Report by the Betsi Cadwaladr University Health Board (BCUHB) to the
Public Accounts Committee 4.3.19
1 Purpose of the Report
The purpose of this report is to provide the Public Accounts Committee (PAC) with an updated position in relation to:
· finance and performance
· progress against PAC recommendations for the Health Board from the February 2016 report ‘Wider issues emanating from the governance review of Betsi Cadwaladr University Health Board’ (recommendations 12 and 13)
· improving Mental Health Services, including the action taken in response to the Health & Social Care Advisory Service (HASCAS) investigation and Donna Ockenden Governance Review published in 2018
· special measures
· concerns (complaints and incidents management)
2 Key Improvement Headlines - Summary
The evidence provided in this report will demonstrate the range of improvements achieved since the last PAC report. The key improvements are as follows:
· Mental HealthServices - strengthened leadership and governance arrangements, together with additional investment from Welsh Government to drive improvement and support, have led to support numerous developments which provide a solid foundation for the future and are already having positive impacts. These include implementation of the Together for Mental Health Strategy in partnership, innovative approaches to better dementia care, safer care environments, successful involvement of service users and communities in campaigns and projects which are reducing stigma and encouraging mental health and well-being, and a focus on reducing inappropriate out-of-area patient placements which has led to this practice being largely eradicated.
· HASCAS and Ockenden- the Health Board’s commitment to responding fully to the recommendations is providing assurance that the necessary actions are being driven forward in partnership and that improvements will become embedded into future practice.
· GP out of hours services- noteworthy progress has been made, including the creation of the new role of Executive Director of Primary & Community Care to oversee transformation of services, better performance against national indicators and positive patient feedback – such that the Health Board now compares favourably to a number of other health boards in Wales.
· Concerns management- changes to the leadership and governance of complaints and incidents have led to a sharper focus on harms reduction, improved timeliness and quality of complaints responses, a reduction in the number of reported serious incidents, and reduced MRSA and c.difficile infection rates since the launch of the Safe Clean Care campaign.
· Special measures- the Health Board, with support from Welsh Government, continues to work at pace on fully meeting the expectations set out in the Special Measures Improvement Framework, some of which will be addressed by the progress detailed above. Of note, the Health Board has continued to improve in terms of staff engagement as evidenced by the increase in the overall staff engagement index score from 3.35 in 2013 to 3.51 in 2016 and 3.76 in 2018. In addition the responses to the key questions on advocacy and proud to work for BCUHB have increased by over 15% since the 2013 survey and are now all above 60%.
· In a November 2018 statement following the Health Board’s most recent special measures progress report submission to Welsh Government, the Cabinet Secretary for Health & Social Services highlighted a range of improvements that had been achieved. However, ongoing challenges relating to finance, planning and performance were also noted. The Health Board recognises the serious nature of these challenges and is very clear on the sustainable improvements required and steps (agenda item 3.3) to be taken, not least in respect of its forecast deficit outturn position of £42m.
3 Finance
3.1 Financial performance over the last 4 years, together with the forecast for 2018/19 is shown in the table below:
|
Financial Year |
Deficit £m |
Deficit as % of Revenue Resource Allocation |
Savings delivered £m |
Agency Spend £m |
|
2014/2015 |
£26.6 |
2.1% |
£34.9 |
£31.0 |
|
2015/2016 |
£19.5 |
1.5% |
£34.5 |
£37.4 |
|
2016/2017 |
£29.8 |
2.2% |
£33.5 |
£45.0 |
|
2017/2018 |
£39.0 |
2.7% |
£41.7 |
£34.2 |
|
2018/2019 (M9 forecast) |
£42.0 |
2.8% |
£38.9 |
£30.1 |
3.2 The Health Board approved a financial plan in March 2018. This acknowledged a deficit budget of £35m, which required the delivery of £45m savings, £22m of which were cash releasing.
3.3 The current forecast has increased the deficit of £35m to £42m, which reflects the significant risks around the underperformance of savings plans that are currently forecasting to under deliver by £6.2m and cost pressures in secondary care, continuing healthcare (CHC) and packages of care, and Mental Health Services.
3.4 The Health Board has been able to contain cost growth in most areas, but secondary care costs have significantly increased during the year, though partly offset by additional Welsh Government funding (waiting times, unscheduled care, drugs and operational capacity). The secondary care division has incurred circa £13m costs on agency staffing at Month 9, £5.2m on medical agency and £7.7m on nursing agency.
3.5 The ring fencing of Mental Health Services was established in 2008. The Health Board currently spends significantly in excess of the ring fence with an expected year end overspend of circa £4.5m, and an expected year end shortfall against the savings plan of £2.6m. Increased expenditure on Mental Health Services predominantly relates to CHC/individual packages of care and staffing costs.
3.6 Agency Costs - the Health Board has worked hard to deliver a reduction in agency staffing costs over the last three years but there has been a marked change in the spend by staff group, with the use of nursing agency being an increasing area of concern:
3.7 Investments - the Health Board has continued to invest in key clinical services and staffing and in 2018/19 made a number of investments to improve patient outcomes and experience.
These include:
· Sub-regional Neonatal Intensive Care Centre (SuRNICC) at Ysbyty Glan Clwyd - £1.3m
· centralisation of vascular surgery - £0.6m
· increase in medical consultants for women’s clinical services - £1.3m
· Healthy Child Wales / paediatric diabetes Initiatives - £0.6m
· WHSSC specialised services - £1.0m
3.8 Savings - the Health Board has delivered significant levels of savings over a number of years (see data above). Much of this has been through transactional action and the Board has recognised that this approach will not bring about a sustainable financial position. During 2018/19 the Board appointed a Director of Turnaround and through dialogue with Welsh Government has secured additional resources which will build capacity and capability to design and deliver the substantial recurring savings required in future years. This additional capacity will enhance the Board’s central Programme Management Office, increase programme management capacity for change programmes and further develop service improvement skills and capacity to support clinical teams to deliver change. In 2018/19 the Board is anticipated to deliver £38.9m of savings which equates to a 2.6% reduction in spend. As at the end of December savings achieved were £25.7m of which £24.7m are recurrent in nature, which equates to 96%, with £1m non-recurrent. The forecast for the full year is for £35.7m of recurrent and £3.2m of non-recurrent.
3.9 Original plans for the year were set at £45m, however significant elements of the programme relating to increased efficiency and effective use of resources have not been achieved. The non-achievement derives from an ambitious plan with, to date, insufficient capacity within the organisation to focus upon these requirements alongside other operational service pressures.
3.10 During 2019/20 the approach to savings will progressively shift from a predominantly transactional model to one which is aligned to transformational change.
4 Performance
4.1 Two key performance areas, both in terms of important targets and our current challenges, are access times for elective care, and time to receive unscheduled care in the Board’s Emergency Departments (EDs) and Minor Injuries Units (MIUs). Information on our performance and a supporting narrative is provided below.
4.2 Access to elective care - our target is to treat 95% of people waiting for planned care within 26 weeks of GP referral.
4.3 An equally important measure is the number of people waiting over 36 weeks, where the target is zero.
4.4 On both these measures, BCUHB is currently the lowest performing health board in Wales. That said, for the last seven months the number of people waiting over 36 weeks has been lower than the equivalent month in the previous year. Our most challenged services are orthopaedics, urology and ophthalmology where demand outstripscapacity – together these three represent the vast majority of our elective access challenge.
4.5 There is a Board approved plan to improve our orthopaedics services comprising outsourcing, additional consultant capacity, improved productivity, and site reconfiguration (our three main acute sites will continue to provide trauma and elective orthopaedic services). Discussions are underway with Welsh Government on resourcing this plan.
4.6 Planning is at an advanced stage for a proposed reconfiguration of urology services including the establishment of a pelvic cancer centre for north Wales.
4.7 In ophthalmology, we have benefited from Welsh Government project management support as we commence our reorganisation of ophthalmology services in line with new national eye care standards.
4.8 The Health Board is also working urgently to review established processes through dedicated leadership of planned care put in place in January 2019. Further specific remedial actions, including additional capacity, are being pursued to seek to ensure 2018/19 delivery. More generally the Health Board has an estate that is significantly worse than the rest of Wales in age and functional suitability, which at times impacts on service delivery. For example, recent building failures led to the closure of a day case unit in Wrexham.
4.9 Access to unscheduled care - the key measure relates to the percentage of new patients spending no longer than four hours in an ED and MIU. The target is 95%.
4.10 The Board is currently performing the least well of all health boards against this measure.
4.11 The Health Board faces a similar challenge in terms of the numbers of people waiting over 12 hours.
4.12 A new improvement approach – based on 90 day improvement cycles – has started to deliver some results. The outcomes work is centred around three key workstreams:
· Demand – we have established an innovative clinical assessment and triage service in collaboration with the Welsh Ambulance Services Trust (WAST). Although volumes are currently low, results (in terms of providing an alternative to hospital emergency departments) are encouraging.
· Flow - speeding up flow through hospitals by embedding the SAFER principles including early discharge and review by senior clinical decision makers.
· Discharges - including the provision of improved patient literature.
4.13 Progress has also been seen in reduced ambulance handover delays.
4.14 Improvements are being seen in numbers of ambulance handover delays and lost hours. In addition, serious incidents have reduced by 25% and no Coroner ‘Regulation 28’ notices have been issued.
4.15 There have also been significantly fewer delays in transferring patients out of our hospitals, as can be seen below.
4.16 It should be noted that staffing gaps such as consultant vacancies in emergency departments and dermatology and in middle grade doctor and nurse levels impact on the Health Board’s elective and unscheduled care performance.
4.17 The Welsh Government funding for winter resilience has supported a number of schemes to respond to winter pressures and increased demand. The schemes include an admission avoidance initiative.
5. Progress against PAC Recommendations for the Health Board
5.1 Background and Context
5.1.1 The PAC report, entitled ‘Wider issues emanating from the governance review of Betsi Cadwaladr University Health Board’ was published in February 2016 and considered by the Health Board in public in March 2016. Welsh Government, Healthcare Inspectorate Wales and BCUHB responded jointly to the report in June 2016.
5.1.2 The two recommendations specific to the Board were:
Recommendation 12 – We recommend that Betsi Cadwaladr UHB provide an update to our successor Committee in the fifth Assembly on progress towards improving mental health services by June of 2016.
Recommendation 13 – The Committee does not believe that GP Out of Hours coverage is acceptable in BCUHB and we recommend the Health Board urgently address this.
5.2 Progress towards Improving Mental Health Services (Recommendation 12)
5.2.1 Improvement in Mental Health Services is one of the key expectations within the Special Measures Improvement Framework (SMIF) as noted above and regular update reports on progress have been scrutinised via the committee structure and by the Board itself.
5.2.2 Leadership and governance - improvements in the effectiveness of leadership and governance structures have been led by a Director of Mental Health & Learning Disability (MHLD), who was appointed as an Associate Member of the Board with the permission of the Minister. This work has been supported by significant additional investment from Welsh Government since 2015. The Mental Health & Learning Disability (MHLD) Division’s senior team was further strengthened and Emrys Elias was appointed by Welsh Government to work with the Health Board and test progress on the range of improvements required, including the reduction of out of area placements (now largely eradicated), to help achieve financial improvement alongside improved clinical outcomes. Focused action has been taken in key areas including the Division’s structure, operational controls, delayed transfers of care processes, out of area placements and continuing healthcare.
5.2.3 Strategy development - the strategy for Mental Health Services, Together for Mental Health was developed with extensive input from service users and other stakeholders. It was approved by the Board in April 2017 and has continued to be developed, informed by engagement with partners.
5.2.4 The strategy has been written with the view that it is all-age and whole-system and accordingly addresses Child and Adolescent Mental Health Services (CAMHS), Substance Misuse Services, Adults of Working Age, Forensic Services, Learning Disabilities and Older People’s Mental Health. The focus has now moved forward from the initial strategy and engagement onto the mainstreamed future model for MHLD services. Responsibility for implementing the strategy has been delegated by the North Wales Together for Mental Health Partnership Board to three Local Implementation Teams (LITs) covering Anglesey & Gwynedd, Conwy & Denbighshire, and Wrexham & Flintshire. The LIT membership comprises representation from the Health Board, patients, carers, the third sector and partner organisations including WAST, police, local authorities, benefits agencies and the Community Health Council. Work undertaken by the LITs has informed a successful bid submitted to the Healthier Wales transformation fund to provide the pump-priming needed to support the strategy’s pathway development. In addition to the 3 LITs there are 7 clinically led Quality & Workforce Groups responsible for developing the detailed plans for the clinical service model across Mental Health Services.
5.2.5 Compliance - some key challenges remain in relation to sustained compliance with the Mental Health Act and Mental Health (Wales) Measure, and additional support has been provided by the Welsh Government Delivery Unit. Compliance is being closely monitored and overseen by the Mental Health Act Committee of the Board. This committee has been refreshed and stabilised and has put more effective governance arrangements in place. There has also been a roll out of regular training for Mental Health Act Managers and Associate Hospital Managers to ensure they are up to date with the changes to the Code of Practice in Wales.
5.2.6 Community Mental Health Teams (CMHTs) - the Welsh Government Delivery Unit has undertaken a review of CMHTs across Wales, following which the Health Board has examined capacity and demand across the region. This will inform future workforce planning and contribute to consistent achievement of the Mental Health Measure.
5.2.7 Quality metrics - in respect of work on improvement trajectories, a ward based dashboard has been introduced and this provides the latest available position against performance targets. The dashboard is accessible via the Division’s new intranet page to ensure visibility for all staff. This also provides links to IRIS data, other divisional reports and NHS Benchmarking information. The ward based dashboard format is now being used to develop a community-based dashboard, to ensure that the CMHTs’ performance management tools are aligned with those of the wards. The intention is to roll out the Health Board’s overarching quality dashboard, with mental health indicators added, so that there is MHLD Division-wide coverage and linkage with the ward and community based dashboards.
5.2.8 Quality improvement - a Quality Improvement and Governance Plan for Mental Health Services was approved by the Board in August 2018. The document is aligned to the overall corporate Quality Improvement Strategy and governance framework and sets out a clear response to recommendations from the HASCAS and Ockenden reports.
5.2.9 Service improvements - a procurement exercise was undertaken to commission training for the ‘Today I Can’ methodology and the first 90 day change agent initiative took place in early October 2018. The MHLD Division has also progressed recruitment for Service Improvement Leads. These posts will support the Area Teams to develop and embed their plans, and will ensure that the change programme is sustained across north Wales.
5.2.10 Using Welsh Government transformation funds, the Health Board has recently commissioned a full review of access to psychological therapies, which will include provision under Part I of the Mental Health Measure. In addition, the Health Board and the 6 local authorities, in partnership with third sector colleagues, have been successful in securing financial support for the provision of crisis cafes and alternatives to admission.
5.2.11 There have been a number of recent Healthcare Inspectorate Wales (HIW) visits to inpatient and community facilities. Whilst not all formal reports are yet available, informal feedback and statements in those reports already published, comment positively on staff morale, leadership and the quality of patient interactions. HIW has also commented on the improvements seen in mandatory training compliance
5.2.12 In respect of Child & Adolescent Mental Health Services (CAMHS), there is now a single point of access in place to offer advice and signposting for concerned professionals working with children in north Wales. Given increasing demand for CAMHS services, the Health Board recently held its first ‘deep dive’ session to better understand demand and capacity challenges. A follow-up session will be held with referrers and other stakeholders. The aim is to focus on prevention and early intervention.
5.2.13 An all Wales neuro-development pathway is in place, which means that children who show signs of conditions such as autism and ADHD will be seen by a community paediatrician and receive a multidisciplinary developmental assessment, with referral to CAMHS if required. A north Wales integrated team is in place to provide services for adults with autism.
5.2.14 Following completion of a risk assessment for every MHLD Division inpatient ward and environment including the assessment of ligature risks, a 2 year programme was developed to remove high risk ligature points and improve the general environment across all inpatient settings. This addressed many of the quality and safety issues raised by HIW, the Welsh Government Delivery Unit and the Community Health Council, as well as enhancing the patient, relative, carer and staff experience. An ongoing assessment process is in place using an agreed risk assessment tool and is managed by senior ward managers and matrons.
6 Progress in GP out of hours (OOH) services (Recommendation 13)
6.1 Work has continued since 2016 to improve GP out of hours services, and to meet the revised national standards. Significant progress has been made. Over the last 18 months rota fill rates have continued to improve and patient feedback in July/August 2018 described the service as ‘excellent’ (80%) or ‘good’ (13%).
6.2 Work is continuing to transform the service model so it remains fit for purpose and is sustainable. This includes taking steps to reconfigure the service across north Wales to align with the expectations of the 111 service and also working collaboratively with WAST within an integrated clinical hub. Additional evidence on the progress made is included in the May-September 2018 Special Measures Overview Report (section 4.4.2).
6.3 Peer reviews took place across Wales in the autumn of 2018 and the peer review of the Health Board’s GP out of hours services took place in October 2018. The purpose of the review and team was to act as a “critical friend” and to offer some direct support and advice for the local team ahead of anticipated winter pressures. In his covering letter, the Chair of the OOH Peer Review Panel noted: Overall, the Panel was impressed by the ongoing dedication and commitment that was demonstrated by all staff and their continued focus on delivering high quality care to patients within OOHs. It was clear that was a passion to deliver long-term sustainable change (24/7) and that your proposed service vision aligns with the wider 111 transformation agenda too.
6.4 A draft action plan was produced by the Panel for the local team. The broad themes of which address:
· current service model
· appropriate and effective clinical triage
· multidisciplinary workforce
· clinical and corporate governance and risk
· clinical pathways
· the OOH management team
7 Special Measures
7.1 In November 2014, Welsh Government determined that the Health Board should be escalated to ‘targeted intervention’ under the NHS escalation and intervention arrangements protocol. The reasons for this increased concern related to:
· significant challenges in the financial plan for 2014/15
· significant concerns around the delivery, safety and quality of Mental Health Services
· the management and control of capital schemes.
7.2 The first stage of targeted intervention was a diagnostic review. This work was undertaken between December 2014 and February 2015 and it included a financial and governance review. The Health Board published the final report in June 2015.
7.3 In June 2015, the then Minister for Health and Social Services wrote to the Chairman of the Health Board and issued a written statement to advise that the Health Board would be placed in special measures following a tripartite meeting between Welsh Government officials, HIW and the Wales Audit Office (WAO).
7.4 The Special Measures Improvement Framework (SMIF) was issued in January 2016, containing milestones against which the Health Board’s progress would be measured. The Framework covered:
· Leadership
· Governance
· Strategic & service planning
· Engagement
· Mental health
· Maternity services
· Primary care
7.5 In April 2016, the Board approved the establishment of the SMIF Task & Finish (T & F) Group. The purpose of this group was to advise and assure the Board on the effectiveness of the arrangements in place to respond to the expectations within the SMIF. The group was chaired by the Vice-Chair of the Board, with the rest of its membership comprising key directors, independent members and an independent adviser. Now chaired by the new Health Board Chair, the group oversees progress, and continues to report to the Board after each of its meetings.
7.6 The End of Phase 1 progress report (covering the period November 2015 to April 2016) was approved for submission to Welsh Government at the May 2016 Board meeting. The progress noted included key appointments at Executive level and approval of a Board Assurance Framework, Risk Management Strategy and Engagement Strategy.
7.7 The End of Phase 2 progress report (covering the period May 2016 to November 2016) was approved for submission to Welsh Government at the November 2016 Board meeting. Progress was noted across a range of areas, including Board development, clearing the historic backlog of concerns, patient/public/staff engagement, strengthened internal governance in mental health services, appointment of a Director of External Investigations to coordinate input into the HASCAS investigation and Donna Ockenden governance review, better cluster working in primary care, and more robust and sustainable maternity services.
7.8 In April 2017 Welsh Government advised that it was felt that the Health Board had made progress in a number of areas and that the direction of travel was generally good. However, there remained a number of challenges in key areas that required continued focus and attention.
7.9 In June 2017, the joint review undertaken by HIW and WAO formally reported on the actions taken by the Health Board to address the governance concerns that were originally identified in 2013. The report acknowledged that the Health Board was making progress in some areas, evidenced by successful recruitment in maternity services, a new model of primary care in Prestatyn, improved governance arrangements, and partnership working to develop a mental health strategy. The review also noted that the Board continued to face a number of significant challenges. These included financial performance, strategy/plan development and fully embedding quality assurance arrangements.
7.10 In July 2017, the Cabinet Secretary for Health, Well-being & Sport published a written statement confirming that the Health Board was to remain at the current level of escalation - special measures. The Board fully accepted the Cabinet Secretary’s conclusions, and those of the HIW/WAO joint review. The SMIF T&F Group was tasked with driving forward and monitoring the necessary actions.
7.11 In August 2017, it became necessary to elevate specific discussions on finance and performance. Welsh Government remained concerned about the deteriorating financial and performance position and it was decided that in addition to the action being taken with regard to special measures, it was necessary for the Health Board to have the same discussions in relation to finance and performance that had been occurring in organisations under Targeted Intervention. The organisation therefore effectively moved into turnaround as part of its financial forecast and performance / delivery, and commensurate actions were put in place to address the significant and ongoing challenges.
7.12 The End of Phase 3 progress report (covering the period between December 2016 and November 2017) was approved for submission to Welsh Government at the January 2018 Board meeting. This report noted that, throughout the reporting period, Welsh Government had continued to have regular discussions with the Health Board with regard to special measures - scrutinising and challenging in order to drive improvements in performance and delivery. The report also noted key achievements in the areas of greatest transformation since 2015, namely the leadership, governance, maternity services, primary care and engagement themes.
7.13 In February 2018 the Cabinet Secretary for Health & Social Services provided an update on the escalation status of health organisations under the escalation and intervention arrangements. The update statement outlined additional support for the Health Board. The Cabinet Secretary noted that the Board had made some progress against the expectations set out in the SMIF, in particular in the areas of leadership and governance - with a full Executive Team in place, established Board committee structure and development programme, and improvement in clinical oversight and the management of concerns. Key milestones had also been achieved in respect of mental health strategy development, public engagement, staff survey feedback and innovative primary care delivery. Significant improvement had taken place in maternity services, to the extent that this area was de-escalated from special measures.
7.14 Despite the improvement in some important areas, the Cabinet Secretary also noted that the Health Board continued to face significant challenges, particularly in terms of finance and performance, and also in relation to mental health services quality improvement and leadership (following a loss of momentum resulting from the sickness absence of key senior managers). A set of intervention actions and additional support (including input from Mr David Jenkins, Independent Adviser appointed by Welsh Government) was therefore announced, with improvement criteria to be progressed by April 2018. The Board published a report on these actions in June 2018.
7.15 A further SMIF Framework for the period May 2018 – September 2019 was issued by Welsh Government in May 2018. It comprised the four themes of leadership & governance, strategic & service planning, mental health and primary care including out of hours services, with expectations spread across three time periods. It was made clear by the Cabinet Secretary that future progress assessments would need to demonstrate that sustainable solutions were in place to maintain improvement.
7.16 Welsh Government published an update on the Joint Escalation & Intervention Arrangements in July 2018.
7.17 Also in July 2018, the Health Board received a report on the ‘Review of the governance arrangements relating to the care of patients on Tawel Fan ward prior to its closure on 20th December 2013 and governance arrangements in older people’s mental health at BCUHB from December 2013 to the current time’ undertaken by Donna Ockenden. In response, the Board agreed governance and oversight arrangements for the implementation of the recommendations arising from the Ockenden review. Similar arrangements were also agreed for the recommendations made as a result of the HASCAS independent investigation, which had been commissioned in August 2015.
7.18 In September 2018, a new Chair, Mr Mark Polin, took up post and the recruitment of a new Vice-Chair and 5 Independent Members plus 2 Executive Directors took place. The Chair immediately assumed responsibility for chairing both the SMIF T&F Group and the Finance & Performance Committee. Expectations as to governance and scrutiny were reset and Board meetings placed on a bi-monthly footing to allow more in depth scrutiny of key topics during intervening discrete workshops. The effect of this was noted by the WAO in their most recent structured assessment issued in November 2018:
“We looked at how the Board organises itself to support the effective conduct of business. We found the Health Board has good arrangements to support board and committee effectiveness, and shows recent signs of strengthened scrutiny, and is working to develop a strong focus on fewer but key priorities”.
7.19 In November 2018 the Board approved for submission to Welsh Government a special measures progress report covering May – September 2018. This report highlighted progress relating to Board capability and stability, development of a comprehensive response to the HASCAS and Ockenden recommendations, staff engagement, clinical involvement in service change proposals and achieving a culture of not placing mental health patients out of area.
7.20 The SMIF T&F Group has, as already mentioned, focused on scrutinising progress and on assuring the Board as to the effectiveness of the arrangements in place to respond to the SMIF.
7.21 The Finance & Performance Committee, aided by the recent recruitment of a specialist adviser on finance by the Chair, has turned its immediate attention to financial management and turnaround activity. In this regard the Chair is about to commission, with the support of Welsh Government, an external review of the existing arrangements with a particular focus on plan development and associated delivery arrangements. In terms of performance, the Committee is concerned to see improvement in referral to treatment times and in unscheduled care in particular and both are the subject of monthly reporting. The Board performance report has been revised to provide greater focus on key challenges, progress and improvement actions.
7.22 In November 2018, the Health Board considered in detail the additional investment agreed by Welsh Government in July 2018, totalling £6.8m, to support special measures work across 2018/19 and 2019/20.
7.23 In an oral statement on 6th November 2018, the Cabinet Secretary for Health & Social Services highlighted improvements made by the Health Board in respect of Board capability, assurance systems, partnership working and mental health. Of note, the improvements in the results of the NHS Staff Survey since 2016, were acknowledged in relation to staff engagement. However, ongoing challenges relating to finance, planning and performance were noted.
7.24 In the same month, the Board received a report setting out progress made against the Staff Engagement Strategy, together with the findings of the 2018 national Staff Survey. The improvement across a range of measures was noted and the proposed development of an overarching improvement plan together with Divisional improvement plans was approved. This approach is fully supported by the staff association.
7.25 The Health Board continues to drive improvements as measured by the SMIF. The next formal update report to be submitted to Welsh Government will cover the October 2018-March 2019 element of the Framework.
8 HASCAS Investigation and Ockenden Governance Review
8.1 Background and Context
8.1.1 As a result of concerns regarding care raised by relatives of Tawel Fan ward patients, in December 2013 the Health Board took the decision to close the ward, which provided services to older people with dementia. Such was the seriousness of the concerns raised, the Health Board commissioned an independent external investigation in February 2014 from Donna Ockenden, an independent investigator (with her report and recommendations being received by the Board in June 2015).
8.1.2 In August 2015, the Health Board commissioned an independent, comprehensive and evidence-based clinical investigation from HASCAS into the care and treatment provided to patients on Tawel Fan ward. The commission also required an evaluation and assessment of the reasonableness of any acts or omissions by Health Board staff in order that management decisions might be taken in line with workforce policies. In November 2015, Donna Ockenden Ltd was commissioned by the Health Board to undertake a governance review into older people’s mental health services across north Wales.
8.1.3 In January 2017, the Cabinet Secretary for Health, Wellbeing and Sport announced his decision to set up an independent oversight panel for the HASCAS investigation and Ockenden governance review, to provide assurance on the integrity of the work and ensure it was concluded in a timely manner.
8.1.4 In May 2018, the Health Board published ‘Independent investigation into the care and treatment provided on Tawel Fan ward: a lessons for learning report’ by HASCAS.
8.2 Progress Update
8.2.1 In July 2018 at its public meeting, the Health Board considered its initial response to the HASCAS report and approved the governance and reporting arrangements alongside the terms of reference for an Improvement Group guided by a Stakeholder Group to oversee the implementation of the recommendations from the HASCAS report and the Ockenden Governance review jointly.
8.2.2 The Improvement Group and the Stakeholder Group were established with membership agreed and confirmed in line with the respective terms of reference.
8.2.3 The Stakeholder Group, which is a subgroup of the Improvement Group, comprises representatives of the Community Health Council, Bangor University, St Kentigern Hospice, North Wales Police, north Wales local authorities, community voluntary councils, the North Wales Adult Safeguarding Board and Care Forum Wales as well as 6 Tawel Fan family members. Staff from the psychology service are also in attendance at these meetings to offer support to members if required.
8.2.4 In November 2018, the Health Board received a paper providing a progress report against the recommendations.
8.2.5 Early positive feedback had been received from third sector representatives who attend the Stakeholder Group and assurance provided that the Health Board was strengthening its approach to partnership working.
8.2.6 All recommendations from both the HASCAS and the Ockenden reports have been mapped together to ensure the necessary actions identified are embedded across the organisation and are not dealt with in isolation.
8.2.7 A paper detailing the progress made against each of the recommendations was considered by the Health Board’s Quality, Safety & Experience (QSE) Committee in January 2019 and by the Board itself in the same month. Whilst noting the progress made the Board asked that formal feedback be obtained from members of the Stakeholder Group as to their satisfaction with the current arrangements and that this be reported back to its next meeting.
8.2.8 Work is underway in relation to end of life care on older persons’ mental health (OPMH) wards. This includes seeking to provide care in the patient’s environment of choice, and the implementation of advanced care planning, treatment escalation plans and the all Wales arrangements for care decisions for the last days of life. Risk assessments will be undertaken with families to ensure early conversations in respect of care planning and choice. Palliative care training is to be delivered to staff within all care settings.
8.2.9 Work has progressed with the implementation of a number of initiatives that aim to improve the experience for people with dementia, who are presenting for unscheduled care to the emergency departments. Specifically, the three hospital sites are involved in the Dementia Friendly Hospital programme with good work underway at all sites but notably, Ysbyty Gwynedd was awarded Dementia Friendly Hospital accreditation by the Alzheimer’s Society at the end of last year - the first hospital in Wales to achieve this. As part of this programme of work the following initiatives are also underway:
· Butterfly alert cards are being rolled out, which allow a person affected by a dementia to alert emergency department staff as to their needs. The cards aims to support patients in ensuring that their dementia and any anxiety are recognised, that this leads to quicker triage, that triage is dementia friendly and the triage nurse identifies with the person and their family/carer how the person can be best supported to receive the most appropriate treatment.
· Orange wallet is a scheme that supports people with forms of disability that may not be visible and any conditions that impact upon understanding and communication when using public services.
· An Emergency Department Dementia Pledge is in place which is a public facing statement that sets out what each department has committed to.
8.2.10 The post for a second consultant nurse with a special interest in dementia was successfully appointed to following interviews in January. It is expected that they will commence in post in early Spring 2019
8.2.11 Dementia Friends training has been delivered to the Board.
9 Concerns (complaints and incidents management)
9.1 Background and Context
9.1.1 At the outset of special measures in 2015, the improvement framework issued by Welsh Government reflected concerns about the management of complaints. An expectation was set to ‘improve response times to concerns and complaints, ensuring the backlog is cleared urgently with lessons learnt and implementation of actions evidenced’. In addition, the PAC report of February 2016 included a recommendation for Welsh Government to ‘ensure that concerns/complaints are adequately dealt with at Board level or escalated sooner’.
9.1.2 In addition to the PAC concerns and the expectation set within the SMIF, in 2016, the WAO made a specific recommendation that “the Health Board should look at further steps to improve clinical leadership and ownership of Putting Things Right processes, to support the improvement needed in response times and learning from complaints, incidents and claims”. The Health Board recognises that the investigation and understanding of concerns (complaints and incidents), alongside the views of service users, is an important source of learning and improvement.
9.2 Complaints management progress under special measures
9.2.1 Throughout the earlier phases of special measures during 2015-16, improvement of complaints management was an area of focused action. The process began with investment in building and training the corporate complaints team, introducing enhanced reporting mechanisms with better identification of lessons learnt and also clearing the historic backlog of complaints. It progressed to the setting of improvement trajectories scrutinised via more robust performance and accountability arrangements, resulting in better response times and a shift in focus onto the reduction in the number of open concerns once the backlog was cleared.
9.2.2 In May 2017, responsibility for Putting Things Right (PTR) processes transferred to the Executive Director of Nursing & Midwifery with the aim of improving the degree of clinical leadership within the PTR processes. As part of this transfer an Associate Director, Quality & Assurance was appointed in December 2017, with concerns management forming part of their portfolio.
9.2.3 The work of improving the quality and safety of care led by the Executive Director of Nursing & Midwifery has focused on the identified areas of improvement within the Quality Improvement Strategy (QIS). The priorities within the QIS reflect the main themes raised by patients and their families through the concerns process. The aims of the strategy are to:
· reduce avoidable deaths
· continuously seek out and reduce patient harm
· achieve the highest level of reliability for clinical care
· deliver what matters most: work in partnership with patients, carers and families to meet all their needs and better their lives
· deliver innovative and integrated care close to home which supports and improves health, wellbeing and independent living
9.2.4 In terms of the reduction of harm within the strategy the areas of focus are:
· venous thromboembolism (VTE)
· healthcare acquired infections (HCAIs)
· response to the deteriorating patient and adherence to early warning scores
· pressure ulcers
· falls
· medication safety
· identification and early treatment of sepsis.
9.2.5 In respect of leadership and governance, under the clinical leadership of the Executive Director of Nursing & Midwifery, the governance arrangements in respect of concerns handling have been reviewed. An independent board member has been identified to fulfil the role of concerns champion. This role involves responsibility for a greater level of focus on this key area of work. The champion has a deeper level of insight and knowledge, allowing them to better support the Board in understanding key issues. The individual has also, importantly, taken the role of Chair of the QSE Committee.
9.2.6 The Board is sighted on the key issues through the QSE Committee and the Quality and Safety Group (QSG). The Quality and Safety Group is led by the clinical Executives. It provides multi-disciplinary review and oversight of quality issues and promotes learning. All divisions of the Health Board provide monthly reports on their quality and safety issues, including concerns. The QSG provides an exception report to the QSE Committee at each meeting.
9.2.7 Weekly incident review meetings take place, chaired by the Associate Director, Quality & Assurance. These provide a forum for the review of all serious incidents reported via the Datix electronic management system in the previous 7 days, and to track progress of investigations and learning. The meetings also review all upcoming inquests and complaints open beyond 3 months.
9.2.8 Corporate concerns management and support structures have been revised to enable the corporate team to devote more time to training, supporting and mentoring colleagues on the concerns management and lessons learnt processes. All investigations are led by the relevant service team, to ensure that lessons are identified and addressed early in the process and closer to the point at which care is delivered.
9.2.9 The Health Board is rolling out a series of ‘harm summits’ to promote avoidable harm reduction activities and to ensure that there is a clear, shared understanding of the management of harm.
9.2.10 In order to achieve more timely management of concerns, the Health Board has invested in building greater capacity. As a result, in the last two years there has been some improvement in the timeliness and quality of responses to complaints and serious incidents:
9.2.11 There has been a sustained improvement in the management of all incidents. In particular, better management of serious incidents has resulted in a reduction in the overall number of such incidents being reported. This trend has been particularly evident over recent months, as shown below.
9.2.12 As stated above, the management of complaints forms part of the wider quality and safety agenda being driven by the QIS. Below are some of the improvements being delivered.
· The introduction of a ‘harms dashboard’, providing data on two levels. Firstly, each ward sister has access to their own real-time ward-level data relating to the 4 core potential harms of falls, healthcare acquired pressure ulcers, infection and medication. Secondly, the Board level harms dashboard provides an overview for senior leaders at Health Board, hospital site and area level, as shown in the screenshot below.
· During January 2018 the Safe Clean Care Campaign was launched in all three of the Health Board’s acute hospitals. This campaign is a call to action, setting out essential steps to be taken by all staff to significantly reduce patient infection rates, supported by training and resources. Positive outcomes in infection control include a 63% reduction in MRSA, and a 29% reduction in c.diff cases.
· In July 2018 the Health Board initiated the development of a new accreditation programme which is being rolled out across all inpatient wards/units. Building upon the success of the Safe Clean Care Campaign, this programme involves implementing a set of standards to frame the quality, safety and patient care agenda.
· The Health Board has been focusing on improving pressure ulcer reporting and conducting root cause analysis in areas with the highest prevalence of pressure damage. In November 2018, a Pressure Ulcer Collaborative was launched to support improvement and culture change. There is a similar focus on using improvement methodology to reduce patient falls.
· Agreed improvement trajectories are in place for complaints and incidents for each division. These have been agreed with and are monitored by the Associate Director, Quality & Assurance.
· The Health Board has collaborated with the Welsh Risk Pool to play a key role in driving the national claims process reform on behalf of NHS Wales. This aims to promote more effective learning from claims.
9.2.13 Concerns management was an element of the findings of the HASCAS and Ockenden reviews. A key finding related to the need to ensure that families were easily able to make a complaint and would feel listened to. Improvement work on these two points has included;
· establishment of a Patient Advice and Support (PAS) Service at Ysbyty Glan Clwyd, to be rolled out to Ysbyty Gwynedd and Ysbyty Wrexham Maelor in 2019/20. PAS officers listen to comments and suggestions from service users and seek to quickly resolve any issues
· launch of an online complaints form from January 2019 to enable direct submissions into the corporate concerns process
· regular audit of the availability of concerns posters and leaflets in main patient and public areas, designed to ensure that service users are provided with relevant information
· roll out of the ‘View Point’ real-time feedback system, which provides service users with a mechanism to record their views or concerns online or on paper at a time best suited to them. Daily monitoring of submissions enables prompt action and learning to take place
9.2.14 Sustainable timely and effective management of concerns (complaints and incidents) remains an important priority for the Health Board, and work continues at pace to build upon the improvements already made.
10 Conclusion
This report demonstrates the progress to date and highlights continuing challenges. However, the Health Board is very clear that it still has much work to do to ensure sustainable high quality services across the organisation, with improved performance and financial balance. The Health Board is very grateful for the additional support provided by Welsh Government in recent years, which has undoubtedly enabled much of the progress seen to date. Going forward the Health Board is determined to deliver further improvement, at greater pace, through:
• the agreement and implementation of a more robust plan, with rigorous resource allocation and project planning, grounded in a stronger clinical strategy alongside finance, workforce, estates and digital strategies
• further strengthening leadership capacity and capability
• improved joint ownership and system working, led by the Executive Team and enabled by a revised Accountability Framework
• building on successful quality improvement/90 Day processes to implement a consistent, robust Health Board wide methodology
• building on the steps already taken to strengthen and develop partnership working
• the next stage of the successful drive to improve staff engagement and morale
We look forward to the opportunity to meet the Committee to discuss the contents of this report and other areas Committee members would like to examine.