SCRUTINY SESSION WITH THE HEALTH AND SOCIAL CARE COMMITTEE – 19 MARCH 2015

 

NATIONAL ASSEMBLY FOR WALES: HEALTH AND SOCIAL CARE COMMITTEE

Date: 19 March 2015

Venue: Senedd, National Assembly for Wales

PART 1: GENERAL SCRUTINY SESSION

 

Purpose

 

1. This paper provides an update on key priorities across the Health and Social Services Ministerial portfolio, with specific reference to those areas of interest identified by the Committee in Annex A of their letter of 30 January.  A separate paper (Part 2) covers our response on financial matters.

 

Overview of recent progress and achievements, and portfolio priorities 

 

2. Since my last attendance at the Committee general scrutiny session on 18 September 2014, continued progress has been made in taking forward the Health and Social Services contribution to the Programme for Government.  The latest progress report was published in June 2014 and work is in hand to inform the health and social service contribution to the 2015 report which will set out the detailed progress being made on health and social services commitments.

 

3.  In terms of portfolio priorities much of the detail is set out later in the paper but  continued delivery of the actions contained in Together for Health and Sustainable Social Services: A Framework for Action remain relevant and at the forefront of our work. However, as would be expected in a changing policy and fiscal environment there is a need continually to adapt so that we can respond to current challenges. Therefore, my priorities are driven by a growing emphasis on prudent healthcare; an increased focus on a shift to primary care; effectively utilising our new approach to three year integrated planning and our ongoing development of the quality and safety agenda.

 

4. Added to these priorities and in the context of the overarching framework of Together for Health and Sustainable Social Services, tackling poverty remains a key priority as we address health inequalities in line with the NHS-related commitments included in the Building Resilient Communities: Taking forward the Tackling Poverty Action Plan.

 

 

 

Session 1: General Scrutiny Issues

 

PRUDENT HEALTHCARE

 

5. Over the last 12 months as part of our continued response to the austerity challenges facing the NHS and social services, work has been undertaken to develop, codify and embed prudent healthcare principles into health services across Wales. Effort is being concentrated on the things that make a real difference and make the most effective use of resources.  In doing so, it is clear that a renewed effort is needed to embrace a preventative, primary and community care-led NHS which is integrated with social care, and delivers as much care as possible closer to patients’ homes, shifting the balance between primary and secondary care.

 

6. The latest set of chapters describing how prudent healthcare could work in Wales became available on the ‘Making Prudent Healthcare Happen’ online resource www.prudenthealthcare.org.uk in January 2015 at the annual Welsh NHS Confederation Conference. The first set of chapters, videos and case studies were made available on the website in October 2014.

 

Bevan Commission

 

7. The Bevan Commission has undertaken a further piece of work, published in January, to finalise the prudent healthcare principles for Wales, to help ensure that everyone involved in securing a healthier future for the population of Wales follows a common set of principles.

 

8. The Bevan Commission’s final four principles are:

 

·         Achieve health and wellbeing with the public, patients and professionals as equal partners through co-production;

·         Care for those with the greatest health need first, making the most effective use of all skills and resources;

·         Do only what is needed, no more, no less; and do no harm.

·         Reduce inappropriate variation using evidence based practices consistently and transparently.

 

9. The further prudent healthcare concept of ‘only do what only you can do’ remains a powerful one, especially for a prudent health and social care workforce for the future. It will therefore be important to maintain the concept that no professional should routinely be providing a service, which does not require their level of clinical ability or expertise – only do what only you can do – as Wales continues its prudent healthcare journey.

 

Next Steps

 

10. The Welsh Government and NHS Wales will focus on four key areas where putting the prudent healthcare principles into practice will be especially important in the year ahead. Together we will:

 

·         Continue to put primary care in the driving seat of the NHS in Wales;

 

11. To support this, the Welsh Government will host its first prudent healthcare conference this summer, which will be opened by the First Minister. It will have an international reach and involve key partners who are furthering the prudent healthcare movement, including health boards and NHS trusts, the Royal Colleges, NICE and the BMA.

 

TOGETHER FOR HEALTH DELIVERY PLANS

 

12. Delivery Plans for Cancer, Mental Health and Stroke were published in 2012, and Plans covering Respiratory Health, Oral Health, Eye Health, Heart Disease, Diabetes, Neurological Conditions, End of Life Care and Care for the Critically Ill have been published within the last 18 months.  A delivery plan for Liver Disease has been developed and following a public consultation period, is being finalised to take account of feedback received.

 

13. National Clinical Lead posts have been established for diabetes, stroke, end of life, unscheduled and planned care with implementation groups meeting on a regular basis to take forward the actions in the plans. 

 

Cancer

 

14. We are making good progress in implementing the Cancer Delivery Plan. Our third annual report published in January 2015 highlighted progress made in cancer services over the past 12 months and identified areas for future improvement.

 

15. The Cancer Implementation Group was established to ensure that the requirements of the Cancer Delivery Plan are delivered, and has an important role in monitoring progress. The Group is chaired by Paul Roberts, Chief Executive of Abertawe Bro Morgannwg University Health Board and is made up of senior clinicians and Welsh Government officials. 

 

16. The transparent publication of national and local annual plans and reports means local communities, organisations and other groups are able to challenge health boards on progress. We have accepted the Committee’s recommendation to strengthen these arrangements further to drive faster progress.

 

17. The five priorities for the next year are: the organisation of cancer support services to ensure improved services; delivery, planning and performance; primary care oncology; the development and piloting of a single urgent cancer pathway; patient experience including the delivery of consistent key worker policy, improving patient information and a national focus on lung cancer.

 

Diabetes

 

18. The Diabetes Delivery Plan was published in September 2013.  It picked up the recommendations made by the Committee as part of its Inquiry into the National Service Framework (NSF) for diabetes. The first national annual report on the Diabetes Delivery Plan was published in January 2015 and shows how diabetes services are improving and what challenges remain to be tackled.

 

19. The Diabetes Implementation Group, chaired by the Chief Executive of Cardiff and Vale University Health Board, has met quarterly, and is taking forward the Diabetes Delivery Plan and the recommendations from the Committee’s inquiry into the delivery of the Diabetes National Service Framework.

 

20. Progress is being made on the recommendations, and a detailed update progress against each of the Committee’s recommendations is attached at Annex A.

 

Respiratory Conditions

 

21. Following the publication of the Respiratory Health Delivery Plan in April 2014, health boards have developed their local delivery plans, which were peer reviewed at the Implementation Group meeting on 20 January. Common issues across the plans were consideration of Chronic obstructive pulmonary disease (COPD), asthma, Interstitial lung disease (ILD), sleep, pneumonia, lung cancer and bronchitis; as well as provision of smoking cessation, end of life care, pulmonary rehabilitation, vaccination and psychological support.

 

22. An addendum to the delivery plan is being developed to focus on paediatric respiratory services and a subgroup to the Implementation Group is also to be established on this issue. The addendum will take into account the recommendations of the National Review of Asthma Deaths report, which highlighted specific issues relating to paediatric care.

 

Liver

 

23. Deaths in Wales from chronic liver disease have more than doubled in the last twenty years.  A delivery plan for liver disease has been developed and following a public consultation period, is being finalised to take account of feedback received. The plan is expected to be published by the end of April.

Mental Health Strategy

 

24. The second annual report on progress against the Together for Mental Health Delivery Plan (2012-16), was published in January 2015, and set out the progress made in the second 12 months in delivering against the commitments.

 

Mental Health (Wales) Measure (2010)

 

25. The recommendations of the recent Health and Social Care Committee’s post legislative scrutiny of the Measure reflect the work that is being undertaken in the overall Duty to Review the Measure. The final Duty to Review report will be published later this year. In the new local primary mental health support services over 75% of people have assessments within 28 days and over 90% of people in need of therapeutic interventions are seen within 56 days. Now that over 90% of people in secondary mental health services have a care and treatment plan, our focus has turned to the quality of those plans and a service user satisfaction survey and quality audit will be undertaken this year. Work will continue to ensure that the intentions of the Measure, to provide better and more accessible services, continue to be supported and promoted across all sectors in Wales.

 

Mental Health Ring-fence

 

26. Mental health accounts for the largest single area of health expenditure in Wales. Our continued commitment to mental health is demonstrated by ring-fenced funding (which has increased from £387.5 million in 2008-09 to £587 million in 2014-15.  We have committed to review the effectiveness of the Mental Health ring-fence in our Together for Mental Health Strategy and I expect to receive a report on this shortly.

 

CAMHS

 

27. The Service Improvement plan was developed in 2013, bringing all CAMHS issues and areas requiring further attention together. The Plan was developed in response to a range of concerns reported to Welsh Government, including those contained in the WAO/HIW December 2013 review of CAMHS safeguarding.

 

28. To support the implementation of the plan we have established a CAMHS project steering group, chaired by the Welsh Government.

 

29. More generally, the NHS is leading service change and development within CAMHS, this work formally commencing in February and running throughout 2015.  The Welsh Government is supporting this work through the appointment of Professor, Dame Sue Bailey, who will provide the external advice, support and scrutiny to the NHS.

 

Dementia

 

30. Over 30% of GP practice teams in Wales have now completed the Wales Mental Health in Primary Care Network dementia training, with 97% then agreeing a dementia lead and action plan.  This should result in real improvement in diagnosis rates as well as provision of care. We are also actively exploring ways of improving diagnosis rates in care settings.  

 

31. The Alzheimer’s Society has now recruited more than 300 Dementia Champions and over 8,000 Dementia Friends across Wales: Welsh Government is funding the charity to continue this important work in Wales.  We are also committed to the further development of Dementia Supportive Communities in Wales, to increase understanding, compassion and tolerance about dementia at a community level.  Twelve months ago there were two pilot communities active; now there are ten communities at different stages of development, and plans are underway for a further three.

 

32. We are now working with key stakeholders in Wales to update Dementia – How to reduce your risk guidance.  We will develop a tailored communication strategy to raise awareness of the new guidance with a focus on physical activity. The Caerphilly Cohort Study is increasing our understanding of the steps one might take to reduce risk, and the Blackfriars Consensus – which the Welsh Government signed up to last year - commits us to tackle the lifestyle choices that could reduce the risk of dementia emerging in later life.

 

33. Following on from the Trusted to Care spot-checks which took place in the summer of 2014, a series of randomly selected spot-checks of older people’s mental health wards took place in November and December.  I issued a Written Statement on 4 March setting out the progress of this latest round of spot checks.  This is in line with the same process used for Trusted to Care spot check visits. 

 

34. The Welsh Government has also recently provided £1.1million from the Invest to Save funding to assist Cwm Taf University Health Board in establishing a consultant-led Psychiatric Liaison Service for older people with mental health needs and a new Acute Assessment Service covering unscheduled care activity between 9am and 6pm.

 

Support for Veterans

 

35. The Welsh Government continues to meet its Programme for Government commitment to meet the mental health needs of veterans through support for Veterans NHS Wales, which provides dedicated veteran therapists in each health board, with £485,000 of Welsh Government funding. 

 

36. Since its inception the service has received 1,115 referrals, an average of 278 per year.  In 2013-14 the service received 395 referrals.  Recognising the need to ensure timely access to treatment, in June 2014 the Welsh Government announced an additional £100,000 investment in the service during 2014-15 to reduced waiting lists. 

 

37. This investment has enabled all health boards to reduce waiting times to access treatment considerably.  As at December 2014, these ranged from no waits at Betsi Cadwaladr UHB to a maximum of 17 weeks at Cardiff and Vale UHB.  This is within the Royal British Legion’s General Election Manifesto, which is calling on the future UK Government to commit to a maximum of 18 weeks wait for veterans to access mental health treatment.

 

38. In 2014, the Welsh Government also commissioned a review of the Veterans NHS Wales service, undertaken by Public Health Wales.  The review made a range of recommendations to improve the service.  Officials are currently working with the service and health boards over the detailed implementation of the proposals.

 

HEALTH SERVICE PLANNING

 

Integrated Medium Term Plans

 

39. Over the last 12 -18 months, the planning arrangements across NHS Wales have been strengthened.  The NHS Planning Frameworks (2014/15 and 2015/16), underpinned by the NHS Finance (Wales) Act, set out the ambition for the new planning arrangements.  All NHS Wales organisations are required to set out how resources will be used over a three year period to: address areas of population health need and improve health outcomes; improve the quality of care; and ensure best value from resources.

 

40. Four organisations secured Board and Ministerial approval for their integrated medium term plans (IMTPs) in the first planning cycle (2014/15).  The remaining organisations agreed one year plans with their Boards and set out the steps they would take to strengthen their medium term plans for submission in January 2015.  Delivery against all plans is being tracked through the national performance and delivery arrangements including, where appropriate, use of escalation and intervention arrangements.

 

2015/16 Integrated Medium Term Plans

 

41. All health boards and trusts submitted their 2015/16 IMTPs to the Welsh Goverment on 30 January.  The assessment of 2015/16 IMTPs builds on the approach taken to the 2014/15 planning round. 

 

42. Following a series of IMTP review meetings with all NHS organisations during late February and early March I will make a further announcement on approved plans/next steps by the end of April.

 

Service Change

 

Mid and West Wales

 

43. In the Hywel Dda University Health Board area, maternity services transferred successfully in August and the changes have worked well.  The midwife-led unit in Withybush Hospital has exceeded expected usage, with positive feedback. Neonatal services in the region are now compliant with many of the all-Wales neonatal standards, which was not previously the case.  Staffing is more sustainable and there has been successful recruitment to training posts.

 

44. The same is true for paediatric services, which were reconfigured in October 2014.  Inpatient care is provided at Glangwili Hospital, with a high dependency unit on site.  There is a 7 day a week, 12 hour children’s assessment unit at Withybush Hospital (most emergencies needing this service happen during the day) and the emergency department has a paediatric nurse supporting the other staff out of hours. This offers an appropriate and responsive service that is based on the health board’s analysis of need and service demand, and represents effective use of resources.

 

45. The safety-net measures required have been implemented, including the dedicated ambulance for transferring mothers, babies and children which has had ample capacity. The health board is monitoring the new arrangements continuously to ensure they are providing a safe and effective service, and this information will be fed into a full independent review of the first year of the newly configured maternity service.

 

North Wales

 

46. Betsi Cadwaladr University Health Board is continuing to implement changes to health services in North Wales.  A number of old and outdated community hospitals, which were not capable of providing the levels of care necessary for local communities, have closed or partially closed.  Project teams are working with partners and stakeholders to develop replacement primary care resource centres which are currently being considered as part of the capital business programme.  These new facilities will ensure more care is provided closer to patients’ homes in these areas.

 

47. On the basis of clear clinical advice, the health board has decided to make interim changes to obstetric and gynaecology services in North Wales.  Inpatient consultant–led maternity services will, therefore, be suspended temporarily at Ysbyty Glan Clwyd in the interests of patient safety.

 

48. The health board is expecting all the interim arrangements to be completed by May this year. We expect the Health Board to carry out continuous widespread public engagement on their proposed new service models.

 

49. This decision will not affect the long term plans for the Sub Regional Neonatal Intensive Care Centre (SuRNICC) at Ysbyty Glan Clwyd and its support services announced by the First Minister in May last year. 

 

50. I have written to the chair and chief executive of Betsi Cadwaladr University Health Board, to secure assurances on the decision taken by the board.  The health board’s response has now been published on their website.

 

South Wales Programme (SWP)

 

51. As a result of working together through the South Wales Programme and now the Acute Care Alliances, the NHS Wales chief executives are developing the NHS Wales Health Collaborative to take forward a number of strategic programmes, which cross health board boundaries. It will bring together the work of the South Wales Health Collaborative, the programme management unit and the chief executive support office. The NHS Wales Health Collaborative will be led by Bob Hudson and will be established from April.

 

Mid Wales Healthcare Study   

 

52. On 23 October the Welsh Institute for Health and Social Care (WIHSC) published the findings from its independent study of healthcare in Mid Wales, which provides a comprehensive analysis of the issues and opportunities for providing accessible, high-quality, safe and sustainable healthcare for people living in Mid Wales.

 

53. I have now received formal board-level responses to the report from the chairs of the Welsh Ambulance Services NHS Trust (WAST) and the three health boards covering the Mid Wales area (Powys Teaching Health Board, Hywel Dda University Health Board and Betsi Cadwaladr University Health Board).

 

54. I recently announced the appointment of Dr Ruth Hall CB and Mr Jack Evershed as independent co-chairs for the Mid Wales Health Collaborative which is being established through the three health boards and WAST. This formally sets in motion the first key recommendation made by Professor Longley. 

 

55. The Mid Wales Rural Healthcare Conference – another recommendation of the Study Report - will be held at the Cefn Lea Conference Centre in Powys on 12 March. This will be an excellent opportunity to bring together leading thinkers and those with experience of providing innovative service models in rural areas.

 

Lessons Learned Review 

 

56. Ann Lloyd’s report of lessons learned following the first phase of service reconfiguration was published on 10 November. The report made a number of recommendations to reform the current system of engagement and consultation. In particular, continuous engagement by health boards should become the main vehicle for service change in the future and CHCs should immediately begin forging closer links with their respective local services boards to discuss matters of mutual interest and concern.  

 

57. Officials are leading a Task and Finish Group of key stakeholders to revise the national guidance on service change in line with Mrs Lloyd’s recommendation. It is expected that the revised guidance will be published in June this year.

 

IMPROVING NHS PERFORMANCE

 

58. We are exploring new outcome indicators that will result in better outcomes for patients.  We need to develop measures and outcome indicators that identify and quantify clinical benefit and outcomes for patients, and we need to communicate these better to the public.

 

59. Current performance against our  existing targets is set out below:

 

 

 

 

Unscheduled care

 

A&E Performance

 

60. 82.0% of patients to access Emergency Departments in January 2015 were admitted or discharged within 4 hours, a rise of 1.0 percentage points on the previous month.  The quarterly A&E statistics show that A&E departments in Wales in December 2014 had the highest number of patients aged 75 and over since the current data recording system began. 

 

61. This spike in demand will have had lasting implications for hospitals’ ability to discharge in a timely way, given elderly patients tend to have longer stays in hospitals and can require more support following their discharge.

 

62. Pressures on emergency care and hospital services over the winter period are a UK-wide problem, linked to an increase in the number of elderly patients with complex needs requiring hospital care.   Overall, Welsh A&E departments are seeing more patients; around 116,000 more patients compared to 1999 figures

 

63. The number of patients who waited over 12 hours in an Emergency Department before admission or discharge was 3,051 in January 2015. The number of patients waiting over 12 hours is unacceptable and we expect health boards to work with local authorities and other partners to ensure that patients can be treated, admitted and discharged appropriately and receive safe and effective care.

 

Emergency Ambulance Service

 

64. Improving emergency ambulance responsiveness is a priority for the Welsh Government. We expect health boards and the ambulance service to work together to improve performance.

 

65. The latest published performance data for January 2015 shows 48.5% of Cat A calls were answered within 8 minutes, an improvement of 5.9 percentage points compared to December 2014. There were 14,635 cat A calls in January 2015, an increase of 900 (7%) compared to January 2014.

 

66. The performance of the Welsh Ambulance Service is not where the public, health boards, the ambulance service or we want it to be.

 

 

67. These figures should be seen in the context of the significant pressure NHS Wales was under in January. The ambulance service responded to a 24% increase in the most serious calls compared to January 2014.  However, there has been an improvement in performance on December’s figures. There is a clear expectation that this improvement will continue.

 

68. The £11m package of investment announced in January underlines the Welsh Government’s commitment to support improvement to ambulance performance. This will allow the ambulance service to purchase 17 new additional frontline emergency ambulances. A further £8m will ensure the ambulance service is in a better position to provide a swift response to life-threatening calls across Wales.

 

69. This package complements the extra £7.5m investment from the Emergency Ambulance Services Committee to employ 120 additional frontline emergency ambulance staff this financial year.

 

70. The McClelland review clearly highlighted there is little clinical evidence to support the eight-minute response time target for the vast majority of 999 calls, which are currently classified as “life threatening”.

 

71. The eight-minute response time target was initially developed in 1974 and does not reflect the breadth of clinical care ambulance clinicians are able to provide at the scene of an incident and before a patient reaches hospital – in many cases a patient may never need to go to hospital. The ambulance service has moved on significantly in the past 40 years but the way we measure the quality of service delivery has not.

 

72. Following the announcement of two ambulance response time pilots in England and after receiving representations from the medical director of the Welsh Ambulance Service about the clinical validity of the eight-minute target, Wales will also test new ambulance response measures for category A calls. These will be developed in conjunction with clinicians and will be informed by the approach taken in England. I expect to receive further advice from clinicians about making best use of resources and improving clinical outcomes in coming weeks.

 

73. In the first instance, the Welsh Government will publish more data relating to the ambulance speed of responses to those patients who are classified as having the most life-threatening conditions, where there is clinical evidence to support an eight-minute response – known as Red 1 calls. This data will be included in the official ambulance response statistical release from 25 March 2015.

 

74. More clinically focused measures of the clinical care delivered by WAST have already been introduced and are being published on My Local Health Service. These reflect the critical role paramedics play in the treatment of a sick or injured person. The results of this work show that 95% of stroke patients are successfully receiving a specific package of care measures from administered with the stroke care bundle by paramedics in Wales and up to 86% of patients with a fractured hip received immediate pain relief in line with clinical guidelines in 2014-15.

 

Patient handover

 

75. As well as expectation for ongoing improvements in the ambulance response times, the Welsh Government continues to expect individual health boards to focus on handover times so that ambulances can be back on the road as quickly as possible. A new handover policy has been developed by the Improving Unscheduled Care Programme and was distributed across NHS Wales for implementation on 25 February 2015.  The guidance sets out 10 key actions for Health Boards and Trusts to incorporate within their existing protocols intended to ensure timely handover.

 

76. Improving handover improves the resilience and performance of the system and helps to understand when plans are working well to stay ahead of pressures. This remains a key measure of unscheduled care performance for Welsh Government.

 

Winter pressures

 

77. Quarterly Seasonal Planning meetings were held in March, June, September and December 2014 with a focus on lessons learned and actions for NHS to take to improve delivery of services when under pressure. While the improved, integrated approach to the winter planning process has appeared to have resulted in an increased resilience in the system, managing peaks in pressure remain a challenge. 

 

78. Local Health Boards (LHBs), Welsh Ambulance Service NHS Trust (WAST) and Local Authorities (LAs) are expected to regularly keep their joint plans under review to understand how they impact on their performance over the winter period, and Welsh Government officials will provide scrutiny on a regular basis for assurance (through weekly calls).

 

79. The Welsh Government continue to monitor pressures via weekly Chief Executive and Executive level calls; daily Executive level emergency pressures conference calls; and through the NHS Wales Unscheduled Care dashboard which provides live data and information on a range of indicators, including bed capacity, handover delays and escalation levels.

 

80. Maintaining and building on the successes of last year, health and social care organisations implemented many positive actions over winter including:

 

a.    stronger joint working with GP Out of Hours services;

b.    extended working hours to include weekends and evenings;

c.    increase in 7-day working;

d.    increasing community resource team capacity;

e.    increased consultant cover, strengthened senior management and clinical presence (including therapy and social workers);

f.     a focus on reducing DTOCs and Lengths of Stay; and

g.    maximising MIUs and increasing use of discharge lounges.

 

81. We have seen periods of higher activity reflected in record levels of increases in GP out of hours activity; and the impact of older and complex patients being cared for and admitted through A&E Departments. Alongside this we saw a 24% increase in life-threatening calls to the ambulance service in January.

 

82. Pressures and demand have continued throughout winter, but we have seen some signs of improvement over recent weeks and weekends with reduced reported escalation levels at the majority of Emergency Departments. This reflects an ongoing focus and attention from health boards, trusts and their clinical teams and staff supported by the winter plans that have been developed since March 2014.

 

83. There will continue to be times when the demand places services under great pressure, needing local escalation. We have not however seen a major incident declared in a Welsh hospital as a result of winter pressures.

 

Additional resource

 

84. On 15 January, the Finance Minister allocated an extra £40m to the NHS in 2014-15 to support winter pressures.  This extra investment, which comes from the Welsh Government’s reserves, follows the announcement that an additional £200m was being allocated to the NHS in 2014-15.

 

85. With the exception of an immediate allocation of £8m to the Welsh Ambulance Service Trust (WAST), the remaining £32m funding will be held as a contingency reserve.

 

86. The pressures in the ambulance service are well known.  An additional £8m ring fenced funding for Ambulance services has been provided to ensure the Emergency Ambulance Services Committee, health boards and WAST continue to focus on maintaining and improving services during this difficult period.

 

87. The Committee will be aware that the Deputy Minister and I have been holding NHS organisations to account for the delivery of Board plans approved in 2014/15.  This approach reinforces the continued improvement in financial management arrangements recognised by the Auditor General for Wales in his latest published NHS Finances report.

 

Lessons learned

 

88. NHS Wales and social care partners will build on the winter plans put in place for this year and lessons learned from this challenging period.

 

89. The first national winter planning forum of 2015 reviewing the experience of 2014/15 and planning for 2015/16, with representation from all Welsh health and social care organisations, will take place on 29 April. 

 

90. Challenges, lessons learned and potential resolutions will be discussed and will inform organisations’ integrated winter plans for 2015-16.

 

Waiting times

 

91. In January, All-Wales RTT delivery was 84.3%, against a target of 95%.  The median wait remains 11 weeks with the majority of patients continuing to wait less than 26 weeks. We have made it clear to health boards that progress on removing 36 weeks breaches is not optional. [The January data will be published on 12 March 2015 – a verbal update will be provided at the meeting].

 

Diagnostic waiting times

 

92. In January All Wales Diagnostic delivery was 70.6% against a target of 100% waiting less than 8 weeks. Additional money, over £4 m has been provided to health boards to support improvement against this measure at the end of March. There is expectation of further removal of all waits over 8 weeks for the reported diagnostics.  8,000 waits over 8 weeks have already been removed since January 2014. [The January data will be published on 12 March- a verbal update will be provided at the meeting].

 

Ophthalmic waiting times

 

93. In January All-Wales delivery of ophthalmology in regards to breaches over 36 weeks was 4,790 against a target of zero. Health boards are expected to target capacity to manage follow-up care for high risk patients from clinical harm and make progress on the overall 36 weeks backlog.

 

94. The two pilots in Abertawe Bro Morgannwg University and Betsi Cadwaladr University health boards have shown an improvement in the reduction of long waits for high risk ophthalmology follow-up care. This has been achieved by targeting resources based on clinical need and improving the use of the total workforce capacity including specialist nurses and primary care optometrists to better manage patient care. These are key principles of prudent health care in action.

 

95. Through the Planned Care Programme a national Ophthalmology plan has been published to direct health boards how to plan and deliver sustainable services in the future. Each health board is required to demonstrate as part of their 3 year IMPT a more sustainable delivery model that demonstrates delivery of RTT as well as appropriate clinical management of follow-up care. This will support an improvement against the number of over 36 week breaches.

 

Cancer

 

96. The latest figures for December 2014 show that the health service in Wales is either hitting or is very close to achieving its targets in cancer treatment. For the urgent suspected cancer route, performance was 87.7%.  This indicates that the NHS in Wales is moving in the right direction, as the health boards continue to work towards achieving the targets.

 

97. Although we cannot directly compare, 31 day performance in Wales for the third quarter of 2014/15 was 97.3%, compared with 97.7% in England; and 62 day performance in Wales for the third quarter of 2014/15 was 88.0% compared with 83.3% in England.

 

98. Over the course of the last 12 months (January 2014 to December 2014) there has been a 13% increase in the number of patients starting treatment within the 62-day target time – 651 more patients than the previous 12-month period (January 2013 to December 2013).

 

PUBLIC HEALTH

 

99. The Welsh Government commitment to supporting people to live more healthily is supported through a range of policies, programmes and legislation. In 2015, this will include a number of actions to reduce smoking and alcohol consumption, targeted public health campaigns, and progressing the Well-being of Future Generations (Wales) Bill and the proposed Public Health (Wales) Bill.

 

100. We have to work harder to create the conditions in which people are better able to take care of their own health and then explain the responsibility people have for creating conditions for good health in their own lives, effectively ‘co-producing’ good health in partnership with patients, the wider public and partner organisations.  Each of us has a duty to look after ourselves - we must all become custodians of our own health, instead of handing ownership of our health to the nearest professional as we have traditionally done. At an individual level, the health professional and patient must work together, rather than the patient putting their health problem in the hand of the nurse, GP or consultant.

 

101. The promotion of good health is a joint responsibility between public health organisations, the Welsh people and public services. Where appropriate, we will use our legislative powers in Wales to focus on healthy lifestyles, as we have demonstrated our intention to do as part of our proposed public health legislation that we intend to introduce before the summer recess.

 

Preventative care

 

Immunisation and Vaccination

 

Measles-mumps-rubella (MMR) immunisation:

 

102. Measles infection can be prevented by a highly effective and safe vaccine which is part of the measles-mumps-rubella (MMR) immunisation. Uptake of 95% of the population or above with the MMR vaccine is crucial to establishing a level of immunity in the population which prevents major outbreaks.  Since the low point in 2003, uptake of MMR has seen a sustained, upward trend. 

 

103. The large 2013 outbreak of measles centred on Swansea provided a reminder of the importance of maintaining high vaccine uptake levels. The NHS Delivery Framework introduced in 2013, includes as a Tier 1 measure the need for 95% of children in Wales to be fully up to date with all scheduled vaccinations by the age of four years.  Achieving this will ensure that uptake of both required doses of MMR will reach the target.

 

104. The annual (Coverage of Vaccination Evaluation Rapidly)COVER report for 2013-14 showed that annual uptake of the first dose of MMR at 2 years had increased to 96.5%, its highest ever level.

 

105. The latest quarterly COVER report, for July-September 2014, reflected a drop to 95.2%; this ranged by local authority from 93.2% (Cardiff) to 98.0% (Blaenau Gwent). Thirteen local authority areas achieved the target of 95% uptake.  Whereas the annual reports provide a more complete picture this target is being closely monitored.

 

Human Papillomavirus (HPV):

 

106. The Human Papillomavirus (HPV) national childhood vaccination programme was introduced in 2008 for secondary school year 8 girls (12-13 years of age) as a three dose schedule given within a six month period. 

 

107. The latest COVER report found uptake for the first dose of the HPV vaccine in girls in the 2013-14 school year 8 was 89%, uptake of the second dose was 87% and uptake of the third dose was 80% at the time of data collection.

 

108. In March 2014, the Joint Committee on Vaccination and Immunisation (JCVI) revised its existing recommendation on the HPV vaccination programme for adolescent girls to change from a three-dose to a two-dose schedule.  The change to the programme started in September 2014 at the beginning of the academic year.

 

 Seasonal Flu:

 

109. Percentage uptake rates for the seasonal flu vaccination for at risk groups are similar to the position at the same time last season, but the number of individuals vaccinated has increased due to population growth.  The overall trend in recent years is gradual improvement.  At 17 February, uptake for over 65s across Wales was 68%, ranging from 64.9% in Hywel Dda UHB to 70% in Betsi Cadwaladr UHB;

 

110. Continuing from work started last season, PHW has instigated a number of actions to support GPs at individual practice level to increase uptake. The impact of these actions will be reviewed at the end of the season.

 

111. Flu vaccine uptake in health board employed health care workers increased to 41.7% in 2013/2014, up from 35.5% in 2012/13.  Data for the current season is still being being collated but uptake has already reached 43.9%. Two health boards, Betsi Cadwaladr and Velindre, have achieved the 50% target in 2014/15.  This significant improvement demonstrates that the additional emphasis and effort directed towards staff vaccination is continuing to have an impact.  It is important that we continue to build on this progress to protect those most at risk of flu and its complications.

 

Tackling poverty

 

112. Building Resilient Communities: Taking forward the Tackling Poverty Action Plan, includes a number of NHS-related commitments which reflect the Welsh Government’s commitment to use resources differently to help those most in need. There is a wide range of work being undertaken to support this, particularly the developing links between health boards, public health organisations, local authorities and primary care providers, contributing to the objectives of mitigating and preventing the impact of poverty by improving health and access to health care.There is a more consistent understanding of the value of working with Communities First, Flying Start and Families First programmes.

 

113. Our central aim is to improve healthy life expectancy across Wales. There are significant gaps in healthy life expectancy between each income group, with the wealthier doing much better.  We aim to close these gaps by an average of 2.5 per cent - by 2020.  The Chief Medical Officer has ensured that all NHS chief executives are fully aware of the cross Government commitments to action on poverty and the responsibilities of health boards to contribute.

 

114. The latest data available to us shows that the gap is not yet closing, but nor is it getting worse. This should be seen in the context of the period of the recession where we would have expected a worsening of the gap. The target will remain in place with a much stronger focus on getting the NHS to take action as part of the new planning arrangements. 

 

115. Health inequalities are one of the most stubborn and complex issues facing Wales and other countries. Tackling the inequalities gap requires concerted long term action across the breadth of society, not just by what we immediately think of as the ‘health system.’ Elimination and prevention of health inequalities can only be achieved when linked to the underlying inequalities of income, wealth and power across society.  Five years into the age of austerity, the NHS and our social services see the impact on people’s lives of income reductions and widening inequality.

 

116. We know we need to do more to reduce the inequalities which currently exist in the health outcomes of people of all ages living in poverty.  In the short term, our approach to delivering this objective will be based on four elements. These are:

 

·         Improving the quality of all services while ensuring people in greatest need get the most support;

·         Giving every child the best start in life;

·         Helping people get and remain fit for work; and

·         Using the NHS’s employment practices to help give skills to people from workless households. 

 

117. We are taking forward these elements through primary care improvement, improved planning and continuing to embed prudent healthcare.  We expect primary care ‘clusters’ to help provide clearer focus on tackling inequalities and poverty. We will carefully monitor the impact of clusters and aim to share learning.

 

118. The Welsh Government will continue to promote our Inverse Care Law Programme.  The new Living Well Living Longer Programme in Aneurin Bevan University Health Board and similar work developing in Cwm Taf University Health Board will offer a working example of the needs-based approach which is informing our work in other areas. We will also ensure our maternity strategy and the developing Healthy Child Programme help all children during the early years develop sound physical and mental health in a manner sensitive to the needs of particular groups and localities. We will continue with schemes to support the health of people in work.

 

119. To support all this, we will improve our information systems to pinpoint where needs are most acute and targeting services there, and move money nationally and locally to where it is most needed. This will engage Public Health Wales, the NHS, local government and the broader community, in efforts to reduce health inequalities. DHSS will work across all policy areas to seek and take up opportunities to reduce health inequalities.  The NHS will work closely with people and communities to improve their health, and with other agencies to help people access whatever services best suit their needs. We will monitor progress through the NHS planning arrangements and by tracking progress in national outcomes frameworks.

 

120. In relation to the NHS as an employer, the Chief Medical Officer confirmed the NHS in Wales will provide 1,000 of the 5,000 opportunities to be delivered through the LIFT programme, which aims to offer training or employment opportunities to people living in workless households by the end of the 2017 calendar year. 

 

Health checks for people aged over 50 - Add to Your Life

 

121. Add to Your Life aims to support and empower the public by giving them greater control over their health and well-being.  It provides specific feedback to people aged 50 or over about areas of risk to their health and well-being, and gives them advice on the small steps they can take to help lower those risks.

 

122. The Programme is now in the user phase and current activities are focussed on encouraging people to use the website, as well as integrating Add to Your Life with  preventative services (e.g. smoking cessation ) and  other on-line health portals such as My Health Online. 

 

123. A wide range of roll out activities are taking place including a direct mail to members of the public around their 50th birthday (around 42,000 people turn 50 annually in Wales) who are registered with a GP.  Since the beginning of October 2014 nearly 16,000 letters of invitation have been posted out in weekly batches.  

 

124. Since Add to Your Life was rolled out nationally over 10,500 people have accessed the site with over 5,500 completed assessments undertaken.

 

125. Welsh Government officials are working with Public Health Wales to develop proposals for phase 2 of the programme.

 

Patient responsibility/Choosing well

 

126. In accordance with prudent healthcare principles, we continue to encourage patients to take personal responsibility for their own health and wellbeing and choose wisely to ensure they access the most appropriate service for their needs.  This is supported by the roll out of the My Health Online resource, advice from NHS Direct Wales or local services such as pharmacies and the Choose Well app, which have been proven to reduce unnecessary attendances to Accident and Emergency departments.

 

127. There is an ongoing collective effort with NHS Wales to deliver choose well messaging. The Deputy Minister for Health and the Chief Executive of NHS Wales have worked to strengthen our message about the need to choose well when thinking of dialling 999 and accessing an Emergency Department.

 

128. The Choose Well app has been downloaded by over 6,000 people, and there has been an approximate 900% increase in NHS Direct Wales web based activity since the campaign began in March 2011.  This indicates the public are increasingly aware of the information available to guide responsible decision-making.

 

129. Campaigns that aim to change behaviour need to have a long term approach for the benefits to be realised and can be difficult to evaluate in the short and medium term.

 

QUALITY AND SAFETY

 

Independent external reviews

 

Trusted to Care

 

130. Considerable action has been taken in response to findings of the Trusted to Care review.  All NHS organisations have been expected to reflect on the findings and take any action needed. Specifically, a series of unannounced spot checks to all acute hospitals were ordered to be assured that the failings in report relating to fundamental standards of care were not widespread.

 

131. A total of 70 wards were visited over a six week period and the findings were published in October 2014. Work is well underway to tackle areas of concern identified, specifically in the management and safe storage of medicines and in streamlining the documentation of patient records, especially nursing care.

 

132. Spot checks of older people’s mental health wards followed in November and December 2014, and 22 of the 51 wards across all heath boards in Wales were visited. The spot checks were undertaken by peer review teams comprising senior older people’s mental health nurses, pharmacists, occupational therapists and for some of the spot checks, an older people’s psychiatrist was also available.

 

133. These visits revealed many areas of good and excellent practice right across Wales, as well as identifying some areas where improvements need to be made. There was considerable variation in standards and practice between and within health board areas. The issues identified which will require action from health boards for some wards relate to:

 

·         prescribing and the storage of medication;

·         the skill mix of staff available to provide the most appropriate care;

·         staff training;

·         the quality and ‘dementia friendliness’ of the ward environment;

·         the application of mental health and mental capacity legislation in practice; and

·         the provision of catering services.

 

134. Work is underway to prepare public facing reports of each of these visits, together with a national report, all of which will be published in due course.

 

135. A steering group chaired on my behalf by the Chief Medical Officer and Chief Nursing Officer is overseeing this work, as well as implementation of the specific recommendations made by Professor June Andrews and Mark Butler in their report. This includes meeting regularly with ABMUHB to monitor their progress ahead of a follow-up review this summer.

 

Using the Gift of Complaints

 

136. Keith Evans’ review of how concerns (complaints) are handled in NHS reported in July 2014 and concluded that while the principles of Putting Things Right were sound, there was great variation in how the arrangements had been implemented. 

 

137. Views on the report were sought over the summer period and analysed along with the concerns raised by the Committee. I published a Written Statement setting out the Welsh Government’s response.

 

138. A sub group of the National Quality Safety Forum has led a series of work streams to take forward the review’s recommendations.  The work streams centred on complaints data/ information and publication; Putting Things Right guidance and communication; and learning from concerns, supported by a public engagement reference group.  

 

139. The groups will be making a series of recommendations to the National Quality and Safety Forum in April.  I plan to provide a further update following that.

 

Report on mortality data

 

140. Professor Stephen Palmer’s review of the way in which mortality measures are collected and used was published in July 2014.  The review focused on six hospitals with a Welsh Risk Adjusted Mortality Index (RAMI) score of more than 100 in the data published on Friday 21 March 2014.

 

141. Professor Palmer concluded that RAMI is not a meaningful measure of quality and advocated the use of case note mortality review alongside a more meaningful set of measures and information to describe quality. The Transparency and Mortality Taskforce, chaired by the Deputy Chief Medical Officer has been reconvened to take forward Professor Palmer’s conclusions. They will report to me in the coming months.

 

Independent Review of Healthcare Inspectorate Wales

 

142. I published a Written Statement on 8 January setting out the Welsh Government’s response to Ruth Marks’ independent review of Healthcare Inspectorate Wales (HIW). The findings and recommendations provided in Ms Marks’ report, The Way Ahead: To Become an Inspection and Improvement Body, give a timely assessment of where HIW’s current regulatory and inspection work need to be reformed and improved.

 

143. The terms of reference for the review were designed to assess whether the regulatory and inspection functions of HIW needed to be reformed and improved.  This was with a view to developing proposals to inform a Green Paper to encompass any legislative changes that may be required, but with the ability to make recommendations for any immediate actions that may be needed.

 

144. The report concludes the role and function of HIW is largely fit for purpose, though it acknowledges that HIW is a complex regulator, responsible for regulating and inspecting a substantial number and variety of health bodies across the NHS and the independent sector. Ms Marks also reminded us that the delivery of safe and effective care cannot be achieved by inspection and regulation alone – that it can be no more than a third line of defence.

 

145. The report made a total of 42 recommendations. Within those directed at Welsh Government, there is a strong emphasis on developing a more collaborative and integrated system of healthcare inspection. It is therefore my intention to bring forward a series of proposals to address these recommendations in a Green Paper focused on improving or quality system this summer. This will be the main vehicle by which response to the report will be made.

 

146. Many of the immediate actions recommended fall directly to HIW to consider.  HIW has been on a journey of improvement and has made significant progress over the past year, achieving what it set out in its ambitious work programme. Many of the areas highlighted in the review are already being addressed. However I am assured HIW will use the review findings to inform its work programme for the coming year.

 

Fundamentals of Care National Audit 2013

 

147. The annual national audit of the Fundamentals of Care (2003) standards has been in place since 2009. The audit tool was reviewed and updated in 2013 and has been used by all NHS organisations for the annual national audit since that date. Data collection for the 2014 audit took place across Wales in October and November 2014 and will be published in May 2015.

 

148. In light of the significant revisions made to the format, number and types of questions included in the 2013 audit, no direct comparison can be drawn between the 2013 and previous annual audits. It is also important to note that the operational audit, patient experience and staff survey questions have been reviewed independently and not combined as in previous audits.

 

149. The NHS Healthcare Standards were reviewed in 2014/15 and the revised standards are scheduled to be published on 1 April 2015. The revised standards will, for the first time, incorporate the Fundamentals of Care standards and in future monitoring of fundamentals of care will form part of the overall monitoring of compliance with these revised Healthcare Standards.

 

Annual Quality Statements

 

150. All NHS health boards and trusts in Wales published their second Annual Quality Statement in September 2014 providing an account of their achievements, challenges and improvement priorities. These statements are designed to give the public an accessible, open and honest account of how well an organisation is doing.

 

151. An all-Wales Quality Statement will be published shortly which draws together the learning from local statements and captures the national priorities.

 

Cardiac care 

 

Cardiac Surgery in Mid, West and South East Wales – improving outcomes and waiting times project

 

152. Health boards in mid, west and south east Wales, working with the WHSSC, have initiated a multi-faceted project to improve outcomes and waiting times for cardiac surgery in order to meet current and future demand. 

 

153. Health boards have put in place additional short-term capacity for heart surgery, through a variety of internal arrangements and temporary outsourcing of patients to hospitals in England. They have also been working to increase cardiac surgery capacity in the medium to long-term.

 

154. Outsourcing patients from south east Wales has now completed.  Cardiff and Vale University Health Board has continued to treat patients within the waiting times target since first achieving the target in October, and expects to sustain this position to March.

 

155. The waiting time position for Abertawe Bro Morgannwg University Health Board has improved in January, with the total number of patients waiting falling from 215 in December 2014, with 71 of those patients waiting over 36 weeks, to 165 in January 2015, with 31 patients waiting over 36 weeks.

 

156.   There has also been a 60% reduction in the total number of patients waiting since March 2014, and a reduction of 69% in the number of patients waiting over 36 weeks over the same period.

 

157. Agreement has been reached to establish a referral pathway from ABMUHB to CVUHB to support delivery of recurrent demand in 2015/16 while capacity is increased at Morriston Hospital. Progress continues to be made towards a fully collaborative service across the two centres to support sustainability and resilience of cardiac surgery in south Wales.

 

Cardiff and Vale University Health Board – Royal College of Surgeons Report

 

158. At the end of January, there were 2 patients waiting over 36 weeks for cardiothoracic surgery within Cardiff and Vale UHB, out of a total of 301 patients waiting.  The number of patients waiting over 36 weeks has fallen by 97% since March 2014, with the total number waiting falling by 25% over the same period.

 

159. In response to a visit by the Royal College of Surgeons in March 2013, Cardiff and Vale University Health Board and the Welsh Government have invested nearly £4m to tackle cardiac surgical waiting lists, dramatically to cut the time people wait for planned surgery. As indicated above this investment has seen a significant reduction in waiting times.

 

160. As part of the long-term plan, the health board have agreed through WHSSC a business case to increase capacity for major cardiac surgery which it is proposed will commence on 1 April 2015.

 

161. An internal project team has been established to manage the expansion, including timescales for recruitment of key posts, capital works required to expand the existing Cardiac Intensive Therapy Unit and procurement of additional equipment. There is also ongoing work with the Cardiac Network, WHSSC and referring Health Boards and Cardiologists to ensure that patients referred to Cardiac Surgery are assessed and referred in a timely fashion.

 

162. In addition, cardiac surgery mortality data is being captured monthly and is submitted to the Clinical Board and WHSSC. All case notes are reviewed and risk assessed to understand whether the death was avoidable.

 

163. The RCS has recently confirmed to CVUHB that since 2013 significant progress has been made to improve the management of waiting lists for cardiac surgery at CVUHB, including improved clinical engagement with the CVUHB’s wider programme of work to improve patient services. They do not require any further assurance about the action plan put in place to address the concerns originally raised during the visit in March 2013.

 

DEVELOPING PRIMARY AND COMMUNITY CARE

 

Plan for Primary Care Services

 

164. In November 2014, we launched our national plan for a primary care service for Wales, backed by a £10 million primary care fund, building further on the £3.5 million provided to health boards in 2014-15.  Following a period of further engagement and discussion, a refreshed second version of the plan has now been published. 

 

165. The plan articulates what people can increasingly expect from primary care and identifies five priority areas for action up to March 2018.  The aim is to draw in all those organisations and services which can help identify and meet local need and to work collaboratively in planning and delivering more services closer to home and, very importantly, to develop and diversify the primary care workforce.

 

166. To support action locally to remodel the workforce, we are developing a national primary care workforce development plan. We are also refreshing our eHealth Strategy which will support action to modernise the way people access services in the future.

 

167. £6 million of the £10 million primary care fund for 2015-16 will support the 64 primary care clusters to implement their own local solutions to local challenges and this demonstrates the Welsh Government’s commitment to the need to develop clusters to plan and meet need at very local level. £3 million will support strategic pathfinder schemes or allow health boards and their clusters to accelerate primary care service reform. £1 million is to be used to support a programme of work best done once for Wales, including training to remodel the local workforce and education and organisational development support.

 

168. The Welsh Government announced its plans for the use of the additional £70 million for health services from 2015-16. The majority of this funding, £50m - will directly support the delivery of our ambitions in the national plan for a primary care service for Wales of improved population health, reduced inequalities in health and better and more modern access to a preventative and integrated health and social care system.

 

169. Examples of primary care service reform expected from this new funding include:

 

·         New ways of providing ambulatory care for chronic conditions;

·         Community based eye care;

·         Non medical clinical support for GP services by increased clinical capacity from other professionals working in GP practices or elsewhere in the community;

·         Education and training to up skill professionals to undertake advanced practice and expanded scope roles; and

·         Extended community nursing

 

GP access

 

170. Work is underway to offer working people a wider choice to access GP services more conveniently during the day/late evening.  A key example of this work is the out of area unregistered day patient pilot scheme which is currently being undertaken within four health board areas.

 

171. The pilot scheme started in December 2014 and provides access to GP services to a person living outside the participating GP practice boundary area, present in the participating GP practice area for less than 24 hours (for example, as a commuter who travels into and out of the area each day) and who wishes to remain registered with their current practice. 14 GP practices are participating in the scheme - 3 in Swansea; 3 in Wrexham; 3 in Newport; and 5 in Cardiff. 

 

172. GPC Wales and health boards have agreed a service specification for the scheme, including clinical governance arrangements. The roll out of the out of area pilots are at an early stage.  The pilots are envisaged to run for a period of 12 months.

 

173. As part of the work to develop a 111 service for Wales a sustainable model for primary care out of hours is also being planned from October 2015.

 

WORKFORCE AND ORGANISATIONAL DEVELOPMENT

 

National Workforce Plan

 

174. The Welsh Government has confirmed that it will prepare a 10 year national workforce plan for the NHS.  This will include consideration and action on how to train and recruit sufficient doctors, nurses and other health care professionals to ensure that health and social care across Wales is ready for the future.

 

175. This work presents an opportunity to bring together a range of work that is already in hand in respect of planning for the workforce of the future, chief amongst which is the need fully to embed the principles of prudent healthcare which must increasingly govern how NHS Wales plans the commissioning, education and use of its workforce.

 

176. The Bevan Commission, are also due to consider workforce planning in NHS Wales as part of their 2015-16 work plan.

 

177. In addition to the 2015/16 NHS integrated medium term plans the national workforce plan will be informed by the two areas of work below: 

 

Primary Care Workforce Plan

 

178. Workforce related actions required to support the delivery of the Welsh Government’s plan for a primary care service in Wales up to 2018 are being developed and will be set out in a workforce development plan to be published for consultation with the service before the summer.

 

179. This plan will tackle a number of the immediate issues faced by the primary care workforce in Wales including what can be done to support local health boards to resolve difficulties in GP recruitment and retention. Alongside this, it will set out investment in the wider primary care team and emphasise the importance of a multidisciplinary approach and the role that can be played by enhanced roles and advanced practice.

 

180. It will also take a longer term view of how the onward development of clusters can be supported by local health boards, the Welsh Government and other partners, and what actions are required to make better use of data in primary care as well as how workforce planning can be improved in partnership with education commissioning.

 

Independent Review of the NHS Wales Workforce

 

181. The creation of a time-limited independent review of the NHS Wales workforce was a key component of the Agenda for Change pay agreement for 2014-15 and 2015-16.

 

182. The Review will gather evidence and make recommendations for the consideration of Welsh Ministers on matters arising from the Nuffield Trust’s 2014 report A decade of Austerity in Wales, and will be led by a small panel of experts, academics and other professionals who are familiar with the areas of investigation and who are independent of the Welsh Government. 

 

183. An announcement on the Review membership and terms of reference will be made shortly, but I have appointed David Jenkins, Chair of Aneurin Bevan University Health Board, to Chair the Review. The Review will produce a report at the end of 2015 / beginning of 2016, and will be publically available.

 

Health Professional Education Investment Review

 

184. The Health Professionals Education Investment (HPEI) Review was established in August 2014.  The review considered a range of issues including the suitability of the current education commissioning arrangements, the investment made in health education in Wales at present, the approach to workforce planning and the potential use of incentives to attract NHS employees and students to Wales and to retain them in both primary and secondary care once their training has been completed. 

 

185. The final report from the Health Professional Education Investment Review Panel is currently being finalised. Party Health spokespeople will be provided with an opportunity to meet with the panel to raise any questions they may have on the issues covered by the review prior to the final report being submitted.  A period of wider engagement will then take place which is expected to last for 6 weeks and focus on specific questions arising from the report.

 

186. This work will inform the way forward for the £350m education investment the Welsh Government makes in medical and non medical training each year.  

 

European Commission consultation on the working time directive

 

187. On 5 February a telephone conference was held with officials from the UK Department for Business Innovation and Skills (BIS) and Welsh Government officials from a number of portfolio departments, including Health and Social Services.  The discussion was led by officials from Economy Science and Transport (EST) and focussed on the process being followed.

 

188. BIS have confirmed that they will be submitting a UK Government-wide response on the consultation.  The response will primarily be based on the UK National Implementation Report 2014 and the evidence obtained. I understand that BIS will be submitting the proposed response to the European Affairs Committee (EAC) and will copy it to Ministers in Scotland and Wales. 

 

189. BIS have not yet confirmed when the EAC and Welsh Ministers will receive the proposed response to the consultation of the Working Time Directive.

 

Doctors in training and consultant contracts

 

190. Formal negotiations commenced in September 2013, with the aim of agreeing a new contract for doctors in training by the end March 2015. The BMA withdrew from doctors in training contract negotiations. As a result of this withdrawal, the Review Body on Doctors’ and Dentists’ remuneration (DDRB) has been remitted to make recommendations on contractual arrangements and pay for doctors in training.

 

191. As is the case with the doctors in training negotiations, the BMA have also withdrawn from the consultant contract negotiations for England and Northern Ireland on the basis that the proposals from management side could undermine patient safety.  This is disappointing as Heads of Agreement were due to be finalised by the end of October 2014. However, the BMA made it clear that they wanted significant concessions that went above and beyond employers’ ‘red lines’.

 

192. Moving forward, the Department of Health has confirmed that it has also written to the DDRB asking them to make observations on pay related proposals for the consultant contract.   This is in the context of the policy aim to deliver financially sustainable seven day services, reviewing the payment of clinical excellence awards and linking pay progression with responsibility and performance. The same observations will extend to Wales.

 

193. The DDRB will report after the UK general election.

 

Recruitment

 

Nurse Staffing Levels

 

194. The responsibility for determining a safe, appropriately skilled workforce lies with NHS organisations.  However, in this instance a partnership approach across NHS Wales and the Welsh Government has been established to develop tools to assist individual organisations in this area. 

 

195. The Welsh Government has not set mandatory minimum ratios of registered nurses to support staff, nor minimum numbers of staff per in-patient bed. However, in May 2012 the Chief Nursing Officer (CNO) and health board chief executives agreed a set of principles for nurse staffing levels to be used during the time it would take to develop, fully test then implement a workforce acuity and dependency tool for adult in-patient wards. It was agreed at that time to establish a programme of work to develop a suite of tools that will ensure staffing levels and skill mix are tailored to meet the specific needs of patients in each care setting.

 

196. In May 2012, chief executives also agreed to develop individual organisational plans to comply with the nursing principles for medical and surgical wards over a three-year period. In July 2013, following publication of the Francis Enquiry into Mid Staffordshire Foundation NHS Trust, I allocated an additional £10 million (recurring) funding to support these plans.

 

197. These principles are:

·         Professional judgement will be used throughout the planning process;

·         Ward activity and demand will be considered when establishing staffing levels as well as the number of beds, environment and ward layout;

·         Nursing establishments on acute wards should not normally fall below 1.1 Whole Time Equivalent (WTE)/bed including a head-room of 26.9% (to cover annual leave, mandatory training, etc.);

·         Numbers of patients per Registered Nurse should not exceed 7 by day;

·         The skill mix of Registered Nurse to Health Care Support Worker in acute areas should generally be 60/40; and

·         The Ward Sister/Charge Nurse should not be included in the numbers when calculating patients per Registered Nurse ratio.

 

198. Health boards have been asked to provide regular progress reports to the CNO including details of their compliance with these principles, utilisation of the additional funding, and of the assurance frameworks or processes they have in place for continued safe nurse staffing levels.  The latest set of reports was provided in December 2014.

 

199. Monitoring of the compliance of the principles has been on-going since 2012, and during this period, health boards have continued actively to address nurse establishments in adult acute medical and surgical wards.  They have also made significant improvements to the number of wards with more that 1.1 WTE nurse/support worker per bed, with some areas now reaching 100% compliance.  All organisations have assurance frameworks and action plans to continue to ensure appropriate safe staffing levels.  Skill mix has improved significantly with the majority of wards with a 60:40 registered nurse to support worker skill mix.

 

200. Some areas have not managed to recruit to the establishments identified, and have had to consider their recruitment plans in an increasingly competitive global market for nurses.

 

201. There has been an improvement in the compliance of their medical wards; in respect of no more than 7 patients per nurse, the number of compliant wards has increased by up to 75% in some health boards.

 

Acuity tool

 

202. The acuity tool is being validated for use in adult acute medical and surgical wards. It is supported by the following NHS documents:

 

·         Fundamentals of Care System User Guide: Adult Acute Nursing Acuity & Dependency Tool; and

·         Adult Acute Nursing Acuity & Dependency Tool Governance Framework.

 

203. The acuity tool for adult acute medical and surgical in-patient settings was rolled out in April 2014.  This tool works as a forward planner which measures acuity and dependency of patients to help health boards plan for future workforce requirements.  It is not as a day-to-day allocator of nurses. It is essential, therefore, that along with use of the tool, professional judgement and nurse sensitive indicators, such as the number of patient falls, should be used to consider the correct staff establishments.

 

204. Two validation runs are needed before the results of the acuity tool can be relied upon, and the first of these was undertaken in June 2014.  The second was undertaken in January 2015.  The results will inform the triangulated approach used to determine staffing levels at local level.

 

205. Once data has been captured and validated within the national system, organisations should develop local reports which triangulate local workforce data and nursing metrics to provide intelligence which can be used to support local decision-making about deployment of nursing resource within the overall workforce planning process. 

 

206. Research shows that the issue of nurse staffing levels is a complex one and therefore use of a triangulated methodology is advocated.

 

GP Recruitment

 

207. Changes to the GP contract for 2014-15 strengthen local collaborative working between GP practices linking with community nursing teams and social care partners to provide more care in the community and/ or closer to home.   

 

208. Since 2003, investment in general practice has increased by £147m, rising from £322m to £469m in 2012-13. As a result, GP numbers have increased by 11.2% between 2003 and 2013, resulting in the number of patients per practitioner falling by 5.4% over the same period.  

 

209. Whilst GP numbers have increased, an ageing GP workforce in Wales (at 2013, 23.1% of GPs in Wales are aged over 55 years), together with changes to GP UK pension arrangements, has contributed to GP recruitment difficulties in Wales. These recruitment difficulties, however, are not unique to Wales. In England, at 2013,  22.3% of the GP workforce were aged over 55 years ; 19.5% of the GP workforce in Scotland were aged over 55 years; and 24.8% GP workforce in Northern Ireland  were aged over 55 years.  GP recruitment challenges in Wales, and indeed, across the UK, are further accentuated given that other countries in Europe are also experiencing GP shortages, resulting in an increasingly competitive global market for GPs.

 

210. We continue to work in collaboration with the RCGP, the Wales Deanery, GPC Wales and health boards to promote Wales as an attractive place to live and work.  Alongside work being undertaken by health boards, a number of actions are being taken forward at a national level to address the difficulties in GP recruitment.  These  include helping GPs who wish to step back from full time work to be retained in the workforce on a different basis; making it easier  for GPs to return to work in Wales; reforming  the incentives regime to try to retain more GP  who train for general practice in Wales to stay in the Welsh workforce. 

 

211. Consideration is also being given to make it easier for GPs, based in England, to work in Wales by amending the GP Performers’ List (Wales) Regulations to allow GPs, who are on a Performers List in England, to be able to work in Wales for up to six months (in a 12 month period) without the need to complete the full (extensive) application process to be placed on a Performers List in Wales. The intention is to develop these proposals and others, as part of the workforce development plan to underpin the plan for a primary care service in Wales for engagement over the coming months.

 

212. Through the Welsh Risk Pool, arrangements have been put in place to make it easier for GPs to work in Out of Hours by including sessional GPs professional indemnity arrangements within the scope of the NHS indemnity arrangements.  In addition, new GP contractor models will drive new and innovative ways of delivering services using other or new professional roles are being considered to allow GPs to develop a more effective skill mix across GP practices and to encourage GP practices to work together, for example, as a federation of practices or as part of a primary care cluster network.

 

213. Investment in primary care health services has been increased significantly.  A further investment of £3.5m for primary health care services for 2014-15 was announced to target action to improve health and reduce inequalities in the most deprived communities, develop primary care teams and provide eye care services closer to people’s homes. This is in addition to the recent announcement of a £10m primary care fund for 2015/16 to support delivery of the primary care plan for Wales.  This investment will result in a wider range of healthcare professionals delivering care in or close to people’s homes, freeing up GPs’ time and expertise to care for people with more complex needs.

 

214. Changes to the GP contract for 2015-16 were announced on 2 March and provide a good platform to continue the improvement of the provision of core services provided by GPs.  These changes directly address GPs’ concerns about unnecessary bureaucracy.  They place more trust and reliance on the professionalism of GPs to use their clinical judgement and allow GPs to spend more time caring for the most vulnerable people with complex care needs, in particular, the frail and elderly.

 

NMC Nurse Revalidation

 

215. The NMC is committed to commencing some form of revalidation for nurses and midwives by December 2015. The Council set out a model to be tested in pilot sites in early 2015 at their December meeting. The Chief Nursing Officer has set up the Wales Revalidation Steering Group, with representation from stakeholders and the NMC. Aneurin Bevan UHB will pilot the revalidation model for NHS registrants and practice nurses from January 2015.

 

216. At the January 2015 Council meeting the NMC accepted the report by Kings Fund on the regulation of midwives. It has agreed to cease statutory supervision and is now seeking primary legislative change with the Department of Health, which may take 1-2 years to introduce.

 

IMPROVING ACCESS TO MEDICINES

 

Wales Patient Access Scheme

 

217. The balance of cost against clinical benefits is a key element of appraisal and we actively encourage the pharmaceutical industry to engage with AWMSG and submit an application to the Welsh Patient Access Scheme. This initiative was established in April 2012 to encourage manufacturers to offer a cost discount with their submission for appraisal; ensuring the reduced price can be considered by AWMSG during the appraisal and increasing the likelihood of a positive appraisal recommendation.  There are currently eleven new medicines available in Wales using the Wales Patient Access Scheme.

 

Orphan and Ultra Orphan Medicines

 

218. Following the independent review of the appraisal process for orphan and ultra orphan medicines, AWMSG have been developing a new, whole-system approach to the identification, appraisal and monitoring of this group of medicines; the aim being to ensure that patients with rare diseases have fair and equitable access to appropriate, evidence-based treatments.

 

219. AWMSG have worked closely with a wide range of interested parties in developing the new process, including clinicians, patient groups and the pharmaceutical industry.  The new appraisal process is currently being introduced and will come into full effect in September 2015. 

 

Independent Patient Funding Request (IPFR) Process

 

220. In November 2014, a Welsh Government Written Statement announced next steps for implementing the report’s recommendations.  That work is underway, led by the All-Wales Therapeutics and Toxicology Centre (the executive arm of AWMSG) in collaboration with health boards and the Welsh Health Specialised Services Committee (WHSSC).   Key areas of work include increasing the appraisal capacity of AWMSG and developing a robust, evidence based mechanism to make one-Wales IPFR decisions where there is an identified patient cohort. 

 

Access to medical technologies

 

221. The Efficiency through Technology Fund will support organisations to develop and implement new service models using the latest technologies and solutions, across a range of infrastructure and activity themes.

 

222. As part of an additional investment of £70million allocated to help NHS reform in 2015-16, £10m has been allocated to this area.  This additional funding will be prioritised based on evidence and results, to support the demonstration and scaling up to national adoption of technological or innovative solutions that demonstrate significant measurable impact on costs and outcomes.

 

223. Examples include:

 

·         Wet AMD partnership at the Lakeside Ophthalmology Unit, UHW;

·         3D scanning and bespoke implants pilot project;

·         Mobile lymphodaema service;

·         Telemedicine platforms and projects; and

·         Redefining orthopaedics surgery pathway.

 

LEGISLATIVE PROGRAMME

 

224. We have continued to make good progress in delivering the health and social service contribution to the Welsh Government legislative programme.

 

Public Health White Paper

 

225. The Public Health White Paper consultation summary report, together with the individual responses, was published on 6 November 2014. The proposals stimulated lively debate on a number of important issues, and attracted over 700 responses from a range of stakeholders and members of the public. There was particular debate regarding the proposals to restrict the use of e-cigarettes in enclosed public places, introduce a minimum unit price for alcohol, and improve provision and access to toilets for public use.

 

226. The responses to the consultation illustrated general support for what we are trying to achieve, and for the principle of utilising legislation as a mechanism for further improving and protecting health in Wales. A full spectrum of responses was received on every issue, ranging from those suggesting that the proposals should go even further, to those calling for more modest reform.  

 

227. We have continued to reflect on the responses received to the consultation as detailed work on each topic has progressed in recent months. I aim to bring forward public health legislation for consideration by the National Assembly for Wales before the summer recess, and look forward to discussing the detail of the legislation with the Committee at the appropriate time.

 

Regulation and Inspection of Social Care Bill

 

228. In Wales, the latest figures show there are 1,780 regulated social care and support settings, which fall within the scope of the current regulatory regime. More than 70,000 staff work in the sector.

 

229. The Regulation and Inspection of Social Care Bill rebalances accountability in the social care system, away from just those working on the frontline to ensure employers and company owners and directors also share the responsibilities in law. Each service provider will be required to designate an owner or board member as a ‘responsible individual’ as part of their registration, ensuring a clear line of sight from the boardroom to the frontline.

 

230. It will also introduce a new model of regulation, which will allow regulators to press for improvement across one care setting site or across a provider’s entire range of services – including care homes - if deemed necessary. It will make it easier for the regulator to act where care is considered beyond repair and, if necessary, cancel the registration of those providers, services and settings which fail to implement improvements. It also includes stronger penalties for certain offences.

 

231. The Bill was introduced to the National Assembly for Wales on 23 February and a date for Stage One scrutiny is expected over the coming months.  If passed, the Bill will be implemented in 2017.

 

Implementation of the Human Transplantation (Wales) Act

 

232. A two-year public awareness and engagement campaign to ensure people are aware of the new law and their choices under it is now well into its second year.  Specific engagement work is being undertaken with students, BAME groups, workplaces and those with specific needs. The redevelopment of the Organ Donor Register, enabling it to record opt-out decisions, will be completed in summer 2015. The impact of the legislation will be evaluated in 2017.

 

233. Consultation on draft regulations finished in January.  These cover materials which will be excluded from deemed consent, such as that used for face and limb transplants; appointed representatives; and living donors who lack capacity to consent to donation. When finalised, these regulations, together with the Human Tissue Authority Code of Practice will be put before the National Assembly for Wales for approval in early September 2015.

 

234. A Section 150 Order, which will allow organs removed under deemed consent in Wales to be used in transplants in the rest of the UK, will be discussed by a House of Lords Committee in March, followed by a debate in a Commons Committee.

 

Implementation of the Food Hygiene Rating (Wales) Act

 

235. Trade to trade food businesses have been included in the statutory scheme from November 2014. 

 

236. Food businesses receiving “5” (very good) ratings increased from 2012 to January 2015, by over 24% from 32.2% to 56.6%. The percentage of food businesses receiving ratings requiring improvement fell by 12.9% between 2012 and 2015 from 19.2% to 6.3%. It is considered that the requirement to display the rating is a major motivation in this respect.

 

237. I agreed to develop further regulations to require certain food businesses to include a statement on their hard copy publicity materials that will assist consumers to find out their food hygiene rating. These regulations were consulted upon in 2014, and the responses received identified a number of issues that required further consideration.    I therefore intend to introduce revised draft regulations later this year that will retain the concept of a statement of hard copy materials, but will refine the details of the requirements in light of the consultation responses received.  The regulations will also address any misuse of food hygiene ratings on certain food businesses publicity materials.

 

Implementation of the Social Services & Well-being (Wales) Act 2014

  

238. Arrangements are in hand to supplement the statutory framework established by the Act with regulations, codes of practice and statutory guidance on the various subject areas covered by the Act.  We have consulted on the first tranche regulations, codes of practice and statutory guidance, covering general functions, assessing the needs of individuals, meeting needs, safeguarding and miscellaneous and general.  The 12-week consultation ran from 6 November 2014 to 2 February 2015. 

 

239. We are now in the process of analysing responses to prepare the final regulations, which will be laid before the National Assembly for Wales from May 2015.   Each will be accompanied by an Explanatory Memorandum and at the same time we will publish full consultation summary reports.

 

240. The second tranche of regulations, statutory guidance and codes of practice, principally in relation to charging and financial assessment, looked after and accommodated children and co-operation and partnership.  The regulations in relation to this tranche will be drafted by spring 2015, consulted upon during summer 2015 and laid in November 2015.  At this time we will also lay the full suite of codes of practice and also publish the complete statutory guidance. 

 

241. This work is being supplemented by a programme of awareness-raising and training for key staff. Local authorities and local health boards, working in partnership on the basis of the public sector delivery footprint, have undertaken a self assessment activity to review readiness.  We have now received completed self assessment tools and the information provided is being considered in tandem with the outcomes of the tranche 1 consultations.  The assessments themselves provide an evidence base for the work that needs to be put in place for the detailed implementation plans that are currently under development. 

 

242. Successful implementation will require enhancing strong regional and local leadership bringing health, local authorities, the third sector and private providers together to co-deliver transformational change.

 

243. To support each region in completing the self-assessment of their readiness to implement the Act, a £1.5 million Delivering Transformation Grant has been made available to the six regional partnerships and selected national partners in both 2013-14 and 2014-15.  This funding will double to £3 million in 2015-16 and is expected to remain at this level for 2016-17, with a view to transferring this grant in to the Revenue Support Grant from 2017-18 onwards.  This transitional funding is specifically aimed at enabling local government and its partners to put in place the requirements of the new Act.     

 

244. The Care Council for Wales has been asked to lead on development and implementation of a National Learning and Development Strategy, which is critical to the implementation of the Act.  This work will be supported by £1m in 2015-16.

 

245. The Care Council will take this work forward with key stakeholders to develop a comprehensive approach to learning and development to ensure staff across the social care sector, and partners, have the knowledge and skills to deliver the new requirements under the Act.  It will also ensure organisations are supported to make the culture changes that are necessary. The strategy itself will include a training deployment plan and development of a “one stop shop” information hub.

 

246. This cumulative activity will lead to implementation of the Act from April 2016.  

 

SUSTAINABLE SOCIAL SERVICES 

 

247. Social services support over 110,000 adults, providing statutory care for people with mental health problems, physical and learning disabilities and frail older people. There were 16,525 children in need and over 35,000 children referred to social services in Wales last year. Child protection registers record 3,135 cases of neglect, emotional, physical and/or sexual abuse. There are 5,703 looked-after children in Wales. 

 

248. Gross public expenditure on social care was over £1.9 billion in 2013-14, with £0.3 billion raised in fees as many adult social services are means-tested.  Demographic pressures through increasing life expectancy, both for older people and the severely disabled, together with a growth in demand for children’s services has lead to a near doubling in social services expenditure since 2002-03. 

 

249. Local authorities have the statutory duty to deliver social services and provision is a mix of direct delivery and commissioned services from independent providers.  As demand and service user expectation increases, and budgets are constrained, the current approach to social services has to be redrawn.

 

250. The Welsh Government’s principles and priorities for the delivery of social services in Wales are set out in Sustainable Social Services for Wales: A Framework for Action.

 

A New Accord (Leadership) for Social Services

 

251. This project has developed the leadership infrastructure and arrangements to support implementation. Work is currently focussed on developing guidance on the role of Directors of Social Services as part of the transformation, and on the duty on local authorities to promote social enterprises, co-operatives, user-led services and the third sector. 

 

252. As part of the development of the commitment to strong national leadership set out in Sustainable Social Services – A framework for Action, collective leadership arrangements were put in place. These go back to 2011, and have been reviewed and revised over time.

 

253. The leadership alliance includes:

 

·         National Social Services Partnership Forum (Partnership Forum)

·         National Social Services Leadership Group (Leadership Group)

·         National Social Services Citizen Panel (Citizen Panel)

 

254. Key issues explored by the groups over the last few months as part of their leadership role in supporting the implementation of the Social Services and Well-being (Wales) Act, have been early intervention and prevention, new models of service, safeguarding paying for care and integration between health and social care. This work is important in securing the wider leadership and involvement cross sector in the implementation process.

 

255. The requirement for regional leadership arrangements to be put in place was announced in June 2014 and has been supported by the Delivering Transformation Grant. This has enabled an approach to leadership which has involved social services, health and the third sector. The requirement is to replicate the national arrangements at a regional level on the basis of the Public Services footprint, building on what is in place where there are appropriate arrangements.

 

Social Enterprise, co-operatives, user led services and the third sector

 

256. The Social Services and Well-being (Wales) Act 2014 places a new general duty on local authorities that will require them to promote models of service which are social enterprises, co-operatives, which involve people who need care and support in the design and delivery of their services, and the third sector. It requires local authorities to promote:

 

·         social enterprises;

·         co-operatives;

·         the third sector; and

·         involve people more in the design and operation of services.

 

257. This work is directly linked to the population assessment and early intervention/prevention.  In addition to the legislation and the development of further underpinning guidance, a specific action plan is in place to support local authorities in this duty and that will be continued in 2015-16.

 

A New Improvement Framework

 

258. Draft regulations and codes of practice to support the requirement for local authorities and local health boards to undertake a strategic population assessment of care and support needs (including the support needs of carers) as well as to provide preventative services has recently been subject to a 12-week consultation.  The responses to that consultation are currently being considered.

 

259. The Social Services Complaints Procedure (Wales) Regulations 2014 and Representations Procedure (Wales) Regulations 2014 came into force on 1 August 2014.  These regulations and supporting guidance provide for a new two-stage social services complaints procedure and brings the social services complaints process in line with the Model Concerns and Complaints Policy and Guidance adopted across public services, notably the NHS complaints process. 

 

260. Linked to this, the first provisions in the Social Services and Well-being (Wales) Act 2014 were commenced on 1 November.  These include provisions which enable the Public Services Ombudsman for Wales to consider complaints from adults who fund their own social care or palliative care for the first time.

 

A Strong Voice and Real Control for Citizens

 

261. Our approach to change in social services is to give a stronger voice and real control for citizens, putting them at the heart of their care and support, and promotes control through a reform of core processes to ensure that frontline services are coproduced with citizens. 

 

262. We are delivering a new approach to: information, advice and assistance; eligibility and assessment; direct payments; and changing the way people pay for care. Draft regulations and Codes of Practice on these core processes were developed with the expert advice of Technical Groups and they have all been subject to a 12-week consultation.  They set out how the new approach underpinning the Social Services and Well-being (Wales) Act will operate.  We are currently analysing the responses from the consultation in detail so the final regulations and codes of practice take account of the comments received.

 

263. We are addressing improvement for children’s advocacy through partnership with local government to develop a coherent national approach to deliver improved experience for service users.  The key principles are similar to those for taking forward people advocacy under Part 10 during tranche 2.

 

A Strong and Professional Delivery Team

 

264. We are investing over £8m in the Welsh social care workforce to build confidence and competence, and further professionalise the sector and ensure that people are prepared for new models of care and support following the Social Services and Well-being (Wales) Act.  We are working with the social care employers to ensure that this sector plays a full and active role in the economy of Wales, e.g. contributing to the Welsh Government’s LIFT programme for creating employment opportunities in Communities First areas.

 

265. We are developing a workforce strategy to build up the quality of data on the workforce and address wider issues relating to the long term sustainability of the workforce.

 

A Stronger Framework for Safeguarding

 

266. We are strengthening the safeguarding of people in Wales and improving arrangements to ensure citizens remain free from exploitation and abuse. Most Adult Safeguarding Boards and Children Safeguarding Boards are making the transition from local to regional arrangements. We are monitoring the ongoing developments.   Through the Social Services and Well-being (Wales) Act 2014 we are strengthening the protection of vulnerable adults particularly through the introduction of new duties to enquire; to establish Adult Safeguarding Boards and the introduction of Adult Protection Support Orders.

 

267.  Consultation on the regulations and statutory guidance which will give legal effect to this framework ended in February. We are currently reviewing responses received.

 

Integrated Services

 

268. The revised National Framework for Continuing NHS Healthcare (CHC) in Wales was published on the 30 June 2014, with implementation from 1 October 2014. The Framework emphases the importance of CHC as an entitlement for those eligible to receive it and eligibility is to be determined by health need and not financial considerations.

 

269. The £50 million Intermediate Care Fund (ICF) for 2014/15 is being used to support older people to maintain their independence and prevent unnecessary hospital admission and delayed discharges.  Additional funding of £20 million has been announced (as part of the overall £70 million) to take forward projects funded by the Intermediate Care Fund this year that have proven to be effective  in linking out-of-hospital care and social care to strengthen the resilience of the unscheduled care system.

 

270.  The Integrated Family Support Service (IFSS) was rolled out across Wales at the end of April 2014 and is now fully operational. The Integrated Family Support Service supports families when there are concerns about the welfare of children.  IFSS teams work with families to help them to make positive changes, so that children can remain safely at home. They provide targeted support and help connect children and adult services, focusing on the family as a unit.  

 

271. The National Adoption Service for Wales was launched on 5 November 2014.  All five regional collaboratives are operational, and the central functions are being managed by Cardiff under the direction of Suzanne Griffiths, Director of Operations, and in line with the new Performance Management Framework.  

 

272. The directions under Section 170 of the Social Services and Well-being (Wales) Act have been consulted on and will be issued in early March, thereby delivering on the commitment we gave during scrutiny. 

 

273. The Welsh Government funds the Wales Adoption Register which was launched in June 2014, and the Independent Review Mechanism.  Both are managed under contract by BAAF Cymru.  The research we commissioned from the universities of Cardiff and Bristol (regarding adoption support and adoption disruption) has been published and the findings are being used to shape the National Adoption Service.

 

274. The When I am Ready scheme, which allows young people in foster care to remain living with their foster carers once they turn 18 (up to age 21), has been successfully piloted in three local authority areas.  Revised guidance for local authorities will be published in March, so that all authorities in Wales can develop their local schemes ready for when their new duties with regards to post-18 living arrangements come into force in April 2016.  Two seminars have been arranged for local authorities and other key stakeholders in April 2015.

 

Preventative Services – Social Services

 

275. Prevention is at the heart of the Welsh Government’s programme to transform social services.  There is a need to focus on prevention and early intervention in order to make social services sustainable into the future.  It is vital that care and support services do not wait to respond until people reach a crisis point.

 

276. Section 15 of the Social Services and Well-being (Wales) Act 2014 requires that local authorities must provide a range of preventative services.   These services must seek to achieve various purposes, including: 

 

·         Contributing towards preventing or delaying the development of people’s needs for care and support;

·         Reducing the needs for care and support of people who have such needs;

·         Promoting the upbringing of children by their families, where that is consistent with the well-being of children;

·         Minimising the effect on disabled people of their disabilities;

·         Contributing towards preventing people from suffering abuse or neglect;

·         Reducing the need for care proceedings against children;

·         Encouraging children not to commit criminal offences; and

·         Enabling people to live their lives as independently as possible.

 

277. This requirement follows, and is linked to, Section 14 in the Act that requires local authorities to and health boards jointly to undertake an assessment of local care and support needs and support needs for carers.  As part of that assessment, there is a need to set out the range and level of preventative services required to achieve the purposes set out above.

 

278. Additionally, Section 16 of the Act puts a duty on local authorities to promote social enterprises, co-operatives, user led services and the third sector. The duty in Section 16 offers an opportunity to consider alternative models in relation to early intervention and prevention, which are values based and give people who use services and carers a much stronger role.

 

Social Services Expenditure

 

279. The latest published figures on local authority budgeted expenditure for the current financial year show an increase of 2.2 per cent in overall social services expenditure compared with 2013-14.  Local authorities are in the process of finalising their budgets for next year.

 

280. Providing the majority of funding for local government through the settlement in the form of unhypothecated funding provides local authorities with the flexibility to deliver resources in the way that best meets the needs of that authority and minimises grant administrative costs. To maintain that flexibility, authorities have responsibility to demonstrate the delivery of shared outcomes.

 

OTHER PORTFOLIO ISSUES

 

Substance Misuse

 

281. The Welsh Government continues to invest almost £50 million annually to tackle drug and alcohol related harm in Wales. This funding has supported the implementation of a range of actions and we are making good progress in delivering the commitments in the Substance Misuse Delivery Plan 2013-15.  The latest Working Together to Reduce Harm Substance Misuse Strategy annual report, which was published in October 2014, outlined the good progress that we have made in taking forward the current Delivery Plan.

 

282. The time that people have had to wait between referral and the start of treatment for substance misuse has continued to improve. In 2013/14, 87% of all clients commenced their treatment within the KPI target of 20 working days, an increase of 1.5% on 2012/13 figures.

 

283. Given the increasing levels of alcohol related harm, we are strengthening our response, using all the policy levers available to us. We are continuing to tackle alcohol misuse through our Change4Life campaign Don’t let drink sneak up on you; our Have a word alcohol brief intervention training and our Add to your Life online health checks for the over 50s.

 

284. In addition, the Welsh Government is supporting UK Government initiatives such as the Local Alcohol Action Areas in Pembrokeshire and Swansea, and the Public Health Responsibility Deal Alcohol pledges through the establishment of the Welsh Government Alcohol Industry Network.

 

285. Despite the initiatives outlined above and other non-legislative actions, the Welsh Government believes that additional legislative measures in the form of a minimum unit pricing system in Wales are necessary to both help support and strengthen these actions. Inclusion of the proposal to introduce a minimum unit price for alcohol of 50p per unit within the Public Health White Paper was subject to a 12 week consultation, ending in June 2014. The consultation evidenced broad support for introducing minimum unit pricing in Wales and the Welsh Government is now taking forward this proposal through the legislative process. We are also continuing to press the case for the UK Government to agree the devolution of alcohol licensing.

 

286. The new Substance Misuse Delivery Plan for 2016-18 is currently in development. High level outcomes have been agreed and stakeholders will be consulted on specific actions throughout the spring and Early Summer. The new plan is expected to be subject to formal consultation in the autumn.

 

 

 

Part 2: FINANCIAL SCRUTINY SESSION

 

1.    The Committee will now have received the information requested in its letter of 10 December.  A copy of my response is attached at Annex B.

 

2.    The additional information requested in the Committee’s letter of 30 January is given below:

 

LATEST END YEAR FORECAST OF THE BREAKEVEN POSITION OF LHBS AND TRUSTS

 

3.    The following table sets out the end of year forecast position reported by each LHB and Trust as at 31st January 2015

 

NHS organisation

End of Year Forecast

£m

Local Health Board

 

Abertawe Bro Morgannwg

0

Aneurin Bevan

-2.2

Betsi Cadwaladr

-27.5

Cardiff and Vale

-24.9

Cwm Taf

0

Hywel Dda

-9.2

Powys

-2.0

Trust

 

Public Health Wales

0

Velindre

0

Welsh Ambulance

0

 

 

Total NHS Wales deficit as at month 10

 65.8

 

 

 

4.    The Committee will no doubt appreciate that the Deputy Minister and I have been holding NHS organisations to account for the delivery of the plans their Boards approved in 2014/15. This tougher approach is in line with the continued improvement in financial management arrangements recognised by the Auditor General for Wales in his latest published NHS Finances report.

 

5.    The deficit reported above is likely to reduce in future months as LHBs and Trusts manage their position to achieve the best position against their approved plan.

 

6.    I have made it clear to all NHS bodies that they must achieve the above without compromising quality or patient safety.  I currently have resources available in the form of generated central savings, some additional income and the extra Winter Monies to cover the above.

 

7.    I will look to allocate any winter monies after the winter period and during the normal year end arrangements correctly to cover any specific winter pressures identified.

 

 

PROGRESS ON THE CONSIDERATION AND APPROVAL OF LHBS’ PLANS FOR 2016-17 TO 2018-19

 

8.    The progress on Integrated Medium Term Plans covering the period from 2015/16 to 2017/18 is set out earlier in the evidence paper. 

 

9.    The plans were received on 30 January and are still going through a thorough assessment and robust challenge process to ensure that the integrated plans cover service priorities, quality, and performance and workforce requirements within the resource envelope that was set out in the 2015/16 approved budget.

 

10. I would not expect to be asked to consider the approval of the LHB plans until the process outlined above is completed.