position has deteriorated in April due to combined impact of( i) Treating more

urgent cases, ( ii) Treating long waiting patients who have had previous pathway

adjustments( iii) inability to secure proposed specialty level outsourced capacity from

NHS England or the private sector.


Discussions are continuing with WG over plans for 2016/17. The quarter 1 plan is not

likely to be delivered as noted above, however internally all efforts are being taken to

increase productivity and capacity with additional lists and clinics running. This work is

intended to deliver the internal plan and assist with reducing impact of lack of

alternative capacity. However this alone will not be sufficient to prevent further

deterioration during the quarter. Most internal specialty level Q1 plans are forecast to

deliver the internal Q1 profile position. The notable exception is the Orthopaedic

service where the gap is growing. A sustainable service review has commenced for

this specialty which will report via the planned care transformation group later in the

year. External capacity is being scoped for both availability and cost (note this

specialty was not originally part of the outsourcing plans for Q1). Operational

challenges have increased with the loss of 2 daycase theatres and an endoscopy

suite due to water damage to roof and electrical supply.


At this time the plan for the year is heavily dependant on outcome of on-going

discussions with WG and therefore an accurate forecast can not be provided. There is

an urgency to completion of these discussions to provide clarity for the year ahead.

0%

20%

40%

60%

80%

100%

The percentage of patients waiting less than 26 weeks for treatment

Actual Plan Target

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

Number of 36 week breaches- all specialties

Actual Plan Target

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

2.6 Exception Report: Diagnostic Waiting Times Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh


Morag

OlsenYes 100.0% 100.0% 95.0% 99.9% 98.7% Apr-16 3rd% of patient waiting less than 8 weeks for diagnostics

Diagnostic Waits

Where we are

Performance had breached the target at the end of the month.


We are undertaking a service improvement intervention to support improved and more

timely appointment booking in radiology and we will commission more robust solutions

to support endoscopy including outsourcing.

• Wrexham continues to outsource Flexible Diagnostic Cystoscopy to Spire Wrexham

whilst the sustainable solution is implemented.

• A review of the video urodynamic service is required to ensure that the current

capacity constraints when one Consultant is away does not compromise the length

of wait

• Bangor Endoscopy – Medinet, an external endoscopy company, to utilise four all

day lists each month to achieve position in May and June.

• Approval for development of 3rd endoscopy room given for 2016/2017 and will

significantly contribute to a sustainable service.

All operational teams are focussed on minimising waits for diagnostics so as to reduce

clinical risk for patients by enabling clinical decisions to be made based on outcome of

diagnostics. Additional capacity is being provided both internally and via private sector

contracts for radiological and endoscopic investigations, with a high % of these being

undertaken within 8weeks of referral.


We are aiming to achieve a target that all patients wait under 8 weeks by the end of

June 2016.

84%

86%

88%

90%

92%

94%

96%

98%

100%

% of patient waiting less than 8 weeks for diagnostics

Actual Plan Target

0

500

1000

1500

2000

2500

3000

3500

4000

Apr-14 Sep-14 Feb-15 Jul-15 Dec-15

BCU Diagnostics > 8 week Waiters April 14 to April 16

Total

Grand Total

Total > 8 weeks

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete


Page 56

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

2.6 Exception Report: Four Hour Target Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh


Morag

OlsenYes 95.0% 90.0% 76.0% 72.9% 74.8% Apr-16 6th

% of new patients spend no longer than 4 hours in A&E

(inc Minor Injury Units)

ED Waits

Where we are

Combined Emergency Department(ED) and Minor Injuries Unit (MIU) 4 hour

performance in April was 76.79%. Emergency Department 4 hour performance in April

was 69.36% a marginal improvement on last month (67.75%). There is a significant

way to go for the Health Board to be achieving the required 95%. Improvement

trajectories for 2016/17 have been agreed .

What are we doing about it (continued over the next few slides).

Wrexham Maelor (WM)

Increased pace on improvement plans with weekly performance review meetings now

in place, chaired by CEO. Action plan agreed and in progress, this is aligned to the

agreed site specific improvement trajectories. Focused Enhanced Nurse Practitioner

(ENP) capacity in ED will positively impact on low acuity patient breaches, and this is

a key deliverable for the site this month. The site performance for April has improved

(62.65% v’s 59.19%)

Ysbyty Glan Clwyd (YGC)

Implementation of a consistent Rapid Assessment and Treatment Service (RATS)

has seen some improvement in the 4 hour target. There remains much to do in

delivery against the agreed site trajectory. Further plans are being drafted and will be

in place by the end of April. There was a deterioration in the performance in April

compared to that in March (68.68% v’s 69.27%)

Ysbyty Gwynedd (YG)

The Unscheduled Care Coordinating Hub has been implemented within the planned

timeframe. The model is evolving daily and close monitoring and performance

reporting is reviewed daily. The site has seen consistent increase in the number of

attendees and patient acuity has been higher than average. The site managed a

marginal improvement on March performance (77.96% v’s 76.42%)

0%10%20%30%40%50%60%70%80%90%

100%

% of new patients spend no longer than 4 hours in A&E (inc Minor Injury Units)

Actual Plan Target


Page 57

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

2.6 Exception Report: Twelve Hour Target Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh


Morag

OlsenYes 0 0 1,170 1,254 1,133 Apr-16 7thNumber of patients spending 12 hours or more in A&E

ED Waits over 12 Hours

Where we are

1,133 Patients waited over 12 hours in an Emergency Department during April, 122

fewer than March. Wrexham has seen the greatest improvement against March

performance (357 patients in April v’s 425 in March)

What are we doing about it (continued)

Ysbyty Glan Clwyd (YGC)

Further plans are now required for YGC due to sustained numbers of patients being

delayed in the department waiting for inpatient beds. These plans are being

formulated this week as a result of continued poor performance against the 12 hour

target. The Hospital Management Team (HMT) have made clear that the solution to

much of this is a clear focus in addressing the discharge issues which perpetuate on

the site.

Wrexham Maelor (WM)

Weekly performance reviews are now in place, meetings chaired by CEO. Enhanced

improvement plan which covers the 12 hour target and includes the agreed

improvement trajectory.

Ysbyty Gwynedd (YG)

YG 12 hour position has seen marginal reduction in the number of patients held in the

department for 12 hours or more (-32). This was delivered against a backdrop of

increased attendance and higher acuity patients presenting throughout the month of

April. A whole system review has identified increased numbers of delayed

discharges of care and a longer Average Length of Stay across Unscheduled Care.

0

200

400

600

800

1,000

1,200

1,400

Number of patients spending 12 hours or more in A&E

Actual Plan Target


Page 58

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

2.6 Exception Report: Ambulance Response Times Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh


Morag

OlsenNo 65.0% 65.0% 65.0% 69.8% 66.0% Apr-16 2nd% of Cat A Ambulance responses within 8 minutes

Morag

OlsenYes 0 0 1,150 1,251 981 Apr-16 6thNumber of ambulance handovers over one hour

Ambulance Performance

Where we are

Category A ambulance response time in April was 66%.

During April the number of ambulance handovers greater than 1 hour was 506 a

significantly worse position than in March (367). Proportionately this is an even

greater % increase due to a marginal reduction in the number of ambulances

conveyed to our three District General Hospitals (variance -136). The greatest

deterioration was seen at Wrexham Maelor with 104 more patients being held for 60

minutes or more at the Emergency Department front door than in March (203 in April

v’s 99 in March). Both YGC and YG saw increased numbers of patients delayed (+20

; +15 respectively) which contributed to the overall Health Boards deterioration in

performance.


Detailed improvement action plans and weekly performance reviews at Wrexham

Maelor, chaired by CEO.

Unscheduled Care coordinating hub brought on line at YG with the intention of

converting unplanned demand into planned episodes of care. This will reduce the

number of Welsh Ambulance Service Trust (WAST) conveyances, of those conveyed

there will be a receiving service which in turn will facilitate speedy handover.

YGC have renewed focus on ED handover with plans being put in place this week for

stepped improvement.

0%

10%

20%

30%

40%

50%

60%

70%

80%

% of Cat A Ambulance responses within 8 minutes

Actual Plan Target

0

200

400

600

800

1,000

1,200

1,400

Number of ambulance handovers over one hour

Actual Plan Target


Page 59

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

2.6 Exception Report: Cancer Treatment (62)

Morag

OlsenYes 95.0% 95.0% 89.0% 91.1% 88.0% Apr-16 1st

% of patients referred via the USC pathway definitively

treated within 62 days of referral

Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh


Urgent Suspected Cancer

Where we are

112 out of 123 Urgent Suspected Cancer (USC) patients (i.e. those referred

urgently with symptoms suggestive of cancer) were treated within 62 days of

referral in March 2016. This equates to 91.1%. One of the breach patients was

on a complex diagnostic pathway.

While data for April has not been fully validated the estimated performance is

between 86% and 90%.


The Cancer Performance Group continues to meet fortnightly to review progress

and implement remedial action as required.

The areas under most pressure are:

• Colorectal services in Central – additional outpatient capacity has been created

but there remain pressures within the endoscopy service; the Central Planned

Care team is urgently seeking additional capacity to reduce waiting times

• Urology surgery – additional capacity for cystectomies has been secured.

Potential solutions for increased capacity for other major surgery are currently

being explored and will be finalised by the middle of May.


We expect to improve the levels of performance in 2016.

70%

75%

80%

85%

90%

95%

100%

% of patients referred via the USC pathway definitively treated within 62 days of

referral

Actual Plan Target


Page 60

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

2.6 Exception Report: Primary Care Dental Access

Bernie

CuthelYes 54.7% 50.0% 50.3% 50.0% 50.1% Mar-16 6th

Percentage of the health board population regularly

accessing NHS primary dental care

Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh


NHS Dental Access

Where we are

Last 3 months performance:

January – 49.8%

February – 50.0%

March – 50.1%


• Taking action to ensure the use of available funds is maximised for the provision

of additional service activity and patient access during 2016/17. All practices were

written to at the end of April with an invitation to submit applications for additional

activity to this end.

• Encouraging contractors to implement National Institute for Health and Care

Excellence (NICE) patient recall guidelines thus potentially freeing up capacity for

additional patients.


The additional service activity is expected to be in place by June after which a

gradual improvement in patient access rates is anticipated.

47%

48%

49%

50%

51%

52%

53%

54%

55%

56%

Percentage of the health board population regularly accessing NHS primary dental

care

Actual Plan Target


Page 61

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete


Page 62

2.6 Exception Report: Follow Up Appointments Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh


Morag

Olsen

Not

Available- 55,697 59,890 60,271 59,951 Apr-16 6th

Morag

Olsen

Not

Available- 5,997 6,836 4,966 4,493 Apr-16 -

Morag

Olsen

Not

Available- 6,854 8,532 6,260 6,612 Apr-16 -

Morag

Olsen

Not

Available- 33,229 34,907 26,835 26,521 Apr-16 -

All patients overdue on the Follow Up Waiting List



Follow Up Waiting List (Over 100% overdue)

Follow Up Waiting List

Urology

Orthopaedic

2,000

4,000

6,000

8,000

10,000

12-Jul 12-Aug 12-Sep 12-Oct 12-Nov 12-Dec 12-Jan 12-Feb 12-Mar

Follow Up Waiting List Unbooked Patients Only

Urology Plan Urology

Orthopaedic Plan Orthopaedic

Ophthalmology

Gastroenterology2,000

4,000

6,000

8,000

10,000

12,000

12-Jul 12-Aug 12-Sep 12-Oct 12-Nov 12-Dec 12-Jan 12-Feb 12-Mar

Follow Up Waiting List Unbooked Patients Only

Ophthalmology Plan Ophthalmology

Gastroenterology Plan Gastroenterology

At the time of writing this report had not been provided.

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

2.6 Exception Report: Waiting for Therapy Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh


Morag

OlsenYes 0 0 0 3 0 Apr-16 -Therapies Waits Over 14 weeks

Therapy Waiting Times

Where we are

There were no Breaches at the end of April and the administrative issues which gave

rise to recent breaches have been resolved.


We expect the position to be maintained.

02468

101214161820

Therapies Waits Over 14 weeks

Actual Plan Target


Page 63

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

2.6 Exception Report: Out of Hours GP Service Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh


Morag

OlsenYes 98.0% 85.0% 80.0% 65.9% 82.6% Apr-16 -

Morag

OlsenYes 98.0% 90.0% 84.0% 68.4% 89.4% Apr-16 -

Out of Hours : Urgents triaged/assessed within 20

minutes

Out of Hours : Non-urgents triaged/assessed within 60

minutes

Out Of Hours

Where we are

For Urgent cases triaged within 20 minutes we have seen an improvement from

76.2% in April15 to the current level of 82.6% in April 2016.

For Non Urgent cases triaged within 60 minutes we have again seen an improvement

from 78.4% in April15 to the current level of 89.4% in April 16. This is an improvement

from January despite the combination of sickness & special leave in East, maternity

leave in Central and recruitment in West. There has been an increase in activity this

first 4 months compared to last five years, so far this year we have had 48,156

contacts, 4,821 more than last year.


We did have, following recent health board wide successful recruitment campaigns, a

full complement of Triage Nurses. After successfully training some of our triage nurses

to Nurse Practitioner level we now have advertised for a further 58 hours of triage

nurse time.


We are expecting performance to improve again month by month and we envisage

achieving the required 98% achievement for both standards by the end of June 2016.

The performance directorate has explored benchmarking of performance in relation to

20 and 60min response times for OOH. Welsh Government have advised that this is

not presently available for a number of reasons. These reasons include:

organisational agreement required together with data quality issues. These mean that

the data for 2015-16 is not suitable for benchmarking. Improvement in consistency of

data is expected in 2016 and this will be supported via the Data Change Notice route.

0%

20%

40%

60%

80%

100%

120%

Out of Hours : Urgents triaged/assessed within 20 minutes

Actual Plan Target

0%

20%

40%

60%

80%

100%

Out of Hours : Non-urgents triaged/assessed within 60 minutes

Actual Plan Target


Page 64

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

2.7 Staff & Resources Overview – National Standards

The Finance & Performance committee scrutinises the indicators in the Staff & Resources domain.

Where we are not achieving the required standard, we have included an exception report.

The statutory duty to financially break even has been included to the national template.

SicknessAppraisals:

medical

Financial

Balance

Outpatient

DNAs

Appraisals:

non medical4 4

Use of Staff

& Resources

Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh

BenchmarkStaff and Resources

Martin

JonesYes 4.55% 4.55% 4.50% 4.86% 4.86% Mar-16 2nd

Mark

WalkerNo - 98.0% 97.0% 98.1% 98.0% Apr-16 2nd

Russ

FavagerYes 0.0% 2.2% 2.2% 1.5% 2.7% Apr-16 -

Morag

OlsenYes - 5.0%

Not

Submitted5.6% 5.1% Feb-16 2nd

Morag

OlsenYes - 6.4%

Not

Submitted7.4% 6.5% Feb-16 3rd

% staff absence due to sickness (rolling 12mths)

% of total medical staff undertaking appraisals

Finance - % variance against budget

New Outpatient DNA rates for selected specialties

Follow up Outpatient DNA rates for selected specialties

Martin

JonesYes - 85% 90% 36% 46% Mar-16 -PADR (Appraisal for non-medical staff)

Staff & Resources National

Summary


Page 65

2.7 Staff & Resources Overview – Local Standards

Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh


Martin

JonesYes - 85.0% 90.0% 58.0% 62.0% Mar-16 -

Russ

FavagerYes - 4,400 2,400 4,351 3,469 Apr-16 -

Mandatory Training overall percentage trained

Agency & Locum Spend in £000's

Agency

Locum

Mandatory

Training4 4

Use of Staff

& Resources

Staff & Resources Local

Summary


Page 66

2.7 Exception Report: Staff Sickness Rate Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh


Martin

JonesYes 4.55% 4.55% 4.50% 4.86% 4.86% Mar-16 2nd% staff absence due to sickness (rolling 12mths)

Sickness

Where we are

We ended the financial year with an overall absence rate of 4.86% for the year, a

significant improvement on the 5.18% for the previous year. This resulted in a saving

on sick pay of more than £1.5 million. Although absence rates are still above target,

this is the lowest sickness rate for the large health boards across Wales.

Staff health and wellbeing remains a key priority for the Health Board. Managers and

trade unions continue to work together to reduce absence and promote staff health

and wellbeing. This work was recognised by the re-accreditation of the Corporate

Health Standard Gold award during the month of March.

There continues to be a high correlation between sickness absence and the lower pay

bands.

What are we doing about it?

• Training: A new training package has been developed in partnership with Trade

Unions and is currently being rolled out.

• Processes: 1,770 staff reported sick during the month. CARE referrals fell from

60.31% to 48.36% of all absences for the month this equates to 856 people being

referred to the service.

• Other: The link between poverty and ill health is widely recognised. With effect from

1st January 2016 the living wage for NHS staff in Wales has been uplifted to £8.25

an hour, this means the lowest full time salary in the Welsh NHS is now £16,132.

The absence rates for the lowest paid will continue to be closely monitored to

establish whether the new living wage has impacted upon sickness absence rates.

4.0%

4.2%

4.4%

4.6%

4.8%

5.0%

5.2%

5.4%

% staff absence due to sickness (rolling 12mths)

Actual Plan Target

0%1%2%3%4%5%6%7%8%

Band

1

Band

2

Band

3

Band

4

Band

5

Band

6

Band

7

Band

8a

Band

8b

Band

8c

Band

8d

Band

9

M&

D

No

n A

FC

BCU Sickness Absence by Pay band March 2016


Page 67

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

2.7 Exception Report: Health Budget Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh


Russ

FavagerYes 0.0% 2.2% 2.2% 1.5% 2.7% Apr-16 -Finance - % variance against budget

Financial Balance

Where we are

The Health Board has approved the 2016-17 Financial Plan and

this contains a projected deficit of £30 million for the financial year.

The financial position for April is an overspend of £2.9 million which

is higher than the forecast deficit of £2.5 million (1/12th of £30

million).


The Health Board has approved a financial strategy which includes

a savings target of £30.334 million, the full delivery of this savings

target will leave a projected deficit of £30 million. £26 million of

savings plans have been identified to date but £2.6 million of these

schemes have been classified as having a high risk in terms of

delivering savings. A further £4.3 million of schemes are still to be

identified.

When we expect to back on track

The Health Board is dependent on the delivery of its savings

schemes in order to meet its financial targets. Further Saving

Schemes are being developed and implemented. Progress will

continue to be monitored and reported to the Board. Further

information can be found in the detailed finance reports issued by

the Director of Finance.


Page 68

-8.00%

-6.00%

-4.00%

-2.00%

0.00%

2.00%

4.00%

6.00%

Apr-1

5

Ma

y-1

5

Jun-1

5

Jul-1

5

Aug-1

5

Sep-1

5

Oct-1

5

No

v-1

5

De

c-1

5

Jan-1

6

Feb

-16

Ma

r-16

Apr-1

6

Finance - % variance against budget

Actual Variance %

Forecast Variance %

£10.3 million financial

support provided by WG

and 9/12ths applied to

Dec-15.

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

2.7 Staff and Resources: Exception Report Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh


Morag

OlsenYes - 5.0%

Not

Submitted5.6% 5.1% Feb-16 2nd

Morag

OlsenYes - 6.4%

Not

Submitted7.4% 6.5% Feb-16 3rd



Outpatient DNA

Where we are

The position for New Outpatient Department (OPD) Did Not Attend (DNA) rate has improved. The

reduction DNA rates within outpatients for both new and follow up patients are being addressed

through three key streams of SIMPLER work.

Appointment Reminder Scheme: The Appointment Reminder Scheme which contacts patients

either by text or phone prior to their appointment is on-going and is well received by the majority of

patients. Efforts to improve mobile and up to date telephone numbers continue in both primary and

secondary care, it is believed that improving data quality will further improve DNA rates.

Improvement Events: An Outpatient Improvement event was held in April 2016 to review progress

against our objectives and revised milestones will be issued in May 2016 which will further support

delivery of OPD targets. The Simpler methodology continues to be implemented across all hospital

sites with weekly planning cells being held to review progress while also agreeing actions against

the targets. All actions are intended to DNA rates by 31 March 2016. Persistent DNAs are being

identified and each site continues to enforce the Health Boards DNA policy which is reviewed by

operational management teams.

Improvement Training: A plan has been implemented to increase numbers of staff who require

training. Service Improvement personnel have also been identified at each Acute Hospital to deliver

this training and create sustainability of the Simpler methods. Additional training has been arranged

for clerical staff to ensure accurate recording on PAS. Direct Booking has been piloted in 2 areas

with good outcomes for patients and staff and no negative impact on DNA rates. The Welsh

Government have given approval for this process to be rolled out across all specialties and plans

are underway to support this change. The impact of this process will be carefully monitored to

identify any positive or negative impact on DNA rates.

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

Apr-

15

Jun-1

5

Aug-1

5

Oct-15

Dec-

15

Feb

-16

Apr-

16

Jun-1

6

Aug-1

6

Oct-16

Dec-

16

Feb

-17


Actual Plan Target

0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

Apr-

15

Jun-1

5

Aug-1

5

Oct-15

Dec-

15

Feb

-16

Apr-

16

Jun-1

6

Aug-1

6

Oct-16

Dec-

16

Feb

-17


Actual Plan Target


Page 69

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

2.7 Exception Report: Staff Appraisal Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh


Martin

JonesYes - 85% 90% 36% 46% Mar-16 -PADR (Appraisal for non-medical staff)

Appraisals (Non Medical)

Where we are

The March 2016 performance is 46%, an increase of 10% on the previous month.


Data has been cleansed to ensure PADR recording is current and up to date.

Bespoke training and briefing sessions are being carried out where requested in

service teams. Short one hour briefing sessions continue to be advertised for

Reviewers/Appraisers about PADR/Pay Progression process and benefits.


We are expecting compliance to rise incrementally as Pay Progression rolls out from

April 2016. Further work on ensuring the Electronic Staff Record (ESR) is accurate

will also continue with management teams.

0%

50%

100%

Apr-

15

Jun-1

5

Aug-1

5

Oct-15

Dec-

15

Feb

-16

Apr-

16

Jun-1

6

Aug-1

6

Oct-16

Dec-

16

Feb

-17

PADR (Appraisal for non-medical staff)

Actual

Plan

Target


Page 70

0% 50% 100%

Finance Executive

WF & OD Executive

Strategy Executive

Office of the Board…

Medical Executive

COO Management

Area Teams

Mental Health & LDS

Womens

Nursing Executive

Medical Education

Chief Executive

Secondary Care

Corporate Executive

Misc/Recharges

R&D

Estates & Facilities

Public Health

PADR % Compliant (1st Mar 2015 to 31st Mar 2016)

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

2.7 Exception Report: Staff Training Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh


Martin

JonesYes - 85.0% 90.0% 58.0% 62.0% Mar-16 -Mandatory Training overall percentage trained

Mandatory Training

Where we are

The March 2016 overall compliance figure is at 62%, an increase of 4% on

the previous month and now 28% short of the 90%


Mandatory training days have seen an increase in attendance. During March

we offered 14 Mandatory training days with Mental Health Divisions also

holding specific area mandatory training days.

• The Statutory and Mandatory Training Policy has been updated illustrating

all Mandatory training requirements for all health board staff.

• Compliance reports this month have illustrated all level 1 compliance in line

with the Core skills framework.

• We continue to further review the compliance report and identify areas of

lower compliance and review correct compliance is attached in relation to

staff position number and role within service. One option for offering

resource is newly development of workbooks/leaflets in specific subject

areas.


Discussions are ongoing with Area, Secondary Care and Mental Health

Divisions on improvement trajectories. New trajectories will be set out in future

reports.

0%

50%

100%

Apr-

15

May-

15

Jun-1

5Ju

l-15

Aug-1

5S

ep-1

5O

ct-15

Nov-

15D

ec-

15Ja

n-1

6F

eb-1

6M

ar-

16

Apr-

16

May-

16

Jun-1

6Ju

l-16

Aug-1

6S

ep-1

6O

ct-16

Nov-

16D

ec-

16Ja

n-1

7F

eb-1

7M

ar-

17

Mandatory Training overall percentage trained

Actual Plan Target


Page 71

0% 50% 100%

Violence & Aggression…

Resuscitation Level 1 - Once…

Infection Prevention and…

Moving and Handling - L1 - 2…

Fire Safety - 2 Years

Information Governance…

Patient Handling - 2 Years

Health, Safety and Welfare -…

Violence & Aggression - 2…

Safeguarding Children L2 - 3…

Safeguarding Adults L2 - 3…

Safeguarding Children L1 - 3…

Safeguarding Adults L1 - 3…

Infection Prevention L2 - 1 Year

Equality, Diversity and…

Core Mandatory Training Compliance

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

2.7 Exception Report: Agency and Locum Spend Executive

Lead

Exception

Report?

National

Target

March 17

Plan

Current


Welsh


Russ

FavagerYes - 4,400 2,400 4,351 3,469 Apr-16 -Agency & Locum Spend in £000's

Agency and Locum Spend

Where we are

The total Agency costs for April was £3.469 million, a reduction of

£882,000 from March. This is £350,000 above the average

expenditure for 2015/16 which was £3.119 million. The April

agency expenditure for the 3 hospital sites was £1.817 million

during the month. The other main areas of expenditure are

£552,000 for mental health and £255,000 for Women’s.

Agency Nursing has risen from an average of £520,000 per

month in 2015/16 to £635,000 in April but this is offset by an

increase in Medical Agency which is £2.496 million in April this

year compared to an average of £2.367 million per month last

financial year.

Locums are paid via the Health Board’s Payroll and the total costs

for April are £453k or 0.8% of total pay, an increase of £228k from

March expenditure. This is £192k above the average monthly

expenditure of £261k in the last financial year.


The operational teams are working with the financial leads to

reduce agency and locum costs, recruit to funded posts and fully

utilise bank staff at reduced costs where available.


Page 72

Intelligence

Triangulated

Root Cause


Actions

Underway

Actions

Complete

01,0002,0003,0004,0005,000

Apr-

15

May-

…

Jun-1

5

Jul-15

Aug-1

5

Sep-1

5

Oct-15

Nov-

15

Dec-

15

Jan-1

6

Feb

-16

Mar-

16

Apr-

16

May-

…

Jun-1

6

Jul-16

Aug-1

6

Sep-1

6

Oct-16

Nov-

16

Dec-

16

Jan-1

7

Feb

-17

Mar-

17

Agency & Locum Spend in £000's

Actual

Plan

Target

2.7 Exception Report Theatre Efficiency Executive

Lead

Exception

Report?West Central East

Health

Board

Morag Olsen Yes 89.8% 92.3% 82.8% 88.3%

Morag Olsen Yes 92.9% 82.0% 92.5% 88.6%

Morag Olsen Yes 1.9% 0.9% 2.6% 1.7%

Morag Olsen Yes 30.2% 31.2% 36.8% 32.5%

Morag Olsen Yes 11.9% 11.6% 17.9% 13.5%

Morag Olsen Yes 22.1% 26.6% 30.3% 26.2%Percentage of lists finishing more than 30 minutes early

Staff and Resources

Available used time as a percentage of total planned time

Actual used time as a percentage of total available used time (above)

Percentage of lists starting more than 15 minutes early

Percentage of lists finishing more than 30 minutes late

Percentage of lists starting more than 15 minutes late

0% 10% 20% 30% 40%

West

Central

East

Percentage of lists starting more than 15 minutes late

0% 10% 20% 30% 40%

West

Central

East

Percentage of lists finishing more than 30 minutes early

Operating Theatres

Where we are

Average late starts 32.5%, planning cell meeting breaks the data down to minutes and also

highlights the financial impact.


Continuing to discuss at weekly planning cell meetings in implement improvements where

possible. Alturos working on all 3 sites with clinicians and secretarial staff to start using the

Theatre Optimisation Model (ATOM).


Quarter 2 is expected start date for using model in selected areas.


Page 73

3.0 Activity

Position

The table reports activity for internally provided within North Wales.

April 2015 – March 2016

Plan Actual

Emergency Inpatients 87,934 90,313 2,379 2.7%

Elective Daycases 25,321 26,242 921 3.6%

Elective Inpatients 18,015 19,882 1,867 10.4%

Endoscopies 20,667 21,495 828 4.0%

Minor Outpatient Procedures (cleansed Day Cases) 1,827 2,009 182 10.0%

Regular Day Attenders 44,601 47,890 3,289 7.4%

New Outpatients 218,419 204,448 -13,971 -6.4%

Review Outpatients 443,072 447,829 4,757 1.1%

New Emergency Department Attendances 208,975 213,999 5,024 2.4%

Review Emergency Department Attendances 11,396 12,254 858 7.5%

Grand Total 1,080,226 1,086,361 6,135 0.6%

Patient TypeHealth Board

Difference % Difference

Hospital Activity


Page 74

3.1 Referral Rates (GP and Consultant)

These referrals represent new elective Referral To Treatment pathways for our health board. *Top 20 Specialties by the number of

referrals in 2016/2017 to date.

-30% -20% -10% 0% 10% 20% 30% 40%

Child & Adolescent Psychiatry

Pain Management

Midwife Episode

Geriatric Medicine

Paediatrics

Trauma & Orthopaedics

Ophthalmology

Rheumatology

Endocrinology

General Medicine

Maxillo-Facial Surgery

Cardiology

Clinical Haematology

Gastroenterology

ENT

Respiratory Medicine

Dermatology

Urology

General Surgery

Gynaecology

All Specialties

Top 20 Specialties* Referrals % Difference

comparing same time period last year

2015/2016 2016/2017

Apr Apr

General Surgery 2,043 2,720 677 24.9%

Trauma & Orthopaedics 1,907 1,831 -76 -4.2%

Dermatology 1,478 1,746 268 15.3%

ENT 1,402 1,634 232 14.2%

Ophthalmology 1,490 1,464 -26 -1.8%

Gynaecology 840 1,323 483 36.5%

Urology 873 1,128 255 22.6%

Gastroenterology 847 985 138 14.0%

Cardiology 882 922 40 4.3%

Maxillo-Facial Surgery 807 841 34 4.0%

Rheumatology 816 813 -3 -0.4%

Paediatrics 589 548 -41 -7.5%

Respiratory Medicine 401 468 67 14.3%

Child & Adolescent Psychiatry 397 322 -75 -23.3%

Endocrinology 316 316 0.0%

Midwife Episode 327 303 -24 -7.9%

Pain Management 335 286 -49 -17.1%

Geriatric Medicine 250 232 -18 -7.8%

General Medicine 162 166 4 2.4%

Clinical Haematology 124 134 10 7.5%

Nephrology 127 115 -12 -10.4%

Orthodontics 123 96 -27 -28.1%

Plastic Surgery 40 70 30 42.9%

All Specialties 16,754 18,903 2,149 11.4%

SpecialtiesDifference

15/16 to 16/17

%

Difference

Detailed work is underway at locality and practice level to

understand variation based on registered practice populations for

both elective and emergency demand. It is important to note that

demand change on secondary care services arises from a

variety of sources including: consultants to consultant, and

screening services.

Referrals


Page 75

Appendix A – Further Information

Performance Report April 2016 Page 76

Further detailed information is available

• Further information is available from the office of the Chief Operating Officer

which includes;

• performance reference tables

• tolerances for red, amber and green

• the Welsh benchmark information which we have presented

• Further information on our performance can be found online at:

• Our website www.pbc.cymru.nhs.uk

www.bcu.wales.nhs.uk

• Stats Wales www.statswales.wales.gov.uk

• We also post regular updates on what we are doing to improve healthcare

services for patients on social media:

follow @bcuhb

http://www.facebook.com/bcuhealthboard

Appendix A – Further

Information

3.3 16/118 Finance Report – Month 1

1 16_118 Finance Report Month 1- Final 16th May 2016.docx

Board Meeting 23.6.16 Item


Title: Finance Report Month 1

Author: Huw Thomas, Finance Director: Operational Finance


Russell Favager, Executive Director of Finance


Public

Strategic Goals


inequalities


closer to home


NHS’ best







Scrutiny provided by the Finance and Performance Committee prior to submission to the Board.

Purpose: The purpose of this report is to brief theFinance and Performance Committee and the Board on the financial performance and position of the Health Board for the month, alongside the forecast for the year.


The Health Board approved an Interim Financial Plan on 17 March which approved a deficit budget as a planning assumption of £30m; following a need to deliver savings of £30.3m. There is an assumption within the budget that the Health Board will receive an additional allocation of £4.8m to support in the delivery of issues arising from the Health Board’s Special Measures status. Being placed under Special Measures has put a greater focus on addressing longstanding service issues. This has resulted in risks against the Health Board’s ability to deliver the transformational financial savings schemes previously identified. To date, the Health Board has overspent by £2.9m; of which £2.5m relates to the planned deficit and £0.4m relates to unidentified savings, slippage in savings delivery, and other operational pressures. This position will need to be recovered over the remainder of the financial

2

year in order to achieve the forecast position of £30m.


Not applicable

Recommendation/ Action required by the Committee

It is asked that the report is noted.

3

Finance Report

Month 1 (April) 2016/17

Russell Favager Executive Director of Finance

Betsi Cadwaladr University Health Board

1. Executive Summary

1.1 Purpose

The purpose of this report is to outline the financial position for the year to date; performance against savings targets for the year and the outlook for the remainder of the year.

1.2 Context

The Health Board has two statutory duties to achieve: 1 To ensure that its expenditure does not exceed the aggregate of the funding

allocated to it over a period of 3 financial years (the first of which commenced on 1 April 2014 and will end on 31 March 2017), and

2 To prepare a plan to secure compliance with the above duty, providing healthcare and improving the health of the population, and for that plan to be submitted to, and approved by the Minister (required for the first time in 2014/15).

The Health Board has, in agreement with Welsh Government, not submitted a three-year plan in either 2014/15 or 2015/16 and will not do so for 2016/17. As a result of this, the Health Board has been operating under Annual Operating Plan arrangements.

The Health Board’s deficit for 2014/15 was £26.6m, and the (unaudited) deficit for 2015/16 was £19.5m. Consequently, the aggregated deficit for the first two financial years of the first three year period is£46.1m.

The agreement of a deficit budget in 2016/17 of £30m therefore means that the Health Board is forecasting an aggregate deficit of £76.1m for the three year period ending 31 March 2017.

The Minister for Health and Social Services placed the Health Board in Special Measures in June 2015, expected for a period of two years. The implementation of the Special Measures Improvement Framework has resulted in additional costs for the Health Board, necessitated to address longstanding areas of concern. Nonetheless, this requires further resources, and £4.8m of additional resources have been assumed for the financial year from Welsh Government.

5

1.3 Summary of key financial targets

Key Target Annual target

Year to date

target

Year to date

actual Risk

Achievement against Revenue Resource Limit (Performance against £30m budget deficit)

(30,000) (2,500) (2,930)

Performance against savings (Internal target)

30,334 1,855 961

Achievement against Capital Resource Limit 50,219 2,337 2,288

Compliance with the requirement to pay Non-NHS invoices within 30 days of receipt of a valid invoice

95.0% 95.0% 95.5%

Cash balance at month-end 0 7,300 5,283

1.4 Revenue position

At Month 1, the Health Board has overspent by £2.9m. Of this, £2.5m relates to the Health Board’s planned budget deficit and £0.4m represents an adverse variance against this plan.

1.5 Cash releasing efficiency savings

Of the savings target of £30.3m, £26.0m have been identified to date. £1.0m of savings were achieved in Month 1, against an expected delivery of £1.9m.

1.6 Forecast revenue position and risk assessment

The Health Board is managing a number of financial risks, but the forecast position is a £30m deficit, in line with the interim Financial Plan.

1.7 Balance sheet

The Health Board is required to pay non-NHS invoices within 30 days of receipt of a valid invoice. The benchmark requirement is to pay 95% of valid invoices within this period. During Month 1, the Health Board paid 95.5% of its invoices within 30 days.

The closing cash balance as at 30 April was £5.3m. This represents 1.45 days turnover, which is within of the Health Board’s internal target to carry less than the equivalent of 2 days of turnover. Cash remains a key risk for the year end as the Health Board will be required to repay cash support received in 2014/15 of £20.6m.

1.8 Key actions to be taken

The agreement of the Operational Plan will be critical in ensuring that the operational and performance expectations of the Board are clarified within the available financial resources.

The Health Board needs to ensure that savings targets are identified in full; and that delivery of savings is a priority alongside cost management.

2. Revenue position

2.1 Cumulative revenue position by division

Red: represents adverse variances in excess of 0.5% Amber: represents adverse variances equal to, or less than, 0.5% Green: represents favourable variances

2.1.1 Commentary

Area Teams as a whole have achieved a breakeven position, mainly as a result of services provided across North Wales, in particular healthcare contracts which underspent by £0.1m.

Secondary Care teams have overspent by £0.5m as a result of unidentified and undelivered savings in Month 1 (£0.4m) alongside operational pressures arising from agency staffing.

Mental Health and Learning Disabilities have overspent by £0.5m, largely as a result of unidentified and undelivered savings in Month 1 (£0.3m) alongside continued pressures on agency staffing.

Corporate Services have underspent by £0.2m as a result of slippage in appointing to vacancies.

Other variances of £0.4m relate to the phasing of reserves, including those to support the development of the organisational management structure and to address cost pressures. These reserves will be transferred to operational budgets as appointments are made.

2.1.2 Actions

It is imperative that action is taken across the East health community to address the system-wide issues on identifying and delivering savings; and on addressing operational pressures.

In addition to this, Secondary Care need to focus on identifying and delivering savings in Ysbyty Gwynedd.

Management grip within Mental Health and Learning Disabilities needs to be enhanced, and this will be an area of immediate focus for the new Director.

£’000

Area 9 0.1% 10 0.1% 153 0.9% (173) (1.1%) (1) (0.0%)

Secondary

Care221 3.1% 42 0.5% 173 2.4% 45 0.5% 481 1.5%

MHLD 489 5.9% 489 5.9%

Total

divisions230 1.2% 52 0.2% 326 1.3% (177) (0.5%) 430 0.4%

Corporate (159)

Other (379)

Total 430

TotalWest Centre East HB-wide

7

2.2 Cumulative revenue position by expenditure category Annual

Budget Current period

variance

Year to date actual

Year to date

variance

Section

£’000 £’000 £’000 £’000

Primary Care 158,453 (42) 13,162 (42) Section 2.2.1

Pay 649,687 268 55,300 268 Section 2.2.2

Non-pay 440,356 635 33,792 635 Section 2.2.3

Healthcare contracting

172,077 (84) 14,118 (84) Section 2.2.4

Continuing Healthcare and Funded Nursing Care

84,826 163 7,232 163 Section 2.2.5

Total expenditure 1,505,400 940 123,605 940

Income (107,760) (510) (10,637) (510) Section 2.2.6

Net expenditure 1,397,640 430 112,968 430

Budgeted deficit (30,000) 2,500 0.0 2,500

Position against plan

1,367,640 2,930 112,968 2,930

2.2.1 Primary Care

Primary Care services is balanced overall.

Within General Dental Services, work is ongoing to develop investment plans for additional activity to improve dental access across North Wales. This work will be focussed on areas with the lowest access levels.

Within General Medical Services, there is a significant risk against this forecast as the Doctor and Dentist Pay Review Body has agreed a 2.2% uplift for the GMS contract for 2016-17, which equates to £2.2m for North Wales and which cannot be contained within the current budget. However, the Health Board is currently appealing against the rateable value of a number of GP premises within North Wales, back dated to 2010. This may result in a benefit of up to £2.9m to the Health Board in the current year.

8

2.2.2 Pay

Pay costs, in particular variable pay costs arising from the use of Agency staffing in particular is a serious concern, as demonstrated above.

9

The total Agency costs for April was £3.5m compared to average monthly expenditure of £3.2m in quarter 3 and £3.8m in quarter 4 in the last financial year.

Agency Nursing has increased from an average of £0.5m per month in 2015/16 to £0.6m in April. Medical Agency costs are £2.5m in April compared to an average of £2.4m per month in 2015/16. Further Agency analysis is shown in Appendices 2 and 3.

The total Agency costs for 2015/16 where £37.4m, further efforts are required to reduce expenditure in 2016/17; with continued problems with medical recruitment this remains a significant challenge.

2.2.3 Non-pay

The majority of the £0.6m overspend relates to undelivered savings which were phased in Month 1.

Other non-pay variances have arisen with drugs, utilities and rates. 2.2.4 Healthcare contracting

The Health Board’s externally delivered Healthcare Contracts is under spent by £0.1m.

BCU Managed Welsh and English contracts are balanced at the end of April and the net position on WHSSC-commissioned contracts is an under spend of £0.2m.While WHSSC is forecasting a year-end underspend of £0.8m, the historic performance of WHSSC means that this is an area of volatility and risk to the financial position.

No outsourced RTT activity has been charged in Month 1. 2.2.5 Continuing healthcare

Continuing Healthcare and Funded Nursing Care is overspent by £0.2m in Month 1.

This is an area of known risk, and the service demand, complexity of care packages and issues with the stability of the provider market mean that it will be subject to close scrutiny over the year.

2.2.6 Income

Favourable income variances have arisen from: o Services commissioned from the Health Board by WHSSC; o Income from R&D and grants; and o Income from non-contract activity with other Health Boards, Private Patient

Income and Local Authorities.

3. Cash Releasing Efficiency Savings

3.1 Savings requirement

The Health Board has a challenging savings target of £30.3m for 2016/17. A 3% target has been applied across all non-ringfenced budgets.

A programme board framework has been introduced. The framework is made up of a number of strategic work streams, which feed into a total of ten programme boards, each led by an Executive Director. All savings schemes will be allocated against a relevant work stream.

3.2 Identified Savings

Savings plans of £26m have been developed at Month 1 against the target (85.81%).These have all been financially risk assessed as follows.

o Low: £9.45m o Medium: £13.93m o High: £2.61m o Unidentified: £4.34m

Of the above planned savings, £21m are considered to be recurrent while the remaining £5m have been identified as non-recurrent. Work is ongoing in order to identify recurrent and non-recurrent schemes which will in turn reduce the unidentified savings figure.

3.3 Performance

Cash releasing Savings of £1.0m have been delivered as at Month 1 against a planned profile of £1.9m (53%).This variance in Month 1 can largely be attributed to MHLD, which did not record any savings (£0.4m variance) and Secondary Care (£0.4m variance).

It is expected that delivery will increase over the coming months once reporting processes have been fully embedded.

4. Forecast position and risks

11

4.1 Financial year forecast revenue position

The Health Board’s financial position has been subject to a financial risk assessment in order to understand the risks to achieving the financial plan.

The effect of this is shown below, which demonstrates a best case favourable variance against plan of £0.9m; and a worst case adverse variance against plan of £6.0m. The most likely position at the current time is a balanced position against plan.

Consequently, the planned deficit of £30m is the forecast position at this stage. Best

case £’000

Most likely £’000

Worst case £’000

Risk level

Explanation

Risk factor

Continued use of agency staffing

1.0 5.0 10.0 Medical Agency staffing, in particular, continues to grow.

GMS uplift 1.0 2.0 2.2 Uplift in GMS contract cannot be contained within the ringfenced budget.

Hepatitis C drugs 0.0 3.0 3.0 Pressure on expensive Hep C drugs develops in line with WG expectations

Savings non-delivery 0.0 2.0 5.0 Savings do not deliver as expected.

Demand growth in WHSSC

0.0 0.0 2.0 New treatments and growth in numbers exceed allocated resources.

Anticipated Special Measures funding not allocated by WG

0.0 0.0 4.8 WG are unable to fund Special Measures costs arising for the Health Board.

Total gross quantified financial risks

2.0 12.0 27.0

Mitigation measure

Primary Care Business Rate rebate

(2.9) (2.0) (1.0) Business Rate rebate review provides a non-recurrent benefit.

Additional funding provided by WG relating to Hep C

(3.0) (3.0) WG agree to fund additional Hep C drugs costs.

Commissioning controls put in place through WHSSC

(2.0) The Health Board works with other Boards and with WHSSC to manage demand growth and activity.

Additional savings measures required

(2.0) (3.0) Additional non-recurrent savings required to manage the financial position.

Mitigating actions to address agency usage

(5.0) (5.0) Medical Agency issues are managed closely through the Managed Service provider.

Urgent recovery actions needed to recover position

(7.0) Additional non-recurrent actions could be required to address residual financial risks.

Residual risk (2.9) (12.0) (21.0)

Residual risk (0.9) 0.0 6.0

There is also a contingent risk not included within the above, arising from Continuing Healthcare fees which are subject to ongoing dialogue with Local Authority partners, Welsh Government and providers.

5. Balance Sheet

5.1 Cash

The Health Board is required to not draw down cash from the Welsh Government ahead of need and has an internal target of holding a maximum balance of £7.3m. The month end balance was £5.283m which is within the target.

The effective management of cash remains a key priority has the Welsh Government will not provide cash funding to meet deficits and a year-end cash shortfall is anticipated. Further work will be done on this over coming months.

5.2 Capital expenditure

The Capital Resource Limit for Month 1 is £50.219m. The Welsh Government issued the initial allocation for the 2016/17 financial year in March 2016.

Actual expenditure for Month 1 was in line with the budget of £2.3m.

6. Conclusions and Recommendations

13

6.1 Conclusion

The Health Board has agreed an interim Financial Plan which includes an assumed deficit of £30m as a planning assumption. This forecast assumes that additional funding will be provided to the Health Board of £4.8m to address issues arising from the Special Measures Improvement Framework.

The Health Board has overspent by £2.9m at the end of April in the new financial year, or £0.4m (0.4%) against the plan for the year after accounting for the original £30.0m budgeted deficit.

The agreement of the Operational Plan will be critical in ensuring that the operational and performance expectations of the Board are clarified within the available financial resources.

The Health Board needs to ensure that savings targets are identified in full; and that delivery of savings is a priority alongside cost management.

Achieving the financial plan, while not compromising the quality and safety of its services, is an important element in developing trust with Welsh Government, the Wales Audit Office, Health Inspectorate Wales and the public.

As such, the adverse variance incurred in Month 1 will need to be recovered over the remainder of the year through reviewing the delivery expectations of savings schemes and cost control.

6.2 Recommendations

It is asked that the report is noted, recognising the risks to the financial position which are outlined in Section 4.