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SUMMARY REPORT ABM University Health Board

Health Board Date: 27

th November 2014 Agenda item: 7 (ii)

Subject Integrated Medium Term Plan (IMTP)

Prepared by Karen Pearman, Acting Assistant Director of Strategy David Osborne, Programme Manager

Approved by Siân Harrop-Griffiths, Executive Director of Strategy

Presented by

Siân Harrop-Griffiths, Executive Director of Strategy

Purpose

This report requests the Health Board: 1. To receive and consider progress against delivery of 2014/15

IMTP. 2. To note Welsh Government (WG) expectations in line with the

2015/16 NHS Planning Framework. 3. To note the proposed Health Board process to refresh the

2014/17 IMTP in line with WG timescales. 4. To receive an update on progress in refreshing the 2015/18

IMTP.

Decision x Approval X Information

Other

Corporate Objectives Excellent

Population Health

Excellent Population Outcomes

Sustainable & Accessible

Service Strong

Partnerships Excellent

People Effective

Governance

X X X X X X

Executive Summary

A six monthly review of the Integrated Medium Term Plan (IMTP) has been completed and this report provides progress against each of the Strategic Change Programmes and highlights the Programme Plans for the remainder of the year. It also outlines the 2015/16 IMTP refresh process in line with the 2015/16 NHS Planning Framework. The 2015/16 NHS Planning Framework was published on the 31st October 2014 which provides guidance on the development of the 2015/16 Health Board IMTP. This report summarises the Welsh Government process for the planning and development cycle, timescales for the completion of the Health Board IMTP and a framework to consider, against which, Welsh Government will test plans submitted in January 2015. This report also outlines the Health Board’s internal process and proposed governance arrangements; and provides an overview of where we are in the planning and development cycle.

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Key Recommendations 1. To receive and consider progress against delivery of 2014/15 IMTP. 2. To note Welsh Government (WG) expectations in line with the 2015/16 NHS

Planning Framework. 3. Consider and agree the proposed Health Board process to refresh the 2014/17 IMTP

in line with WG timescales. 4. To note update on progress in refreshing the 2015/18 IMTP.

Corporate Impact Assessment Financial Implications There are no specific resource impacts in preparing this report

but delivery of the measures within the report could release resource and increase quality of care.

Quality and Safety The Report link to the following standards: - • 1 – Governance and accountability framework. • 6 – participating in quality improvement initiatives • 7 – Safe and clinically effective care.

Risk n/a Legal Implications n/a

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MAIN REPORT ABM University Health Board Health Board

Date: 27th November 2014 Agenda item: 7(ii)

Subject Integrated Medium Term Plan (IMTP) Prepared by Karen Pearman, Acting Assistant Director of Strategy

Approved by Siân Harrop-Griffiths, Executive Director of Strategy

Presented by Siân Harrop-Griffiths, Executive Director of Strategy

1. PURPOSE This report requests that the Health Board:

1. Receives and considers progress against delivery of 2014/15 IMTP; 2. Notes Welsh Government (WG) expectations in line with the 2015/16 NHS Planning

Framework; 3. Notes the proposed Health Board process to refresh the 2014/17 IMTP in line with

WG timescales; and 4. Receives an update on progress in refreshing the 2015/18 IMTP.

2. BACKGROUND Abertawe Bro Morgannwg University Health Board’s Integrated Medium Term Plan (IMTP) for April 2014 to March 2017 sets out our plan to fulfil our civic duty, both as a commissioner and provider of services, to meet local health needs. This includes our responsibilities to deliver high quality effective and efficient services and as a major employer and contributor to the local health economy. Our IMTP sets down how, over the next three years, we aim to improve the health of our population, the quality and safety of the services we provide, to meet Tier 1 standards and meet additional demand on the NHS through new ways of working and new models of care. The IMTP sets out how we will change for the better over the next three years. The Strategic Change Programmes are key delivery vehicles for how the Health Board will create high quality, safe and sustainable services, achieving both national and local performance standards, using robust monitoring arrangements and effective governance systems. Each Programme has been specifically designed to support the delivery of our Health Board strategy, with focused membership and engagement throughout the organisation. The success of the Strategic Change Programmes is critical to meeting the aims of the next 3 years.

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The seven key Strategic Change Programmes set out within the IMTP are:

Changing for the Better Clinical Service Programme

Unscheduled Careand Patient Flow Programme

Commissioning Development Programme

Surgical Pathway Efficiency Programme

Patient Experience Programme

Patient Safety Programme

Effective Use of Information Systemsand Technology Programme

Seven Key Strategic Change

Programmes

Enabling Programme

Enabling Programme

Quality Programmes

Service Change

Programmes

. 3. 2014/15 Plan A summary of the 2014/15 IMTP has been prepared and is attached at Appendix 1. This document summarises the key themes and priorities in the IMTP, and will be made widely available through our internet and intranet as a much more accessible document for the public, staff and stakeholders. The focus of this paper is to update the Board on progress against the 7 Strategic Change Programmes. The Board will be aware that the Programmes are complex and contain several projects within each. A detailed 6 month review report setting out the progress of the seven programmes is attached as Appendix 2. This sets out in a level of detail the considerable activity and service change that has been implemented across the UHB in the first six months of the year to support delivery of the UHB’s Strategic Change Programmes. It also identifies that there are areas of risk in terms of full delivery of plans and outcomes. The plans to implement the Programmes are currently being reviewed to confirm their deliverability and expected outcomes; this will inform the development of next year’s IMTP. Progress against the IMTP is reported to the Board and its sub committees through a variety of routes throughout the year. Performance against the target measures within the overall IMTP, is covered by the routinely reported integrated performance report for the Health Board. For the November 2014 Health Board meeting this is attached as report 7(i). The position statement on the financial performance of the IMTP is included in the papers as report 7 (iii).

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4. 2015/16 NHS PLANNING FRAMEWORK The 2015/16 Planning Framework was published on the 31st October 2014. The following section summarises the planning and delivery cycle, and the timetable for the 2015/16 IMTP. 4.1 The Planning Cycle The planning cycle is designed to ensure that the development or refresh of an IMTP does not become an annual “one off” event but is a dynamic activity, embedded into the way the Health Board conducts and manages its business and critically delivers improved outcomes for populations and communities. Figure 1 below demonstrates the three key components of the cycle: • Plan Development • Plan Approval • Plan Delivery, Monitoring and Escalation These three main components of the cycle provide the structure of the 2015/16 NHS Planning Framework: Figure 1: Planning and Delivery Cycle

Planning & Delivery

Cycle

Scrutiny & Assurance

Cycle

RefreshPlanning

Framework issued

Diagnostic &

Engagment Phase

IMTPs recalibrate

d

Board Scrutiny & Approval

National Scrutiny & Approval

Escalation Options

Delivery & local

assurance

Integrated Monitoring

Escalation Options

Plan Developement

Plan Approval

Plan Delivery & Monitoring

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The 2015/16 NHS Planning Framework was published on the 31st October 2014 by Welsh Government. Following feedback from Health Boards the guidance has been strengthened in the following ways;

• National planning requirements have been clarified, with a focus on defining success and setting out expectations of the IMTPs;

• Clear policy imperatives for strengthening primary and community care, embedding prudent healthcare and reducing health inequalities have been added;

• Decision making and approval responsibilities have been made clear; and the steps that will be taken to strengthen the planning profession across NHS Wales have been identified.

As outlined in the framework, the submission of the final draft 2015/16 IMTP to Welsh Government is required by 30th January 2015, and will be submitted to the Board on 29th January 2015 for approval. Board members will be given the opportunity to see and comment on the draft prior to submission to the formal Board meeting. 4.2 Timetable (2015/16 Integrated Medium Term Plans) 2015/16 IMTPs must be submitted by 30th January 2015. The final draft plan will need to be approved by the Health Board prior to submission to Welsh Government. The timetable for the development, scrutiny and approval of the 2015/16 Integrated Medium Term Plan is provided in Table 1 overleaf:

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Table 1

Action Date WG NHS

Pl

an D

evel

opm

ent

Integrated Planning Framework developed between Welsh Government and NHS

June – October 2014 √ √

Integrated Planning Framework issued to NHS October 2014 √ NHS organisations develop 2015/16 Integrated Medium Term Plans in accordance with Integrated Planning Framework

October 2014 – January 2015 √

Indicative budgets and financial assumptions to NHS organisations

October 2014 √

Financial Allocation letters issued to Health Boards and Trusts

December 2014

√

Welsh Government sponsored peer review – draft organisational plans ready for sharing

December 2014 √

Pl

an A

ppro

val

NHS Organisations’ Boards approve “Final Draft” versions of Integrated Medium Term Plan

January 2015 √

NHS organisations submit the ‘Final Draft’ Board-approved plans to Welsh Government

31 January 2015 √

Welsh Government scrutiny process February – March 2015 √ Boards respond to feedback from scrutiny process and amend Plans accordingly. Boards then approve these final versions

Prior to 31st March 2015 √

Pl

an D

eliv

ery

Delivery agreements for approved IMTPs April – May 2015 √ Integrated Delivery Board Meeting (WG internal) Monthly √ Quality & Delivery Meetings (WG and NHS) Bi – monthly or

monthly(dependent on escalation levels

√ √

Joint Executive Team Meetings Six monthly √ √ Quarterly Planning Review Meetings June 2015

September 2015 December 2015 Feb/March 2016

√ √

4.3 Framework for the Development of the IMTP Figure 2 provides the strategic context for the development of 2015/16 IMTPs. The Health Board is not required to structure the plan around the diagram; rather it provides a framework, against which Welsh Government will test plans submitted in January 2015. It will heavily influence the Welsh Government’s approach to assessment and therefore must be considered in developing this year’s IMTP.

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Figure 2: Framework for the Development of the IMTP

FRAMEWORK OF NATIONAL PLANNING REQUIREMENTS

CENTRAL ORGANISING PRINCIPLES

golden threads running through entire planning process, they are values and principles that must underpin plans in

the Welsh NHS

ENABLERS

the key resources and assets that will allow a plan to be delivered

SYSTEM SHIFTS relate to the development of new ways of doing things rather than doing things

better within existing models. They should be evident through all aspects of

the plan

PATHWAYS whilst there are many, often designed to

respond to local circumstances, the advent of national programmes for

unscheduled and planned care have and continue to set common

requirements that must be evident in all organisations

SPECIFIC NEEDS the diagnostic stage will identify

particular populations with a higher level of, or different, needs from services.

Meeting those needs will be common to all services across the NHS and

therefore reflected in national plans

Prudent Healthcare

Quality and Safety

Prevention & Health Improvement

Strengthening primary and community care

Integrated Care and Partnership Working

Service Change

Unscheduled Care

Planned Care

Children, Young People and Maternity

Delivery Plans

Older People

Mental Health

Workforce and OD

Estate and

Infrastructure

Revenue Innovation Research

Health Inequalities

Outc

omes

and

Deli

very

Fra

mew

ork

IMT

4.4 Peer Review Process Welsh Government has appointed the Good Governance Institute to help support and facilitate this exercise, which will run in December 2014. The proposal is for 3 clusters of Local Health Board to peer review each others’ plans, together with a day facilitated by the Good Governance Institute in December to support the provision of feedback. In order to achieve these timescales, this means the Health Board will need to submit draft plans to the Good Governance Institute by the middle of December. 5. HEALTH BOARD IMTP PROCESS FOR 2015/18 The objectives of the IMTP refresh are:

• To maintain focus on delivering our priorities; • To refresh the 2014/17 IMTP as follows:

a. Provide a position statement against year 1 of the 2014/17 IMTP b. Agree year 2 delivery plan;

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c. Identify year 4 developments; d. Ensure commitments given during last year’s IMTP process about

improvements in 2015/16 are delivered; e. To ensure the document reflects the 2015/16 NHS Planning Framework.

The document will be re-drafted in the context of:

• Organisational change; • Revised Quality Improvement Strategy (incorporating Action after Andrews); • Outcomes from the Values work; • Updated Joint Strategic Needs Assessment; • Learning from the Patient Safety and Experience Programmes during 2014. • 2014/15 being a transition year as new Strategic Planning and Commissioning

Boards are developed; • Ministerial Priorities:

o Prudent Health Care o Primary and Community Care o Supply and Demand Balance o Workforce Planning

• Any new national drivers eg. o New Social Services and Wellbeing (Wales) Act 2014; o Future Generations Bill o NHS Outcomes and Delivery Framework.

It must be noted that the document is a refresh not a rewrite and it is planned to retain sections on life courses, strategic vision and aims. Sections 1 to 4 and 9 and 10 will be updated in line with the above. Sections 5 to 8 will be reviewed in line with updated Directorate and Locality plans and the NHS planning framework. Where are we?

• IMTP Refresh Group established July 2014. • IMTP refresh template issued to Directorates and Localities in August 2014. • IMTP Sharepoint site set up at the beginning of October to share relevant information

(Link: http://brosps:8081/sites/Finance/CorpDir/Planning/IMTP/default.aspx) • Mid-year performance reviews with Directorates and Localities held in October 2014

to share initial thoughts; • Draft plans will be received by the 21st November 2014. • Draft plan to be populated by the 16th December 2014 in preparation for the peer

review. • Final draft to be completed by the 31st December 2014 for presentation to January

Board meeting. 6. RECOMMENDATIONS The Board is requested to:

1. To receive and consider progress against delivery of 2014/15 IMTP; 2. To note Welsh Government (WG) expectations in line with the 2015/16 NHS

Planning Framework;

http://brosps:8081/sites/Finance/CorpDir/Planning/IMTP/default.aspx

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3. Consider and agree the proposed Health Board process to refresh the 2014/17 IMTP in line with WG timescales; and

4. To note update on progress in refreshing the 2015/18 IMTP.

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Appendix 1

3 Year INTEGRATED PLAN

3) COMMISSIONING PLANS

2) ORGANISATIONAL STRATEGY

Local resource and delivery

proposals and plans

Community Networks, Localities, Clinical Directorates, Service

Improvement Team

Process & forum to be decided

Board, Executive Team, Clinical Assurance Group, Commissioning Boards, C4B Team,

WBP Board

Commissioning plans to deliver system change

Strategy to deliver vision,

priorities, outcomes

CITIZENS &

PARTNERS

1) ORGANISATIONAL VISION & PRIORITIES

10 year STRATEGIC PLAN

1 year OPERATIONAL PLANNING

Vision, Aims, Priorities,

Outcomes, Values

Workforce, IT, Capital, Finance, Implementation

6) INFRASTRUCTURE PLAN NING

5) BUSINESS CASE PRIORITISATION LOCAL PLAN AUTHORISATION

4) LOCAL DELIVERY PLANS BUSINESS CASES

MONITORING & PERFORMANCE MANAGEMENT: Outcomes, Quality, Targets, Delivery Plans, Activity/Cost

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APPENDIX 1

ABERTAWE BROMORGANNWG UNIVERSITY HEALTH BOARD Strategic Change Programmes IMTP 6 Month Review 2014/15

1.0 Introduction This report provides an update on the 7 Strategic Change Programmes detailed in the IMTP. These programmes are: - 1. Changing for the Better 2. Commissioning Development 3. Patient Experience 4. Patient Safety 5. Effective Information Systems and Use of Technology 6. Surgical Pathway 7. Patient Flow

2.0 Changing for the Better Programme The 9 Projects within the programme are:

• C4B Staying Healthy Project • C4B Community Services Project • C4B Rapid Access Services Project • C4B Pre Hospital Services Project • C4B Hospital Services Project • C4B Women, Children and Families Project • C4B Trauma Centre Development Project • C4B Outpatient Modernisation Project • C4B Elective Procedures in Primary and Community Care 2.1. Changing for the Better Staying Healthy Project The Staying Healthy Project has adopted a life course approach and aims to reduce health inequalities observed in our most vulnerable and disadvantaged communities. Progress The Smoking Cessation Project has been significantly progressed, supporting the Health Board towards achieving the Tier 1 target. A thorough prioritisation exercise was undertaken which resulted in 38 Community Pharmacies (out of 125 across ABM) being selected, to run a Level 3 stop smoking service. The commitment made within the IMTP was aimed at 23 Community Pharmacies, with the Executive Team agreeing to an extension of the commitment. Training and accreditation for the Level 3 services commences in September 2014, with a view to having a proportion of the pharmacies up and running by 1st October (this also co-incides with the Stoptober campaign, for which there are several local events and activities planned to create publicity and demand for this service).

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In addition to local service developments, the Project has developed a local marketing campaign, ‘Start Here’, to drive up demand for these services. In order to tailor this campaign to our most deprived communities, the Project has liaised with Communities First teams throughout the development of the campaign. Planning is also progressing with the hospital-based smoking cessation service, during September; the Integrated Pharmacy and Medicines Management Directorate has been selected to host and manage the service with a view to being operational by the end of the year. Following an obesity needs assessment that was recently completed for the ABM area, an adult weight management business case has also been developed, to be ratified by the Staying Healthy Project Board, followed by C4B Programme Board and C4B Delivery Board in Oct/Nov. Scoping work has also begun on developing a children & young people’s weight management business case.

2.2. C4B Community Services Project The Community Services Project is centred on delivering improved services for Frail Older People and those with Dementia. This is a joint project between Western Bay and Changing for the Better. A Joint Commitment was agreed by all four partner organisations in September 2013. The first priority was to start with Intermediate Care and then phase into development of wider proimary and community services. Progress Intermediate Care The Intermediate Care programme has been rolled out across the three locality areas following investment of the £7.8m investment from Welsh Government in 14/15. 140 permanent staff members are being recruited through a comprehensive recruitment campaign started in the summer – this is nearing completion, with 80% of staff recruited, against a re-profiled position which reflects slippage. An Intermediate Care implementation manager commenced in August 2014. The initial focus of the post is to develop a consistent infrastructure to support the operational leads with the delivery of Intermediate Care across the region. In addition, the Project has commissioned Whole System Partnership (WSP) to establish a performance framework for Intermediate Care implementation. A provider has been commissioned to advise on the Section 33 and Pooled Fund arrangements for the Western Bay Programme including the Intermediate Care business case. Detailed financial arrangements across the four partner organisations are being remodelled. These arrangements are planned to be in place by March 2015. WSP prepared the Quarter 1 reporting on Intermediate Care fund expenditure for Welsh Government. Given the lead in time for commencement of posts being recruited, the expenditure against the fund was under profile for quarter 1; any slippage has been re-profiled into subsequent quarters as well as proposals directed into other initiatives in line with the Intermediate Care investment themes. Any redirection of slippage will require the approval of the Programme Board.

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Managed Care Closer to Home Executives from both Health and Social Care took part in the initial scoping of this work in August 2014 and have requested that the work of Abertawe Bro Morgannwg University (ABMU) Community Networks merge to form a comprehensive programme of work to develop primary and community care across Western Bay. The initiative has secured some minor investment through the Regional Collaborative fund and executives has asked to commission external support from the Better Care Fund in England in order to scope this significant work programme. Older People’s Mental Health (OPMH) There are historical issues in designing a service model for OPMH across the four organisations with complex issues between the physical frail and specialist mental health diagnoses. A considerable amount of work has been undertaken to model service for memory assessment and management. A planning session with Psychiatrists, Acute Physicians, Nurses, therapists, social workers, the third sector and managers took place on September 2nd 2014 to try to establish an integrated model for delivering services across western bay. A detailed options appraisal is now being put together based on the discussions and issues raised at the session for submitting to Programme Board for discussion and decision.

Frailty Model Work has begun to design a frailty model for community services by March 2015, spanning primary, community and hospital care. A symposium is being planned for the winter which will invite academics and experts in the field of frailty in order to agree the definition of frailty and start to tackle the issues relating to the management of these service users, e.g. generalist v specialist. Detailed preparatory work to prepare for that, which builds the practical side of managing frail older people, is happening in the meantime, e.g. comparison of the various indices we use to assess frail older people which then provide inconsistent care packages. Community Resilience In support of the strategic aim around older people keeping well and supported in the community, the project has been working with Welsh Government and Third Sector to develop a proposal on innovative ways of adopting social finance into mainstream service delivery. The proposal is currently at the funding stage and a ‘proof of concept’ bid has been submitted to the Primary and Community Care fund. The proposal focuses on using time credits to address loneliness in isolated communities in order to stop the exacerbation of these vulnerable people to more complex care packages and hospital admissions. 2.3. C4B Rapid Access Services Project The overall objective is to provide a model for rapid access services in each of the localities in ABMU that are specialty specific and proactively provide a range of rapid interventions. These are split into three distinct areas Rapid access to assessment and treatment (initially through development of an ambulatory unit at Singleton), rapid access to specialist advice (GP to specialist advice lines) and rapid access to diagnostics (radiology) Progress

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There has been a delay in implementing the ambulatory unit (ward 10 expansions) in Singleton and the rapid access radiology services across all localities due to the situation with availability of capital investment and lack of agreement on investment by Localities, as agreed to in the Integrated Medium Term Plan. Discussions with Localities have taken place through August and September in order to agree operational delivery arrangements as well as clarification of the investment requirements. A number of solutions are currently being finalised for discussion in individual localities and then C4B Delivery Board Ambulatory Care Following Programme Board endorsement of the Ambulatory Care model and way forward, discussions have taken place with the Ambulatory Emergency Care Network (part of the NHS Improvement Agency in England) to establish a cohort for ABMU. The network has come back with a number of options which are being discussed within key groups. As a result of the meetings in August and September the locality have agreed the model for the ambulatory unit in Singleton. A working Group has been established consisting of the Rapid Access Project leads and key members of Swansea Locality. The purpose of the Group is to operationalise the cold site ambulatory unit, forming immediate, medium and long term options, dependant on the infrastructure and investment dependencies. Specialist advice for GPs Through initial planning work, the Rapid Access project has attracted interest from the NHS Wales Informatics Service (NWIS) to begin a pilot in ABMU with regards the use of the Welsh Clinical Communication Gateway (WCCG) as a mechanism for establishing specialist advice lines between GPs and specialists. NWIS have established test versions of the Scottish version of WCCG for ABMU ICT programmers to begin development work ahead of piloting with GP practices and specialties in the autumn. Good progress has been made with the development of specialist advice governance structures and discussions with Rheumatology, Gastro-enerology, Cardiology and MCAS. Rapid Access to Diagnostics Following sign up to the radiology models, the localities requested further information in the summer. The Clinical Support Services Directorate has collated detailed analysis of access to radiology, the detail of which is to be shared with Directorates and Localities towards agreement of the benefits of the Project, efficiency gains and investments required for delivery. An extended pilot is being considered to increase the understanding of the improvements that can be realised through the Project. 2.4. C4B Pre Hospital Services Project The aim of this project is to develop and strengthen services, with the Welsh Ambulance Service and other partners, to provide alternatives to the public / patients arriving unnecessarily at the Emergency Department and within Primary Care. Progress Frequent attendees The Project is piloting work that identifies a numbers of frequent attendees at the Emergency department who are then contacted by the third sector (Red Cross) who work with them closely for a 12 week period on a behaviour change programme.

Public Education

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The project is focused on continuing to inform the public of what unscheduled care services are available and when they should be appropriately accessed. This is being progressed through the “Choose Well Campaign” a priority of this Campaign is to communicate and engage with ABMU staff on the Key messages.

Direct Access This project will be working with Specialities to develop Direct Access Pathways for Patients from the Community and Patients who WAST are conveying. This work is closely linked to the developments of an acute hub. Alcohol Treatment Centre (ATC) - The “Help Point” will open on 20th September 2014 ready for Freshers Fortnight, this has a focus on reducing inappropriate attendences to the emergency department, and a significant role in reducing vulnerablity in the nighttime economy through creating an accessible safe haven Care Home Conveyance- The project continues to have a significant focus on Care Home Conveyances and, through a range of actions, aims to see the number of conveyances (currently 4000+ per year in ABMU) reduce over the next 6 months. The project will continue to oversee the “Choose Well” campaign, through September, working with Welsh Government on planning to develop the brand. 2.5. C4B Hospital Services Project The purpose of this project is to establish and improve the coordination of services within hospitals (serving our Health Board Area) into a ‘network’ of hospitals serving the health care needs of the population of Swansea, Neath Port Talbot and Bridgend and wider region.

Progress

Medical Workforce The recruitment of the additional medical workforce has commenced, however, the full recruitment scheduled within the IMTP is subject to the resultant savings being operational deliverable, and these are currently in development. Detailed work is ongoing to describe the specialty service models for each of the specialties once worforce are in place. All of the speciality plans are in line with the C4B principles and supports the implementation of the appropriate Welsh Government Delivery Plans. Surgical Strategy – Swansea & Neath Port Talbot (NPT) As the next step in developing a medium term surgical strategy which outlines how / where surgical procedures should be delivered at the 3 main Hospitals in Swansea and NPT the Project Team have completed the data analysis of each surgical procedure, by site, age, bed stay etc. A group from Corporate Planning, Information, & Finance are sourcing an appropriate modelling tool which will be an essential resource in progressing the development of a strategy. Oncology & Haematology The Oncology & Haematology group has two primary aims: firstly to develop an interim plan for the Management of Acute Oncology & Haematology following the proposed co-location of acute inpatient medicine at Morriston. A plan has been developed and during August 2014, clinicians have used a retrospective audit to test and inform the plan.

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Following discussions with Swansea University a proposal has been received by the Project Team. The proposal from the University is to model the future demand for Cancer Services over the next 10 / 20 years. This will be important information for the Cancer Commissioning Board once established, and will inform the priorities for service development in coming years. Relocation of Therapies and Ward space Work will continue during August and September with the Physiotherapy, Occupational Therapy and SALT service regarding the relocation of their services from the 2 ward template currently utilised by their services in Morriston. All services have identified and described the service that is required to remain on the main hospital site and the outpatient service which could be provided in different locations. Work is underway to identify options for where the inpatient service could be alternatively based. 2.6. C4B Women, Children and Families Project The objective is to transfer maternity, obstetric, neonatal and in-patient gynaecology services from Singleton Hospital to Morriston Hospital, when capital funding allows. The actual delivery of this will be beyond the current 3 year plan. Progress An audit has been undertaken within Paediatric Assessment Unit (PAU), Morriston, to better understand attendances at the unit. The data was then discussed with key personnel, in order to determine the best way in ensuring that where it is safe to do so, children are managed within the community. The next steps are to circulate some of the key findings to GP’s along with guidelines on how to manage particular conditions that wouldn’t necessarily require an admission or PAU attendance. An educational programme is also being considered in order to better equip GP’s with the skills required to care for children. Site visits have been undertaken to the Serennu Centre, Newport and the Kaleidoscope Centre, Lewisham, to explore local integrated models for children with disabilities (additional needs). Both centres provide examples of co-located services which provide a one-stop shop approach for families, where care is better co-ordinated both in terms of assessments and the planning and evaluation of care and interventions. It should be noted that co-location is considered to have provided the basis for improved working relationships and greater co-ordination, however there are still systems and processes under development that will enable a more stream-lined approach to assessment and care planning. Following on from the site visits, a workshop was held on 18th July 2014 with partners, looking at ways in which the Project can improve services for children with disabilities in Neath Port Talbot. A draft specification has been put together (this is due to be taken to WC&F Project Board and Think Families Board in September 2014), with a view to then creating a delivery plan for how this can be put into place. A further workshop was held on 27th August 2014, again with partners across ABMU, but looking at some of the broader challenges facing Children & Young People’s services (services discussed at the workshop included CAMHS, Continuing Care and Looked After Children). The output of the workshop has been prepared for a meeting with the Western Bay Programme Director and key individuals to discuss plans for improving services for children & young people by utilising a partnership approach.

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The project had a follow-up engagement session with the Youth Councils for NPT, Swansea and Bridgend on 12th July, in order to briefly update them on the Programme’s progress to date and to obtain their views on particular work that is underway in respect of the Women, Children & Families Project and also the Staying Healthy Project (for example smoking cessation and weight management schemes). 2.7. C4B Trauma Centre Development Project This project will support the implementation of the output from the South Wales Trauma Network Collaborative. A gap analysis of appropriate services, against the national standards for Major Trauma, has been completed. The gap analysis identified a number of areas that will require development including:

• Major Trauma Rehabilitation – ability to meet the requirement for a rehab prescription

within 72hrs and the additional rehab that is required. • The requirement to establish a system / service for the coordination of care for patients

with complex major trauma, once the patient leaves intensive therapy unit (ITU). • Ability to provide 24/7 major trauma lead. Progess A meeting of the South Wales Major Trauma Network Project took place on 11th September 2014. From ABMU, 8 clinicians represent their services on the Clinical Reference Group including 2 Clinicians who represent the Emergency Medical Retrieval & Transfer Service. In early September the post of Clinical Lead for Major Trauma was advertised to all ABMU Consultants, interviews are to be held on 16th October 2014. 2.8. C4B Outpatient Modernisation Project The scope of this project is to: - • National Benchmarking (look at other areas that may have had successes and failures

in increasing collaboration and reducing demand on traditional outpatients and learn from these.)

• Look at innovative ways to provide the core benefits of an outpatient attendance in the patient’s home.

• Intelligence on medical training requirements (i.e. does this negatively affect the way we plan to undertake outpatients in the future in terms of learning opportunities)

• Effectiveness of booking systems and alternatives approaches used elsewhere • Effectiveness of our communication back to referrer or GP via electronic transmission.

Could we discharge more and offer "See on Symptom" access? Can we improve communication in terms of e-advice?

• Why do we bring so many patients to a hospital clinic and what are the alternatives that have been proven effective in other areas / countries.

• What is the quality of information sharing both referral in and appointment summary etc? Are we sending the patient appropriate accurate information? What IT/hardware is available to help with this?

• Are we getting the best use out of our consultant time (sessional use, and could we consider virtual clinics or rapid access email advice for GPs etc)?

• Patient pathways and how do these need to change to modernize our service?

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Progress Several pilot initiatives are underway which include: • ENT telephone and email advice line (commenced August 2014); • Dermatology digital images in primary care (proposed pilot from October 2014); • Epilepsy email advice line; • Mental Health Care Home Virtual Clinic; • Parkinson’s Disease telephone follow up; • Digital images for early identification of oral cancers

In addition the following are being reviewed for the next phase: • electronic outpatient booking system to allow patients to more easily book and

rearrange appointments; • improved communication with patients to ensure patients are notified in a timely and

appropriate manner; • systems are in place to ensure that all patients have a clinically appropriate

appointment date for follow up. 2.9. C4B Elective Procedures in Primary and Community Care Minor surgical procedures identified as suitable will be carried out in a primary/community care setting in order to provide a better service to patients and address capacity issues within current secondary care services. Progress The intitial phase of the project has focussed on vasectomies. A comprehensive procurement exercise has been completed; two Community Networks (one in Swansea and one in Bridgend) have been commissioned to provide 250 cases per annum (per Network) across the ABMU area.

3.0 Commissioning Development Programme The Commissioning Development Programme has a specific commissioning development project within it which aims to further improve health board planning and delivery of services on the basis of population health need, evidence of clinical effectiveness, value for money and demonstrable improvements in population health outcomes. The key workstreams establised by the Programme to focus on the delivery of the aims and objectives are: • Joint Strategic Needs Assessment • Planning and Commissioning Frameworks and Commissioning Boards • Communication and Workforce Development • Improving Clinical Engagement in Commissioning • Improving use of Data for Commissioning Progress Significant progress has been made across each of the work streams. Meetings on the Joint Strategic Needs Assessment have taken place with the Western Bay Programme Team and plans are being developed for production of a JSNA and an annual refresh process to inform IMTP refresh which incorporates the implications of the new Social Services and Well Being (Wales) Act 2014. Planning and Commissioning Framework - a series of engagement and discussions have taken place across a number of forums both internally and with the Western Bay. A

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partnership with Swansea University, Public Health and ABMU is driving forward the creation of several Changing for the Better Commissioning Boards, including terms of reference, governance and incorporation of an approach to allocative efficiency; Programme Budget Marginal Analysis. It is the intention of the PBMA exercise to support the health board in delivering a discrete piece of work based on a defined budget area which delivers improved quality and patient outcomes for the same investment level. The first Commissioning Board is due to convene in November 2014 with a further two in March 2015 and three more by Summer 2015. A review of the Unscheduled Care Board has been undertaken to inform the development of the unscheduled care commissioning board. Terms of Reference along with Operating guidance for the commissioning boards has been produced. The staff engagement approach is continuing to build, the commissioning boards will be clinically led and have strong out of hospital clinical representation as part of this, work to develop links with the community network leads is also underway. The Workforce and OD lead is currently working on a communications approach to improve awareness and understanding for staff of the programmes work. The programme is working very closely with the changing for the better team, planning department and finance team to ensure that existing skills and capacity are aligned with commissioning programme plans where possible and appropriate. The support of data and information for use in commissioning has mapped current system capability and capacity to meet the organisational requirements. Joint collaboration with Swansea University and the Informatics service has completed its first phase on the use of the SAIL database, with the second phase scheduled to be completed September 2014. A Prudent Health Care Unit partnership proposal between the health board, public health Wales and Swansea University is currently under review.

4.0. Patient Experience Programme The Programme’s overarching vision is one of: Being a listening organisation – knowing how well we are doing – Learning from Experience Progress “You Tell Us” has been agreed as the overarching Patient Feedback Brand, co- ordinating the benefits delivered by the Programme. SNAP and DATIX have been procured which will provide a Ward to Board patient experience electronic analysis and reporting platform. Timescales for implementation areas follows:

• DATIX web Project is on track for 1st December 2014. • The SNAP Project responded to a shared roll out with Welsh Government of the “I

Want Great Care” patient feedback system, which is a 4 month pilot on the NPT site which commenced 15th October 2014;

Work is also underway with the University of Swansea to scope wider integrated reporting and the link to longer term health outcomes integration with the Secure Anonymised Information Linkage (SAIL) database.

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The Friends and Family Test has been fully implemented across all clinical areas within Princess of Wales site. The roll out to Neath Port Talbot is planned, but dependent on Private Finance Initiative (PFI) approvals. The formation of a single Health Board wide Volunteer service is on target. The Patient Feedback Team structure has been developed, with staff consultation commenced. The Patient Reported Outcome Measures (PROMs) Project has been deferred to the autumn of 2014, to prioritise the roll out of the SNAP patient experience system. The initial focus of the PROMs is intenedd to be for Trauma and Orthopaedics. There has been a redevelopment of the Health Board’s Intra and Inter-net “You Tell Us” patient feedback sites, led by the SNAP Project Manager with support from the Communications department.

5.0 Patient Safety Programme The overarching vision set for the programme is to ensure: Continuous improvement in patient safety, creating confidence in our services Progress In recognition of the need to put quality (of which safety is an integral part) at the heart of everything we do, a Quality Strategy is being developed by the Medical Director and Director of Nursing & Patient Experience. An initial draft of the strategy has been discussed at the Quality and Safety Committee where it was confirmed that the Committee was content with the focus and progress of the strategy. The strategy will be discussed at the C4B Delivery Board in December.

To support the implementation of the strategy an Integrated Quality Programme, incorporating key priorities from the Patient Safety and Patient Experience Programmes, actions from the AQuA (internally commissioned quality review) and Andrews (Trusted to Care) reports and learning from mortality reviews will be developed, and incorporated into the 2015-8 IMTP.

As part of the development of the Quality Strategy, an assurance framework will be put in place that will clarify the outcomes and benefits for our patients and public as well as the mechanisms for measuring and monitoring their delivery.

The Health Board’s safety priorities have been reviewed drawing on lessons learned from patient experience and external reviews. The Patient Safety agenda will be re-launched as part of the Integrated Quality Programme and IMTP for 2015-8.

It is important to note that whilst the structured Patient Safety Programme has not progressed as well as expected improvement work has progressed in a number of key areas. The Quality & Safety Committee receive regular progress reports on these work programmes.

To support the identification of potential Hospital Acquired Thrombosis (HAT) cases and learning the lessons, Welsh Government had mandated that monthly incidences are reported quarterly, with each case being investigated to determine whether it was avoidable and what lessons can be learned. A dashboard has been built to support this, where each case is treated as a critical incident and forwarded to the relevant Clinical Director. This demonstrates the linkage of the Patient Safety and Experience

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Programmes. 1000 Lives Improvement sponsored HAT Steering Group continues to raise awareness within the Health Board, other external organisations and the public.

Embedding Universal Mortality Reviews into practice has been a success. Three of the four main hospitals consistently review all their deaths and the fourth has now reached 90% compliance. The initial focus was on inpatient deaths on acute sites, this has now expanded to include Maesteg Community Hospital. To broaden the scope of mortality reviews and increase the opportunities for learning a pilot is being undertaken in three GP practices, one in each Locality, to review deaths that have occurred within 30 days of discharge from hospital. In-depth Stage 2 reviews that follow on from a sample of UMRs have highlighted a number of themes that have informed the review of safety priorities such as inconsistent recognition and response when a patient’s condition deteriorates. With support from the 1000 Lives Improvement Team the Health Board is working to promote and embed early recognition and intervention e.g. the Sepsis Care Bundle. A review of training provision, effectiveness and prioritisation is underway, covering the Resuscitation Training Team and “Last days of life – the Health Board’s End of Life delivery plan”.

Primary Care indicators are being refined, to provide assurance on quality and safety and encourage peer review. Compliance with care bundles and the documents used are under review to ensure effectiveness and efficiency.

In order to achieve the Tier 1 target of a reduction in C. difficile infection and improvements in antimicrobial stewardship / Proton Pump Inhibitor prescribing across ABM. A business case is nearing conclusion to develop a Programme Team, to undertake the following:

• Comprehensive, regular and consistent analysis of practices progress, including in-practice audits for the poorer performing practices.

• Enhanced surveillance of C. difficile ribotype. • Targeted interventions based on data from Heat Mapping software • Multidisciplinary prescribing reviews • Education and awareness sessions with GPs and non medical prescribers • Develop and co-ordinate a network of GP antimicrobial prescribing champions • Improve access to the Primary Care Antimicrobial guidelines. • Develop a visible ongoing Health Board wide campaign to raise awareness of

the dangers of inappropriate antibiotic use and associated antibiotic resistance, building on the existing ‘Big Fight’ campaign.

6.0 Effective Information Systems and Use of Technology The aim of the informatics strategy is to provide clinical staff with an electronic, patient-centred view of information in order to support high quality care. This information needs to be up-to-date, accurate, and available wherever care is being delivered, with reduced variation in IT systems. Progress The Informatics Strategic Outline Programme (SOP) has been submitted to Welsh Government, and been approved by the Capital Investment Board (CIB) in September 2015. The Strategic Outline Programme has been developed by Informatics and Finance to establish an innovative investment strategy, maximising the utilisation of sources of funding. This has been supported by individual Business Cases to establish funds for key

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projects in the areas of unscheduled care and surgical pathways. Funding requirements include:

• Procurement and implementation of the National Emergency Department system; • Hardware to support the rollout of the ABMU Clinical Portal and the TOMS Theatre

system across Swansea; • Hardware and resources to take forward the implementation of Microsoft SharePoint, to

support and streamline clinical and administrative processes across the organisation

A bid was put forward for the Welsh Government Health Technologies Fund to provide improvements to community and social care services through the use of technology. The bid was based on joint working between the Health Board and the 3 local authorities, with plans to also utilise Western Bay revenue funds. Unfortunately, ABMU were not successful, the requirements will now be taken forward under the Strategic Outline Programme.

Informatics, Finance and Planning secured an additional £500k of discretionary capital, to further the investment in technology, enhancing the infrastructure for our services. Additional discretionary capital is being pursued to extend the investment and improvement opportunity.

Progress on the deliverables set out above is as follows:

Digitising the Health Record – The submission of a business case to procure and implement a scanning solution has been recommended by Welsh Government, following a scoping session with WG Business Case scrutiniser. The plan is to take forward the implementation in 15/16

Document Management System (DMS) - The new Document Management System (DMS) for creating and managing clinic letters has been rolled out to all sites. The DMS solution enables secretaries to continue using Microsoft Word, but ensures that all letters are stored centrally against the patient record, enabling them to be easily retrieved at a later point. Existing letters currently stored inconsistently across multiple locations can also be uploaded to form part of a central patient record. The only areas that are not part of this first phase are Mental Health, Learning Disabilities and Sexual Health. Further work will be required to understand the needs of these services, given the sensitivity of the information that they hold.

ABMU Clinical Portal - On 7th July 2014, the ABMU Clinical Portal was rolled out to the Swansea hospitals. This implementation built upon the launch of the ABMU Clinical Portal on 1st July in the Bridgend and Neath Port Talbot Hospitals. This now provides staff with the ability to:

Maintain real time admission lists across the organisation Plan discharges more effectively using estimated discharge and medically fit dates Improve the quality and timeliness of discharge communication by providing junior

doctors, pharmacy staff and consultants with one standard solution for completing discharge summaries.

Seamlessly view electronic pathology results

The ABMU Clinical Portal Clinician View, providing a patient electronic document via the Clinical Portal is progressing well, with development started on the infrastructure commenced.

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ePrescribing – A business case is currently being prepared to identify the benefits of taking forward ePrescribing in both Outpatients and Inpatients settings.

eReferrals – ABMU is now receiving approximately 80% of GP referrals electronically. The next step is to conduct a pilot of electronic prioritisation by Consultants in Urology and Dermatology in the Princess of Wales during December/January.

ED System - Ministerial approval is required for the Emergency Department Clinical Information Management System (EDCIMS) following a preferred supplier being chosen. Meanwhile, ED departments are working through their business processes in readiness to go “paperless” when the new system is introduced. Finance Colleagues are meeting with the Medical Director, Informatics Directorate and NHS Wales Informatics Service (NWIS) to evaluate the contractual and funding options open to the Health Board and NWIS in progressing this matter.

Theatre System (TOMS) - The rollout of TOMS to Swansea will include the electronic capture of the Theatre Care Plans and WHO Checklists, and is due to go live in November 2014. The rollout requires capital investment. The requirements of this investment need to be described in a business case, specifically setting down the benefits of the required investments. This has been communicated to the Directorates and Project Management. On the basis this is provided, a funding solution is being sourced with Planning and Finance.

Pathology - The implementation of the National Laboratory Information Management System (LIMS) is scheduled for January through to March 2015. Financial resources have been made available to accelerate the implementation of the Pathology Directorate Analyser procurement to meet ABMU Health Board obligations in the LIMS Project.

Radiology – The PACS Project has received clinical signed off, with a 2 phase approach, implementation at Neath and Bridgend during early 2015, followed by replacement at Swansea by December 2015.

New Morriston Outpatients - The “Outpatient Flow System- in touch with health” implementation plan is on schedule for patients to self register upon arrival in the new outpatient department.

Patient Experience Feedback System (SNAP) – The implementation of the SNAP system is being piloted during October 2014.

Digital Dashboards (Qlikview) - The latest version of the Patient Flow dashboard went live on 26th September 2014. This version continues to improve dashboard functionality to aide Service Improvement using FISH methodology and now includes “vitals charts” at Hospital, Ward and ED levels along with further improvements in functionality when viewing charts. The screen shot below show the ED Vitals chart for Morriston Hospital. The first version of the Surgical Pathways dashboard will be available from early October 2014. Issue with theatres data has delayed the implementation of this dashboard and it is planned that the first version will be released for UAT prior to the next Surgical Pathways Programme Board on 15th October. This will provide a weekly view for users of Theatre information. This will expand to include RTT/waiting list/FUNB profiles for waiting list management.

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7.0 Surgical Pathway Programme In December 2012 our Health Board instigated a Surgical Pathway Efficiency Programme, in recognition of the opportunities that existed to improve patient experience and maximise the utilisation of theatres across the Health Board. The latter was based on an external consultancy review by CAPITA in 2012. Progress Efficient Standard Operating Procedures for Whole Pathway • Implementing and auditing use of the WHO checklist is underway • Actions following Medical Director’s letter on WHO Checklist are in place, taken

forward by a WHO checklist flag on the system, auditing compliance in theatres, and reported on Datex

• Index of Theatre Services Department Standard Operating Procedures reviewed and circulated

• Site based Surgical Pathway User Groups established • Desk top standardised process for cancellation of theatres and backfill in place

Right Workforce and Right Working Patterns • Bottom up work commenced to agree the theatre timetable for 2014/15 to meet

the RTT targets for the year • Good progress is being made on estimating the workforce capacity needed to

run Morriston theatres over a 50 weeks, 48 weeks and 46 weeks, matched against current budget staffing levels

• Good response to current theatre vacancies with the potential to appoint over 20 registered and 10 non registered nurses dependent on funding available

• New anaesthetic rota system in place together with changes to Consultant Anaesthetic job plans

• Good progress against plan being made with Pre Operative Assessment. Plan covers space and move to HVS; IT systems; Workforce and Financial Plan.

Beds and Equipment Available when Needed

• Cardiothoracic hold twice daily ward board rounds to coordinate and optimise patient flow across the pathway

• Weekly Morriston Surgical Pathway User meetings are to start following the example of the cardiothoracic weekly capacity planning meeting to review theatre lists with all specialties and anaesthetists

Fit Patients

• Anaesthetic component of Enhanced Recovery After Surgery (ERAS) pathway for Hip and Knee replacement at Morriston is being reviewed.

• Work started to widen ERAS to include some foot & ankle procedures led by clinicians within the MSK Foot and Ankle sub-specialty group

• Gynaecology and Plastic Surgery are starting discussions on ERAS good practice principals

• Supporting the ERAS pathway for vascular services additional therapies input has been invested to undertake a 1 year pilot to improve patients post operative recovery and rehabilitation

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• Morriston Pre-Operative Assessment (POA) Team transferred to Clinical Support Services as part of a planned incremental development of POA, the appointment of a senior nurse and the move to a new build in early 2015

• Three Consultant Anaesthetists appointed to commence POA sessions in September 2014

• POA IT system specification and demonstration been written and developed • Work continues on improving the availability of case notes and data collection to

inform the Day of Surgical Admission (DOSA)

In addition to the above: The Surgical Pathway Programme had been established to build upon the findings and recommendations by CAPITA, which described a number of efficiency gains that could be made in theatre utilisation, specifically improved start and finish times. The progress of this work has been discussed at the Programme Board; however, it has been limited pending the support of the Service Improvement Team. Women & Child Health has appointed a fixed term Surgical Pathway Coordinator to focus on the efficiency and effectiveness of the gynaecology pathway in Singleton Hospital. From August the Coordinator will be joined by a new consultant with a job plan that includes lead for surgical pathway improvements. A particular focus for Surgery is on improving the pathway for patients with peripheral vascular disease, organised by a multi disciplinary group and using patient stories. Small tests of change are being implemented using A3 problem solving improvement process, such as providing a dedicated wheelchair stock for the ward. In addition, Public Health Wales have facilitated a joint piece of work between ABMU and Hywel Dda to establish the baseline demand for this service and a joint workshop with Hywel Dda on 21st July held to review and improve the high level pathway from a network basis, which concluded with a joint set of actions. In Musculoskeletal Services the current focus is on data collection. Consultants are leading a review to identify every procedure currently carried out in all our hospitals from an orthopaedic and spinal perspective. The purpose is to understand exactly what we could potentially do on each site and what we would need in terms of infrastructure and workforce to deliver. Also a prospective data collection based on a set of criteria looking at delays in trauma care and impact on elective capacity, started in July by Professor Nick Rich, Swansea University. For Regional Services work on understanding the patient pathway through plastic surgery started 7th July 2014. Data captured on the system has already highlighted significant level of late starts on the registrar day case list and levels of early finishes on consultant lists. Work is underway on the diagnostic undertaken to understand the patient journey through Plastic Surgery and where improvements need to be made. Also using procedure time data to improve efficiency of theatre time In Cardiothoracic Surgery the focus has been on building the team, leadership and encouraging front line staff to make changes to help improve patients care. The whole directorate has undertaken ‘Human Factors’ training, which has led to an improvement programme for Theatres. For example, the Cardiac Theatres Team is hold ‘team briefings’ every morning prior to the commencement of the theatre lists, which has improved list start

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times. External evaluation was extremely positive and improvements to address the feedback are being made. For Theatres it was reported that the Singleton Efficiency Group were focusing on a standardised process for cancellation of theatres including circulating and agreeing backfill theatres; data; and improving flow through Ward 2. NPT continue to look at validating their theatre data and work on understanding the workforce needed to match theatre capacity and demand is progressing. The Albatross Benchmarking system, with the support of the Programme, identified a planned reduction in beds, through improved length of stay as a result of the measures introduced by the Programme. The planned reductions were based on a “peer group”, which was comprised of organisations of similar size which perform better than ABMU Health Board, but weren’t the top performers. Work is being progressed to identify the deliverable opportunity, with the reductions due to commence in 2015/16. Albatross has also been used to identify efficiency gains in “time on table”. The benchmarking work whilst shared with Directorates as an opportunity, it has limited integration into operational plans.

8.0 Patient Flow Programme The focus for this year is on two key components:

• implementing the recommendations from the Finnamore Report produced in December

2013, in relation to ‘Front door’ emergency developments at both the Princess of Wales and Morriston.

• rolling out the Patient Flow Programme to ensure that capacity is effectively managed through efficient operational processes, 7 day working and appropriate staffing.

Progress

Improving the Flow • Weekly ‘Big Room’ standing meetings are held on the Morriston, Neath Port Talbot and

Princess of Wales sites focusing on unscheduled care flow of the frail older patient • Healthcare colleagues from Denmark and Scotland visited the Princess of Wales

Hospital in September to demonstrate the work of the National Flow Programme by looking at our work to improve flow in ED and flow for frail older patients on the medical wards.

• In Morriston the ‘Big Room’ has redefined its high level A3 problem solving process to focus on ensuring frail older patients receive the right assessment and care plan following arrival at the ‘front door’. A high level current state process map has been completed and work is currently underway collecting data and undertaking value stream mapping to understand the problem. This will be used with existing knowledge and where we want to be to decide on the improvements we need to make and test the changes out.

• A further ‘Big Room’ for the flow of all patients through Morriston ED started in September, reorganising the work already underway as part of the Finnamore’s report

• Morriston Radiology undertaking A3 problem solving looking at the flow to Radiology when in ED

• The Princess of Wales Hospital is looking at improving flow in ED, senior decision making in Acute Medical Unit, and flow on the medical wards. PoWH Big Room also

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undertaking a mapping exercise on the process for referring patients in Bridgend for social services to support discharge from the acute hospital.

• Continue to be actively engaged with the 1000 Lives + Patient Flow collaborative - ABMU acknowledged nationally as having made the most progress in understanding our system and giving staff the skills and support to make changes for improvement.

• Visit by Kate Silvester from the Health Foundation on 17th June to Morriston and the Princess of Wales and delivered ‘information for measurement’ coaching session. Key messages from her visit were: 1. Every patient must have a clinical plan documented on admission which

indicates the physiological and physical goals for the patient. Patients with ongoing medical needs must have care plans for their management in primary care/care homes etc

2. The 4 VITALS charts (demand, activity, Work in progress (WIP) and Lead time) are the key measurements of analysing our systems flow

• Alex Howells presented at the National Learning set on 19th June with key staff and the Health Minister in attendance. Our ‘Big Room’ progress was also on display.

Developing capacity and capability • 8 clinicians attended the National Clinician Workshops on 2nd & 3rd July, led by Kate

Silvester with Dr Sarah Spencer, ABMU Consultant, presenting • 34 staff have completed the Foundations of Improvement Science in Healthcare

(FISH) with a 32 in progress, which continues to increase. • Two staff are undertaking the Improvement Science Practitioner (ISP) level with further

3 to start • Two further internal 2 day Patient Flow workshops have taken place in June/July, one

each for Swansea and Bridgend, facilitated by 1000 Lives + Patient Flow team. 50 plus clinical and managerial staff have participated in these 2 day workshops which supports them to put the FISH training into practice.

• A patient flow resource section is available on the information portal with data dashboard, relevant documents, videos and templates. This is useful for those directly involved in delivery.

• Latest figures (18 August) show over 1,581 ABMU staff are holders of Bronze Improving Quality Together (IQT) with nearly 400 in the process of completing the training.

9.0 Programme Risks and Issues The following table provides the risk status of delivery across key risk categories for each of the Programmes/Projects.

Programme/ Project

Investment Delivery)

Saving Delivery

Environment Strategic Timescale Benefit Measure

Operational plans for delivery are in place

Operational plans for delivery are in place

Capital, Equipment & Interdependencies are achievable

Strategy is understood and owned by Dir/Loc

Programme/ Project will meet IMTP Timescale

Measures and Monitoring is established

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Programme/ Project

Investment Delivery)

Saving Delivery

Environment Strategic Timescale Benefit Measure

C4B Staying Healthy

Acceptable Low Low Low Acceptable Significant

C4B Community Services

High High Low Low Significant Significant

C4B Rapid Access Services

High High Significant Acceptable Significant Significant

C4B Pre Hospital Services

Significant High Low Low Significant Significant

C4B Hospital Services

Significant High High Low Significant Significant

C4B Women, Children & Families

Acceptable Low Low Low Low Significant

C4B Trauma Centre Development

Acceptable Low Low Low Low Significant

C4B Outpatient Modernisation

Acceptable High Low Low Significant Significant

C4B Elective Procedures

N/A N/A Low Low Low Significant

Commissioning Development Programme

Acceptable Low Low Low Acceptable Significant

Patient Experience

Low Low High Low Significant Significant

Patient Safety Significant High Low High High Significant

Effective Information Systems

Significant Low High Low Significant Significant

Surgical Pathway

Significant High Low High High Significant

Patient Flow Low Low Low Acceptable Acceptable Significant

The individual risks and issues are held by the respective Programmes; the key themes are summarised below.

Revenue Funding – Each of the Strategic Change Programmes has identified a number of investments, the initiation of these investments is determined by the Health Board. As previously described, the total investment required at the outset of the IMTP was £5.7m which needed to be prioritised into £4m, predicated upon £2m planned savings. Robust

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operational plans for delivery of the £2m planned savings are not in place at present. This has resulted in a restricted amount of investments being initiated. In the absence of robust savings plans, the investments will continue to be held, limiting the progress of the Programmes, impacting on the timeframe for delivery.

Mitigation – The Strategic Change Programmes in collaboration with the operational services are continuing to create robust plans for investments and savings delivery, inclusive of recruitment schedules, and specific areas and timing for efficiency gains such as planned bed reductions.

Availability of Capital Funding – Due to the limited amount of funding available, the Programmes dependent on capital are restricted in the progress that can be made. These include infrastructure changes (Changing for the Better Hospital Services, Women, Children & Families and Rapid Access Projects) and equipment (Patient Experience and Effective Information Systems and Use of Technology). Sources other than discretionary Capital funding are being sourced to create opportunities for progression.

Mitigation – Finance, Planning and Informatics are pursuing sources of funding to increase the opportunities for capital investment. Where there is limited capital funding the Health Board and Executive Team will be required to prioritise this funding, in line with Strategic Change Programmes readiness and strategic priorities.

Planned Bed Reductions - A paper has been produced for a September 2014 meeting of the Annual Planning Implementation Group (APIG) which describes the operational status for plans to deliver the bed reductions identified within the IMTP. The paper described that whilst plans are in development they are limited plans at present. The majority of savings identified for Strategic Change Programmes are based on bed reductions and release of the associated funding. As the plans become more robust, the initiation of investments becomes available. The paper focuses on bed reductions, however, the status of operational delivery plans holds true for each of the savings.

Mitigation – APIG will oversee the delivery of operational plans, with validation of the robustness. These plans continue to be developed collaboratively with the Strategic Change Programmes and Services.

Governance – The role of the Health Board and required reporting arrangements is presently under review. The frequency of reporting has been raised as a concern, with a suggested bi-monthly or quarterly provision to the Delivery Board, enabling the time allocated for discussion of each Strategic Change Programme to be increasingly effective. These discussions could be expanded in terms of progress, escalation of risks and issues, and funding requirements.

Mitigation – The role of the Health Board and supporting governance arrangements are presently under review by the Executive Team. In addition the establishment of Board Sub Committees for specific elements of Health Board performance may also provide some opportunities to strengthen governance.

Workforce – The availability of the required workforce has been raised as a consideration, for example General Practitioners availability (Changing for the Better Hospital Services), Informatics staffing, and the scale of Nursing and Support Workers (Changing for the Better Community Services). The development of the IMTP for future years will need to further consider workforce availability when planning.

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Mitigation – The working Group for the development of the IMTP for 2015/18 has workforce representation, with the delivery plans submitted by Localities and Directorates to be assessed in recruitment considerations.

Engagement – Across the Strategic Change Programmes there is a variance in the knowledge, adoption and ownership of the Programmes by the Health Board. This includes the transition from strategic planning to operational delivery, for example bed closures. The first six months of 2014/15 has seen a marked increase in this transition, however, further engagement and ownership is required for the delivery of the IMTP.

Mitigation – The Health Board, APIG, Strategic Change Programmes, Directorates and Localities continue to engage and ensure ownership of the strategic transition to operational delivery.

Culture – The newly established Service Improvement Team, which will support the progress of the Surgical Pathway and Patient Flow Programmes, will drive a changing culture of improvement measures and science. This requires the culture of the organisation to respond to a new understanding of performance management. Organisational support for the Patient Safety and Patient Experience Programmes in promoting a culture of timely management and intervention, evolving from a monitoring perspective.

Mitigation – The newly established Service Improvement Team will continue to drive the improvement culture.

Benefit Measures – Whilst there are clear benefits targeted by the Strategic Change Programmes, the mechanisms for measurement and monitoring vary in their strength and consideration. To determine the success and realisation of the service changes which are introduced, effective systems and appropriate measures are required, with reporting aligned to the performance reporting of the Health Board.

Mitigation – Planning, Finance, Informatics and Strategic Change Programme leads continue to consider and build these mechanisms and measures, such as bed reductions and patient experience feedback and actions. Each Strategic Change Programme is required to give further focus on the benefit measures, such as improved outcomes for patients. This is an essential requirement for the success of the Strategic Change Programme initiatives.

10.0 Conclusion and Next Steps Whilst progress has been made in a number of areas, the delivery of planned savings is critically at risk. Operational plans are continuing to be developed, however, at present they are limited. In the absence of robust savings plans, the investment for both current and future years is unable to move forward. The completion of delivery plans will inform the development of the IMTP for 2015/18, and as such should be completed as an integrated production.

Next Steps

• Increased engagement with and ownership by the Directorates and Localities of the Strategic Change Programmes

• Continued development of operational plans for delivery of strategy (APIG and Operational Management Teams). These should include the robust plans for delivery of the planned savings, enabling the investment in current and future years.

• The operational plans for delivery should be integrated with the IMTP for 2015/18

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• To review governance arrangements for the Strategic Change Programmes, including the role of the Health Board and Health Board Sub Committee. And advise the Strategic Change Programmes and SPMO accordingly.

• To consider the endorsement of the Patient Experience Programme commitment from the Strategic Change Fund

• To hold further investment beyond the £2m cumulative investment, subject to transfer of the Patient Experience commitment above, until robust operational plans for delivering savings are in place, as agreed by the Health Board.

• For the Health Board to consider the risks and mitigating actions as described by the Strategic Change Programmes and advise the SPMO and Programmes of any additional action required.

• To note that an updated position to be provided to the Health Board in March 2015.

Changing for the Better: Integrated Medium Term Plan (IMTP) 2014-2017 – Summary Paper

CHANGING FOR THE BETTER

OUR INTEGRATED MEDIUM TERM PLAN - SUMMARY

Changing for the Better: Integrated Medium Term Plan (IMTP) 2014-2017 – Summary Paper

Published by: ABMU Health Board, One Talbot Gateway, Seaway Parade, Baglan Energy Park, Port Talbot SA12 7BR. This document is available in Welsh and a range of alternative formats including Large Print. Please let us know if you require an alternative version of this document by calling 01639 683311 or emailing catrin.evans2@wales.nhs.uk

Copies of the full and summary versions of the Integrated Medium Term Plan are also available on our website www.abm.wales.nhs.uk.

mailto:catrin.evans2@wales.nhs.ukhttp://www.abm.wales.nhs.uk/

Changing for the Better: Integrated Medium Term Plan (IMTP) 2014-2017 – Summary Paper

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August 2014

Chair and Chief Executive’s Introduction

The NHS in Wales is facing real challenges of rising demand, increasing expectations of what health services can be provided, difficulties in recruiting staff and limited cash.

We are clear we cannot meet these challenges by doing “more of the same”. Working closely with our patients, citizens, staff and other organisations, we have developed solutions to meet these challenges. They are ambitious, innovative and are motivated by national and local standards. They build on our successes to transform the quality, safety and the way our services are delivered. This plan explains how we will consistently deliver high quality care, in the right place, at the right time, by the right people.

This is the first time that NHS organisations in Wales have been able to plan for the medium term – next three years - rather than for just the year ahead. Our plan is ambitious and we will change how we deliver healthcare, support and advise our citizens living in Swansea, Neath Port Talbot and Bridgend and indeed more widely.

Over the next three years we will:

We are proud of our University status and know that through closer working with the Universities we will deliver better care for you, our patients.

• Increasingly deliver excellent care, where people live, instead of in hospital; when it is safer and better to do so;

• Support citizens to have more control of their own health so that they are less dependent on the NHS;

• Create a health service that allows people and their GPs to get advice and support from specialists without delay, if they need it;

• Develop a community network, made up of groups of local primary care services, who are best placed to understand local health needs and solutions and to help halt the widening health inequalities. This will mean increased investment to help people personally make healthier lifestyle choices, particularly regarding smoking and managing their weight and activity.

• Increasingly work in an integrated way with local authority, third and voluntary sector partners to create joined up, more efficient and effective systems of care.

Changing for the Better: Integrated Medium Term Plan (IMTP) 2014-2017 – Summary Paper

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This plan describes how we expect to do this and how, over the next three years, we will change for the better, whilst using the resources available to us responsibly in all that we do.

This summary report provides a shortened version of our three year plan for the future of healthcare services provided by your Health Board.

The paper describes:

• Where we want to be (our purpose, vision and aims); • The challenges we face; • What the future looks like; • How we will deliver the plan; and • What support is needed to deliver our plan? • The next steps; • How you can get involved.

About Us Changing for the Better: Integrated Medium Term Plan (IMTP) 2014-2017 – Summary Paper

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1 About Us Abertawe Bro Morgannwg University Health Board was established in October 2009, as a result of merging the former Local Health Boards (LHBs) for Swansea, Neath Port Talbot and Bridgend and the Abertawe Bro Morgannwg University NHS Trust. The Health Board covers a population of approximately 500,000 people and has a budget of £1.3 billion. At the end of March 2014, the Health Board employed 15,758 members of staff, 70% of whom are involved in direct patient care.

We are responsible for improving the health of our communities as well as the planning, commissioning and provision of both primary (General Practitioner, Optometry, Pharmacy and Dental services), and secondary (Hospital) care services. We are also responsible for a range of community based services delivered within patients’ own homes, community hospitals, health centres, and clinics. In addition we provide a range of highly specialised services such as Burns and Plastic Surgery Services (for South Wales and the South West of England), Forensic Mental Health Services (for the whole of South Wales) and Learning Disability Services (Swansea, Cardiff and the Rhondda Cynon Taf and Merthyr Tydfil areas).

Where we want to be Changing for the Better: Integrated Medium Term Plan (IMTP) 2014-2017 – Summary Paper

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2 Where we want to be 2.1 Our purpose (why we exist)

Our purpose is to ‘fulfil our civic responsibilities by improving the health of our communities, reducing health inequalities and delivering effective and efficient healthcare in which patients and users feel cared for, safe and confident’.

2.2 Our vision (where we want to be)

We will be an excellent healthcare, teaching and research organisation for the ABMU area and the wider region. This means we will:

• Respect people's rights in all that we do and plan our services and their care with them and their carers. Wherever it is provided, care will be delivered to a consistently high quality, 24 hours a day, and seven days a week. This means it will be safe and compassionate, meeting agreed national standards, providing outcomes valued by patients and citizens and an experience that is as good as it could be;

• Make it easy for everyone to get the information and advice they need

to be in control of their own health and to live healthier lives;

• Work with our partner agencies to provide integrated health and social care in or close to people’s homes:

• Support high-quality research, education and innovation that benefit

our patients and staff. We will encourage everyone to share their care experiences with us so that we can learn how we can do even better.

2.3 Our Aims

In achieving our vision, we have identified six key aims:

To support our citizens to be as healthy as possible; To provide excellent patient care and experience; To provide sustainable and accessible services; To create strong partnerships; To promote and develop excellence amongst staff and To develop clear accountability arrangements.

We have used our vision and aims to help us develop our three year plan.

The challenges we face Changing for the Better: Integrated Medium Term Plan (IMTP) 2014-2017 – Summary Paper

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3 The challenges we face We are facing a number of challenges:

Increasing demand for healthcare

The recent report on the health needs of our population shows that: • Our population is increasing; • The number of older people with one or more long

term conditions is increasing • More people are making poor lifestyle choices which

have a negative effect on their health. These challenges will increase demand for healthcare services.

Delays in people being seen in hospital

We are having difficulties assessing and treating people as quickly as we would like.

The quality of our services varies between services and across the days of the week

Quality is a big issue across the NHS. The tragic failings of the healthcare provided by Mid Staffordshire NHS Foundation Trust have led to a number of recent national reports and guidelines being produced.

Locally the Advancing Quality Alliance (AQuA) carried out an independent quality and safety review of the Princess of Wales Hospital. Professor June Andrews has also led an independent review of patient care. Both reports identified failings and recommendations for improvement. Our Board is committed to using these recommendations to drive forward high quality care.

Some of our services are not sustainable in the longer term

The way our hospital services are organised, across many hospital sites and the availability of suitably qualified staff is not sustainable and adds costs without improving quality of care.

Our services are not joined up

We need to develop stronger networks of joined-up community services with our partners who also