23 May 2019

Written Evidence Submission to the Health, Social Care and Sport Committee


1.       We are pleased to provide this written evidence to contribute to the Committee’s general inquiry and to attend the Committee to provide oral evidence on 13th June 2019.

Powys and the health board

2.       Powys makes up a significant footprint in the rural heartland of Wales, covering a large geographical area of 2000 square metres. Powys borders England and all but one of the other health boards in Wales. The economic, social and healthcare links across these areas form part of the distinct characters of North Powys, Mid Powys and South Powys Clusters.

3.       Powys Teaching Health Board (PTHB) serves a population of approximately 133,000 people living in Powys and covers a quarter of the landmass of Wales, yet it has less than 5% of the population, making it one of England and Wales’ most sparsely populated areas.

4.       The population in Powys is older compared to the rest of Wales and the working age adult population is smaller compared to Wales. It is predicted that there will be an 8% decline in the Powys population by 2039. The number of young people and those under 65 will decrease while the number of older adults will increase.

5.       There are generally good health outcomes in the County and people in Powys live longer and spend more years in good health than the national average, eating more healthily and being more physically active. Fewer people feel lonely when compared to the national average and there is a greater sense of community and satisfaction with life.  83% report that they feel they belong to their local area, compared to 75% in Wales as a whole. (See Powys Well-being Assessment for further detail and sources https://en.powys.gov.uk/article/5794/Full-Well-being-assessment-analysis).

6.       There are however pockets of deprivation and health inequalities, with hidden poverty and low income employment.  Five areas (Lower Super Output Areas) are among the most deprived 30% in Wales and these are clustered around the main market towns with higher residential populations.  A child born in the most deprived area will live 10 years less than a child in the most affluent so there is still significant work to do and this has driven the shared ambition in our health and care strategy as highlighted below:



7.       The health board is both a commissioner and a direct provider of healthcare. The health board is distinctly different to other health boards in Wales in relation to the proportion of services that are provided to the population by other health care providers. The budget over circa £300M for example is split as follows:

a.       25% is spent on directly provided services

b.       25% is spent on primary care services

c.       50% is spent on secondary and tertiary care type services.

8.       The directly provided services are delivered through a network of community services and community hospitals which includes mental health, learning disabilities, maternity and children’s services.  Care is also provided in Powys through primary care contractors such as General Practices, Dental Practices, Pharmacists and Optometrists, as well as the Third Sector. There is also provision of an increasing range of consultant, nurse and therapy led outpatient sessions, day theatre and diagnostics in community facilities, bringing care closer to home.

9.       In relation to commissioning, there are some unique characteristics that set the Powys context. Being an entirely rural County with no major urban conurbations and no acute general hospitals, people in Powys have to travel outside the county for many services, including secondary and specialist healthcare, higher education, employment and leisure.

10.   The main patient flows for secondary care are into the North Midlands and the West Midlands in England and Aneurin Bevan, Swansea Bay and Cwm Taf Morgannwg Health Boards in Wales, however the organisation commissions services with 15 main NHS provider organisations.  This covers all specialities, however PTHB is not the majority commissioner of any acute provider.

11.   The majority of the PTHB budget is spent on externally commissioned services with these 15 organisations.

12.   Shrewsbury and Telford Hospitals NHS Trust makes up the largest proportion of our commissioned activity and Wye Valley NHS Trust is the second largest.


Excerpt showing activity in Wales; and main provider areas of England for Powys population

Health and Care Strategy ‘A Healthy Caring Powys’ and PTHB Integrated Medium Term Plan

– supporting delivery of ‘A Healthier Wales’

13.   We are now moving into the second year of our Health and Care Strategy, ‘A Healthy, Caring Powys’, developed jointly with Powys County Council and other partners in the Powys Regional Partnership Board, following extensive engagement with residents and stakeholders in Powys. When first launched in 2017 ‘A Healthy, Caring Powys’ was the first joint strategy between health and social care in Wales.



14.   This in turn is set in the context of the long term, intergenerational Powys Well-being Plan, ‘Towards 2040’, overseen by the Powys Public Service Board. Two of the twelve steps in this plan are specifically linked to the Health and Care Strategy and provide a ‘golden thread’ that runs throughout the strategic planning framework for Powys.


15.   There is a strong connection between our vision for ‘A Healthy, Caring Powys’ and the ambition for ‘A Healthier Wales’ set out by Welsh Government. The Powys Health and Care Strategy sets out how we will transform the way we provide care for the Powys population, enabling people to start well, live well and age well. It is an important part of the journey towards the very long term, sustainable and inter-generational approach in ‘A Healthier Wales’.


16.   We developed our Health and Care Strategy based on extensive local engagement as well as taking into account the Well-being of Future Generations Act and Social Services and Well-being Act. We assimilated the national well-being goals, five ways of working and the sustainable development principle into our own approach. In liaison with the Office of the Future Generations Commissioner, we developed Well-being objectives for Powys which are shared across the Regional Partnership Board. We also incorporated the quadruple aim and design principles into our local strategy, mapping across these to ensure alignment in our goals.

17.   The evidence that we gathered as part of the Powys Well-being Assessment enabled partners to fully understand the current picture of well-being in Powys, which formed the basis for an in depth exploration of long term impact and sustainability. For example, taking the evidence base from the Well-being analysis enabled partners to clearly articulate the scenario if the current focus and approach remained the same, strongly demonstrating the case for change.

18.   The work carried out with the Regional Partnership Board is fundamental to our local strategy and forms a response to the complexity of commissioning arrangements, which in key providers includes a number of fragile services and strategic change programmes around our borders. Powys has a statutory duty to ensure appropriate engagement and consultation with the Powys population on changes that impact on them and we have over recent years been able to successful influence a number of key programmes.

19.   The current main programmes being progressed by neighbouring areas are shown below:


20.  Regional planning and collaboration is key to delivering against this complex landscape in Powys, as it is for the whole of Wales, and our IMTP is taking an increasingly whole system approach.


21.  PTHB has a key role in the Mid Wales Joint Committee for Health and Social Care, which was formally recognised as a Regional Planning Area in 2018. There is a programme of work to deliver against the shared ‘Statement of Intent’ for health and care in Mid Wales.


22.   In addition, there are the NHS Wales Collaborative Programmes, National Delivery Plans, Shared Services, Welsh Health Specialised Services Committee (WHSSC), Emergency Ambulance Services Committee (EASC), Welsh Ambulance Services Trust (WAST) and NHS Wales Informatics Service (NWIS) workstreams. These have a potential to change pathways or services for people in Powys.


23.  We have an ambition to grow an even stronger rural alliance for health and care, building on our ambition to be leaders in primary and community care and the strengthening partnership working in Mid Wales. There has never been a better time to develop joint solutions between partners and across sectors in key areas including workforce, so that all our staff and partners can clearly see their role in delivering the shared vision.

24.   Our priorities within the IMTP for 2019/20 – 2021/22 continue to be shaped around the jointly agreed Well-being objectives in ‘A Healthy Caring Powys’. We have refined these taking into account the learning from the first year of delivery and alignment with ‘A Healthier Wales’:



25.  There is a greater emphasis this year on the delivery of transformational models for primary and community care, with clinical change programmes to tackle the ‘Big Four’ causes of ill health and disability in Powys. These are cancer (neoplasms), respiratory diseases, circulatory diseases and mental health disorders as these all feature prominently from the early years across the life course. These priorities are evidence based and feature strongly in the Public Health Wales NHS Trust work on Burden of Disease.

26.  We are progressing the development of Primary Care clusters in North Powys, Mid Powys and South Powys, reflecting the natural geographies and community identities in these areas.

27.  There is a greater emphasis on connecting communities to improve resilience and create opportunities for co-production. The recently approved Transformation Bid will allow us to accelerate our flagship programme of work on the North Powys Well-being Programme. This work will seek to meet not only the objectives in ‘A Healthier Wales’ but in ‘Prosperity for All’.

28.  There are a number of key service developments over the last few years that already help set the ambition for service developments focused on care closer to home. The Powys Virtual ward has now been established for several years, services such as Wet AMD is now provided in community hospital setting, leg clubs are developed across the geography seeing over 350 people each week, and an investment of 13 Community Connectors is helping to prevent loneliness and isolation.



29.  The health board has delivered a balanced plan across four years of successive IMTPs and has an approved financial plan for 2019/2020 as part of our ongoing approved IMTP status.

30.  In 2018/2019 the health board has delivered against the statutory duty to ensure that revenue expenditure does not exceed the aggregate funding allotted over a three year period. There was a £65K surplus in 2018/2019 and a £246K surplus for the three year period 2016 – 2019.

31.  The health board also met its statutory duty of ensuring that its capital expenditure does not exceed its funding over a three year period. There was a £13K surplus in 2018/19.

32.  We also met the Public Sector Payment policy to pay 95% of non NHS invoices within 30 days during 2018/19.

33.  There are continuing economic pressures that challenge public finances and ensuring that PTHB remains in a balanced financial position whilst maintaining good quality health services that meet growing and more complex needs is a significant challenge over the next three years. Public services in Powys will be reliant upon creating efficiency through the establishment of strong, strategic and operational relationships with a range of partners including other health boards, the Primary Care Sector, the Third and Independent Sectors.

34.  The savings programme established over the life of the financial plan assumes significant avoidance of future growth from our externally commissioned services through implementation of best practice supported by business intelligence development.

35.  The Efficiency Framework is a key source of information to target opportunities which will be critical in addressing the impact of the current and predicted growth in secondary care service demands and shifting care towards more preventative, early help and support. Independent reviews have identified that there is scope for greater service and financial sustainability through the redesign of services.

36.  Strengthening arrangements with providers of services as well as via regional and All Wales collaborative mechanisms will be fundamental to delivering the transformation envisaged in our own strategy and A Healthier Wales.

37.  The implementation of the Clinical Health Knowledge System in PTHB has provided invaluable commissioning intelligence and this will continue to be developed to support the delivery of our financial plan.


Performance, Escalation and Intervention

38.   PTHB has a ‘routine’ monitoring status and continues to have an approved status for its Integrated Medium Term Plan (IMTP).


39.   The health board continues to perform well against most of the directly influenced key targets set by Welsh Government.  We are also performing well against the well-being objectives set jointly as part of the Health and Care Strategy, A Healthy Caring Powys.

40.   The following provides an overview of achievements for the period 2018 – 2019:


Directly Provided Services

41.   As a provider of services we are able to consistently able to meet the timely care access targets for referral to treatment within 26 weeks and ended the year exceeding 99% compliance against a target of 95%. No patient has waited longer than 36 weeks for treatment in our own provided services.

42.   Our own provider performance in unscheduled care continues to be very good with our minor injury units maintaining 100% compliance for admission to discharge within the four hour target and zero patients waiting over twelve hours. Winter Resilience planning in Powys takes a whole system approach and includes both activity as a provider and a commissioner in relation to care co-ordination and flow across health systems used by Powys patients. (Further information on commissioned services is provided in the following section).

43.   We have made significant improvements during 2018/2019 in diagnostics and ended the year with no patients waiting more than 8 weeks. There had been delays in the months prior to the year end in relation to clinical capacity within speciality services that had caused some delays. Actions were taken including recruitment to specialist nursing to increase diagnostic capacity.

44.   Since returning to direct delivery by the health board, access to mental health services has shown significant improvement, consistently achieving low levels of delayed transfers of care and meeting the key measures for assessments and contact with an independent advocate. An improvement plan for therapeutic interventions has seen significant progress although further work is required to close the gap further as this remains under the national target. We are continuing to review and improve our referral to treatment times for psychological therapies and reduce waiting lists. The use of Psychology Assistant posts to improve the matching of clinical capacity to demand and the development of a personality disorder pathway are included as key actions to deliver against a 26 week referral pathway in 2019/2020.  

45.   There are challenges in relation to primary care sustainability which are not unique either in Wales or the wider UK geography in terms of workforce and capacity. PTHB has implemented a sustainability toolkit with general practices to enable an assessment across a number of domains and assist with the short and longer term planning for primary care. There has been significant progress in developing primary care roles and functions in dentistry, optometry and community pharmacy. The Common Ailments Scheme in particularly has been a home grown success that is sharing learning and promoting good practice on an All Wales basis. We have also seen an extension of roles in community optometry, contributing to improved follow ups and supporting the management of Wet Age-related Macular Degeneration (Wet AMD). Powys has also led on the development of Physician Associates in general practice.

46.   Childhood vaccination rates in Powys compare well with other health boards in Wales and we have achieved an improvement in MMR vaccination at 90.9% although similarly to other health boards we have not met the national target of 95%. We have engaged in the national work to address data quality and further action is planned to ensure the most accurate position is available and all reasonable steps are taken to close the gap further.

47.   We continue to achieve high levels of uptake of flu vaccination amongst our staff and have been enhancing the staff groups engaged in delivering flu vaccination to our population with a focus on at risk groups, particularly as there was a decline in uptake nationally for these groups over the past year. We are building on the success of our midwifery-led immunisation pilot by exploring a similar approach with other allied health professionals including therapy staff.

48.   We continue to have low rates of health care acquired infections, with a further reduction in C.difficile rates and no reported cases of S.aureus bacteraemia (MRSA and MSSA) in 2018/2019.  This is a particular achievement in the context of the new stricter testing last year.

49.   We have had zero never events over a four year period in Powys. However we did not achieve compliance with the national measure or our own planned trajectory in relation to Serious Incident compliance in the period 2018/2019. To resolve this, intensive work and additional resource has been assigned in this area, to address the historical open incidents and ensure both the capacity and the systems for recording incidents are improved. Significant progress has been made and the health board has set a trajectory for 2019/ 2020 that will achieve compliance with the national measure by September 2019.

50.   We have developed and implemented an integrated performance framework which enables us to track delivery against our ambitions. We will continue to build this approach to ensure we are measuring what matters and strengthening the collaborative approach with the Regional Partnership Board, Public Service Board and key partners.


Commissioned Services

51.   Due to our unique position as a commissioner rather than a provider of secondary care, PTHB has a role in relation to a number of Welsh and English health boards and Trusts and a collaborative commissioning role in relation to Ambulance Services and Specialised Services.

52.   There are areas of commissioned providers’ performance which are not achieving target measures or where there are a range of service fragility and sustainability issues. These include Ambulance Services response rate for red calls in Powys, Shrewsbury and Telford Hospitals NHS Trust and Wye Valley NHS Trust which are at stages of escalation within the regulation and inspection framework in England and have strategic change programmes in place.

53.   The health board therefore takes a whole system approach to robustly manage this complex landscape and has approved aStrategic Commissioning Framework which reflects the values and arrangements of NHS Wales. This has enabled the implementation of a Commissioning Assurance Framework across our main NHS providers.

54.   This Commissioning Assurance Framework provides a robust mechanism to track and identify emerging patterns of poor performance and areas of risk specific to use of services by Powys residents. The framework encompasses the domains of patient experience, quality, safety, access, activity, finance, governance and strategic change.

55.   We maintain a Fragile Services Log, which ensures an up to date picture across our 15 main providers by speciality and geography and provides critical intelligence to feed into our commissioning processes.

56.   In addition we also maintain a Stocktake of Strategic Change programmes across our neighbouring areas and carry out targeted impact assessments and engagement planning on those live programmes with a material impact on the Powys population. 

57.   We are currently extending the Commissioning Assurance Framework with Primary Care and plan to extend further with speciality specific services and residential care, in liaison with the local authority.

58.   We recognise that there is still work to do to maintain and strengthen our own performance in Powys and contribute positively to the All Wales position. Whilst there is investment in NHS Wales this year, there remain financial challenges across the whole system.

59.   We are strengthening the alignment between delivery and strategy this year with an Organisational Development Strategic Framework, ‘Best Chance of Success’.



Workforce and integrated working

60.   There are significant challenges and opportunities relating to the workforce in Powys, including recruitment, retention, an ageing workforce and workforce fragility. We have an ambition to  become an employer of choice and to grow more of our own workforce capability, flexibility and sustainability.

61.   Our workforce profile shows that 26% of our workforce are aged 55 and above. Despite the age profile in Powys, sickness seems to remain at a steady state. The health and well-being of the workforce needs to be seen in the context of the working population we serve. We therefore consider the Population Health Assessment is crucial in understanding the workforce health and wellbeing needs. Our staffing compliment is made up of 76% of Powys residents and 24% of staff commuting into Powys County to work for the Health Board.

62.   PTHB had some of the most positive results in Wales across key areas of the NHS Wales Staff Survey in 2018 and is above the overall NHS Wales scores for most of the questions asked. The results show continued positive improvements since the survey of 2016, however there are a few areas which have shown less positive movements in scores. The health board continues to have low sickness absence levels, meeting the Welsh Government target at year end 2018/2019. The measures for training and appraisals were narrowly missed (81% against target of 85%) and an improvement programme is in place to address this.

63.   Recruitment of clinical staff remains a challenge: Medical, nursing, therapies, and allied health professionals workforce pressures in Powys reflect the national picture.  This picture is mirrored in Social Care, Primary Care, the Third Sector, and the independent sector in Powys.

64.   To address this challenge, we have identified Workforce as a key enabler in our Health and Care Strategy and we have a specific well-being objective for ‘Workforce Futures’. Successful delivery will include co-operation with our partners on joint workforce planning including the workforce of our commissioned services.

65.   Through the Regional Partnership Board, we are taking a unique joint approach to workforce planning in Powys.  Employing the first joint Health & Social Care Workforce Planning Manager in Wales, we are making links across sectors. This work includes a detailed analysis of workforce needs across boundaries including volunteers and carers, now and into the future, enabling us to better understand the workforce requirements of new models of delivery. 

66.   We already have an integrated workforce either as a direct provider or a commissioner, in key areas such as the Integrated Autism Service and substance misuse services and we have plans to strengthen this further with the Local Authority and Regional Partnership Board, for example integrated commissioning of care home services.

67.   Powys does not have its own university in the county, however we are building strong working relationships with HEIW and local educational providers including universities and further education providers.  Through the Workforce Futures programme we are exploring the development of a Health and Care Academy of Learning.

68.   We are progressing with a Nursing project in partnership with Hywel Dda University Health Board, Swansea University and Aberystwyth University to provide degree level nurse education in rural mid Wales.

69.   As noted in previous points we have made significant progress in key areas including the implementation of physician associates in general practice and the development of advanced or enhanced nursing roles, to improve diagnostic and triage capability. 

70.   The health board takes a strategic approach in its ambition not just to respond reactively but to implement the Powys Health and Care Strategy, with positive and productive partnership working. We have embarked on an Organisational Development Strategic Framework, ‘Best Chance of Success’ which is ensuring that our culture, people, structures and processes are aligned to deliver against our IMTP and ‘A Healthy, Caring Powys’.  

Brexit preparations

71.  The Director of Public Health at PTHB is the nominated Executive Director and Senior Responsible Offer (SRO) for ‘no-deal’ Brexit preparations, and contributes to a national Senior Responsible Officers (SROs) group across health and social care which was convened by Welsh Government. 

72.  Executive and officer support is also being provided to support wider multiagency Brexit planning arrangements under Local Resilience Forum partnership arrangements.   

73.  Preparations within the health board have included internal exercising arrangements to identify, test and mitigate ‘no-deal’ Brexit related risks.  The results of this exercise have informed changes to business continuity and resilience planning, and ensured that major risks against a ‘no-deal’ Brexit are embedded into robust and realistic plans for those areas that fall within the remit of health boards.   

74.  The health board has actively participated in all regional and national planning arrangements, regular communications have been issued to staff, and ‘no-deal’ Brexit has been a regular item at Board meetings.   

75.  Work continues ahead of the 31st October deadline to plan for a possible ‘no-deal’ scenario.


Concluding remarks

76.   We would like to thank the Committee for the opportunity to provide evidence in this written submission and at the Committee itself. Our health and care strategy, and thus our Integrated Medium Term Plan is a collective effort, which includes many others across the Welsh NHS system including the providers of acute, primary, community and specialist care, ambulance services and our colleagues in social care, the independent sector and the third sector.  It also importantly includes our own residents, patients, carers, members of friends groups and other community groups as well as the Community Health Council. We all have a shared ambition of ‘A Healthy, Caring Powys’, as part of A Healthier Wales, and we look forward to keeping you updated on our shared progress.