Ysbyty Gwynedd, Penrhosgarnedd, Bangor,

Gwynedd LL57 2PW

National Assembly for Wales / Cynulliad Cenedlaethol Cymru

Health and Social Care Committee / Y Pwyllgor Iechyd a Gofal Cymdeithasol

Safe Nurse Staffing Levels (Wales) Bill / Bil Lefelau Diogel Staff Nyrsio (Cymru)

Evidence from Betsi Cadwaladr University Health Board - SNSL AI 18 / Tystiolaeth gan Bwrdd Iechyd Prifysgol Betsi Cadwaladr - SNSL AI 18

Ein cyf / Our ref:   AH/MM

Eich cyf / Your ref:   


Gofynnwch am / Ask for:   Marina Marzelos


Dyddiad / Date:   12 March 2015


Ms Nesta Lloyd-Jones

Welsh NHS Confederation













Dear Nesta


RE: Safe Nurse Staffing Levels (Wales) Bill




The purpose of this briefing is to provide the Health and Social Care Committee with additional information from Betsi Cadwaladr University Health Board (BCUHB) regarding arrangements the Health Board currently has in place to manage NHS commissioned care.


The briefing will provide an update on key developments related to improve and develop a more robust formal system of governance and accountability for commissioned services. Furthermore the briefing will consider the importance of strengthening the commissioning arrangements from within BCUHB in relation to the provision of NHS commissioned care within the independent sector and recognizes the associated key risks and statutory legislative requirements in line with the Health Act (2006).


The NHS is responsible for assessing, arranging and funding a wide range of services, both short and long term, to meet the health needs of the population. Continuing NHS Healthcare (CHC) is a package of care arranged and funded solely by the NHS where it has been assessed that the individual’s primary need is a health need. This paper will consider;


·    How health boards monitor compliance with the contracts / agreements that are in place for the delivery of care they have commissioned.


Continuing Health Care


The review of the Continuing NHS Healthcare National Framework for Implementation (2014) across Wales has identified the requirement for Health Boards to strengthen commissioning arrangements for the delivery of NHS Continuing health care (CHC).  The purpose of the Framework is to provide a consistent foundation for assessing, commissioning and procuring Continuing Health Care for adults across Wales. The legal framework for implementation of NHS Continuing Healthcare is provided through the National Health Service Act 2006, which requires the Secretary of State to provide comprehensive health services and, by the duties placed on Local Authorities, through Section 47 of the National Health Services and Community Care Act 1990, and Section 21 of the National Assistance Act.


Betsi Cadwaladr University Health Board (BCUHB) has a statutory duty under the Health and Safety at Work Act (HSWA) 1974 to protect the health, safety and wellbeing of NHS patients including where a provider is providing services on behalf of the NHS for example in care homes, independent hospitals and domiciliary care settings. A statutory duty is owed to individuals both by provider and NHS commissioning/funding body.


The review of the revised National framework (2014) promotes improving governance arrangements and promotes establishing outcome focused commissioning. The framework covers all areas where the NHS commissions care, driving improvements in clinical practice regardless of the care setting. This briefing presents a summary of the current approach being undertaken to both build capacity within existing CHC teams and Practice Development Teams and identifying areas for service development. The LHB has the responsibility to plan, specify outcomes procure services and manage demand and provider performance for all services that are required to meet the needs of individual’s eligible for Continuing Health Care.


The revised framework places emphasis on the Health Boards to improve commissioning functions across all sectors in delivering contractual and procurement arrangements with independent providers. The guidance drives forward the effective delivery of Continuing Health Care as a key component of the Health Boards Business; that each Health Board identifies a named executive, at Director Level to drive forward performance management arrangements and build upon those systems already in place.


The delivery of quality commissioning needs to be at the forefront of service review; with the development of a governance framework for sustainability and continuous improvement and clinical effectiveness.


The North Wales Commissioning Hub has driven forward further integration between our partner agencies with the development of regional procedures for implementation of the proposed Pre-placement agreement and Escalating Concerns procedures. Whilst these developments have improved integration, this area remains a risk for the Health Board in ensuring that there are robust systems in place to deliver on the contract. Furthermore, there remains uncertainty with regards to the reporting mechanisms and the functions of the Commissioning Hub through to the Board.


During the past 12-18 months there have been increasing concerns raised within the Independent sector; these have been in relation to safeguarding and poor practice issues invoking the escalating concerns procedure across 19 care homes over the last 12 months within North Wales.  This has placed an increasing workload on the existing Continuing Health Care and Practice development teams.


The Health Board recognises there is a requirement for a review of all current arrangements pertaining to commissioning services from Non-NHS providers; to develop a mechanism that considers the following:



Current arrangements:


The Continuing Health Care (CHC) teams are primarily responsible for the assessment and review of patient placements commissioned by the Health Board within non NHS providers; these include Low secure/ Independent hospitals, Nursing/Residential care homes and domiciliary care settings. The primary focus of the CHC team functions is to ensure patients receive care of a quality which meets best practice guidance and national standards. The team take a more proactive role in driving the Quality agenda forward within care homes and Independent hospitals; they will address quality issues in relation to evidenced based practice and standards of care with the provider through clinical review and escalating concerns procedures (WG guidance 2009). This includes the assessment of nurse staffing levels to deliver care.


The Practice development Team work alongside the CHC team and has developed within BCUHB a Quality Monitoring Tool (QMT) to identify the standard of quality of care with a focus on the fundamentals of care being delivered within Nursing homes. The aim of the QMT is to encourage improvement in the quality of healthcare provided to people residing in nursing homes across North Wales.


The QMT assesses Fundamentals of Nursing Care and best practice. This then generates a score and identifies key themes, which helps direct training and development within the home.  Areas for improvement and structured recommendations are developed in the form of a joint action plan. This assessment includes a review of nurse staffing within the home. Regular feedback and on-going support is provided in the home to ensure improvements are evident. High standards are praised and areas of good practice are shared. To assist with training needs an annual rolling training programme has been developed.


The Health Board recognises further consideration needs to be given to the following areas:



There have been some significant key achievements over the last 12 – 18 months within the Health Board;


  1. Development of Clinical Management Group. - This enables both the CHC teams and Practice development Team to drive forward improvements in healthcare within the Independent sector; a mechanism for sharing and reporting on concerns and developing joint action on how to best manage these homes. This group has been influential in developing key processes such as the communication escalation process and providing key reports to the executives on the status of the homes. This is a key vehicle to ensure joint internal BCUHB communications is managed in a proactive and consistent manner. 
  2. Functions of the Practice Development Team: - The Practice Development team (PDT) have been providing additional training into care homes in supporting and maintaining standards of care. The Practice development team has made significant progress in strengthening the governance arrangements within the nursing home sector. The development and implementation of the Quality monitoring framework across all nursing homes has been instrumental with monitoring compliance with regards to Quality Care..
  3. Functions of CHC Nurse Reviewers. Primarily the functions of the Nurse reviewing team is to review and monitor the delivery of care  commissioned by the Health Board; the reviewing team operate across 6 Local authority areas. The CHC teams are currently supporting a high level of care homes that are subject to Escalating Concerns procedures within the North Wales region; this requires a robust response with high levels of interventions and support in conjunction with Practice Development Team and Local Authorities. The demand on the CHC team has placed significant additional demands on CHC operations and constraints/limitations of the team to continue to effectively monitor the services across the provider sector. By default the CHC teams are undertaking contract monitoring functions due to the lack of designated performance management systems for commissioned services within the BCUHB at present.
  4. Improved communications with the Local Authorities. The teams regularly meet with the 6 local authorities to discuss and share intelligence on the independent sectors; however this is at present variable with no formal mechanism for accountability. Further work is underway on a Regional basis within the Commissioning Hub. Capacity within existing CHC teams continues to impact on the ability to manage a quality of care monitoring function and monitoring against the contract.
  5. Improved communications with the Independent sector and BCUHB. All teams regularly meet informally or formally through relevant forums with the independent sector providing a vehicle for the Independent sector staff to raise concerns and or issues and ensure its fed back into the relevant BCUHB service. Provider meetings are established in some areas with Local authority partners.


Next steps


The key principals for the development of a commissioning strategy/ joint strategic needs analysis with Local authority partners is to approach the market collaboratively in order to increase consistency in pricing and expectations around quality with the development of service specifications and agreed collaborative approaches to procuring services. Involvement from NHS Wales Shared Service partnerships to manage the procurement of non- NHS services within legislative procurement framework is essential.


The Health Board is required to develop a governance framework for care homes which needs to integrate NHS Healthcare Standards and Fundamentals of Care. This will include the review of nurse staffing levels. The Governance framework will provide a strategic direction in the monitoring and performance management of services commissioning by the Health Board. However there is presently a lack of resource/system to performance manage the market and assure patient safety and care in terms of staffing levels; this remains a risk factor in the overall management of our commissioned care with the independent sector Within care homes in North Wales there appears to be a growing reliance on the Escalating concerns procedures (WG 2009) as opposed to proactive quality assurance mechanisms with the development of key performance indicators such as Nurse Staffing Levels as a potential for default on an NHS contract. The trend for the number of homes under escalating concerns is increasing and homes are becoming more fragile.  When an embargo is placed on the home it impacts both on the home itself as well as the Health Board. One of the key themes identified is concerns regarding staffing levels with insufficient Registered nurses and poor skill mix.


Performance management and Contract monitoring Functions


Currently there is no designated formal contract monitoring functions being undertaken by the Health Board. The Health Board recognises it is not a sustainable option to solely rely on the Clinical monitoring function of the CHC team or the Quality Monitoring from Practice Development Team. Designated performance management systems need to be explored; these would need to be incorporated into the Pre-Placement agreement and monitoring of Key performance indicators. The implementation of the Pre - Placement agreement is an opportunity for the Health Board to review its functions and current arrangement for performance management and contract monitoring including monitoring staffing levels. As with all service contracts, BCUHB are responsible for monitoring quality, safety, access and patient experiences within the context of provider performance.


The Health Board welcomes the inclusion of nurse staffing levels for commissioned care within the Bill as a clear positive step forward recognising the importance nurse staffing levels to drive quality care within the independent NHS commissioned care sector. Whilst significant progress has been recently made within the Health Board in streamlining and improving systems at an operational level to monitor quality care, the Health Board needs to further consider providing additional resource to strengthen the commissioning arrangements for contract monitoring in the care home sector. The Health Board plans to develop a Commissioning strategy for Continuing NHS health care which will drive identify current models and drive forward improvements and sustainable services with patient and public engagement at the core of it business.


The Health Board Quality Assurance Executive Meeting has also recently considered the Health Boards monitoring of commissioned services with regards to quality of care from outside of Wales. This followed an Internal Audit Report review of Commissioning & Contract Management - Purchaser Review.


In May 2014, it was recognised that the BCUHB contract review group had no assurance with regard to the quality of the care that was being received by our patients where treatment is commissioned from outside organisations (England).  The Director of Nursing and Midwifery Services was approached and the Quality and Standards Manager was co-opted onto the Group to assist in this assurance process.


Since summer 2014 the Quality and Standards Manager has attended meetings with regards to the commissioning of patient care.  There are currently three groups that meet on a monthly basis; the first group is the BCUHB Commissioning Contracts Review Meeting which is an internal group that discusses finance, performance and quality issues with regards to our providers.  The remaining two meetings are held separately with two of our providers, namely Robert Jones Agnes Hunt (RJAH) and the Countess of Chester.  These 2 Trusts account for approximately 75% of the English contracts that are managed directly by the Health Board.


Robert Jones Agnes Hunt (RJAH)


The Quality and Standards Manager has met with the Clinical Governance Manager for RJAH and receives monthly copies of their performance reports that includes a wide range of key quality indicators (See Appendix 1).  In addition, to the report the Clinical Governance Manager is able to identify any of the issues that involved Welsh patients should further follow up be required.  To date, one Serious Incident has been reported relating to the x-ray of wrong toe.


Countess of Chester Hospital (COCH)


The Quality and Standards Manager has met with the Deputy Director of Nursing to discuss reporting on quality and safety.  The COCH currently provide the Quality and Standards Manager with a copy of their monthly report which includes some elements of quality.  In addition, COCH have a web page Open and Honest, safer staffing that provides up to date information for public on a range of quality metrics.  To date, the COCH have been unable identify specific incidents that relate to our patients but work is in progress to achieve this.  No specific issues of concern have been raised with regard to quality issues.


Further work


During January 2015 contact has been made with Wirral University Trust and University Hospitals of North Midlands and reports are now being forwarded for review purposes and any further action required.


Conclusions/Next steps


Welsh Health Specialised Service Committee (WHSSC)


WHSSC was established in 2010 by the seven Local Health Boards in order to lead on the planning of specialised and tertiary services for the population of Wales.


WHSSC are currently in the process of developing a Quality Framework which will strengthen the quality focus for their contracts.   Once this framework is agreed by WHSSC the same framework will be adopted by the Health Board in order to ensure consistent data is captured and provided by our direct providers.


Internal Processes


Contact will be made with other existing providers to ensure that routine data is collected and monitored.


Complaints raised directly to the Health Board regarding care provided via cross border arrangements are currently answered by either the Planning Lead or Performance lead as these tend to relate to waiting times.  Currently the process does not include sharing of these complaints with the quality and Standards Manager.  This process will be reviewed to ensure that the organisation has an over view of all issues.


Kind regards



Angela Hopkins

Executive Director of Nursing & Midwifery