Health and Social Care Committee
HSC(4)-03-12 paper 1
Scrutiny of the Minister for Health and Social Services
Purpose
1. This paper provides background information to inform the Health and Social Care Committee’s discussion with the Minister for Health and Social Services at its meeting on 25 January 2012.
2. This evidence paper covers the following areas at the Committee’s request:
· Recent progress and achievements, and portfolio priorities
· Health Board Service Reconfiguration Plans
· Capital Projects
· Finance Position of Health Boards
· GP opening hours
· Recruitment for doctors
· IT in the NHS
· Over 50 health checks
· Adult Mental Health
Recent progress and achievements, and portfolio priorities
3. The Programme for Government, launched by the First Minister in September, is the Welsh Government’s plan of action for Wales. It represents a real commitment to delivery, measured by the impact Government is actually having on people’s lives. For my portfolio, it sets out the actions we will take to ensure better health for all, with reduced inequalities in health.
4. Two of the priorities set out in the Programme for Government, form part of our ‘Five for a Fairer Future’ – extending access to GPs and extending the Flying Start Programme. I have provided an update on extending access to GPs at paragraphs 24 – 28 below. Our commitment on the Flying Start Programme is to double the number of children and families who benefit from it. We have made available a total of £55 million of revenue funding over the next three years to support the expansion of the programme and £6 million of capital funding for the delivery of additional multi-agency childcare settings.
5. We are also continuing to develop plans and strategies for specific service areas. Our Strategic Vision for Maternity Services in Wales, published in September 2011, sets out our expectations of NHS Wales in delivering safe, sustainable and high quality maternity services. In December 2011, we launched a consultation on ‘Together Against Cancer’ our National Delivery Plan for the NHS up to 2016. Delivery plans for cardiac care and stroke care will follow later this year.
6. We are also continuing to work on an ambitious programme of legislation. Our Organ Donation consultation ends on 31 January 2012 and we remain on track for publication of a draft Bill this summer, with introduction of the Bill following by the end of 2012. Our consultation on cosmetic piercing also concludes at the end of this month. On 14 December 2011 I published a draft Food Hygiene Rating (Wales) Bill, which will make the display of the food hygiene ratings mandatory in food businesses and I intend to introduce the Bill later this year. We also remain committed to introducing a Social Services Bill in October 2012, to provide the legislative basis to take forward the commitments contained in "Sustainable Social Services for Wales: A Framework for Action". We have already begun engaging with key stakeholders on our proposals and we will launch a full public consultation on the proposed content of the Bill in March. We will also be consulting this year on the need for a Public Health Bill to place statutory duties on bodies to consider public health issues.
7. In November 2011, I launched Together for Health – a Five Year Vision for the NHS in Wales. It outlines the challenges facing the health service and the actions necessary to ensure it is capable of world-class performance. It sets out the case for reform - a rising ageing population, inequalities in health, increasing numbers of patients with chronic conditions, medical staffing pressures and some specialist services being spread too thinly. The responsibility for planning, funding and delivering healthcare services at a local level rests with Health Boards, and I expect them to provide healthcare to their local population which is safe, effective, accessible and affordable and to keep services under constant review. Service change is covered at paragraphs 8-13 below, and I will be providing six-monthly updates on progress against Together for Health, starting in May 2012.
Local Health Board Service Re-Configuration Plans – current position
8. As described above, Together for Health sets out the case for reform of the NHS. I am clear as are the Health Boards that change is essential if we are to meet the challenges facing the NHS in Wales. To address these challenges, all Health Boards are currently working on their proposals for reform. Each Health Board will have it’s individual service plans but the 4 South Wales Boards are working collaboratively to ensure planning recognises the common challenges they face.
9. The regions are at different stages of plan development, with Hywel Dda leading the way, closely followed by Betsi Cadwaladr. As such, the precise extent of stakeholder and community engagement to date varies between Boards. However the overall process that has been agreed with the Boards are as follows:
· Pre – Consultation engagement between now and April 2012
· Presentation of Consultation Proposals: May to June 2012
· Formal Consultation Period: June, July, August, September 2012
· Proposals Review: August/ September 2012
· Final Plans Agreed and Implementation: August 2012 onwards
10. We anticipate options for service change will begin to develop during the engagement phase from December 2011 until April 2012. During the engagement period, Health Boards will have full, frank and open discussions with stakeholders and the local communities on the issues faced, and how they might be tackled. In line with the National Guidance on Engagement and Formal Public Consultation in the NHS, Health Boards may reach agreement with local communities and CHCs that some service changes can be progressed and implemented without the need for formal public consultation. However, this will depend on how the engagement process pans out and the scale of the changes that emerge.
11. The purpose of the next four to five months, is to ensure a robust engagement period is undertaken, in which as many people and stakeholders are involved as is possible. It is anticipated a full set of proposals will be available late in May although these may contain a number of different options which will then require formal public consultation.
Local Health Board Service Re-Configuration Plans – role of the NCF
12. The National Clinical Forum (NCF) is a multidisciplinary group of clinicians who hold senior advisory roles in their fields. Each member has been asked to develop a set of high level criteria for their area, against which service plans will be formally assessed during the planning and consultation process. Where required, the NCF will also invite external clinical experts to provide advice and guidance on areas it feels it requires external input.
13. The criteria each member develops for their area, will take into account National Clinical Guidelines/standards, Royal College Guidelines, and any other evidence of best practice that informs as to appropriate service configuration which is both safe and sustainable.
Capital Projects
14. The vast majority of the HSSC capital allocation for 2011/12, £310 million, is being spent on schemes that are contractually committed and on site. Since May 2011, several additional schemes have started on site including the Childrens Hospital for Wales, the Redevelopment of Cardiff Royal Infirmary and the Redevelopment of Operating Theatres at Ysbyty Glan Clwyd. The total value of these schemes is £137 million.
15. A large number of other schemes are being developed by LHBs / Trusts but the proposals are not advanced and business cases are not expected within the next 6 months. Little or no capital expenditure is being incurred on these schemes in 2011/12.
16. Priorities for capital investment are decided by the strategic section/case within the business case developed for each capital scheme. Those schemes with approved business cases are meeting previously identified priorities and so are unaffected by the service plans. Schemes being actively progressed by LHB/Trusts are reviewing their business cases to ensure synergy with the service plans is evidenced.
17. Each business case is developed with consultation of the major stakeholders including clinical, financial and estates professionals. Usually this is evidenced in the option appraisal section of the business case, to determine which of the available options is the preferred one to deliver the investment objectives.
Financial Position of Local Health Boards at the end quarter of this financial year
18. Each year the NHS faces unavoidable and predictable cost increases. These flow from a number of factors including cost inflation, increased demand for services as a consequence of demographic change, new technologies and new drugs.
19. As a result of these cost pressures, at the beginning of the 2011-12 financial year the LHBs reported savings of approximately £456m were required to achieve financial balance. To address this significant gap, each LHB prepared detailed savings plans to mitigate against the identified cost pressures. In all cases, each detailed plan provides key management actions by savings category and has been subject to intense management scrutiny.
20. At the time of the draft budget announcement the LHB plans had forecast a savings achievement by the year end of £295m. These savings plans, together with additional funding provided to the LHBs of £145m (from a combination of additional funding from central Welsh Government reserves and further allocations from the Health Departments own reserves), is expected to ensure the LHBs meet their financial targets for the current year. Although further savings of approximately £16m are still to be achieved, the levels of risk identified by the Health Boards have been significantly reduced by the additional funding provided and are now considered to be at a level which can be successfully mitigated by the year end.
21. I hold regular meetings with Chairs of LHBs, where delivery is discussed and where I make clear my expectations for the service. In addition, the Director General meets with Chief Executives on a monthly basis and delivery against all key priority areas are reviewed. The Director General reiterates to Chief Executives my expectations on delivering targets by year end.
22. The Director of Operations holds regular monthly Quality and Delivery meetings with Senior Operational Executives from LHBs, where specific performance areas can be focussed on.
23. It is the responsibility of LHBs to provide services to meet the needs of the population they serve, whether that be locally within their own LHB area, or for more specialised services, at tertiary centres either in Wales or, in some cases, in England.
GP opening hours
24. We are committed to improving access to GP services for working people by ensuring appointments are available at times which are convenient to them. The current proposals include improving access to appointments in the evenings and also on Saturday mornings.
25. We have considered a range of options on improving access to appointments in the evening, including flexible opening times and extending opening hours. Our favoured approach will initially focus on redistributing appointments during contracted core hours towards the latter part of the day - from 5.00pm to 6.30pm. This will be explored fully before seeking to extend opening hours beyond 6.30pm. There are no additional cost implications of redistributing appointments within contracted core hours.
26. In relation to access to GP services on a Saturday morning, we have commissioned a review to explore the potential for this to be delivered through the Out of Hours Service. This review is expected to be completed by the end of March 2012. For some working people, particularly those in rural areas or who work a fair distance away from their home, morning appointments may be more convenient for them.
27. We are in discussions with the BMA, GPC Wales and Local Health Boards in respect of this commitment. It is for local GP practices, in conjunction with Health Boards, to ensure services are available to meet the reasonable needs of patients within their local area. They are committed to ensuring the delivery of high quality services and are currently reviewing plans to ensure access to GP services continues to meet the needs of local people within their respective area.
28. Our intention is to deliver this commitment within existing budgets, over the period 2012/13 to 2015/16. We will develop a detailed delivery plan for May 2012, to take account of the outcome of the Out of Hours Review and also the local delivery plans for each Health Board and we will establish mechanisms to ensure progress against this commitment is monitored.
Over 50 health checks
29. Our Programme for Government makes it clear activity for 2011-13 is focused on preparatory work to determine what the approach for health checks should be. I am keen to ensure we make full use of the preparatory period to ensure we develop a fit for purpose health checks programme. When I have decided what the approach should be, it will be implemented from 2013-16.
30. My officials are currently reviewing the evidence base and the health checks models which are in place elsewhere, such as the health checks programmes currently in operation in England and Scotland.
31. As part of the developmental phase, we will work to ensure the programme complements and builds upon other relevant work. For example, consideration will be given to Public Health Wales’ work around the identification and management of cardiovascular disease risk. Other guiding principles include the need to target investment proportionately to risk and the need to ensure any programme complements our drive to close the gap on health inequalities. We will also explore the role technology can play, as an online approach has potential to raise awareness of key public health messages and provide signposting to appropriate advice and support, particularly for people who are potentially in a ‘low risk’ category.
32. The development of a health checks programme will be of interest to a number of organisations and stakeholders. I have asked my officials to establish an external reference group, to comprise a range of key stakeholders. This group will assist us to capture a broad range of views, which we will consider during the preparatory phase.
Recruitment plans for doctors
33. It is important to note Wales does not have medical staffing issues across the board. Rather, there are acute recruitment difficulties in particular specialties/grades/geographical areas:
· a UK-wide shortage of doctors in certain specialities, such as Accident & Emergency, Anaesthetics, Obstetrics & Gynaecology and Paediatrics;
· Reduction in doctors from outside Europe to fill posts due to new immigration rules has exacerbated recruitment difficulties.
· Wales has not historically been a particularly popular place to train owing to its rurality and less accessible areas.
34. Nonetheless, we have taken a number of steps to improve matters; for example:
· Our Junior Doctor Review Group is working with the BMA to improve Wales’ attractiveness to junior doctors (Wales providing free accommodation for Foundation Year 1 doctors, promoting the attractiveness of a medical career in Wales - producing DVDs and improved Deanery website, increased presence at UK events, working with Health Boards on co-ordinated recruitment drives abroad)
· I have announced plans to launch a marketing campaign at the end of this month which will be run in the context of the wider comms strategy for Together for Health.
· The Deanery is reconfiguring a number of training programmes to improve training quality and thereby should improve their attractiveness.
35. While these measures aim to fill current vacancies, effective workforce planning is vital to ensure vacancies do not persist into the future:
· The integrated workforce planning process for NHS Wales requires each Board/Trust sets out in detail their anticipated requirement for junior doctors in each specialty (as well as other staff) for six years into the future, giving the Deanery an overview of the number of new junior doctors who need to be trained in the future. .
· NLIAH have developed a software model to compare anticipated future supply versus demand for newly-trained consultants. It can, therefore, identify broadly how many Specialist Registrar (SpR) posts are required in each specialty across Wales allowing the Deanery/Health Boards to determine what would be a reasonable number of junior doctor posts to have.
· NLIAH are also developing a software model that forecasts how many Medical Graduates and Foundation Doctors Wales is likely to produce in future, allowing us to provide forecasts of whether there are likely to be sufficient numbers of new junior doctors to meet Health Boards’ future requirements
36. Where our forecasts identify a future shortage of junior doctors is likely across Wales, we can then consider mitigating action.
IT in the NHS
37. At a plenary debate in March 2011, the National Assembly recognised the good progress made by Wales’ NHS ICT Programme, Informing Healthcare[1], which has established Wales as a leader in the use of digital technology for better patient care.
38. NHS Wales has a long tradition of using computers to support care. However, most have been stand alone systems with their valuable information locked away in silos. To deliver best value for money, the Informing Healthcare Programme aimed to combine existing systems with new digital technologies. Connecting them together would deliver the shared information that is essential for a truly integrated healthcare service.
39. This approach has delivered significant success and has seen integrated electronic health records introduced across primary and secondary care, contributing to better services for patients.
40. GPs are successfully sharing patients’ records with the out of hours doctor services through the Individual Health Record, providing vital and often life-saving information for the emergency care delivered out of hours to around 2,000[2] patients every day. By the end of December 2011, the IHR was available for all GP practices using Egton Medical Information Systems (EMIS) and In-Practice computer systems, providing access to the IHR for over 60% of practices and around 2 million patients. GP Practices using the iSoft GP Computer System will have access to the IHR during 2012.
41. Referrals by GPs for hospital outpatient appointments have been streamlined with the introduction of an electronic referral service, using the Welsh Clinical Communications Gateway (WCCG). This replaces the paper referral letter with an e-form, reducing the referral process from around a week to under 24 hours. It also avoids referral letters being ‘lost in the post’. By the end of December 2011, this service was available for over 50% of practices and had managed over 130,000 referrals. All GP practices will be able to use e-referrals by Spring 2012, to help manage the 700,000 referrals sent annually. We are also trialling electronic discharges from the hospital directly to the GP, using the WCCG.
42. We are also making good progress with My Health OnLine, which allows patients to use the internet to book GP appointments and order repeat prescriptions. Eventually it will allow them to access their own electronic records.
43. There has been a quiet revolution in the way prescription information is shared between GPs and high street and community pharmacies. High-tech barcodes are printed onto all prescriptions issued by every one of Wales’ family doctors. The barcodes hold all the prescription information, including the unique drug codes for the medications or preparations prescribed. Each barcode can hold information for up to four prescription items and the patient's name and address details. Bar codes are now used to scan in prescriptions at all 707 local pharmacies, making it easier and safer to dispense medicines.
44. As our hospitals use many different computer systems, information has been held in silos. To address this, we have developed the Welsh Clinical Portal, an advanced web service that integrates the information about a patient and makes it available in one place, making it easy for staff in hospitals to do their job. No more chasing up paper records.
45. The Portal gives fast access to information about medication, referrals and discharges, allows health professionals to request tests and results from various sources and ultimately improves patient safety and a reliance on paper records. It also gives doctors and nurses a personalised workspace with access to their own relevant patient lists.
46. The Portal is currently in use at hospitals in Hywel Dda Health Board area, and will go live across North Wales (Betsi Cadwaladr Health Board) from February 2012. All other Health Boards will begin implementation by the end of March 2012, with full implementation of version one by Christmas 2012.
47. The Portal is underpinned by a Master Patient Index, which ensures each patient is identified correctly and reduces the number of duplicate records held across the many systems used by our hospitals.
48. We are also making good progress with the introduction of a new Laboratory Information Management System (LIMS). This will replace the current 13 different systems used across 18 pathology laboratories with one national integrated system. In Wales over 69 million pathology tests are ordered each year. The new LIMS will reduce the number of tests that are duplicated and will mean that no matter where a patient receives care, the results of tests will be readily available.
49. Hywel Dda Health Board and Betsi Cadwaldr will implement in February and March 2012. Planning is underway with the other Health Boards and the system is due to be fully implemented by early 2013.
50. Radiology information has been integrated through one upgraded system, known as RADIS2 and has been introduced at 11 of 13 sites, including Velindre Hospital Trust.
51. We are also upgrading and integrating the system we used to manage the 10,000 digital x-rays and scans captured every day by NHS Wales. A few years ago we achieved a major step forward when we introduced electronic Picture Archiving and Communications Systems (PACS). However, contracts with suppliers were all locally let, so we ended up with many systems from a range of different commercial companies, which were unable to share X-ray images. As those contracts are expiring, we are now streamlining and moving to an all-Wales approach, based on a new procurement framework, currently in progress.
52. Use of video conferencing has trebled in recent months particularly for Multi Disciplinary team (MDT) meetings in cancer and cardiac networks. Now available in high definition, video conferencing allows doctors to share and discuss results and see tests in greater detail. There are currently over 400 video conferencing units throughout Wales within GP practices, hospitals and specialist facilities.
53. Great progress has been made in moving to a national Patient Administration System (PAS).The Myrddin PAS was developed by NHS staff in Hywel Dda Health Board and became so successful it was adopted as an integral part of the NHS Wales’ ICT strategy. The system has been externally accredited and in making full use of it we have reduced implementation costs. Myrddin is currently in use at six out of seven health boards and over 15,000 members of NHS Wales use the system daily.
54. All GP practices, pharmacies, Health Boards and hospitals are now connected to the Public Service Broadband Aggregation (PSBA) network. This is a high-bandwidth secure network for the public sector that provides the infrastructure to support joined up care with social care and across all public services.
55. NHS Wales now has a secure national email service that gives staff an email address for the entire length of their career in NHS Wales. There are now over 60,000 email addresses for staff working in NHS Wales with 5 million email messages sent every month.
56. NHS staff also have a single user ID and a single password to remember– making it easier to ‘log on’ to national NHS systems, wherever they are working in Wales.
8. Adult Mental Health
New Mental Health Strategy for Wales
57. On 30 October 2011, I wrote to the Chair of the Health & Social Care Committee to outline a timetable for the development of a new Mental Health Strategy for Wales. That correspondence confirmed the new Strategy will take a unified approach to mental health, address the holistic needs of children and adults of all ages, complement and embed the Mental Health (Wales) Measure 2010, and consolidate existing policy. It will specifically address the need for integrated working and joint strategic planning in line with the requirements of ‘Together for Health’ and ‘Sustainable Social Services’.
58. Presently being developed by a cross-departmental steering group, and informed by engagement of key stakeholders, a draft Strategy will be made available for a formal 12-week consultation in late spring 2012. A National Partnership Board – to be established later this year following the final meeting of the Mental Health Programme Board on 25 November – will play a key role in overseeing and scrutinising implementation of the new Strategy.
‘Adult Mental Health Services: A Follow-up Report’ (Wales Audit Office)
59. The recommendations outlined by the Wales Audit Office (WAO) in ‘Adult Mental Health Services: A Follow-up Report’ (July 2011) will directly inform the new Mental Health Strategy.
60. Since the WAO undertook fieldwork preparatory to the publication of the report, a number of improvements have been made, including the establishment of crisis resolution and home treatment services, and outreach services in virtually all parts of Wales. Where such services do not exist, developmental plans are in place. Our commitment to improving access to psychological therapies was set out in our manifesto, and a review of service availability is underway. We have also invested in new children and adult mental health facilities and introduced new teams to care for people with eating disorders and those with post-traumatic stress.
61. In response to Recommendation 1, it is our intention the new Strategy addresses inequalities in service provision and expedites improved operational working between the health, social care and third sectors. In line with Recommendation 2, the Strategy will actively promote an outcome-focused recovery approach, one that builds upon our existing approach to care planning and the forthcoming requirements of Part 2 of the Mental Health (Wales) Measure 2010. For Recommendation 3, I have confirmed our commitment to the continuation of ring-fenced in 2012-13, but we will continue to monitor the efficacy of this approach and seek to identify material variations in the sums allocated to LHBs and actual expenditure. Recommendation 4 focuses on key posts, guidance and performance management and with this in mind we will review the priority accorded to mental health by LHBs. and continue to advocate the importance of multi-agency strategic planning.
62. The new Strategy will also reflect the findings and recommendations made by the Auditor General in ‘Housing Services for Adults with Mental Health Needs’ (November 2010). In response to that report:
A series of events in November and December 2011 (organised in conjunction with Cymorth and Public Health Wales) brought together health and housing services to discuss the report and other aspects of joint-working
Mental Health (Wales) Measure 2010
63. My letter of 30 October 2011, to the Chair outlined the timetable for implementation of the Mental Health (Wales) Measure 2010 by October 2012 - affording LHBs and local authorities sufficient time to effectively plan and prepare to meet their new duties - and implementation is proceeding in accordance with that timetable.
64.My recent announcement confirmed that allocated funding is in line with the Explanatory Memorandum and Regulatory Impact Assessment. From 2012-13 this amounts to £5.5m per annum - £3.5m to support implementation and running costs for local primary Mental Health support services under Part 1, and £2m p.a. to support the expanded Independent Mental Health Advocacy (IMHA) Service under Part 4.
65. Part 1 of the Measure places duties on LHBs and local authorities to establish prescribed local primary mental health support services, delivered within and alongside GP settings. Part 2 places duties on LHBs and local authorities to ensure all users of secondary mental health services have a care and treatment plan, and that care is managed by a care co-ordinator. Part 3 will introduce an entitlement for former users of secondary mental services to request assessment should they believe their mental health to be deteriorating. Finally, Part 4 expands the Independent Mental Health Advocacy (IMHA) scheme established under the Mental Health Act 1983 to include both certain persons on short-term (emergency) sections and informal (non-detained) in-patients.
Dementia Services
National Dementia Vision for Wales
66. The Vision - launched in February 2011 - outlines the importance this Government places on improving and expanding existing services and information, heightening awareness, improving training and learning resources, and recognising the importance of, and supporting research.
67. In recent months we have supported and funded certain key developments to assist with implementation of the Vision:
68. An improved understanding of the causes and treatment of dementia is critically important, and we have provided support and funding to establish the MRC Centre for Neuropsychiatric Genetics and Genomics at Cardiff University, and the Wales Neurodegenerative Disease and Dementia Research Network.
69. Four dementia-focused Intelligent Targets have been produced to monitor outcomes, providing a good indicator of where improvements are required and how best they might be implemented. One of these focuses on the general care setting, and related work will ensure that LHB progress is monitored through the use of established Dignity in Care monitoring mechanisms (following the production by LHBs of action plans in response to a Royal College of Psychiatrists England and Wales audit of dementia care). Regarding Dignity in Care, my statement of 10 January outlined the action being taken by all NHS organisations in response to the 2011 review of the Older People’s Commissioner for Wales.