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Bundle Finance, Performance & Workforce Committee 25 October 2018

0 Agenda1 Agenda FPW 25 October 2018.docx

1 PART 1 - PRELIMINARY MATTERS1.1 Apologies for absence1.2 Welcome and Introductions1.3 Declarations of Interests1.4 To receive and confirm the Minutes of the meeting held on 20 September 2018

1.4 Draft Unconfirmed FPW Minutes 20 Sept 2018 v2 GR.docx

1.5 Action Log1.5 Action Log FPW 25 October 2018 v2 GR.docx

1.6 Matters Arising2 PART 2 - KEY ITEMS FOR DISCUSSION2.1 To receive a quarterly update report on CAMHS Performance

2.1 CAMHS update FPW 25 Oct 18 GR.doc

2.2 To receive an updte report on the Deep Dive undertaken in Facilities2.2 Update Report on Facilities Deep Dive - FPW 25 Oct 2018 V2 GR.doc

2.2.1 Appendix 1 Sickness deep dive report FPW 25 Oct 2018 GR2.2.1 Appendix 1 Sickness deep dive report FPW 25 Oct 2018 GR.docx

2.2.2 Appendix 2 Five year CRES History FPW 25 Oct 2018 GR2.2.2 Appendix 2 Five year CRES History FPW 25 Oct 2018 GR.docx

2.2.3 Appendix 3 Benchmarking report FPW 25 Oct 2018 GR2.2.3 Appendix 3 Benchmarking report FPW 25 Oct 2018 GR.docx

2.2.4 Appendix 4 Waste performance Report FPW 25 Oct 2018 GR2.2.4 Appendix 4 Waste performance Report FPW 25 Oct 2018 GR.docx

2.2.5 Appendix 5 Porter service redesign FPW 25 Oct 2018 GR2.2.5 Appendix 5 Porter service redesign FPW 25 Oct 2018 GR.docx

2.2.6 Appendix 6 Facilities work plan 18-20 FPW 25 Oct 2018 GR2.2.6 Appendix 6 Facilities work plan 18-20 FPW 25 Oct 2018 GR.xlsx

2.3 To receive a quarterly update report on the organisational risks assigned to the Committee2.3 Org Risk Register, FPW 25 Oct 2018 GR.doc

2.4 To receive a Clinical Deep Dive into Urology2.4 Clinical Deep Dive Urology Paper FPW 25 Oct 2018 GR.doc

2.5 Update report on cancer breaches- FPW 25 Oct 20182.5 Update report on cancer breaches- FPW 25 Oct 2018 GR.doc

2.5.1 Appendix 1 - Monthly Cancer Performance Report Aug 18wj2.5.1 Appendix 1 - Monthly Cancer Performance Report FPW 25 Oct 2018 GR.docx

2.6 INNU update report FPW 25 Oct 2018 GR2.6 INNU update report FPW 25 Oct 2018 GR.docx

3 PART 3 - OTHER MATTERS3.1 To review the Forward Look for 2018/19

3.1 Forward Look FPW 25 October 2018 GR.doc

3.2 To confirm any itmes to be referred to other Committees3.3 Any Other Urgent Business3.4 Date and Time of Next Meeting: Thursday, 22 November 2018, at 1:00 pm

0 Agenda

1 1 Agenda FPW 25 October 2018.docx

CWM TAF UNIVERSITY HEALTH BOARD

FINANCE, PERFORMANCE & WORKFORCE COMMITTEE

The meeting of the Finance, Performance & Workforce Committee will be held on Thursday 25 October 2018 at 1pm in the Rhondda & Cynon

Rooms, Ynysmeurig House, Abercynon.

MR MEL JEHU

CHAIRMAN

AGENDA

ATTACHED

PART 1 - PRELIMINARY MATTERS

1.1 Apologies for absence

Oral

1.2 Welcome and Introductions

Oral

1.3 Declaration of Interests

Oral

1.4 To receive and confirm the Minutes of the meeting held on

20 September 2018

Paper

1.5

Action Log

Paper

1.6

Matters Arising

Oral

PART 2 – KEY ITEMS FOR DISCUSSION

2.1 To receive a quarterly update report on CAMHS Performance

Paper

2.2 To receive an update report on the Deep Dive undertaken in Facilities

Paper

2.3 To receive a quarterly update report on the organisational

risks assigned to the Committee

Paper

2.4 To receive a Clinical Deep Dive into Urology

Paper

2.5

2.6

To receive an update on cancer performance

To receive an update report on Interventions Not Normally Undertaken (INNU)

Paper

Paper

PART 3 – OTHER MATTERS

3.1

3.2

3.3

3.4

To review the Forward Look for 2018/19 (Chair)

To confirm any items to be referred to other Committees

(Chair)

Any other Urgent Business (Chair)

Date and time of next meeting

1pm, Thursday 22 November 2018, Ynysmeurig House, Navigation Park, Abercynon

Paper

Oral

Oral

1.4 To receive and confirm the Minutes of the meeting held on 20 September 2018

1 1.4 Draft Unconfirmed FPW Minutes 20 Sept 2018 v2 GR.docx

Agenda item 1.4

‘Unconfirmed’ Minutes of meeting held 20 September 2018

Page 1 of 11 Finance , Performance & Workforce Committee Meeting

25 October 2018

Finance, Performance & Workforce Committee Meeting

‘Unconfirmed’ Minutes of the meeting held on

20 September 2018 Ynysmeurig House, Abercynon

Present

Mel Jehu Independent Member (Chair) Paul Griffiths Independent Member

Keiron Montague Independent Member (In part) Robert Smith Independent Member

Dilys Jouvenat Independent Member

In attendance

Ruth Treharne Deputy Chief Executive/Director of Planning &

Performance Alan Lawrie ‘Interim’ Director of Primary, Community and Mental

Health Jo Davies Director of Workforce &

Organisational Development (OD) John Palmer ‘Interim’ Chief Operating Officer

Steve Webster Director of Finance & Procurement

Alan Roderick Assistant Director of Performance & Information Marcus Longley Chair of Cwm Taf University Health Board

Emma Samways Internal Audit & Assurance Hywel Daniel Assistant Director of Workforce & OD

Emma Walters Corporate Governance / Committee Secretariat Jacqueline Maunder Governance Lead, Corporate Services

Donna Hill Medical Engagement Officer (In part)

FPW/18/096

WELCOME AND INTRODUCTIONS

Mel Jehu WELCOMED everyone to the meeting, particularly Dilys Jouvenat

who had become a new Member of the Committee and was attending her

first meeting today. The Chair also WELCOMED Hywel Daniel, Donna Hill, Emma Samways and Marcus Longley to the meeting.

FPW/18/097

APOLOGIES FOR ABSENCE

Apologies for absence were RECEIVED from Robert Williams and Gwenan

Roberts.

Agenda item 1.4



25 October 2018

FPW/18/098

DECLARATIONS OF INTERESTS

There were no additional declarations of interest.

FPW/18/099

MINUTES OF THE LAST MEETING

The minutes of the meeting held on 19 July 2018, were RECEIVED and APPROVED as a true and accurate record.

FPW/18/100 MATTERS ARISING

Page 3, Workforce Dashboard, Jo Davies AGREED to confirm whether the

information relating to the work being undertaken on medical agency spend had been circulated to Members.

Page 8, Single Cancer Pathway Performance, Marcus Longley confirmed

that he had discussed with Kamal Asaad and that further correspondence

had been received from Welsh Government. John Palmer advised that a significant amount of work was being undertaken in this area, with a

workshop also being held today.

FPW/18/101 ACTION LOG

Members RECEIVED and REVIEWED the Finance, Performance & Workforce Committee Action Log.

John Palmer advised that in relation to Clinical Efficiency reports, a clear

domain on clinical quality and efficiency was now in in place on Clinical Business Meeting agenda’s along with a matured platform in place in

relation to the Planned Care Board. John Palmer suggested that this was now treated as a discharged item (completed – removed from the

action log).

John Palmer advised that in relation to Interventions Not Normally

Undertaken (INNU), a discussion had been held at the last Efficiency, Productivity & Value Board in relation to Cross Cutting Themes, one of

which was in relation to Value Based Healthcare. Members NOTED that some specific targets were in the process of being set which would be

monitored at Clinical Business meetings. John Palmer AGREED to have a discussion with Kelechi Nnoaham (Director of Public Health) on when he

would be in a position to provide an update to the Committee on progress made.

Jo Davies provided Members with an update in relation to the triangulation

of the performance, workforce and finance dashboards. Members NOTED that a deep dive approach on the proposed triangulation had been

undertaken in Medicine and one meeting had been held to discuss the

comparison of data, which identified some slight anomalies between workforce and finance.

Agenda item 1.4



25 October 2018

Members NOTED that in light of the complexity of the work required and

the lack of headroom to give this focus, this item would be deferred for a

few months (action log updated).

In relation to the development of a central Service Level Agreement (SLA) schedule, John Palmer AGREED to send a note to Members outside of the

meeting outlining current SLA processes. Members NOTED that an update on SLAs was also included in the Commissioning update report which was

presented to the Committee on a twice yearly basis (action log updated).

FPW/18/102

ADDRESSING THE IMPACT OF NHS WALES MEDICAL AND DENTAL AGENCY AND LOCUM DEPLOYMENT IN WALES

Donna Hill was in attendance for this item.

Jo Davies presented the report and reminded Members that Welsh

Government (WG) issued a Welsh Health Circular (WHC) in November 2017

which introduced 2 levels of cap for internal and external agency, and it had been agreed that the Finance, Performance & Workforce Committee

would receive the report for approval of submission to WG.

Members NOTED that it had been agreed to change the frequency of reporting into WG from monthly to quarterly and that the report presented

today reported on the April – June position. Members NOTED that the format of the report had changed slightly as a result of the data issues

identified in the previous report with further discussions taking place in relation to further refinement of the report moving forward.

Members NOTED that the purpose of the report was to provide assurance

to WG on performance against the cap, highlight the issues being faced by the Health Board and identified the actions being taken locally and on an

All Wales basis.

Members NOTED that performance between April – June 2018 was positive

and showed an improved monthly spend of £200k per month, which meant that the demand for Agency Locums had reduced. Members NOTED that

primary care agency was not included in this report, but was being included in the Finance report, which was why there was a discrepancy in the data.

Members NOTED the actions being taken by the Health Board to improve

the position, which included Medical Director challenge to any requests being received and a review of procurement arrangements for agency

locums which had resulted in a tender exercise being undertaken. Members NOTED that a positive response had been received from the

Directorates in relation to the process that had been put into place.

Members NOTED that monthly scrutiny committees were being held and

deep dives were being undertaken into high cost areas, with Accident & Emergency (A&E) being one area of focus.

Agenda item 1.4



25 October 2018

Members NOTED that issues were being experienced with neighbouring

Health Board’s offering higher rates of pay to Locum Doctors which would require further discussion with WG. It was felt that the South Wales

Programme continued to impact on the Health Board compared to other areas, particularly within A&E and Obstetrics & Gynaecology. Members

NOTED that discussions were being held with All Wales Directors that clear intervention was required from Welsh Government regarding capping of

rates with a more joined up approach required. Members NOTED that a discussion would also be held with WG regarding Primary Care Locums who

were currently excluded from the rate cap on an All Wales basis.

Keiron Montague arrived at 2.00pm.

Paul Griffiths expressed his concern in relation to the issues being experienced on rate caps and advised that it would be helpful to have a

total agreement on this on an All Wales basis and questioned whether there

were any incentives in place to stick to the cap. Paul Griffiths also expressed concern in relation to the rates of pay being offered in some areas. Donna

Hill advised that the rate being charged was to the agency and not the employee.

Members NOTED that there was currently no national pay rate for Out of

Hours and the rate being offered to Middle Grade Specialty Doctors was low in Wales.

Members NOTED that the delays experienced in some areas regarding visa

applications had not been an issue for the Health Board, however, there had been some delays in overseas doctors undertaking English tests.

Marcus Longley expressed concern in relation to the Health Board requiring

twice as many hours of staff to cover compared to neighbouring Health

Boards. John Palmer advised that 30-50% of these hours were being used within A&E and advised that the whole A&E rota was being filled with

agency locum staff. Members NOTED that teams were working extremely hard to keep the department functioning efficiently.

Members NOTED the next steps that would now be taken, including

continued discussions with WG on rate caps, a discussion at the October Primary & Community Care Committee regarding Primary Care/Out of

Hours rate caps and the introduction of the new procurement system. Members NOTED that update reports would continue to be presented to

the Committee moving forward.

Members RESOLVED to: • RECOGNISE the complexity of the work being undertaken,

• NOTE the requirement for CTUHB to submit a quarterly report to

Welsh Government in respect of Agency Locum usage, and in

Agenda item 1.4



25 October 2018

particular the requirement to achieve a 35% reduction in Agency

Locum spend over a 12 month period,

• Retrospectively APPROVE the Agency Locum/Additional Duty Hours report submitted to Welsh Government which set out the progress

made in Cwm Taf UHB (CTUHB) in Quarter 1 (Apr-Jun 2018), against the agency locum framework.

FPW/18/103

MONTH 5 FINANCE UPDATE

Steve Webster presented the report which had been refined further

following comments and advice received from Paul Griffiths on the report format and content. Members NOTED that there was now a section at the

front of the report which identified the key messages. Members AGREED that they found the revised format of the report very helpful and much

easier to understand what the key issues were.

Paul Griffiths extended his thanks for the ongoing refinement of the report

and advised that the report would need to be considered as a dynamic document and may need further changes. Steve Webster added that the

Finance Academy across Wales was also undertaking a review of financial reporting across Health Boards in Wales and offered to undertake a tutorial

session with any Members of the Committee, particularly new Independent Members, on finance. Marcus Longley suggested that this could be

discussed further at the next Board Development Session.

In presenting the report, the following key points were highlighted: • There was a forecasted breakeven position in month and year to

date, • There was an overspend against the delegated position of £1.6m,

mainly in relation to phasing and Month 5 being a 5 week month, and high spend against the medical and nursing agency position,

Members NOTED that consideration was being given to phased

budgets for 5 week months for next year, • The delegated overspend was being offset by slippage and the

overspend was largely recurrent, with some elements being non-recurrent, for example, reserves,

• The key area of concern was the recurrent position, and Members NOTED that there was currently a forecasted recurrent deficit of

£6.2m and that an urgent improvement was required in light of the number of changes that would be taking place next year regarding

Transformation and Bridgend, • There had been more slippage in some areas than anticipated,

including the number of retrospective Continuing Health Care (CHC) claims and review of payments in Powys,

• It was likely that funding would be received from Welsh Government for winter pressures, which would take the Health Board to a

forecasted position of £1m underspend. Members NOTED that the

Executive Team would be meeting to discuss priority areas of spend,

Agenda item 1.4



25 October 2018

• Further work would need to be undertaken on savings plans to help

improve the recurrent position, for next year in particular,

• A review would need to be undertaken on the increase in spend in Personal Injury and Medical Negligence claims with 5 months of

higher costs being experienced. Members NOTED that a Scheme of Delegation was in place for reviewing claims and the Claims Scrutiny

Panel regularly undertakes a review of trends.

Paul Griffiths suggested that in light of the concerns raised in relation to the Medical Staffing expenditure and Claims expenditure, deep dive reports

were developed in these areas and presented back to a future Committee.

Members RESOLVED to: • NOTE the report and the update provided,

• REQUEST that deep dive reports were presented to a future Committee on Medical Staffing and Claims Expenditure.

FPW/18/104 PERFORMANCE DASHBOARD

Ruth Treharne presented the report which provided the Committee with a summary of current performance across a range of indicators and key

issues.

The following key points were NOTED:

Unscheduled Care • Performance against the 4 hour target for August was 87.7%.

Members NOTED that work was being undertaken to improve performance at Prince Charles Hospital (PCH) and an improved

performance was now being seen, • August performance against the 12 hour target was 201 patients

waiting, which was a significant increase compared to the same

period last year, • There had been no cancelled patients as a result of unavailability of

beds, • 91.8% performance was achieved against the 15 minute handover

target. John Palmer advised that performance in this area was very symbolic for the Health Board and any breaches of the target were

monitored, • The numbers of patients classified as Delayed Transfer of Care for

August remained stable at 28.

Referral to Treatment • Members NOTED that as of the 23 July 2018, the Health Board was

now aware of the full cohort of patients, • The final reported position on 36 week wait performance was 229

patients, with challenges in orthopaedics, general surgery and

urology, which would continue to be closely monitored,

Agenda item 1.4



25 October 2018

• The confirmed final position for 26 week performance was 91.4% for

August.

Diagnostic Waits

• The final reported position for August was 211 patients waiting over 8 weeks for diagnostic and cardiology tests,

• Members NOTED that some operational issues had been experienced with MRI at PCH which may have an impact on the position and that

a discussion may need to be held with WG on bringing forward the capital bid for a replacement scanner into this year.

Follow Up Outpatients Not Booked (FUNB)

• Members NOTED that work continued to be undertaken by the operations team to address the position. The review undertaken

within ophthalmology identified that 80% of patients still needed a follow up appointment so the scale of the challenge could not be

underestimated. Members NOTED that the Executive Board had

agreed to fund additional resource to address the backlog issues.

Cancer Performance • The 31 day target was not achieved in July with a performance of

98% for July which equated to 3 breaches, which were all in lung services and were patients waiting for tertiary surgery,

• The 62 day target was also not achieved during July, with a performance of 83.8% and 13 breaches, 9 of which were in urology.

Members NOTED that a deep dive was being undertaken within urology which would be presented to a future meeting of the

Committee.

Stroke Performance • During July, there had been 65 patients with a confirmed stroke and

the thrombolysis rate was 10.8%. Members NOTED that the Delivery

Unit was undertaking a review of thrombolysis rates which would be completed by 9 October and Ruth Treharne advised that a deep dive

report on thrombolysis rates would be presented to a future meeting.

Mental Health Performance • Members NOTED that Part 1a and Part 1b were compliant overall

with a slight improvement in community treatment plan performance. Waiting list initiatives were being considered to

improve performance further.

Child and Adolescent Mental Health Service (CAMHS) Performance • Members NOTED that a detailed report on CAMHS performance

would be presented to the October meeting and a response was awaited from Welsh Government as to whether the Health Board’s

bid for waiting list initiative funding had been approved.

Agenda item 1.4



25 October 2018

Paul Griffiths asked whether consideration could be given to changing the

format of the report so that key headlines were included at the start of the

report to help Members understand and focus their attention on the key issues.

Ruth Treharne AGREED to consider how best to capture this in future iterations of the report. Keiron Montague added that it was also quite

difficult to see some of the data contained within the main dashboard as the font was so small.

In response to the concern raised by Mel Jehu regarding Cwm Taf patients

waiting a significant amount of time for treatment at other Health Board’s, Ruth Treharne advised that performance within Cardiff & Vale UHB was

improving and commissioning mechanisms were regularly used to discuss performance issues with other Health Board’s.

In relation to FUNB, Marcus Longley questioned when there would be an

improvement in the position. John Palmer advised that it was difficult to

predict when an improvement would be seen and advised that with funding it could take between 12-18 months and more than two years without

funding. Members NOTED that further funding would be sought after the initial piece of work undertaken. John Palmer AGREED to provide Marcus

Longley with a trajectory of the predicted improvement.

In relation to CAMHS, Marcus Longley questioned why performance was poor when there was only one referral being made per day. Alan Lawrie

advised that the number of referrals this year had increased and that the position should improve marginally during October and November.

Following discussion, Members RESOLVED to:

• NOTE the report and the update provided, • NOTE that the report would be refined further to include an Executive

Summary at the start of the report.

FPW/18/105 WORKFORCE DASHBOARD

Jo Davies presented the report which provided an update on the key

workforce metrics for July and August 2018, with historic trends shown as appropriate. Members NOTED that the report was in a slightly different

format and would continue to be refined moving forward.

Members NOTED that there had been 4 areas of improvement and 3 areas where performance had deteriorated, which included sickness absence,

turnover rates and return to work compliance.

Members NOTED that turnover rates continued to be an area of concern, with particular concerns in relation to Nursing turnover. Members NOTED

that the main issue was the retirement of nursing staff. Members NOTED

that in all 3 categories, the number of not known reasons was quite high,

Agenda item 1.4



25 October 2018

and some focussed work was being undertaken on this. It was NOTED

that there had been an improvement in recruitment activity.

Jo Davies provided Members with an update on the work being undertaken

on Employee Engagement activity. Members NOTED that the staff survey return had been disappointing at 29%, even though a significant amount

of work had been undertaken to try to improve the position. Jo Davies advised that at present it was not possible to tell if response rates were

higher within areas which were experiencing issues and advised that directorate specific reports would be developed once the final report was

issued in early October. Members NOTED that personal development reviews (PDR) compliance had improved to 75%. Members NOTED that

in relation to the staff survey, if more than 11 responses were received in one area, the Directorate would be identified. Jo Davies advised that the

process was anonymous.

Members NOTED that a Medical Engagement event was being held on the

17 October which would be attended by Dr Andrew Goodall and colleagues from Bridgend and that a Chief Executive “Buzz Event” for Senior Managers

would be taking place on the 24 September, in which Senior Managers from Bridgend had also been invited. Members NOTED that the Staff

Recognition Event was about to be launched for next year with a request made from a member of staff for a more regular process to be put into

place.

In relation to Sickness Absence, Members NOTED that the rolling average was reducing, however, there had been an in month increase. Members

NOTED that the position would continue to be monitored; and further work would be undertaken to improve return to work compliance.

Members NOTED that a review was being undertaken on the increase being

seen in the use of temporary staff, particularly Health Care Support

Workers which was a fully established area. Members NOTED that reasons for the increase included cover for vacancies, sickness absence and

increased supervision.

Dilys Jouvenat questioned the difference between available training slots compared to the actual number of training slots required. Jo Davies advised

that progress had been made in improving level 1 compliance and work was now being undertaken on improving compliance against levels 2 & 3.

Jo Davies added that a significant piece of work had been undertaken to identify the exact levels of training required for each member of staff.

Paul Griffiths questioned whether the Health Board were confident that staff

were content in their work, particularly in light of the increase in sickness absence, the reduction in PDR compliance and the increase in staff leaving

the organisation with no reasons being recorded as to why they have left.

Jo Davies advised that there were some positives to be considered including the improvement in sickness absence rates against the all Wales position,

Agenda item 1.4



25 October 2018

staff were still joining the Health Board and the Health Board does

benchmark well against a number of areas.

John Palmer advised that a discussion could be held with staff side

colleagues on their opinions of how staff were feeling and advised that there may be areas where further work was required to improve staff

morale, particularly within areas which had intense environments. John Palmer added that the staff recognition event was very successful and

reflected the positive work being undertaken by staff within the organisation. Paul Griffiths questioned whether a benchmarking exercise

could be undertaken on staff morale against other Health Board areas.

Members NOTED that an Internal Audit Review was being undertaken on Retention of Staff which had been given a limited assurance rating.

Members NOTED that the review identified that further work was required in undertaking exit interviews. Jo Davies advised that she would be happy

to share the report with Committee members.

Members RESOLVED to:

• NOTE the update provided.

FPW/18/106 FINANCIAL DEEP DIVE INTO NON PAY – FOLLOW UP REPORT

Steve Webster presented the report which provided an update on non pay overspends following the report previously presented to the Committee in

June 2018.

Members NOTED that 20 areas had been identified and included in the report which had significant non pay overspends. Members NOTED that

there were a number of complexities that would need to be worked through, particularly within Medicines Management.

Members NOTED that the projected year end spend on Non Pay was broadly in line with budget, with the exception of expenditure against

claims.

In relation to drugs expenditure, further work would be required to clarify the governance around some of the changes to drugs to determine whether

the changes had been appropriately scrutinised and had been considered as value for money.

Members NOTED that the phasing of budgets could be considered in some

areas, but not all areas and Steve Webster advised that Facilities already had a phased budget in place.

Keiron Montague advised that there were a number of areas which had a

high percentage of recurring problems and that there were similar issues

being experienced across a number of areas.

Agenda item 1.4



25 October 2018

Members NOTED that a deep dive would be undertaken into the increase in expenditure against Medical Negligence and Personal Injury Claims.

Ruth Treharne suggested that Committee Members might wish to consider whether the financial deep dive reports coming forward were the most

appropriate, particularly in light of the issues being identified in the Directorate Reviews being undertaken by Internal Audit.

Members RESOLVED to:

• NOTE the report and that further work would be undertaken to analyse the position,

• ADVISE the Board that the Committee were now assured of the position.

FPW/18/107 EFFICIENCY, PRODUCTIVITY & VALUE BOARD ACTION NOTES

Members RECEIVED and NOTED the action notes from the Efficiency, Productivity & Value Board meeting held on 2 July 2018.

FPW/18/108 FORWARD LOOK FOR 2018/19

Members RECEIVED and NOTED the Forward Look for 2018/19. Mel Jehu

AGREED to review outside of the meeting.

FPW/18/109 COMMITTEE REFERRALS

There were no Committee referrals made.

FPW/18/110 ANY OTHER BUSINESS

There was none.

FPW/18/095 DATE OF THE NEXT MEETING

The next meeting of the Finance, Performance & Workforce Committee was

scheduled to be held on Thursday 20 September 2018 at 1pm, in Ynysmeurig House, Navigation Park, Abercynon.

Signed ………………………………………………. Mel Jehu, Independent Member

Date …………………………………………………..

1.5 Action Log

1 1.5 Action Log FPW 25 October 2018 v2 GR.docx

AGENDA ITEM 1.5

Action log Page 1 of 3

Finance, Performance and Workforce Committee Meeting 25 October 2018

FINANCE, PERFORMANCE & WORKFORCE COMMITTEE ACTION LOG UPDATE FOR 25 OCTOBER 2018

MEETING

DATE

SUBJECT KEY ACTIONS/DECISIONS RESPONSIBLE

OFFICER

COMPLETED/

updated

26/05/16 & 27/04/17 &

28/9/2017 21/6/2018

Interventions Not Normally

Undertaken (INNU)

To receive an update on Interventions Not Normally Undertaken (INNU).

Progress report to be presented to a future meeting.

Director of Public Health

October 2018 On agenda

26/01/17&

25/5/2017& 30/11/2017

Follow up

outpatient appointments

not booked

Report on progress to reduce the numbers in

the top 9 areas to be received.

John Palmer Due October 2018

Now January 2019

Added to Forward Look

25/5/2017 Workforce

Dashboard

Proposal to be presented to the September

meeting on how alignment and triangulation between the Performance, Workforce and

Finance Dashboards could be developed further.

Ruth Treharne/

Jo Davies/ Mark Thomas

Deep dive approach

being undertaken within

the Medicine Directorate

prior to full roll out

Agreed to defer

item until further notice

30/11/2017

19/7/2018

Finance Update Further consideration to be given to the format

and style of the Finance report moving forward following review undertaken by Wales Audit

Office on best practice reporting.

Executive summary to be reviewed & strengthened to identify the key issues and the

work being undertaken to address the issues in order to bridge the financial deficits

Steve Webster/

Mark Thomas

Completed .

AGENDA ITEM 1.5



MEETING DATE

SUBJECT KEY ACTIONS/DECISIONS RESPONSIBLE OFFICER

COMPLETED/ updated

30/11/2017

19/7/2018

Pathology

Financial Deep Dive

Consideration to be given to the development

of a Service Level Agreement (SLA) Schedule moving forward.

John Palmer Early 2019

24/05/2018 Workforce

Report

Trends in relation to turnover rates to be

included in future iterations of the report.

Joanna Davies Completed

24/05/2018 Performance

Dashboard

Report on Cancer breaches to be presented to

a future meeting.

Kamal Asaad October 2018 –

On agenda – linked to Urology

Performance report

A report (topic to be confirmed) on one of the projects the Health Board was working on to

improve performance. Committee members AGREED to receive a

Deep Dive report into Urology at a future meeting.

Ruth Treharne October 2018 On agenda

21/6/2018 Non Pay

Overspends

Further update report to be presented to the

Committee at the September meeting.

Steve Webster Completed

Update report to be presented to the September Finance, Performance & Workforce

Committee.

John Palmer Completed

21/6/2018 Demand &

Capacity

Ophthalmology

Progress report to be presented to a future

meeting of the Committee.

John Palmer Due November

2018 Added to forward look

21/6/2018 CAMHS

performance report

CAMHS performance report being presented to

October meeting to include an update on Primary Care CAMHS

Alan Lawrie October 2018

On agenda

AGENDA ITEM 1.5



MEETING DATE

SUBJECT KEY ACTIONS/DECISIONS RESPONSIBLE OFFICER

COMPLETED/ updated

20/9/2018 Month 5 Finance

Update

Financial deep dive reports to be presented to

a future meeting on Medical Staffing and Claims Expenditure

Steve Webster To be confirmed


Dashboard

Cover report to be refined so that key issues

and headlines are included at the front of the report

Ruth Treharne In progress


Dashboard

Trajectory to be developed which shows

predicted improvement for FUNB

John Palmer In progress

2.1 To receive a quarterly update report on CAMHS Performance

1 2.1 CAMHS update FPW 25 Oct 18 GR.doc

Update on CAMHS performance Page 1 of 12 Finance, Performance & Workforce Committee

25 October 2018

AGENDA ITEM 2.1

25th October 2018

Finance, Performance & Workforce Committee Report

UPDATE ON CAMHS PERFORMANCE

Executive Lead: Director of Primary Care, Community and Mental Health

Author: Directorate Manager, CYP and CAMHS

Contact Details for further information: Craige Wilson, Assistant Director of

Primary Care, Community and Mental Health – [email protected]

Purpose of the Finance, Performance & Workforce Committee Report

The purpose of this report is to provide the Finance, Performance & Workforce

Committee with a summary of current performance across Children and Adolescent Mental Health Services (CAMHS).

Governance

Link to

Health Board

Strategic Objective(s)

The Board’s overarching role is to ensure its strategic

objectives, and the related organisational objectives outlined

within the 3 Year Integrated Medium Term Plan 2018-2021, are being progressed. Aligned with the ‘Quadruple Aim’

described within ‘A Healthier Wales’ (Welsh Government, June 2018) these objectives are:

• To improve quality, safety and patient experience • To protect and improve population health

• To ensure that the services provided are accessible and sustainable into the future

• To provide strong governance and assurance • To ensure good value based care and treatment for our

patients in line with the resources made available to the Health Board.

This report aims to support the objectives above.

Supporting evidence

Engagement – Who has been involved in this work?

The data and information contained within the dashboard originates from a

variety of sources which have a number of engagement processes associated with them. This performance information is discussed with commissioners

(Abertawe Bro Morgannwg and Cardiff and Vale University Health Boards) and internally through performance meetings and clinical business meetings.


25 October 2018

Finance, Performance & Workforce Committee Resolution To:

APPROVE ENDORSE DISCUSS NOTE √

Recommendation The Finance, Performance & Workforce Committee is

asked to: • NOTE the content of this update report, the current

CAMHS performance and the actions being taken to improve this across Specialist CAMHS, Primary

CAMHS and Neurodevelopmental services (ND)

Summarise the Impact of the Finance, Performance & Workforce

Committee Report

Equality and

diversity

There are no directly related Equality and Diversity

implications as a result of this report.

Legal implications A number of indicators monitor progress in relation to legislation, such as the Mental Health Measure.

Population Health NA

Quality, Safety &

Patient Experience

The performance data included in this paper relate

directly to the quality, safety and patient experience for CAMHS

Resources This report makes reference to various resource requirements and the current status in terms of

progressing bids for these

Risks and Assurance Within the Integrated Performance Dashboard, actions are listed where performance is not compliant with

national or local targets.

Health and Care

Standards

The 22 Health & Care Standards for NHS Wales are

mapped into the 7 Quality Themes: Staying Healthy; Safe Care; Effective Care; Dignified

Care; Timely Care; Individual Care; Staff & Resources http://www.wales.nhs.uk/sitesplus/documents/1064/

24729_Health%20Standards%20Framework_2015_E

1.pdf The work reported in this summary and related

annexes take into account many of the related quality themes.

Workforce This paper identifies where there are additional workforce requirements within CAMHS

Freedom of

information status

Open


25 October 2018

UPDATE ON CAMHS PERFORMANCE

1. SITUATION / PURPOSE OF REPORT

The purpose of this report is to provide the Finance, Performance & Workforce Committee with a summary of current performance across Children and

Adolescent Mental Health Services (CAMHS).

2. BACKGROUND / INTRODUCTION

Cwm Taf UHB manages the CAMHS services on a Network basis across Cwm

Taf, Abertawe Bro Morgannwg UHB (ABMU) and Cardiff & Vale UHB (C&VUHB). Within Cwm Taf, for performance monitoring purposes, this includes Primary

CAMHS (SCAMHS), Specialist CAMHS (SCAMHS) and Neurodevelopmental (ND) services. Within ABMU this includes PCAMHS and SCAMHS and within C&VUHB

this includes SCAMHS only. This paper provides an update on current performance within these areas.

3. ASSESSMENT / GOVERNANCE AND RISK ISSUES

3.1 Specialist CAMHS

As described above, SCAMHS services are managed by Cwm Taf UHB on behalf

of Cwm Taf, ABMU and C&V Health Boards. The target measures compliance against the percentage of patients on the waiting list waiting <28 days (target

= 80%). The reported waiting times for each UHB at the end of September 2018 are shown below:

Specialist CAMHS ABMU C&V CT Total

Total Waiting List 161 167 176 504

Waiting 0-3 weeks 104 80 62 246 Waiting 4+ Weeks 57 87 116 260

% <4 weeks 64.5% 47.9% 35.2% 48.8% Longest Waiter 11 12 16 16

This data clearly demonstrates that the 80% target is not currently being met in any of the areas, however the situation is improving and the position at 16

October 2018 is as follows:

• ABMU 72% (average wait 2.9 weeks)

• C&V 54.5% (average wait 4.3 weeks) • Cwm Taf 47.5% (average wait 5.2 weeks)

The improvement in the position is as a result of a number of factors, including

tight performance management and the delivery of waiting list initiative clinics, providing additional capacity to core services.


25 October 2018

It is recognised that this ad-hoc provision of additional capacity does not

provide long term sustainability and following the introduction of Choice and Partnership Approach (CAPA) and the improved data availability that this has

supported, the service has now been able to undertake detailed demand and capacity analysis for each of the areas.

Discussions are now ongoing with commissioners regarding the resource needs

in ABMU and C&V; resources will be sought within Cwm Taf for the additional

staff required to deliver a balanced and sustainable service going forward (approximately 3 Whole Time Equivalent (WTE) staff). This is outlined in further

detail later in this section of the paper.

As the following graph demonstrates, the total patients waiting for SCAMHS across the Network has reduced significantly, from a total of 793 patients

waiting in October 2017 to 507 at the end of September 2018, a reduction of 36%. Similarly, the longest wait has reduced from 30 weeks to 16 weeks;

approximately a 50% reduction. It is disappointing that the position has deteriorated since May 2018, however with WLI clinics now running again in all

areas it is anticipated that this will begin to improve again. A daily performance tracker is now in place to monitor progress and fortnightly performance

meetings are held with the locality teams.

Choice and Partnership Approach (CAPA)-

As referenced above and as per previous updates, the CAPA model has been fully implemented in SCAMHS across all 3 localities (Cwm Taf, C&V and ABMU).

As has been demonstrated by the overall improvement in waiting times, this has supported improved performance including reduced waiting times and

reduced total caseloads. The CAPA approach has also provided greater clarity regarding demand and capacity for both new and follow up patients and

therefore provides enhanced knowledge to inform service planning.


25 October 2018

As the following charts demonstrate, total caseloads have reduced significantly,

through a combination of the implementation of CAPA and a focus on discharge plus improved file audit.

Demand and Capacity Analysis

As referred to previously, detailed demand and capacity work has been

undertaken across all of the SCAMHS Network services and this has demonstrated a need for the following additional staff to provide a sustainable

service: ABMU 1.4 WTE

Bridgend 1 WTE

Neath 0 WTE Swansea 0.4 WTE

C&V 2 WTE

Cwm Taf 3.3 WTE

In light of the above, discussions have been held with commissioners from C&V

and ABMU Health Boards identifying the service need and requesting that any underspends in year be re-directed into additional capacity to off-set this. This

principle has been agreed by ABMU and as a result the Waiting List Initiative (WLI) have been running continuously in Swansea and since August in

Bridgend. Discussions will continue with ABMU through the monthly commissioning meetings, regarding the requirement for additional recurrent

funding for future years.

C&V are yet to approve the use of underspend against the Service Level

Agreement (SLA) for WLI, however given the ongoing capacity shortfall the decision has been taken to proceed and WLI activity has therefore re-

commenced during October. The service will repatriate back to C&V management from April 2019, and whilst the capacity gap has been highlighted

in discussions any decisions around future funding will be considered by the C&V UHB.


25 October 2018

The Cwm Taf capacity gap was highlighted to Welsh Government (WG) in a

paper submitted in September 2018 with a request for the resources required to deliver the 80% target in year. This paper set out the scale of the capacity

gap, including the current backlog, and the resource request as follows.

The demand and capacity assumptions to achieve 80% target at year end are as estimated as follows:

Demand

Backlog 156 New demand 356 (6 months x 55.4 referrals)

Total 512

Capacity

Activity (at current rate) 181 RoTT (15%) 27

Total 208

Gap Demand-capacity 304

Proposal Additional new capacity

Additional staff (1 x B7 + 2 x B6 for 6 months) 78 WLI (8.6 per week for 26 weeks) 186*

RoTT (15%) 40 Total 304

*It must be highlighted that these patients will also require follow up and so for 70% of every new patient seen, provision for 7 follow up appointments in WLI

must also be made. The total clinics required is therefore 490 which is equivalent to 18.8 WLI clinics per week for 26 weeks (calculated on the basis of

3 hours per new appointment, 1 hour per follow up appointment, 3 hours clinical time per WLI session to allow the remainder for admin).

The risks in terms of delivery of the above are as follows

• It may not be possible to recruit additional staff, either through NHS recruitment or agency

• There are currently small numbers of staff willing to deliver WLI, therefore it will require a significant increase to deliver this volume of

activity plus the associated follow up work to ensure that core service is not impacted

• There would need to be a plan to manage the cohort of follow up

patients, that would be generated by this work going into 2019/20 • Clinic space would need to be identified to accommodate all of the

additional staff/ clinics.


25 October 2018

Cost

Proposal Cost per staff/ clinic Total cost 2018/19

1 x B7 £32,780 per staff (assume agency) 32,790

2 x B6 £28,590 per staff (assume agency) 57,180

490 WLI

clinics

£540 per session average (assume 50%

medics, 50% B7)

£264,600

Total £353,570

A further discussion with Welsh Government (WG) officers on 15 October, to discuss this proposal, was positive however similar information for C&V and

ABMU was requested by WG before a final response is given; this will be provided by 19 October.

This was an extremely ambitious proposal and a month has passed since the

proposal was submitted, therefore the time to deliver is further reduced. In the meantime, WLI clinics have commenced in order to provide some additional

capacity, however uptake is more limited than had been hoped and so this is not delivering at the rate required.

The delivery of WLI activity is dependent on the availability of staff to deliver

additional sessions. Unfortunately many have opted not to participate in this,

particularly since this is the third consecutive year when this has been requested and staff are expressing fatigue from ongoing requirements above

their contracted time. Without the recurrent investment in additional staff as per the above proposal, and the ability to recruit the staff required, the WLI is

anticipated to provide a limited improvement in the position; achieving the 80% target by year end will prove challenging.

It is however anticipated that ABMU will meet the 80% target by the end of

October or November, the challenge will be maintaining this position. Retention of staff across the Network is problematic and any loss of the staff in the period

prior to end of March could adversely impact on the position.

Detailed WLI plans are now being developed for C&V in light of the potential of additional funding from WG and there is a commitment from staff to undertake

WLI at least until Christmas. This should result in the C&V position improving to

around 70% by the end of December but maintaining this position and any further improved in the position will again be dependent on the commitment of

staff to undertake WLIs in the 2019.

3.2 Primary CAMHS

Primary CAMHS has two targets relating to waiting times, the first measures the proportion of new patients seen each month that receive their initial

assessment within 28 days of referral. The second measures the proportion of patients that commence an intervention that start this within 28 days of their

assessment. The target for both measures is 80% compliance.


25 October 2018

The September position was as follows:

Health Board % assessment within

28 days

% intervention within

28 days

ABMU 21% 92%

Cwm Taf 15% 100%

The above demonstrates that the services are not currently providing patients

with their initial assessment within 28 days of referral, however once patients do enter the service they receive their intervention quickly and within the target

timeframe.

This is seen as a key quality and safety indicator within the service and is significantly ahead of some other HB areas in Wales, where the focus appears

to be very much on the new patient waiting times. It should be noted that due to the way that this target is measured e.g. the proportion of patients that are

seen rather than a measure of the total waiting list, until the total waiting list is

below 28 days then compliance will remain low; assuming patients are being booked in turn.

The waiting lists over time for each area, in terms of total waiting and total

waiting >28 days are as follows:

Cwm Taf

As the above demonstrates, there has overall been a significant reduction in the

total number of patients waiting for a primary CAMHS assessment and the longest wait since a peak was identified in 2017.


25 October 2018

This improvement was achieved through a combination of validation, improved

booking processes and investment in WLI. It is disappointing that the position has since deteriorated, largely due to the team stopping WLI clinics, the cohort

of follow up patients built up from the WLI, and sickness within the team (noting that there are just 4 members of staff in the team).

A bid for additional staff has been included in the recent bids for

transformation/ Psychological Therapies and WG have responded to say that

they are willing to review requirements for in year funding but will make a decision on recurrent funding following the Delivery Unit review which is

planned for December, as part of an all-Wales PCAMHS review.

PCAMHS was included in the paper referenced above that was sent to WG in September 2018. This again provided a summary of the current position, a

proposal to meet the target in year, the risks associated and the cost.

The demand and capacity assumptions to achieve 80% target at year end are as follows:

Demand

Backlog 168 New demand 216 (6 months x 36 referrals)

Total 384

Capacity Activity (at current rate) 126

RoTT (15%) 19

Total 145

Gap Demand-capacity 239

Proposals for additional capacity-

2 x additional B6 staff members (6 months) 120

WLI (4.5 per week for 26 weeks) 88* RoTT 31

Total 239

*It must be noted that these patients will also require follow up and so for every new patient seen, provision for 3 follow up appointments in WLI must

also be made. The total clinics required is therefore 147 which is equivalent to 5.6 WLI clinics per week for 26 weeks (calculated on the basis of 2 hours per

new appointment, 1 hour per follow up appointment, 3 hours clinical time per WLI session to allow the remainder for admin).


25 October 2018

The risks in terms of delivery of the above are as follows

• It may not be possible to recruit additional staff, either through NHS recruitment or agency

• The current staff are reluctant to undertake WLI, the additional WLI activity would therefore potentially be dependent on encouraging them to

re-start this or on the new staff once recruited • There would need to be a plan to manage the cohort of follow up patients

that would be generated by this work going into 2019/20

• Clinic space would need to be identified to accommodate all of the additional staff/ clinics

Cost

Proposal Cost Total cost 2018/19

2 x B6 staff (assume

agency)

£28,590 per staff £57,180

197 WLI clinics £307.5 £45,203

Total £102,383

Again, it must be noted that the risk, in terms of delivery, is significant. Given

that this was an extremely ambitious proposal when submitted and a month has since passed therefore the time to deliver is further reduced. In the

meantime, WLI clinics have commenced in order to provide some additional capacity, however uptake is very limited due to the small number of staff in the

team and fatigue with the ongoing requirement for this. The service is also seeking to recruit additional staff on a fixed term basis until the WG funding is

approved recurrently however this is expected to be challenging due to the

shortage of CAMHS staff that are available. Requests for agency staff through on contract agencies, have not identified any suitable candidates and the

Directorate has not yet received approval to recruit staff from off contract agencies. Additional staff will be essential in order for the position to begin to

improve again.


25 October 2018

ABMU PCAMHS

As the above chart demonstrates, there has been a significant improvement in

terms of total patients waiting and longest wait within ABMU. This has been achieved largely as a result of the ICF investment within ABMU for 3 additional

PCAMHS staff, working in liaison with Local Authorities and also providing additional clinical capacity. These posts are ICF funded and so cannot be

guaranteed recurrently, however the benefits of these posts are clear from the data above. Going forward it will be important to monitor the impact that

enhanced liaison work has in terms of referral rates. It can be observed in the above chart that there was a deterioration in the position from April to July

2018 and this was due to sickness and vacancies within the team but now that these have been filled, the position is again improving. Should this continue it

would be anticipated that the target could be achieved by year end.

3.3 Neurodevelopment service

The target for Neurodevelopment (ND) services is for 80% of patients waiting for ASD and ADHD assessment to commence this within 26 weeks. The

following is the reported position at the end of September.

Neurodevelopmental CT

Total Waiting List 435 Waiting 0-11 weeks 105

Waiting 12-17 weeks 70 Waiting 18-25 weeks 80

Waiting 26-35 weeks 130 Waiting 36-51 weeks 50

Waiting 52+ weeks 0 % <26 weeks 58.6%


25 October 2018

The ND service has been under significant pressure since it was established and

this continues, as a result the service is not currently meeting the 80% target for all patients to begin assessment within 26 weeks of referral. In recognition

of this, WLI activity has been reintroduced in order to support an improvement in the position, although uptake has been relatively limited. In addition to this,

the Community Paediatric service is currently seeking approval to replace vacant Consultant sessions plus a retiring staff member with 2 new posts, both

of which would include additional sessions for ND in order to support this

position.

When the ND service was established the resources allocated were significantly lower than had been requested and it was therefore agreed that the service

should be implemented in 2 phases, with the initial phase to establish the service and the second phase to expand this to meet the demand. Submissions

have been made via the Integrated Medium Term Plan (IMTP) for the resources required to implement phase 2 however this has not yet been approved. The

requirement for this investment is supported by a demand and capacity analysis of the service which demonstrates a capacity gap for 115 new patients

per year plus the associated follow up work, requiring 2 additional clinical staff immediately to sustain the service. This resource will be sought via the IMTP

process for 2019/22.

As with other CAMHS services, uptake of the current WLI has been relatively

low, however this additional capacity is anticipated to prevent the position from deteriorating further and may support a small improvement in the position.

Again, however, recurrent investment in additional staff is required in order to deliver and sustain performance against the waiting list target for ND.

4. RECOMMENDATION

The Finance, Performance & Workforce Committee is asked to:

• NOTE the content of this update report, the current CAMHS performance and the actions being taken to improve this across Specialist CAMHS,

Primary CAMHS and Neurodevelopmental services (ND).

Freedom of

information status

Open

2.2 To receive an updte report on the Deep Dive undertaken in Facilities

1 2.2 Update Report on Facilities Deep Dive - FPW 25 Oct 2018 V2 GR.doc

Facilities Performance Update Page 1 of 20 Finance, Performance and Workforce Committee

25 October 2018

AGENDA ITEM 2.2

25 October 2018

Finance, Performance and Workforce Committee Report

UPDATE REPORT ON FACILITIES DEEP DIVE

Executive Lead: Chief Operating Officer

Author: Assistant Director of Facilities

Contact Details for further information: Russell Hoare 01685 728688

or email [email protected]

Purpose of the Finance, Performance and Workforce Committee

Report

The purpose of the report is to provide the Finance, Performance and

Workforce Committee with an update on the deep dive carried out by the Facilities team into its performance.

Governance

Link to Health

Board Strategic Objective(s)


objectives, and the related organisational objectives outlined within the 3 Year Integrated Medium Term

Plan 2018-2021, are being progressed. Aligned with the ‘Quadruple Aim’ described within ‘A Healthier

Wales’ (Welsh Government, June 2018) these objectives are:

• To improve quality, safety and patient experience. • To protect and improve population health.

• To ensure that the services provided are accessible and sustainable into the future.

• To provide strong governance and assurance. • To ensure good value based care and treatment for

our patients in line with the resources made

available to the Health Board. This report focuses on all of the above objectives.

Supporting evidence

See appendices


The operational team and directorate has worked together with their

Finance, Procurement and WF&OD Business Partners to undertake the deep dive into Facilities performance and address any issues identified and

to develop the actions in this paper.


25 October 2018

Finance, Performance and Workforce Committee Resolution to:

APPROVE ENDORSE DISCUSS √ NOTE √

Recommendation The Finance, Performance and Workforce Committee is asked to:

• DISCUSS and NOTE the content of the report.

Summarise the Impact of the Finance, Performance and Workforce

Committee Report

Equality and diversity

No implications have been highlighted from an equality and diversity perspective

Legal implications No known legal implications

Population Health There are no known population health implications

Quality, Safety &

Patient Experience

The performance of the Facilities Unit can impact on

the patient experience if quality and safety of services is not maintained. Facilities governance and

compliance arrangements are monitored through multidisciplinary groups:

• Housekeeping • Catering and Nutrition

• Environmental Management –ISO 1`4001:15 • Security and Violence and Aggression

Management

• Facilities Integrated Programme IMTP/CRES Board • Facilities Operational, Governance and

Performance Board • Medical Equipment and Devices

• Bridgend Facilities Transition Board

Resources There are no further resource issues than those

identified within the plan

Risks and Assurance Risks and Assurances are captured within Governance score cards and reported through to the

Corporate Risk Committee

Health and Care

Standards

The Board has a duty to ensure that the Standards

for Health Services in Wales are being embedded across services and this report relates to the

following standards: 2.1 - Environment, Risk, Safety and Security

▪ ISO 14001:15 – Standard 2015

▪ Corporate Health Standard ‘Platinum’ level 2.4 - Infection Prevention and Control (IPC) and

Decontamination - Laundry – EN 14065 2.5 - Nutrition and Hydration

2.9 - Medical devices, Equipment and Diagnostic Systems - ISO 9001;15 Quality Standard

Workforce There are no further resource issues than those identified within the plan

Freedom of

information status

Open


25 October 2018

UPDATE ON FACILITIES PERFORMANCE DEEP DIVE


The purpose of the report is to provide the Finance, Performance and Workforce Committee with an update on the deep dive carried out by the Facilities team

into its performance.

The report has concentrated on the following key metrics: • Workforce

• Finance

• Cash Releasing Efficiency Scheme (CRES) • Quality, Risk and Standards

The report presents the financial year 2018-19 Month 5 position for the

Directorate and also provides key performance data for this calendar year with regard to CRES, workforce transactional management, quality and standards.

To frame the deep dive report comparisons have been made to performance

against the same period FY 2017-18 and also includes the latest benchmarking data from the EFPMS FY16-17 data report and Facilities CRES performance over

the last 5 years.


The Facilities Directorate consists of 8 key service departments:

• Catering and Central Production Unit (CPU),

• Housekeeping, • Porter Services, Security and Car Parking,

• General Offices, Residences and Switchboard,

• Environmental, Waste and Grounds and Gardens, • Fleet Transport & Non-Emergency Patient Transport (NEPT),

• Laundry Processing Unit, • Clinical Engineering,

The Senior management team comprises of:

• 1 x Assistant Director of Facilities (ADF),

• 1 x Head of Facilities (vacant), • 4 x senior site and service managers,

• 1 x Facilities business manager, • 1 x Governance and compliance manager

Total Facilities Staff Establishment:

WTE = 754.17 Heads = 940


25 October 2018


3.1 WORKFORCE TRANSACTIONAL PERFORMANCE

Facilities Key Performance Indicators (KPI’s)

Workforce KPIs

Previous %

(August 17)

Month Actual %

(August 18) Run Rate

PDR % (85%) 68.89% 85.18% ↑

Sickness % (4.5%) 8.05% 6.26% ↓

LTS % 6.71% 5.26% ↓ STS% 1.34% 1.01% ↓

Core Skills % 46.9% 73.1% ↑

Datix/ Incidents 11 10 ↓

Personal Injury claims 2 2 ↔

Investigations 2 4 ↑

Grievances 1 4 ↑

Capability/Competency 0 0 ↔

Disciplinary pending 2 3 ↑

Disciplinary dismissals 0 1 ↑

Suspensions 1 0 ↓

Sickness Absence

A review of the proportion of sickness each year classified as Short term Sickness (STS) and Long Term Sickness (LTS) illustrates that the proportion

classified as LTS is growing year on year. This information is provided in the table below:

Time Period LTS STS

2015/2016 71.77% 28.23%

2016/2017 78.55% 21.45%

2017/2018 80.53% 19.47%

This suggests that appropriate sickness management processes are in place to manage sickness as a higher proportion of sickness each year is made up of

more serious sickness cases.

The LTS percentage and STS percentage over a rolling 12 months from August 2017 to August 2018 is included in table 1 below:


25 October 2018

Table 1 - LTS percentage and STS percentage over a rolling 12 months from

August 2017 to August 2018

STS Deep Dive

The Directorate has completed two deep dive analysis exercises in recent months to better understand sickness trends and patterns and to ensure

sickness management is effective.

Workforce business partners were involved in the deep dive analysis and continue to work with managers to ensure the correct management of sickness.

The Sickness deep dive reports are included at Appendix 1 for information.

Performance Development Review (PDR)

The current PDR compliance rate is now 85.18% as at 1 September 2018.

The average compliance rate over a rolling 12 months from August 2017 to

August 2018 is included in table 2 below:


25 October 2018

Table 2 – Average PDR Compliance Rate August 2017-August 2018

A plan has been prepared for the directorate that identifies the number of staff

who require a PDR and the month that staff with a current PDR will require a review. This plan can be used my managers to:

• Ensure all reviews are completed so that overall compliance does not drop,

• Schedule staff requiring a PDR to improve overall compliance rates, • Target service areas that are currently rated red for compliance

Core Skills Training

The current core skills compliance rate has continued to improve each month

and it is 73.1% as at 1st September 2018.

A training plan has been developed to ensure that all staff within Facilities have the training they require, this training is delivered in various formats including

classroom style training days, E-Learning, small presentations and information leaflets. The average compliance rate over a rolling 12 months from August

2017 to August 2018 is included in the table below:


25 October 2018

Table 3 – Average Core Skills Training Compliance August 2017-August 2018

40.0

50.0

60.0

70.0

80.0

Directorate % for all level 1 CSTF Competencies

Investigations/Disciplinary/Suspensions

• 6 Investigations ongoing.

Grievance

• 3 grievances ongoing relating to the changes to services in line with CRES scheme.

3.2 FINANCIAL PERFORMANCE ASSESSMENT

Whole Time Equivalent (WTE) Run Rate

The WTE run rate highlights the impact of the implementation of the FY

2017/18 CRES schemes and also the turbulence associated with the current porter services scheme in FY 17/18, the mitigation carried out to help reduce


25 October 2018

this and a high level of vacancies being processed in the first quarter of FY

2018/19. Some monthly variability also occurs due to the number of weeks overtime paid in individual months, for example months 3 and 4 in 2018/19

had four weeks of overtime payments, whereas months 2 and 5 had five weeks

of overtime payments.

Budget The month 5 position for Facilities is a cumulative variance (adverse) against

budget of £0.393m. This is forecast to be £0.918m at month 12 with a recurrent position of £0.818m which is detailed in the table below.

Description

Annual

Budget

Month 5 Forecast Variance

Budget Actual Variance 2018/19 Recurren

t

£000's £000's £000's £000's £000's £000's

Pay 16,963 7,126 7,177 50 218 276

Non-pay 7,147 2,798 2,762 (36) 12 -

CRES (871) (366) - 366 674 542

Income and

Trading 1,746 737 750 13 14 -

Grand Total 24,985 10,295 10,688 393 918 818

The main items which make up the over spend are shown in the following table and are explained further below.

Description

Month 5

Variance

Outturn

2017/18

Forecast Variance

2018/19 Recurrent

£000's £000's £000's £000's

Porter services 56 365 276 276

Housekeeping PCH 35 0 49 0

CPU (21) 75 (21) 0

Laundry 47 4 47 0

Undelivered CRES 366 609 674 542

Porter Services In order for savings to be realised, the revised appropriate manning rota needs

to be implemented. Following the staff engagement and consultation phases, staff supported by their trade union representatives have raised a grievance

against the revised rota. We are now in the process of hearing the grievance and we are awaiting the outcome report. To reduce the overtime spend on the

existing rota 6 WTE fixed term staff are now being recruited whilst workforce Organisational Change (OCP) and Grievance policy processes are being taken

forward. Further detail on this CRES scheme is provided in the report and at Appendix 5.

Housekeeping – PCH.

There are ongoing levels of long term sickness which is in excess of the

operational flexible ability to redeploy staff to cover this issue. Therefore,


25 October 2018

additional hours (not at overtime rates) are being allocated to cover this. Some

additional temporary staff are being employed to ensure that premium overtime is not necessary, whilst the sickness issues are addressed.

CPU As reported at the April FP&W committee, in 2017/18 there were significant

increases in the cost of provisions and consumables which manifested in a £75,000 adverse position for the CPU. Considerable work was undertaken with

procurement business partners to reduce costs by sourcing alternative providers and to alter menu provision which has resulted in the improvement of

the CPU financial position that is currently showing a £21,000 underspend. This area continues to be a risk due to increases in provisions costs and will continue

to be closely monitored.

Laundry The laundry has experienced lower income levels due to lower customer activity

levels at ABMU sites. ABMU has advised that general activity levels at Princess of Wales (POW) have been lower to August and also the hot weather has had a

negative effect on demand for additional layers. ABMU advised that this is likely to return to historical levels from September. There has at the same time been

a period of high levels of sickness and it was necessary to work overtime to

cover this and which has now reduced.

CRES Savings Plan Progress

The 2018/19 CRES target is £1.177m (4.5%) and the current CRES forecast

delivery totals, as at month 5, are: • 2018/19 – in year £0.503m: full year £0.635m

• 2019/20 – in year £0.421m: full year £0.773m

The in-year CRES forecast has gradually increased during the year which is illustrated in the following chart and the Facilities team continue to seek savings

opportunities not on plan the aim being to reduce the gap.

Since the financial year

2013/14, the Facilities Directorate has always taken on a challenge and has delivered a combination of service transactional and transforming recurrent


25 October 2018

savings totalling £4.314m. The detail of the annual delivery can be seen in

Appendix 2 and is summarised in the following graph.

In March 2016, the facilities team commissioned an external consultancy, to conduct a benchmarking review of the Cwm Taf Facilities costs against UK

benchmarks both public and private sector. The report analysed each of the service areas against a number of known NHS and industry standard key

performance indicators. The report assessed twelve areas of operational delivery namely:

• Administration, General Office & Helpdesk, • Facilities Operational Management,

• Security, • Linen,

• Catering - Patient Feeding, • Catering – Restaurant/Barista,

• Catering - Central Production Unit (CPU),

• Housekeeping, • Porter Services,

• Grounds & Gardens, • Waste,

• Transport.

The report identified the following areas of opportunity for further work and in support of Integrated Medium Term Plan (IMTP) potential savings financial year

2017-18: • Facilities Operational Management,

• Security, • Catering - Patient Feeding,

• Catering – Restaurant/Barista, • Catering - Central Production Unit (CPU),

• Housekeeping,

• Porter services,


25 October 2018

• Grounds & Gardens,

• Transport.

Facilities has taken forward and delivered on the following schemes associated

with this report in financial year 2017-18: • Facilities Operational Management,

• Security services redesign, • Catering - Patient Feeding redesign,

• Housekeeping services redesigns.

The following table shows the status and forecast of the current CRES schemes:

Code Status In year Recurrent In year Recurrent

£000's £000's £000's £000's

Fac 01 CPU outsourcing Appraisal On-going 100 250

Fac 03 Non pay suppliers products volume and price Near completion 120 150

Fac 03a Non pay - VAT Delivered 150 150

Fac 04

Grounds and Gardens Service - Outsourcing

Appraisal On-going 60 150

Fac 05

Restaurants - new service model (capital

investment required) On-going 48 80

Fac 06 YGT Valley Life Service Redesign Phase 1 Delivered 54 54

Fac 06a YGT Valley Life Service Redesign Phase 2 Delivered 26 39

Fac 06b YGT Valley Life Service Redesign Non pay Delivered 38 50

Fac 07

Dewi Sant Health Park Barista (capital

investment required) On-going 5 8

Fac 08 Internal Transport Community/Pathology review On-going 6 58

Fac 10 Unscheduled Transport Spot Purchasing On-going 18 30

Fac 11 CPU Bonus On-going 81 90

Fac 12 General office rationalisation On-going 15 60

Fac 13

NHS Wales Laundry production unit service

review - Memorandum item 2020/21 delivery

Fac 14 Porter services On-going 113 135

Fac 15 Switchboard (New staff rota - centralisation) Near completion 53 100

Fac 16 Salary sacrifice personal lease cars Delivered 5 -

Fac 17

Laundry chemical container deposit

reimbursement (prior years) Delivered 30 -

Fac 18 Electricity Maximum Capacity Delivered 4 4

503 635 421 773

2019/202018/19

Forecast

Scheme Title

Facilities Bench Marking The results of the most recent annual benchmarking exercise that compares the

services provided by the Facilities Directorate at an all Wales level are detailed in Appendix 3. This illustrates that the Directorate are either near the all

Wales averages or are making progress towards those benchmarks.

CRES Project Management Arrangements

The CRES schemes involve a more innovative period of transformational change which requires careful balancing of strategic development and operational

delivery.

The redesign of some key services is at the centre of this planning period and the directorate acknowledge not only the importance of the leadership skills of


25 October 2018

its management teams but also the support of our workforce and stakeholders

in making our strategic plans become an operational reality.

In order to deliver such a challenging transformational change programme

robust project management arrangements are in place.

3.3 QUALITY, RISK & STANDARDS PERFORMANCE ASSESSMENT

Quality KPIs

Service and Target

Actual %

(Quarter 2

17/18)

Actual %

(Quarter 2

18/19) Run Rate

Patient catering

satisfaction (90%) 95% 97% ↑

Restaurant

satisfaction (85%) 71% 68% ↓

Barista satisfaction

(85%) 88% 86% ↓

Cleanliness

satisfaction (85%) 93% 94% ↑

Patient Porter

Services satisfaction KPI’s In development as part of service redesign

Health and Care Standards KPIs

Health and Care

Standards KPI

Previous

Month Actual

% (Aug 17)

Month

Actual %

(Aug 18) Run Rate

EHO (9x5 = 45Pts) 44 44 ↔

CPU STS 100% 100% ↔

National Standards of Cleanliness

High Risk Areas

(95%) 96 95 ↓

Significant Risk Areas

(85%) 90 91 ↑

Low Risk Areas (75%) 91 78 ↓

ISO 14001:15 –All HB

Sites 100% 100% ↔

Clinical Engineering

ISO 9001:15 quality

standard external BSI

audit 100% 100% ↔

Waste Management Waste Performance Report (Appendix 4) Laundry

Decontamination BS

EN 14065

In development

Porter Services KPIs In development as part of service redesign

Facilities Governance and Compliance


25 October 2018

Governance arrangements

• The directorate has an organisational chart in place that was included in the IMTP.

• There is a communication plan and a clear line of communication from

CBM to the Facilities Operations and Governance Group. • There is a Team operational exception report for each service area which

is presented by the Service Leads at the Operational Group meeting. The report includes Workforce KPI scores, Service Quality KPI's, establishment

figures, and updates and actions from previous meetings. • Governance issues such as compliance scorecards, health and safety,

policies and documents for review were discussed in all multi-disciplinary service groups.

• The Governance and Compliance Manager maintains a register of legal compliance for the Environmental Management System and will cross

reference this to the aspects and impacts register. New legislation that is relevant to the department is recorded and shared with the relevant

staff. • The directorate subscribes to the Environmental Legislations Update

Service and Coroner Facilities Management and the Governance and Compliance Manager routinely checks the Health & Safety Executive

(HSE) Website.

• The directorate has compliance scorecards in most service areas and evidence is provided annually to ensure compliance with all legislative

and regulatory requirements. The scorecards are managed by the Governance and Compliance manager who also holds regular meetings

with service managers to update the scorecards. • Legislative requirements for each service within the directorate have been

outlined in the IMTP. This is how the Service Leads are made aware of their responsibilities.

• The Governance and Compliance Manager checks that relevant legislation has been referenced in new and updated policies.

• The directorate has a good working relationship with its business partners and

• Facilities has recently been the subject of an internal audit by the NHS Wales Shared Services Partnership’s (NWSSP’s) audit and assurance

services. The audit was in two parts; (1) Compliance and (2)

Management Arrangements – Porter Services. We have met with the auditors and the report has been finalised. Facilities have provided a

response to the report’s recommendations and are carrying out the actions required and both reports will now be submitted to the audit

committee.

Planning The IMTP was developed in line with the timetable as set out in the framework

and covered all the key areas / priorities that were identified in the current local planning framework.

The relevant staff attended the formal IMTP engagement session held in October 2017 and the directorate was proactive in seeking views of

stakeholders and utilising the support of the business partners. Recognition was


25 October 2018

given to the directorate for this approach in their IMTP feedback. There is a

policy and procedures plan in place that links to the compliance scorecards to monitor policy reviews. There is a Facilities work plan in place that captures

IMTP, CRES, strategic and service operational programmes of work. A copy of

the current plan is detailed at Appendix 6.

Risk Management The Facilities management have been reviewing its risk management process.

The following progress has been made to improve the risk management arrangements within the Facilities Department:

• The Facilities Risk Register has been reviewed and updated and as a result 9 risks that were found to have been mitigated have been

removed, • Each risk has now being reviewed and scored based on four essential

Facilities elements; Financial, Health & Safety, Business Service Delivery & Continuity and Statutory & Mandatory Compliance,

• The Facilities Risk Register has now been added as a formal agenda item in the Facilities Operational and Governance Group to ensure proactive

monitoring of the risks is being undertaken, • Work has commenced, in collaboration with the Datix risk team, to

improve the risk reporting format for the department, including the

development of KPIs, analysis of risks against claims, scrutiny of risk assessments and reducing the amount of risks not being closed.

Risk Register

There are currently 3 high risks, 20 moderate risks and 12 low risks on the risk register that are being managed.

Service Standards & Quality

Cleanliness

The health board is currently achieving the required standard for a clean environment in accordance with the national standards for cleaning in NHS

Wales.

Catering – EHO

The health board is currently achieving compliance with catering environmental health and food safety standard. 8 x very good (5 star rating) and 1 x good (4

star rating) assessment score.

Patient Quality Satisfaction and Experience feedback provided by the Facilities App survey is positive and encouraging.

Central Production Unit (CPU) Green and Kasab Facilities management consultants are currently carrying out

a deep dive review of the Catering Central Production Unit (CPU). This follows


25 October 2018

earlier internal work carried out by the Facilities team and a CBM report which

made preliminary reference to potential savings at the CPU. The deep dive is now necessary to establish what opportunities exist to improve efficiency,

productivity and best value for the health board. In addition to take into

consideration the pending Bridgend Boundary Change and the fact that patient meals at the Bridgend sites are provided by a recognised commercial ready

meal supplier and not ABMU CPU.

The output required of this review is a fully-developed optimal service model for the CPU, which can be considered for adoption by the Health Board, it will

include: • An analysis of the options for the CPU business including the potential to

outsource the service to a third party inpatient meal provider. All meals provided by a third party provider would need to be fully compliant with

the requirements of the All Wales • An assessment of the Estate condition, compliance with the All Wales

nutrition and catering standards for food and fluid for hospital inpatients, environmental health food safety, and STS food processors and suppliers

to the public sector standards and code of practice. • The options appraisal would also need to consider the impact of the

expansion of the Health Board to include Bridgend and the inclusion of

further hospitals and its catering requirements to see whether this provides the existing CPU with a critical mass.

• The deep dive work is being supported by business partners and the Facilities Catering and CPU Management team. An option appraisal

report is scheduled for completion next month and first draft will be provided for CBM in December 2018.

Porter Service Redesign and Modernisation

Since 2016 the Porter Services have been the subject of an in depth service redesign implementation. In the last 5 years the facilities team has taken

forward a number of challenging service redesign and CRES schemes involving large groups of staff, however this one has been the most complex and

challenging change project for management, staff and business partners to date.

This change project is being implemented based on a number of factors not least of which is bringing considerable savings for CTUHB along with service

and working practice modernisation for the benefits stakeholders and our patients. This work also involves improvements in porter career development,

training, staff supervision, operational command and control and tactical response in support of bed management and clinical services and introducing

technology into the work place. The aim being to provide service delivery flexibility and effective support to acute site incident management and all

hospital clinical and security related tasks to the benefit of the organisation and our patients.

A consistent dedicated and determined approach by Facilities management and business partners has been adopted to the redesign of porter services, whilst


25 October 2018

recognising and being sensitive to staff concerns that change is not always

acceptable to all staff.

Further details about this redesign scheme, the risks, benefits and the

challenges that Facilities and its business partners have been working to

overcome to achieve the objective are summarised at Appendix 5.

ISO 14001:2015 Standard Following an external surveillance audit carried out in July 2018, Cwm Taf UHB

has retained ISO 14001:15 certification for all its healthcare sites.

In preparation for the boundary change in April 2019, a gap analysis is being conducted to identify the ISO 14001:15 position for the Bridgend region. This

standard is currently managed by the Abertawe Bro Morgannwg UHB (ABMU) Estates department therefore will be subject of transition transfer / Service

Level Agreement (SLA). Once completed an action plan will developed to ensure the same high standards achieved by CTUHB are retained.

Waste Management

The health board is currently achieving its waste management targets across all waste streams and meets health and care and environmental management

standards. Details of the Facilities Waste management performance which

includes cost and tonnage over the last 5 years can be found at Appendix 4.

Clinical Engineering Following a recent Clinical Engineering external BSI audit. The health board is

currently achieving the quality standard ISO 9001:15 required.

There is a requirement for the majority of patient facing nursing staff to receive medical gas training. Depending on nursing staff responsibility, requirements

are between 1,500 to 3,000 staff requiring the training. This is a significant training challenge for the department and the one member of staff who also

provides medical device training. A Training needs analysis is being carried out. A bid to fund an additional trainer has been submitted. This risk and

requirement has been reported in the Facilities IMTP plan as a discretionary investment requirement.

There is an increasing requirement for Bariatric Beds and Equipment these bed systems have recently been rented. A bid for funding has been approved to

purchase and reduce rental requirements to mitigate the financial and service risks.

There is an increasing demand within community/localities setting for beds at

home for discharging patients. It is likely that further purchases will required from the replacement bed budget to accommodate demand and avoid rentals.

Purchase of a further ten at home beds is in progress and awaiting delivery.

Business managers in the Primary Care & Mental Health Directorate have been asked to provide a business case to clearly identify future at home bed demand

so that supply and cost can be forecast, included in the Facilities IMTP the aim


25 October 2018

being to avoid high rental cost and to ensure we maintain service delivery for

the future.

The Facilities forward work plan includes service deep dive work to be carried

out within bed management services. This may require support from external service related management consultants.

Currently bed management services is provided from a combination of internal

and external (contract) bed management and bed maintenance services and spread across three Directorates within Cwm Taf UHB. The deep dive is now

necessary to establish what opportunities exist to improve efficiency, evaluate bed product requirement and suitability, and ensure quality of service for the

patient, productivity and best value for the health board. In addition to take into consideration the pending Bridgend Boundary Change and what bed

management and maintenance arrangements are in place.

Grounds and Gardens Services The Facilities forward work plan includes service deep dive work which is

currently being carried out within the Grounds and Gardens services. This service deep dive is included in the CRES plan and follows earlier internal work

carried out by the Facilities team and a CBM report which made preliminary

reference to potential savings.

Currently Grounds and Gardens services which also provides a small service delivery element (mainly the smaller primary care and locality sites) of gritting

and snow clearance in support of the UHB winter adverse weather plan.

The services are provided from a combination of internal and external (contract) maintenance services. The in-house service is considerably

stretched to meet the demand of the Estate which has increased in size and geographical scope and there has been very little investment in equipment over

the last 8 years.

The deep dive is now necessary to establish what opportunities exist to improve efficiency, evaluate services, equipment requirements and suitability, and

ensure quality of service delivery, productivity and best value for the health

board. In addition, to take into consideration the pending Bridgend Boundary Change and what grounds, gardens, gritting and snow clearance service

maintenance arrangements are in place.

The deep dive work is being supported by business partners and the Facilities management team. An options appraisal report is scheduled for completion in

December and the first draft will be provided to CBM in January 2019.

Other Facilities Key Areas of Work

Facilities Investment in Technology


25 October 2018

We are currently scoping similar service delivery and transactional management

systems as an investment in technology for Porter and Housekeeping services as there are benefits to bringing in management information systems to the

Facilities services environment. We have met with the system provider to

discuss the benefits further and scope system costs. A Facilities investment in technology paper will then be drafted for CBM and included in the Facilities

IMTP and the project is included in the Facilities work plan 2018-20.

Staff Residences PCH Since the last FP&W report we have met with Tim Burns and Rosie Cavill Capital

/Estates and accommodation options were discussed and identified. It was agreed that the options needed to be drafted into an options appraisal paper for

decisions to be made on the future direction of the residential accommodation at PCH. Early indications are that capital investment even for the minimum

accommodation requirement is around £1.5m with no return on investment as minimum accommodation is funded for F1’s. Public service partner or private

investment appears to be the option that may need to be considered.

Estates/Capital colleagues have now commissioned an architect to provide costs for bringing the residential accommodation up to a good standard and we

expect to receive this shortly.

These costs will be reviewed and evaluated for their cost effectiveness

compared against a complete re-build option which may include a public service partner or a private investment option.

All Wales Laundry Processing Units Review

Work is continuing on an outline business case (OBC) for laundry services. A Risk workshop was held on the 6 September 2018 and a benefits and/or dis-

benefits associated with centralised management arrangements in relation to the All Wales Laundry review was held on the 2 October 2018. These workshops

will further support the information provided to date in refining the OBC. A follow up project group meeting will be arranged to share the OBC as planned.

The Cwm Taf Laundry manager has been tasked with undertaking a Cwm Taf

Laundry gap against the BS EN 14065/WHDM standard, Estates condition

assessment, identify productivity and efficiency improvements and consider future business opportunities. A report on progress with this work and the

findings of the gap analysis against the standard will be provided to CBM.

All Wales NHS Catering IT system Consultants have been engaged by Shared Services to review the benefits and

requirements of an all-Wales catering IT solution. CTUHB were highlighted in the report for best practice in catering and food waste management. The All-

Wales group continues to meet regularly and a representative from CTUHB attends the meetings.

An internal review of the costs and benefits of the IT solution is currently being completed, and a paper will be presented at the October CBM for discussion.


25 October 2018

There are a number of benefits to introducing the Catering IT system, these

include: • Reduced food waste,

• Reduced cost associated with waste,

• Easier ordering for patients, • Need for paper menus eliminated,

• Joined up system from production to meal service, • System can be extended to include modules for IT management of

other services e.g. housekeeping and porter services

Non-Emergency Patient Transport (NEPT) - On the Day Discharge and Transfer Service

One of the Health Boards key priorities is to ensure that a robust service model is in place to facilitate and aid the efficient flow of patients through its Hospitals

and reduce the impact on the number of beds used and associated costs involved.

As part of developing this new service model the Health Board has recently

reviewed and improved patient flow through its two main District General Hospitals (DGH’s) at Prince Charles Hospital (PCH) and the Royal Glamorgan

Hospital (RGH).

The success of this initiative has seen an increase in ‘on-the-day’ demand for

patients requiring either a discharge home or transfer to other health care facilities and the Health Board is seeking to provide an additional Discharge and

Transfer Vehicle to complement the existing two vehicles in operation (provided by the Welsh Ambulance Service NHS Trust) and thereby completing the new

service model.

A detailed service specification has been developed which is currently subject to a competitive tendering exercise.

Once this exercise has been completed the findings will be compared and

contrasted against our own in-house costs and assessed for their relative merits.

PON Transport Model (Paediatrics, Obstetrics and Neonatal Redesign Programme)

The Facilities team have been asked to develop a dedicated transport service to support the work associated with the implementation of the South Wales

Programme in relation to the redesign of services for Paediatrics, Obstetrics and Neonatal.

Again, a detailed service specification has been developed with key stake

holders within the organisation which will shortly be going out to tender. Once completed the findings will be compared and contrasted against our own in-

house costs and assessed for their relative merits.


25 October 2018

Bridgend Boundary Change The Facilities Transition Board was set up in July 18, reporting to Transition

Programme Board. To date 13 out of 27 work streams have been completed.

Service transfer proposals are being developed for all services and will be shared with the Transition Programme Board for consideration at the next

meeting scheduled for November 2018. The service areas that have a critical path for service continuity from April 1 2019 are:

• Clinical Engineering, • Switchboard,

• Waste management, • Transport management,

• Grounds and gardens, • Gritting and Snow,

• ISO 14001:2015

Conclusion

The Facilities Directorate acknowledge that further work is needed to improve the current financial position and to deliver on its IMTP and CRES plans.

The Directorate team are committed to ensuring financial sustainability. We maintain a positive attitude and appetite for seeking opportunity and doing

things differently and supporting our staff, whilst maintaining a good reputation for high quality and standards of service delivery in support of clinical services

and operations.

4. RECOMMENDATION

The Finance, Performance and Workforce Committee is asked to:

• NOTE and DISCUSS the content of the report.

Freedom of information status

Open

2.2.1 Appendix 1 Sickness deep dive report FPW 25 Oct 2018 GR

1 2.2.1 Appendix 1 Sickness deep dive report FPW 25 Oct 2018 GR.docx

Facilities Directorate

Short-term Sickness Deep Dive

June 2018

Compiled by Hayley Davey Sara Minahan

2.2

Appendix 1

Page | 1


Short-term Sickness Deep Dive – June 2018

Introduction

Further to CBM requirements a short-term sickness (STS) deep dive

has been carried out for the Facilities Directorate.

The purpose of this review is to look at short-term sickness, from April 2017 to date, to establish the main causes of absence; to

explore actions or initiatives to potentially reduce the amount of short-term sickness absences by implementing pro-active

management processes across the directorate.

The facilities’ teams have worked hard alongside the workforce

business partners, to improve sickness management practices within the directorate. This hard work can be clearly seen in the table

below which shows STS falling across the directorate suggesting management practices are improving.

The table below shows the percentage of sickness categorised as

Long Term sickness (LTS) and STS out of the total sickness absence.

Time Period LTS STS

2015/2016 71.77% 28.23%

2016/2017 78.55% 21.45%

2017/2018 80.53% 19.47%

The data suggests that appropriate management of STS is in place as the proportion of overall sickness is falling year on year.

There are approximately 135 staff responsible for sickness

management within the directorate. Current records show that a total of 22 line managers/team leaders/supervisors have received

refresher training in managing sickness absence, within the last twelve months.

Findings

According to the Electronic Staff Record (ESR), the total number of short-term sickness cases, from 01/04/17 – 31/05/18 is 973.

Page | 2

The top ten main reasons for short-term sickness are listed below, along with the number of instances:

Reason for Absence Instances

Gastrointestinal problems 172

Cold, Cough, Flu - Influenza 167

Back problems & other musculoskeletal 75

Anxiety/Stress/Depression/Other

psychiatric illness

65

Chest & Respiratory problems 53

Ear, nose, throat 34

Genitourinary & gynaecological disorders 29

Injury, fracture 24

Headache/migraine 20

Unknown causes/not specified 14

Suggested areas for review from CBM were back and musculoskeletal (MSK) problems and anxiety/stress/depression, to

identify if moving and handling training had been completed for staff with back problems/MSK sickness, and if stress risk assessments had

been completed for work-related stress absences.

Back Problems & other musculoskeletal

• Total number of cases: 75 • Number of files randomly selected for checking: 46

• Number of cases work related: 5 • Number of staff compliant at time of sickness: 28

• Number of staff not compliant: 18

Eighteen staff (39%) were not compliant at the time of sickness.

None had received training after returning to work and still require training in moving and handling.

It is worth noting that 30 of the 46 staff files audited (65%) were

aged 50+ and in physically active roles.

Anxiety/Stress/Depression/Other psychiatric illness

• Total number of cases: 65 • Number of files randomly selected for checking: 38

• Number of cases work related: 5 (possibly 6 as there is one not stated)

• Number of risk assessments completed (for work related

stress): 0

Page | 3

There were five definite work-related instances (13%) (possibly six as there is paperwork missing and/or not stated) but none were

stated as such on ESR. There were differences between the self-certificates/RTW documents and GP certificates, namely the RTW

documents stating “work-related stress” and the GP certificates stating “stress”. Also, none of the work-related absences had stress

risk assessments on file.

It is worth noting that 11 of the staff files audited (29%) were for bereavement of a family member. Given this high number of cases

it may be worthwhile to have a sub category on ESR for bereavement as this will remove these and prevent the distorted

view currently presented.

Sickness Management – Third/Formal Final Stage

The Third/Formal sickness hearing process was considered for effectiveness and consistency.

9 Third/ formals have been undertaken in Facilities during the year

April 2017- March 2018, with 4 further Third/ Formals taking place from April 2018 to July 2018.

The number has felt to be considerably more because on numerous

occasions meetings have had to be rescheduled due to the unavailability of member of the management team or Unions,

especially when notified of their attendance at a late stage.

In all case considered within facilities to date the decision has been

to set a further review period, during which if the individual triggered and was absent would return to the final stage for consideration.

This is comparable with the outcomes seen within the other

Directorates which the Scheduled Care HR Team support.

The reason for these decisions have been due to a range of factors including, underlying conditions which are resolved or where further

support can be provided to improve future attendance, significant personal/domestic circumstances which have contributed to ill health

but are now resolved, Occupational Health advice which is advising of a positive prognosis.

The other area which impacts upon management decisions are the

quality of the paperwork which is submitted as a summary of the

absence management case and the level of consideration which has been given to support or actions which can be taken which has been

considered at earlier stages.

Page | 4

At the current time, there are no feedback mechanisms that enable

the outcome of a 3rd formal hearing to be shared with the line manager and HR advisor so that lessons can be learnt.

Given the number of 3rd formal cases, it is important to improve the

quality of the manager’s report to a hearing and to ensure consistency of both reporting and outcome across the directorate. A

formal Sickness Consultancy meeting will be established to implement these improvements and attempt to change the culture of

sickness management across Facilities. This meeting will be held bi-monthly and include membership from:

• Facilities managers with responsibility for presenting

managers reports,

• HR advisors who support the managers, • HR Business partners,

• Senior Facilities managers who hear the 3rd formal sickness hearing

These meetings will also provide opportunity for the discussion of

Long Term Sickness cases and ensure consistency of management and support offered to staff.

Summary

All data checked and collated for back/MSK absences suggests that

65% of staff were aged 50+, with physically active roles. Also, 61% were moving and handling compliant at the time of sickness.

Absences related to anxiety/stress/depression indicate that 13% were work-related but none had been risk-assessed by line

managers. Also, 29% of these cases were due to bereavement.

Over the course of the audit numerous anomalies were identified:

• Several departments using the wrong return to work (RTW) paperwork,

• Some return to work documents, e.g. self-certificates, RTW forms, were missing and/or had not been signed by the absent

staff member, • There were several instances in different departments where:

a) Sickness absence was recorded on the wrong staff member’s record,

b) The reason for absence was inputted on ESR incorrectly,

c) The dates of absence were different on the RTW paperwork to those on ESR,

Page | 5

d) Self-certificates and RTW paperwork stated that absence was work-related stress but GP certificates stated only

“stress”, • ESR statistics show that one department had ten staff with

“unknown causes/not specified”, which should only be used in exceptional circumstances. However, these files were not

audited as they did not appear under back/MSK or stress/anxiety/depression headings.

These anomalies suggest that further sickness management training

is required for all managers, supervisors and team leaders who have responsibilities for sickness absence management.

Page | 6


Short-term Sickness, Further Analysis September 2018

Compiled by Hayley Davey

Page | 7


Short-term Sickness Analysis – September 2018

Introduction

Further to CBM requirements a short-term sickness deep dive was carried out in July/August 2018 (for the period of April 2013 to May

2018) for the Facilities Directorate.

Following submission of the report to the CBM group in August, a further investigation was requested surrounding the current increase

of short term sickness in comparison with the previous five years’ data.

The line graph below displays all short-term sickness (STS) and long-term sickness (LTS) for full time equivalent (FTE) staff for the

last five years.

The chart below shows the number of sickness instances in relation to the top five reasons for sickness, for each financial year.

*N.B. 2018 includes figures from 01/04/17 - 31/08/18.

0.00%

1.00%

2.00%

3.00%

4.00%

5.00%

6.00%

7.00%

8.00%

20

13

/ 0

4

20

13

/ 0

6

20

13

/ 0

8

20

13

/ 1

0

20

13

/ 1

2

20

14

/ 0

2

20

14

/ 0

4

20

14

/ 0

6

20

14

/ 0

8

20

14

/ 1

0

20

14

/ 1

2

20

15

/ 0

2

20

15

/ 0

4

20

15

/ 0

6

20

15

/ 0

8

20

15

/ 1

0

20

15

/ 1

2

20

16

/ 0

2

20

16

/ 0

4

20

16

/ 0

6

20

16

/ 0

8

20

16

/ 1

0

20

16

/ 1

2

20

17

/ 0

2

20

17

/ 0

4

20

17

/ 0

6

20

17

/ 0

8

20

17

/ 1

0

20

17

/ 1

2

20

18

/ 0

2

20

18

/ 0

4

20

18

/ 0

6

20

18

/ 0

8

Sick

nes

s %

Year/Quarter

FTE % STS & LTS 2013 - 2018

Long Term Absence FTE % Short Term Absence FTE %

Page | 8

This data indicates that the highest sickness rates are consistently

for gastrointestinal problems and cold/cough/flu.

Further data was retrieved from ESR and feature in the following pages.

Findings

The chart below states the number of STS instances for the top five

reasons, per quarter, each year.

There are high numbers for cold/cough/flu in quarters 3 & 4 each

year but this is to be expected during the winter months. Likewise,

there is an increase in the chest/respiratory area for the same period.

26

57

8264

5241

2846 52

6544

32

59

122140

111 119 123

1739

61 60 5334

76

165

191 197

168

113

0

50

100

150

200

250

2013 2014 2015 2016 2017 2018

No

. of

Inst

ance

s

Financial Year *

S10Anxiety/stress/depression/other psychiatricillnessesS12 Othermusculoskeletalproblems

S13 Cold, Cough, Flu -Influenza

S15 Chest &respiratory problems

S25 Gastrointestinalproblems

Page | 9

However, the figures for gastrointestinal problems are fairly consistent for every quarter, with all figures ranging from 213 to 252

instances.

Duration of Short Term Sickness (STS)

For each of the top five reasons for sickness, from April 2013 to August 2018, the highest rate of absence appears to be within the

self-certification period of 1 – 7 days at 75%. Below is a summary of the percentage rate of short-term sickness, for each sickness

reason, occurring from 1 – 7 days:

Sickness Reason Duration 1 – 7 days (%)

Gastrointestinal problems 89%

Cold/Cough/Flu - Influenza 80%

Chest/Respiratory problems 63%

Other Musculoskeletal problems 59%

Anxiety/Stress/Depression 42%

Further analysis indicates that, for four out of the top five sickness

reasons, Monday has the highest rate for the first day of absence as summarised:

Sickness Reason Monday - 1st Day of Absence (%)

Cold/Cough/Flu - Influenza 28%

Chest/Respiratory Problems 27%

Other Musculoskeletal Problems 24%

Gastrointestinal Problems 21%

N.B. for Anxiety/Stress/Depression the percentage for reporting sickness on a Monday is 18%. The highest (for a Wednesday) is

19%.

ESR Sickness Sub-Categories

It was noted that many of the sickness absences reported on ESR were not input under sub-headings for each category, e.g. under the

anxiety/stress/depression heading a number of options are available

to select, such as anxiety, stress, etc. but the majority (74%) were left blank.

Page | 10

The following chart displays data, from 01 April 2013 to 31 August 2018, for sickness due to ‘other known causes – not elsewhere

classified’ and ‘unknown causes/not specified’:

Sickness for period 2017/2018 to date

When comparing this year’s data to the same period last year, i.e. April – August, the table below shows that ‘back problems’ now

feature in the top five in place of ‘chest & respiratory problems’.

30

176

3548

5 7 14 19 16 17 8 11

020406080

100120140160180200

S98

Oth

er k

no

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ses

- n

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else

wh

ere

cla

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ied

S99

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ses

/ N

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d

S98

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- n

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else

wh

ere

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S99

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ses

/ N

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- n

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wh

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ses

/ N

ot

spec

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d

S99

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wn

cau

ses

/ N

ot

spec

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d

S98

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no

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- n

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else

wh

ere

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ied

S99

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wn

cau

ses

/ N

ot

spec

ifie

d

S98

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no

wn

cau

ses

- n

ot

else

wh

ere

cla

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ied

S99

Un

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cau

ses

/ N

ot

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d

S98

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- n

ot

else

wh

ere

cla

ssif

ied

2013 2014 2015 2016 2017 2018

No

. of

Inst

ance

s

Sickness due to unknown causes & known causes not classifedApril 2013 - August 2018

Page | 11

Gastrointestinal problems has the highest number of instances in every

month and the number more than doubles from June to July 2018. The rate then falls during August but still remains higher than usual compared

to the months prior to summer 2018.

After consulting the infection control team it was confirmed that were no ward closures relating to gastrointestinal/diarrhoea and

vomiting within the health board, during July and August 2018. There was one bay restricted in Prince Charles Hospital (PCH) for two

days in August but no staff were affected, according to the Infection Prevention Control (IPC) team.

Summary

The additional data collated indicates that:

• Gastrointestinal problems is the main cause of short-term sickness within Facilities at 37%, followed by cough/cold/flu at

27%, over a five-year period,

• Since 01 April 2017 to 31 August 2018, gastrointestinal-related absence is the highest of all short-term sickness at 24%,

followed by cough/cold/flu at 21%.

3

7 7

11

35

68

10

3

67

911

24

7 7

11

23

45

13

13

67

11

34 4 4

14

24

5

23

2 2

6

12

1 1

4

7

17

0

5

10

15

20

25

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2017 2018 2017 2018 2017 2018 2017 2018 2017 2018

Apr May Jun Jul Aug

No

. of

Inst

ance

s

Top 5 Sickness reasons & instances April - August 2017 & April -August 2018

Page | 12

Also, gastrointestinal-related sickness more than doubled between June and July 2018. According to the IPC team, there

were no ward closures relating to gastrointestinal/diarrhoea & vomiting during this period, apart from a two-day bay closure

in PCH in August and no staff were affected,

• The highest rate of sickness occurs between 1 & 7 days (the self-certification period), for four out of the top five sickness

reasons, which accounts for 75% of all short-term sickness (over a five-year period),

• Monday is the most common day for reporting the first day of

sickness, (for four out of the top five sickness reasons) over the last five years,

• Over the previous five years, the majority of short-term sickness absence (69%) inputted on ESR does not appear

under a sub-category/heading. Ensuring this is done will provide a more accurate view when analysing sickness

absence.

Also, sickness for reasons not specified should only be used in exceptional circumstances. Where reasons are not clear at the

beginning of a sickness period ESR should be updated accordingly once the causes are known or when the staff

member returns to work.

2.2.2 Appendix 2 Five year CRES History FPW 25 Oct 2018 GR

1 2.2.2 Appendix 2 Five year CRES History FPW 25 Oct 2018 GR.docx

2.2.2 Appendix 2

FACILITIES HISTORIC CRES DELIVERY

A summary of the annual Cash Releasing Efficiency Savings (CRES) delivery

and associated targets for the period from 2013/14 to 2017/18 inclusive is

shown in the following diagram. The detail of the CRES delivery is presented

in the Tables that follow.

2013-14 Financial Performance Savings Achieved

2013/14 In

Year

Recurrent

delivery

£000's £000's

FYE Savings 199 199

Introduction of Hot vending at Royal Glamorgan Restaurant 11 11

Introduction of Hot vending at Royal Ysbyty Cwm Rhondda

Restaurant 15 15

Introduction of Hot vending at Dewi Sant Hospital Restaurant 14 14

Introduction of Hot vending at YCC Hospital Restaurant 8 8

Reduction in Portering staff through natural wastage 25 25

Capped reduction in Facilities Expenses 6 6

Reduction in sickness levels to reduce sickness related overtime 35 35

Non Emergency Patient Transport 40 40

Reduction in Housekeeping Materials to Benchmark Acute South 23 23

Reduction in Housekeeping Materials to Benchmark Acute North 10 10

Total 386 386

2.2.2 Appendix 2


2014/15 In

Year

Recurrent

delivery

£000's £000's

Clinical Engineering Consumables 24 22

Fuel Cards 17 24

Patient feeding 334 319

Restaurant services B 55 37

Waste management 26 46

Workforce plan 347 486

VER Oct 14 30 120

EBME Structure 10 40

Cross cutting

CPU call off orders - AW contract compliance - non pay cross

cutting 46 50

AW fruit and veg contract 37 83

Gritting contract 6 12

Service redesign - Dewi Sant 162 541

Balance to FYE 13/14 Savings 12 12

Terms and conditions changes 7 16

Total 1,113 1,808


2015/16 In

Year

Recurrent

delivery

£000's £000's

Restaurant services B 230 230

Waste management 19 19

CPU de-gear 50 230

Merge YCC Coffee Shop and restaurant 0 25


Over time reduction 150 100

PCH Coffee Shop (7) 18

Laundry - items per bed 80 60

Cross Cutting

Non Pay 141 141

Total 688 848


2016/17 In

Year

Recurrent

delivery

£000's £000's

RGH Restaurant (profit) 18 18

Kier Hardie Coffee Shop (profit) 5 5

YCR Restaurant (profit) 21 21


CPU - Hywel Dda 18 18

Porter / Security 40 96

Laundry Transport 50 50

Grounds & Gardens outsourcing 14 14

Lease Car Salary Sacrifice 7 0

Total 214 262

2.2.2 Appendix 2


2017/18 In

Year

Recurrent

Delivery

£000's £000's

Housekeeping 104 360

Portering - Porter / Security 83 272

Management and administration 59 59

Coffee beans and coffee cups 15 15

Paper towels 6 80

Laundry price increase 12 12

Catering - price increase, meal changes etc. 100 135

Salary sacrifice 5 0

Laundry 70 76

Total 454 1,009

2.2.3 Appendix 3 Benchmarking report FPW 25 Oct 2018 GR

1 2.2.3 Appendix 3 Benchmarking report FPW 25 Oct 2018 GR.docx

2.2.3 Appendix 3

FACILITIES BENCHMARKING REPORT

The most recent annual benchmarking exercise that compares the services provided by the

Facilities Directorate at an all Wales level was undertaken for the 2016/17 financial year.

The results of this are presented below together with adjusted values for the Cwm Taf

services where savings have been delivered subsequent to 2016/17, pending the

publication of the 2017/18 benchmarking results.

2.2.3 Appendix 3

2.2.4 Appendix 4 Waste performance Report FPW 25 Oct 2018 GR

1 2.2.4 Appendix 4 Waste performance Report FPW 25 Oct 2018 GR.docx

2.2.4 Appendix 4

Waste Cost & Tonnage Trends 2012/13 – 2017/18

The following is an analysis of waste cost and tonnage trends for the UHB

for financial years 2012/13 to 2017/18.

Summary

• Cost and tonnage trends are shown in the graphs below.

• In summary these show:

Cost

➢ The Landfill costs over the period show a downward trend, ➢ Non- burn (infectious) waste has shown a downward cost trend, being

combination of improved segregation and revised contract prices for

collection and disposal, ➢ Offensive Hygiene (Tiger) waste costs has have mirrored the general

increase in tonnage over the period and similarly reflects the decrease

in tonnage in 201/18 (See comment below on tonnage), ➢ Recovery/Recycling waste costs has increased in line with an increase

in tonnage, ➢ High Temperature (incineration) waste costs have remained flat over

the period.

Tonnage

➢ Landfill tonnage has shown a downward trend. Which reflects improved recycling and cyclic fluctuations in annual tonnages,

➢ Non- burn (infectious) waste has also shown a downward trend, ➢ Offensive Hygiene (Tiger) waste has shown an upward trend over the

period 2012/13 – 2016/17. The reduced tonnage in 2017/18 is due in part to in patient changes at YGT, which tiger waste percentages of

90%, ➢ Recovery/Recycling has shown an upward trend, ➢ High Temperature (incineration) waste has remained flat.

Cost Trends 2012/13 – 2017/18

Tonnage Trends 2012/13 – 2017/18

0.00

200.00

400.00

600.00

800.00

1000.00

1200.00

1400.00

2012-13 2013-14 2014-15 2015-16 2016-17 2017-18

Waste Tonnage TrendIncineration

Land Fill

Infectious

Tiger

Recovery/Recycling

£0

£50,000

£100,000

£150,000

£200,000

£250,000

£300,000

£350,000

2012-13 2013-14 2014-15 2015-16 2016-17 2017-18

Waste Cost Trend Incineration

Land Fill

Infectious

Tiger

Recovery/Recycling

2.2.5 Appendix 5 Porter service redesign FPW 25 Oct 2018 GR

1 2.2.5 Appendix 5 Porter service redesign FPW 25 Oct 2018 GR.docx

2.2.5 Appendix 5

Porter Service Redesign and Modernisation Summary

There has been considerable push back over the service and rota change from some of the porter services staff and supported by

trade unions who have often been instrumental in delaying process despite workforce business partner’s intervention. Some of this is

understandable because the service has not been reviewed in depth for many years and the changes impact on staff overtime pay and

their local customer practice working terms and conditions.

The delays in implementing the redesign and new rota have

resulting in additional cost and the continued use of the old rota that has already been identified and confirmed as not cost effective

and non-compliant. The problem has been that the existing old

rotas across all HB Sites are supporting the new service redesign model which is designed and in FY 2018/19 was budgeted for the

new rota.

The Porter Services re-design will support the correct management

of an efficient rota system across porter services at all sites which

includes migration to e-rostering.

The pushback has resulted in a number of staff matters being

worked through with workforce staff.

Following staff engagement and consultation, we are currently at stage 2 of grievance at Royal Glamorgan Hospital (RGH) and Prince

Charles Hospital (PCH). We are working this through with the staff and staff side colleagues and we are effectively supported by the

Workforce & Organisational Development (WF&OD) business partners in this process. This support going forward also involves

addressing dignity at work and I-care issues through training and

PULSE sessions which have been already requested for this group of staff.

A consistent dedicated and determined approach by Facilities management and business partners has been adopted to the

redesign of porter services, whilst recognising and being sensitive to

staff concerns that change is not always acceptable to all staff.

The following key risks and benefits are associated with this service redesign scheme.

Service Risks

• Lack of supervision, command and control, performance management and accountability of contract security staff,

• No command and control or supervision of pool porter staff at

night at RGH,

• At RGH dispatch and supervision is provided by 2 x porters but not 24/7. At PCH this is effectively achieved 24/7 by 1 x porter

supervisor,

• Standards and quality of services along with operating procedures, transactional management procedures, rotas and

service delivery were found to be different on each site,

• Shortfalls were identified in productivity and efficiency at RGH

the main reason being that all porters were operated from a central pool and there were no porters assigned and dedicated

to key high activity areas of the hospital e.g. x-ray, MRI, A&E in direct a support of clinical services. At PCH this service

arrangement has been provided for many years,

• At RGH 2 x pool porters and a nurse are required to carry out patient bed transfers, at PCH with the exception of bariatric

patients it is 1x pool porter and 1 x nurse,

• Communication linkage with site bed management and porter services at RGH in response to site incidents, patient flow

activity and security was found to be limited, with any

communication being restricted to telephone. At PCH bed management and porter services also have open channel radio

communication so that command and control, information can be shared and a rapid tactical response to alarms and incidents

can be provided.

Benefits

The key benefits to the organisation and porter services staff of redesigning the existing porter services role are as follows:

• Clearly defined roles and Porter Services policy and standard

operating procedures, • Cost savings and financial sustainability,

• Improved transactional and service delivery performance

management of rota and service delivery activity using KPI’s,

• Improved control of services over an out sourced security contractor,

• Improved accountability and quality of service providing a more flexible and responsive service for the organisation and

our patients, • Accurate recording of Porter Services data and service

delivery performance, • Access to Porter services using client self-serve approach and

dedicated porters at key hot spot locations e.g. A&E and X-ray/MRI departments,

• Provides clear communication links and support to internal clinical and external emergency services accessing the

hospital during normal and out of hours.

Command, Control and Responsive Porter Services

• Improved command and control of security service resulting

in service delivery based on flexibility, daily risk and requirements,

• Improvement in supervision of staff engaged on porter services and security related duties,

• Improved site communication, • Investment in technology,

• Additional training and career opportunities for porter services staff,

• Part of a multi-role for porter services staff improving career progression, role diversity and service flexibility,

• More direct control of the hospital Estate 24/7, • Auditable incident and activity reporting providing an accurate

record of incidents over 24 hour and 7 days a week using site

Facilities control centre Porter/Security BMS system.

Flexible workforce

• More flexibility in the allocation of duties and approach to day to day service delivery and risk,

• Revised and comprehensive job descriptions, • Duty shift roles and rotas designed around lean flexibility

and the requirement to provide hospital porter, waste management, security and site traffic management, mail

delivery and collection and transport.

Porter Services IT Management Systems

The existing portertrac management system is used to monitor daily

porter task activity. However the system is nearly 20 years old,

has not been invested in, is challenging to navigate and is not

currently used as an end user self-serve system.

Extracting meaningful and effective reports requires labour intensive system interrogation and does not always provide

accurate data as it is heavily reliant on accurate input from the

porter services duty dispatcher.

The Facilities team is currently developing a Facilities Management (FM) service technology plan which aims to further expand and

improve on 24/7 service delivery and staff transactional management using a software management system as an

investment in technology for Facilities core services e.g. Porters, housekeeping and catering.

For example, to date the Facilities management teams in hospitals

have relied upon pen and paper data collection and out of date IT systems. Communication is achieved by telephones between the

porter lodge and wards. In contrast, within the private FM sector

investment has been made and IT systems have been operational for many years.

There is a need to invest in FM management software solutions

which will bring benefits to the Facilities services environment, the clinical services and the patients it supports. A Facilities investment

in technology paper is currently being drafted and will be submitted at CBM and included in the Facilities IMTP.

It is acknowledged that there is an immediate requirement for

moving forward through negotiations with staff and staff side and support from WF&OD to implement the new rota to reduce cost and

realise the final element of the savings associated with this Facilities CRES and service redesign scheme. Despite the push back and

challenges with this scheme, the Facilities management team with

support from WF&OD business partners are committed and doing everything they can within the Organisational Change Process

(OCP) process to progress the scheme to completion

2.2.6 Appendix 6 Facilities work plan 18-20 FPW 25 Oct 2018 GR

1 2.2.6 Appendix 6 Facilities work plan 18-20 FPW 25 Oct 2018 GR.xlsx

FACILITIES BUSINESS WORKPLAN FY 2018-20

Line Facilities Work Stream Linked Process TaskPriority

RAGStatus

2018 2019 2020Jan-18 Feb-18 Mar-18 Apr-18 May-18 Jun-18 Jul-18 Aug-18 Sep-18 Oct-18 Nov-18 Dec-18 Jan-19 Feb-19 Mar-19 Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20 Apr-20 May-20 Jun-20 Jul-20 Aug-20 Sep-20 Oct-20 Nov-20 Dec-20

1 NHS Wales Laundry production unit service review - Memorandum item Compliance & Savings 32 Cwm Taf Laundry Review Compliance & Opportunity 23 Governance and Compliance/Risk Register Review Compliance 14 All Wales Catering Management System Review Efficiency, Compliance & Savings 25 Cwm Taf/Bridgend Catering Management System Benefits Appraisal Efficiency, Compliance & Savings 16 Facilities ICT Systems Services Modernisation Plan Compliance and Efficiency 27 RGH CCTV Upgrade Review Compliance & Security 38 Policies and Procedures Plan Review Compliance 29 Porter Services Procedures & Training Review in Support of HTA Audit Compliance 110 Staff Core Skills Compliance Training Plan Workforce Compliance 111 Staff Skills Level 2 & 3 Training Plan Workforce Compliance 112 PDR Staff Development Plan Workforce Compliance 113 Multi Skilled Staff Development Initiative Workforce, Efficiency & Savings 314 Porter Services Patient Satisfaction and Experience Quality Initiative Quality & Standards 215 Bridgend Facilities Services Transformation 2019 Quality, Standards, Finance 216 Pathology Transport Services & Standards Review - Option Appraisal Quality, Standards, Finance 217 Facilities Customer Helpdesk Systems and Operations Review Support and Customer Services 218 Adverse Weather Plan Review 2018 Contingency 119 IMTP 2019-20 including Bridgend Facilities Services Business Planning 120 UHB Business mileage cap - Memorandum item across organisation initiative Planning and Finance 321 Capital and Non Capital Asset Replacement Plan Planning and Finance 122 Facilities Site Management - Support Control Centre Development Site Command & Control Support 323 Bridgend Facilities Services Transition Organisational Change 124 Transport Paediatric Retrieval Service Options Appriasal Review Organisational Change, Finance 125 Bed Management Review - Acute and Community/Localities Efficiency, Finance, Quality, Standards 226 PCH Staff Residences Estate - Joint Review (with Capital/Estates) Compliance, Quality, Finance 327 CPU Deep Dive - Outsourcing/Investment Appraisal CRES Plan FY 2019-20 128 Non pay suppliers products volume and price CRES Plan FY 2018-19 129 Non pay - VAT Recovery Deep Dive CRES Plan FY 2018-19 130 Grounds and Gardens Service Deep Dive - Outsourcing /Investment Appraisal CRES Plan FY 2019-20 231 Restaurants - new service model (capital investment required) CRES Plan FY 2019-20 232 YGT Valley Life Service Redesign Phase 1 CRES Plan FY 2018-19 133 YGT Valley Life Service Redesign Phase 2 CRES Plan FY 2018-19 134 YGT Valley Life Service Redesign Non pay CRES Plan FY 2018-19 135 Dewi Sant Health Park Barista (capital investment required) CRES Plan FY 2019-20 236 Internal Transport Pathology Community Service CRES Plan FY 2019-20 237 Internal Transport Shuttle bus review CRES Plan FY 2018-19 138 Unscheduled NEPT Transport Spot Purchasing CRES Plan FY 2018-19 139 CPU Bonus CRES Plan FY 2018-19 140 General office rationalisation CRES Plan FY 2019-20 241 Postal Services Review CRES Plan FY 2018-19 142 Porter services redesign and modernisation CRES Plan FY 2018-19 143 Switchboard (New staff rota - centralisation) CRES Plan FY 2018-19 1

2.3 To receive a quarterly update report on the organisational risks assigned to the Committee

1 2.3 Org Risk Register, FPW 25 Oct 2018 GR.doc

Organisational Risk Register Page 1 of 19 Finance, Performance & Workforce Committee

25 October 2018

AGENDA ITEM 2.3

25 October 2018


ORGANISATIONAL RISK REGISTER

Executive Lead: Board Secretary / Director of Corporate Services and Governance

Author: Interim Board Secretary

Contact Details for further information: Gwenan Roberts, 01443 744818 or email [email protected]

Purpose of the of the Finance, Performance and Workforce

Committee Report

The purpose of this report is for the Finance, Performance and Workforce

Committee to receive, review and discuss the organisational risk register and consider whether the recorded risks are appropriately assigned. This

Organisational Risk Register was last considered by the Executive Board and by the Quality Safety and Risk Committee in September 2018 and has

been updated to reflect related discussions.

Governance

Link to Health



objectives, and the related organisational objectives outlined within the 3 Year Integrated Medium Term Plan

2018-2021, are being progressed. Aligned with the ‘Quadruple Aim’ described within ‘A Healthier Wales’

(Welsh Government, June 2018) these objectives are:

• To improve quality, safety and patient experience • To protect and improve population health

• To ensure that the services provided are accessible and sustainable into the future

• To provide strong governance and assurance • To ensure good value based care and treatment

for our patients in line with the resources made available to the Health Board.

This report focuses mainly on providing strong governance and assurance.

Supporting evidence

• The content of this report is informed by the

University Health Board’s (UHB) Risk Management Strategy.


The information contained within this report has been developed following

engagement with senior staff and Executive Directors.


25 October 2018


APPROVE ENDORSE √ DISCUSS √ NOTE √

Recommendation The Finance, Performance and Workforce

Committee is asked to: • DISCUSS and NOTE the update provided

within this report and the risks assigned to the Board and its Committees and,

• ENDORSE the updated risk register and the assignment of risks.

Summarise the Impact of the Finance, Performance and Workforce Committee Report

Equality and

diversity

There are no identified equality & diversity implications.

Legal implications It is essential that the Board has robust arrangements in place to assess, capture and

mitigate risks faced by the organisation, as failure to do so could have legal implications for

the UHB.

Population Health No specific impact.

Quality, Safety & Patient Experience

Ensuring the organisation has robust risk management arrangements in place that ensure

organisational risks are captured, assessed and mitigating actions are taken, is a key requisite to

ensuring the quality, safety & experience of patients receiving care and staff working in the

UHB. Resources The risks outlined within this report have

resource implications which are being addressed

by the respective Executive Director leads and taken into consideration as part of the Board’s

IMTP processes. Risks and Assurance This report and the organisational risk register is

an integral element of the Board’s risk and assurance arrangements. It should be no ted

that this work continues to develop.

Health & Care Standards

The 22 Health & Care Standards for NHS Wales are mapped into the 7 Quality Themes but within

a Governance Framework. This report focuses mainly on Governance & Accountability but also

spans many of the 7 quality themes. Workforce Failure to capture, assess and mitigate risks can

impact adversely on the workforce.

Freedom of Information

status

Open


25 October 2018

ORGANISATIONAL RISK REGISTER


The purpose of this report is for the Finance, Performance and Workforce

Committee to receive, review and discuss the organisational risk register

and consider whether the recorded risks are appropriately assigned. This Organisational Risk Register was last considered by the Executive Board

and by the Quality Safety and Risk Committee in September 2018 and has been updated to reflect related discussions. Changes made since are

identified in RED font. There are six risks for the Committee to consider.


The organisational Risk Register summarises the key ‘live’ extreme risks facing the Health Board and the actions being taken to mitigate them. The

Health Board manages risk through i t s Directorate structures and in

close alignment with the Board’s ‘approved’ Assurance Framework. The Assurance Framework reports into the Audit Committee for periodical

review, monitoring and scrutiny and also features (at least annually) on the agenda of the Board.

It is also important to NOTE that the Executives, as risk owners, are

appropriately sighted and involved in the development of the organisational risk register, providing updates, including reports on

mitigating actions. The organisational risk register is reviewed and where appropriate updated on a bi-monthly basis with input from the Executive

lead as required.

All organisational risks have a lead Executive Director and the risk assigned to either the Board, or as appropriate, a Committee of the Board

to ensure appropriate review, scrutiny and where relevant updating. Each Director is responsible for the ownership of the risk(s) and the reporting of

the actions in place to manage/control and/or mitigate the risks.

The organisational Risk Register is reported quarterly to the Executive

Board and routinely to the Quality, Safety & Risk Committee of the Board, for information and where appropriate, scrutiny of any assigned risks.

Whilst this cover report summarizes the detail, the supporting appendices provide more detail.

Improvement continues to be made with directorates and localities

routinely completing integrated risk reporting templates that are used for exception reporting.

3. ASSESSMENT OF GOVERNANCE AND RISK ISSUES

Following discussion at the Executive Board and Quality, Safety & Risk Committee in September, the following changes to the register were agreed:


25 October 2018

Updates to the Organisational Risk Register:

Action Status

The risk in relation to Board Member changes be

removed

Completed

That the risk in relation to Nasogastric Tube insertion would not be added to the register.

Noted

A further review and assessment of the risk in relation

to Funded Nursing Care would be undertaken after

discussion at Board in March 2018. This has now been concluded and agreed with Mrs L Williams, former

Director of Nursing, Midwifery & Patient Services.

Noted

That the narrative in relation to unscheduled care associated risks was strengthened,

To be discussed with

Executive Team

That a foot note be added to explain the trend / controls

section.

To be

discussed with Executive

Team

That risk 39, failure to provide adequate capacity to

ensure safe and secure storage of patient records, be reassessed, as the records hub would reportedly reach

full capacity in December 2018.

Narrative

amended

That risk 11, failure to achieve financial balance on a

recurring basis, be more appropiately worded by the Director of Finance.

To be

discussed with the Director of

Finance

That an overarching risk be assessed and added to the register in relation to implementation of the Paeds, Obs

& Neonates service change, reflecting also the issues associated with communication and engagement.

Risk 13 updated to

reflect communication

issues. Overarching

riks narrative to be discussed

with Executive Team

That the impending implications of the Welsh Language

Standards and their implementation, be assessed and added to the register.

Added to

register

That the 8 hour target should read 12 hour targets

Completed


25 October 2018

New Risks The following risks have been added to the register:

• The Bridgend Boundary change, • The Human Tissue Authority (HTA) inspection and related report findings

has been assessed and added to the Register and monitoring of related progress with actions assigned to the Quality, Safety & Risk Committee,

as agreed by the Board in its July 2018 meeting • Maternity, Obstetrics and gynaecology – Maternity Services

Overall analysis

The organisational risk register currently includes 33 Extreme / High risks

which are categorised into the following groupings:

Categories / Risk Rating

Extreme (rated 15 -25)

High (rated 8-12)

Business objectives / projects 5 4

Impact on Safety 9 1

Statutory duty / inspections 8 2

Finance (including claims) 1 1

Workforce / Organisational

Development / Staff Competence

1 0

Service Business Interruptions 0 1

Total Risks 24 (+1)* 9 (-1)**

*(+1) = New Risk 43 has been added,

** (-1) = Risk 039 rotation of board members has been removed.

NB - new risk 43 has yet to be risk assessed for a matrix score and not included in the above table

High / Extreme Risks (Rating 20 and above)

In considering the robustness of a developing organisational risk register,

Board Members need to consider whether the top recorded risks are those that Members of the Board can relate to and indeed evidence that they are

informing the work of the Board and its Committees in delivering its related Strategy.

The top risks outlined within the Organisation’s risk register are:

• Failure to recruit sufficient numbers of medical & dental staff

and its related impact on rotas and finance going forward (also aligned with South Wales Programme outcome),

• Reduction in medical staff training posts,

• Failure to recruit sufficient numbers of registered nursing

staff,

• Increasing dependency on agency staff to cover registered nursing and medical staff gaps,

• Deprivation of Liberties Safeguards (DoLS) mainly associated


25 October 2018

with the volume / backlog of related assessments, • Fire Safety compliance and ongoing issues with Prince Charles

Hospital (PCH) site (Ground & First Floor),

• Lack of control and capacity to accommodate all hospital follow up outpatient appointments,

• Failure to ensure delivery of a viable balanced/break even 3

year integrated medium term plan, • Achieving financial break even on a recurring basis,

• Human Tissue Authority (HTA) report,

• Bridgend Boundary Change, • Health Records Storage,

• Welsh Language Standards Compliance.

Of the categorised risks, these have been broken down under one of our

existing Strategic Objectives:

• There are currently 24 extreme (increased by 4) and 9 high (reduced by 1) risk, assigned to the Board and its various Committees

• The majority of assessed risks are linked with workforce shortages and

their related impact, which includes GP shortages and Primary Care

Sustainability.

Organisational Risk Register Page 7 of 19 University Health Board Meeting

27 September 2018

Risk Register Category – Business Objectives / Projects (9 risks)

Strategic

Objective

Risk

Reference

Description of risk

identified

Initial

Score

Current

Score

Trend Controls Last

Reviewed

Scrutiny

Committee

Setting the

Direction and

Performance

and

Operational

Efficiency

028

Failure to ensure delivery of a viable

balanced/break even 3 year

integrated medium term plan.

20

(was 16)

20

September

2018

Health Board

015

Reputational damage & potential legal

challenge on the decision making on

Funded Nursing Care (FNC). 16 12

September

2018 Health Board

029

Failure to invest in and develop

Primary Care Services, across RCT

and Merthyr Tydfil but particularly in

the Rhondda Valleys.

16 16

September

2018 Primary & Community

Care

036 Primary Care Workforce - Recruitment

and sustainability 16 16

September


Care

030

Failure to continue to provide and

sustain GP Out of Hours Services as

currently configured.

16 16

September


Care

002 Failure to achieve Referral to

Treatment targets. 12 12

(was 20)

September

2018 Finance, Performance

& Workforce

003

Failure to achieve the 4 and 12 hour

emergency (A&E) waiting times

targets. 12 16

September

2018 Finance, Performance &

Workforce

013 Implementation of South Wales

Programme outcomes.

12 12 September

2018 Health Board

023

Failure to meet the timescale relating

to issuing concerns (complaints)

responses to patients and/or carers.

16 12

September

2018 Quality, Safety & Risk

The Trend column indicates whether the risk overall (from when first assessed), is increasing (), reducing () or unchanged ().

The Controls column indicates whether assessed controls overall are improved (), reduced () or unchanged () from when first

assessed. Regardless of whether the risks rating has changed.


27 September 2018

Risk Register Category - Impact on Safety (10 risks)

Strategic

Objective

Risk

Reference

Description of risk identified Initial

Score

Current

Score

Trend Controls Last

Reviewed

Scrutiny

Committee

To improve

quality,

safety

and patient

experience.

007

Failure to recruit sufficient medical &

dental staff. 25 20

September

2018

Quality, Safety &

Risk

034

Increasing dependency on Agency Staff

cover in Medical and Nursing areas,

which has the potential to impact on

continuity of care and patient safety and

is actually impacting on the UHB

financial position.

20 20 September

2018

Quality, Safety &

Risk

035 Failure to recruit sufficient registered

nursing staff. 20 20 September

2018 Quality, Safety

& Risk

008

Reduction in medical training posts

within various specialties & capacity to

meet workload demands.

20

20

September

2018

Quality, Safety &

Risk

027

Lack of control and capacity to

accommodate all hospital follow up

outpatient appointments.

20

20

(was 16)

September

2018

Finance,

Performance &

Workforce

032 Sustainability of a safe & effective

Ophthalmology Service.

20

16

September

2018 Quality, Safety

& Risk

005

Failure to sustain services as currently

configured to meet cancer targets.

20 16

September

2018

Finance,

Performance &

Workforce

033

Failure to sustain Child & Adolescent

Mental Health Services across the

Network

16 16

September

2018 Quality, Safety &

Risk

037

Ensuring the development, approval and

implementation of a Strategy for IM&T,

that is clinically led and supports staff in

care delivery

12 12

September

2018

Health Board


27 September 2018

038

Inconsistent approach and arrangements

in place for the management and

monitoring of patients requiring

anticoagulation management within Cwm

Taf UHB.

16 16

September

2018 Primary &

Community Care

(043)

New

Possible Under Reporting of Clinical

Incidents in Maternity Services - - N/A

September

2018

Quality, Safety &

Risk

Risk Register Category – Statutory Duty / Inspections (10)

Strategic

Objective

Risk

Reference

Description of risk

identified

Initial

Score

Current

Score

Trend Controls Last

Reviewed

Scrutiny

Committee

Statutory

Compliance 017 Failure to meet Fire Safety Standards

on ground and first floor PCH. 20 20

September


Risk

021

Failure to ensure all Staff obtain

competency/ compliance with

mandatory training requirements. 16 20

September


Risk

025 Failure to meet Fire Safety

Standards across the UHB. 16 16

September


Risk

018

Failure to achieve statutory and

mandatory planned preventative

maintenance (PPM) programme. 15 15

September


Risk

031

Failure to appropriately apply

Deprivation of Liberties Safeguards

(DoLS) legislation following the West

Cheshire court judgement.

16

(was 12)

12

September


Risk

016 Failure to comply fully with the

arrangements for managing Asbestos 16 12

September


Risk


27 September 2018

039

(New)

Failure to ensure sufficient storage

capacity (or alternative solutions) are in

place to safely store and secure patient

records.

N/A 16 N/A N/A

September


Risk

040

(New)

Failure to fully comply with all the

requirements of the Welsh Language

Standards, as they apply to the

University Health Board.

N/A 15 N/A N/A

September


Risk

041

(New)

Failure to fully meet all the licensing

requirements of the Human Tissue

Authority in relation to Mortuary &

Services for the Deceased.

N/A 16

N/A

N/A

September


Risk

042

(New)

Failure to ensure successful

implementation of the Welsh

Governments decision to realign the

Health Boundary, as it applies to the

resident population of the Bridgend

County Borough.

N/A 15 N/A N/A

September

2018 Health Board

(Joint Transition

Board)

Risk Register Category – Finance / Including Claims (2)

Strategic

Objective

Risk

Reference

Description of risk

identified

Initial

Score

Current

Score

Trend Controls Last

Reviewed

Scrutiny

Committee

Financial

Viability 011

Failure to achieve financial balance

on a recurring basis and mitigate

reliance on in year non recurring

funding slippage.

15 20

September

2018 Health Board

012

Failure to Deliver Major &

Discretionary Capital programmes 12 12

September

2018 Capital

Programme

Board


27 September 2018

Risk Register Category – Workforce / Organisational Development / Staff Competency (1)

Strategic

Objective

Risk

Reference

Description of risk

identified

Initial

Score

Current

Score

Trend Controls Last

Reviewe

dd

Scrutiny

Committee

Workforce

Sustainability/

OD and

Innovation

019

Failure to achieve the Management of

Absence target. 15 12

September

2018

Finance,

Performance

& Workforce

Risk Register Category – Service / Business Interruption (1)

Strategic

Objective

Risk

Reference

Description of risk

identified

Initial

Score

Current

Score

Trend Controls Last Reviewed Scrutiny

Committee

Business

Continuity

006

Failure to appropriately manage

Discharge Delays from Hospitals 12

12

(Was 16)

September

2018

Finance,

Performance

& Workforce


27 September 2018

Quality, safety and patient experience

The Health Board’s risk management arrangements are in place to ensure risks

are assessed and mitigating actions taken to improve the quality, safety and

experience of patients and where appropriate escalation arrangements are in place to inform the Board via its key sub-committees.

Use of resources

There is a significant risk to the service if robust risk based assessment

arrangements are not in place. Good governance arrangements, including effective risk management help to ensure the effective use of resources. It is

important to note that routinely as part of the Internal Audit and Assurance Annual Plan, 3 clinical and 1 corporate directorate undergo a governance review

each year, which includes a review of its risk management arrangements. This

is in addition to the organizational related audit reviews.

Compliance with Legislation There may be an adverse effect on the organization if arrangements are not in

place to manage and mitigate risks.

Performance

Assessment and monitoring of risks within the Health Board is undertaken within Directorates/Localities/Departments. The extreme / high organizational

risks will be monitored by the Executive Team / Board and be reviewed and scrutinized by the Board and/or its Committees.

As a general rule the organisational risk register will be routinely reviewed by

the Quality, Safety & Risk Committee and elements discussed at the Integrated

Governance Committee, although all Committees of the Board have a role to play in ensuring risks assigned to a Board Committee are considered as part of

its work. Risk management arrangements will also be a key element of internal audit work and key risks will help to inform the annual internal audit plan.

4. RECOMMENDATION

The Finance Performance and Workforce Committee is asked to:

• DISCUSS and NOTE the update provided within this report and the risks assigned to the Board and its Committees, and

• ENDORSE the updated risk register and the assignment of risks.

Freedom of

Information

Open

Organisational Risk Register Page 13 of 19 Finance Performance & Workforce Committee

25 October 2018

HEALTH BOARD ORGANISATIONAL RISK REGISTER SUMMARY OF ASSESSED RISKS (OVERALL TREND) – SEPTEMBER 2018

Imp

act/

Co

nse

qu

ence

5 042 Bridgend Boundary change

017 Failure to meet Fire Safety Standards on Ground & First Floor Prince Charles Hospital ↔

031 Failure to appropriately apply DOLS legislation following West Cheshire court judgement

011 Failure to achieve financial balance 007 Failure to recruit Medical & Dental Staff ↔

4

002 Failure to achieve RTT 037 Ensuring the development, approval and implementation of a Strategy for Digital Health, that is clinically led and supports staff in care delivery ↔ 016 Management of asbestos 012 Failure to deliver major and discretionary capital programmes ↔ 006 Discharge delays from acute hospitals ↔ 013 South Wales Plan outcomes ↔ 023 Deterioration in the timescale relating to issuing concerns (complaints) responses to patients and or carers

032 Sustainability of safe & effective Ophthalmology Services

005 Failure to sustain services as currently configured to meet cancer targets

033 Sustaining CAMH Services ↔

029 Failure to Invest in and develop Primary Care Services, particularly in Rhondda ↔

036 Primary Care workforce – recruitment & sustainability ↔

038 inconsistent approach and arrangements in place for the management and monitoring of patients requiring anticoagulation management within CTUHB ↔

025 Failure to meet Fire Safety standards across the UHB ↔ 015 Reputational damage & potential legal challenge (FNC) 030 Continuing to provide GP Out of Hours Services as currently configured 021 Staff competency – compliance with statutory/mandatory training 041 Human Tissue Act compliance mortuary / deceased services

028 Producing Viable balanced 3 year IMTP

034 Increasing dependency on agency staffing (medical & nursing) finance impact↔

035 Failure to recruit registered nursing staff ↔

008 Reduction in medical training posts within various specialities & capacity to meet workload 003 Failure to achieve 4 & 8 hour Emergency access targets.

027 Lack of control & capacity to accommodate Follow Up Outpatients 039 Ensuring Sufficient Health Records Storage

3 019 Failure to achieve the management of absence target

018 Failure to achieve statutory and mandatory planned preventative maintenance programme ↔

040 Compliance with Welsh Language Standards

2

1

C x L

1 2 3 4 5

Likelihood


25 October 2018

Objective: Setting the Direction & Performance & Operational Delivery

Director Lead: Chief Operating Officer

Assuring Committee: Finance, Performance & Workforce

Risk: Failure to achieve Referral to Treatment Times (RTT) Date last reviewed: September 2018

Risk Rating

0

5

10

15

20

25

Jan

-17

Ap

r-1

7

Jul-

17

Oct

-17

Jan

-18

Ap

r-1

8

Jul-

18

Risk Score

Target Score

Rationale for current score:

(consequence x

likelihood):

Initial: 5 x 4 = 20

Current: 4 x 3 = 12

Target: 4 x 2 = 8

The current score reflects year end out turn and the significant

progress made during 2016-18 to address the large volume of

patients awaiting planned treatment.

Rationale for target score:

Effective D&C Plans with improved efficiency in flow, length of stay

and assessment, and some improvement in theatre performance

informs the target score of 8.

Level of Control

=70%

Date added to risk

register

April 2013

Controls (What are we currently doing about the risk?) Mitigating actions (What more should we do?)

• Directorate Demand & Capacity Plans in place (and being further

developed) with regular RTT meetings in place

• Ongoing Flow Programme to address capacity issues

• Improved capacity for Day Surgery and 23:59 case load

• Monthly and Quarterly monitoring of trajectories, routinely discussed

within CBMs

• Routine reporting into Finance, Performance & Workforce Committee

• Surgical Assessment facilities now available on both District General

Hospital sites.

Action Lead Deadline

Continue delivery of the controls in place Ops

Directors

Ongoing

Ensure winter plans to address and respond

to surge in demand are effective and

support continued delivery of RTT

Ops

Directors

Quarter

3 & 4

Develop, implement and monitor

Directorate Demand & Capacity Plans

Ops

Directors

Ongoing

quarterly

Assurances

(How do we know if the things we are doing are having an impact?)

Gaps in assurance

(What additional assurances should we seek?)

Waiting list reductions; better response times from departments / compliance

figures will improve.

Currently off trajectory and improvement actions being taken to

bring performance back in line. F,P&W monitoring progress.

Current Risk Rating

Additional Comments

Ref No.

002

Current Risk Rating : 4 x 3 = 12

The plan last year (and this), was to sustain RTT

position and deliver against the target without (or with

limited) external outsourcing. However, this has not

been possible and additional outsourcing utilised.


25 October 2018

Objective: Setting the Direction & Performance & Operational Delivery



Risk: Failure to achieve the 4, 8 and 12 hour emergency (A&E) waiting times

targets.

Date last reviewed: September 2018

Risk Rating

0

5

10

15

20

25

Jan

-17

Ap

r-1

7

Jul-

17

Oct

-17

Jan

-18

Ap

r-1

8

Jul-

18

Risk Score

TargetScore


(consequence x

likelihood):

Initial: 4 x 5 = 20

Current: 4 x 4 = 16

Target: 4 x 3 = 12

Whilst the target is not being achieved, the current score reflects an

improved position with almost 90% delivery against 4 hour

performance, which needs to be sustained.

Level of Control

=70%


To meet the emergency access targets set by Welsh Government is

dependent on the patient flow and therefore a target of 12 is

challenging for the unscheduled care service (USC). Date added to risk

register

April 2013


Meeting some targets consistently; however, not all of the time.

Need to strengthen minors streams at both DGH sites to sustain improved

delivery of performance against the 4, 8 and 12 hour targets. Also variable

practice across both A&E departments. Additional minors physical capacity at

RGH has impacted positively and more recently improved performance

approaching 90% against the 4 hour target, with reduced 12 hour wait

breaches.


1) Clear discharge planning processes in place. COO Ongoing

2) Improvements in the patient flow and

investments to support seasonal planning.

Dep

COO

Ongoing

3) Stay Well At Home (SW@H) Service

introduced and evaluated (6 month).

Dep

COO

January

2018

4) SW@H 2 developments being progressed COO Ongoing

Assurances


Gaps in assurance


Monthly reporting of 4, 8 and 12 hour performance within the Integrated

Performance Dashboard. Trend overall is one of improvement currently.

None identified although reliant on the recruitment and retention of

appropriate workforce and general improvement in flow across USC.

Current Risk Rating

Additional Comments

Ref No.

003


Recruitment and retention of staff essential; closure of

beds in the operational environment challenging when

the numbers of patients continues to rise.


25 October 2018

Objective: To improve quality, safety and patient experience



Risk: Lack of control and capacity to accommodate all hospital follow up

outpatient appointments


Risk Rating

0

5

10

15

20

25

Jan

-17

Ap

r-1

7

Jul-

17

Oct

-17

Jan

-18

Ap

r-1

8

Jul-

18

Risk Score

TargetScore


Follow up appointments not booked increasing; concern raised by

Board Members, discussed at Audit Committee, Finance Performance

& Workforce Committee and Quality, Safety and Risk Committee.

Improvement actions not reducing the large numbers of patients

awaiting follow up clinic review.

(consequence x

likelihood):

Initial: 5 x 4 = 20

Current:5 x 4 = 20

Target: 4 x 3 = 12

Level of Control

=60%


Agreed actions approved by Executive Board, being implemented

and routine monitoring in place, which is being aligned with

Integrated Performance Dashboard. Date added to the

risk register

November 2014


• Continued monitoring of progress at Quality Delivery Meetings with WG.

Initial progress with reductions in some specialities but need to change the

current operating model, with actions to address the validated position to

be progressed at pace across directorates.

• Note this matter considered regularly at meetings of the Finance,

Performance & Workforce Committee, where concerns relating to progress

and pace of progress were noted and escalated to the Executive.

• Further revised actions agreed along with follow up of progress and related

monitoring at F, P & W.

• Exploring patient safety implications for some categories of follow ups not

booked for consideration by the Executive Board and at Q,S&R Committee

where further audit related action is being undertaken.

• Recently considered at December 2017 IG Committee.


1) Scoping exercise undertaken –small

investment agreed, will require more

COO /

DPC&MH

Ongoing

2) Actions by speciality agreed, the

outcome from which will help capacity and

demand planning.

COO /

DPC&MH

Ongoing

3) Service redesign proposals developed by

speciality, to be implemented linked to D&C

Plans.

COO /

DPC&MH

In

Progress

4) Action plans with agreed timescales

established and linked to D&C plans with

regular monitoring of progress but capacity

not sufficient.

COO /

DPC&MH

Ongoing

Assurances


Gaps in assurance


Some initial progress made. Still further work needed to address and reduce

volume. Further WAO review did not provide assurance of progress.

Need to better understand any safety implications for follow ups not

booked and patients waiting past clinic review dates.

Current Risk Rating Additional Comments Ref No.

027 Current Risk Rating : 5 x 4 = 20

Note Report on actions taken and proposed presented to

Executive Board (September 2018). Additional

investment needed to address backlog at pace. D&C

plans not sufficient – not enough capacity


25 October 2018

Objective: To improve quality, safety and patient experience



Risk: Failure to sustain services as currently configured to meet cancer

targets


Risk Rating

0

5

10

15

20

25

Risk Score

Target Score


(consequence x

likelihood):

Initial: 5 x 4 = 20

Current: 4 x 4 = 16

Target: 4 x 3 = 12

An overall reducing trend in current risk assessed score. Whilst

target not consistently being met, general improvement trajectory

which needs to be sustained.

Level of Control

=70%


Target score reflects the challenge this area of work present the

Board and where small numbers of patients impact on the potential

to breach target. Date added to the

risk register

April 2014


• Tight management processes to manage each individual case on the

unscheduled care (USC) Pathway.

• Initiatives to protect surgical capacity to support USC pathways have been

put in place in RGH and PCH to protect core activity.

• Prioritised pathway in place to fast track USC patients.

• Ongoing comprehensive demand and capacity analysis with directorates to

maximise efficiencies.

• Overall Cancer target performance plateau at around 90% with ongoing

monitoring of related actions in place at F,P&W Committee.

• Small numbers of patients breaching which is impacting on sustained

delivery of the 31 and 62 day target.


Introduction of revised models for rapid

diagnostic review / assessment in cancer

pathways being introduced.

COO /

DPC&MH

Med Dir

In

Progress

(Nov17)

Continue close monitoring of each patient

on the USC pathways to ensure rapid flow

of patients through the pathway.

COO /

DPC&MH

Med Dir

Ongoing

Some speciality challenges remain in Lung

and Urology - Action plans in place, along

with monitoring.

COO /

Med Dir

Ongoing

Assurances


Gaps in assurance (What additional assurances should we

seek?)

General improvement (sustained) trajectory. Need to continue improvement

actions and close monitoring. Early diagnosis pathway launched and impact

being closely monitored.

The need to deliver sustained performance.

Current Risk Rating Additional Comments Ref No.

005 Current Risk Rating : 4 x 4 = 16

Will need to monitor the effectiveness and impact of the

early cancer diagnosis pathway and single cancer

pathway, whilst maintaining review of current service

delivery / performance.


25 October 2018

Objective: Workforce Sustainability/Organisational Development and

Innovation

Director Lead: Director of Workforce & OD


Risk: Failure to achieve the Management of Absence target Date last reviewed: September 2018

Risk Rating

0

5

10

15

20

25

Risk Score

Target Score


(consequence x

likelihood):

Initial: 5 x 4 = 20

Current: 4 x 3 = 12

Target: 4 x 2 = 8

Overall there is a small improvement in trend across the UHB and the

overall risk score aligns to the improvement trajectory and

strengthened controls in place.

Level of Control

=80%


Failure to achieve the Management of Absence target (although

greater risk is the impact absence is having on patient safety / care,

workforce and associated cover costs) Target is 5% Date added to risk

register

April 2012


The Workforce Team, through the business partner model are continuing to

work proactively with Directorates to manage and reduce sickness absence

rates. Regular training is also provided by the Team, including;

• Identification of hot spot areas and deep dives undertaken;

• Improving the processes around access and timeliness of Occ Health

support (Joint consultant appointment with neighbouring Health Board);

• Sickness audits in place and routinely discussed at CBMs;

• Improving availability via ESR of real time data;

• Presentation (including deep dives) on position and actions made to

Executive Board, WIPF and Finance, Performance & Workforce Committee;

• All Wales Sickness Policy adopted and being applied across the UHB.


Maintain existing controls and ensure

consistent application by Line Managers of

the All Wales Policy / Procedures.

JD

All

Directors

Ongoing

with

monitoring

Regular review and assessment of sickness

management to take place routinely at

CBMs.

JD

All

Directors

Ongoing

with

monitoring

Continue the business partner model to

support directorates to proactively manage

sickness absence.

JD

Ongoing

Assurances


Gaps in assurance


Some small reductions in overall sickness levels achieved. Need to continue

to monitor improvement and sustain actions.

Need to maintain improvement actions and continue to reinforce the

role of line management in consistently applying the Policy /

Procedure.

Current Risk Rating

Additional Comments

Ref No.

019



25 October 2018

Objective: Business Continuity



Risk: Failure to appropriately manage Discharge Delays from Hospitals Date last reviewed: September 2018

Risk Rating

0

5

10

15

20

25

Risk Score

Target Score


(consequence x

likelihood):

Initial: 5 x 4 = 20

Current: 4 x 3 = 12

Target: 4 x 3 =12

The current score reflects the overall improvement in reductions in

DTOCs with a number of related initiatives established to reduce, in

partnership with Local Authority colleagues.

Level of Control

=70%


The target score reflects the requirement to reduce the numbers of

patients delayed, whilst the impact can be significant for patients

whose discharge is delayed, for them individually and for those

awaiting admission.

Date added to the

risk register

April 2013


• Grouping of complex discharges; Implementation of Anticipated Date of

Discharge (ADD), significant improvements following focus on flow work.

• Working with Local Authority partners within the consortium to develop a

partnership response.

• General staff awareness being raised with regards the court ruling and its

related impact.

• New UHB Deprivation of Liberties Safeguarding (DoLS) team set up and

strengthened to support assessment and discharge. Prioritisation process

in place for DoLs applications and training for all disciplines.

• Internal Audit report on DoLS to Audit Committee (April 2016) provides

limited assurance in relation to the backlog in assessment required. Action

Plan in place to address and recent additional investment to help address

some of the actions and mitigate the risks provided.


Ensure robust monitoring arrangements are

maintained and actions in place to mitigate

flow barriers and escalate impact on flow

COO /

DPC&MH

Ongoing

Ensure the DoLS action plan is delivered

(monitoring is via Audit Committee)

Nurse

Director

Complete

Maintain Flow improvement work and

ensure all enablers (including planned

benefits) to reduce dependency on hospital

and appropriately support patients in their

own communities are realised.

COO /

DPC&MH

Ongoing

Assurances


Gaps in assurance


The overall reduced trend in numbers, provides assurance that the

improvement actions are having a positive effect.

As there is seasonal volatility in DTOCs, important still to monitor our

position routinely. In relation to DoLS actions important to monitor

progress with Limited Assurance & WAO Report at Audit Committee.

Current Risk Rating

Additional Comments

Ref No.

006


Maintain monitoring and joint working with Partners

2.4 To receive a Clinical Deep Dive into Urology

1 2.4 Clinical Deep Dive Urology Paper FPW 25 Oct 2018 GR.doc

Urology Service Update Page 1 of 14 Finance, Performance & Workforce Committee

25 October 2018

AGENDA ITEM 2.4

25 OCTOBER 2018


UROLOGY SERVICE DEEP DIVE RELATING TO CANCER BREACHES

Executive Lead: Chief Operating Officer, John Palmer

Author: Assistant Director of Surgery, Deb Lewis

Contact Details for further information: Deb Lewis, Assistant Director of

Surgery – [email protected]


The purpose of this report is to provide the Finance, Performance & Workforce (FPW) Committee with a Deep Dive update on the Urology service provision at

Cwm Taf UHB, focussing on the achievement of the Welsh Government’s

Cancer Waiting Time Targets.

Governance

Link to Health Board

Strategic Objective(s)

The Board’s overarching role is to ensure its strategic objectives, and the related organisational objectives outlined

within the 3 Year Integrated Medium Term Plan 2018-2021, are being progressed. Aligned with the ‘Quadruple Aim’

described within ‘A Healthier Wales’ (Welsh Government, June 2018) these objectives are:

• To improve quality, safety and patient experience. • To protect and improve population health.

• To ensure that the services provided are accessible and sustainable into the future.

• To provide strong governance and assurance.

• To ensure good value based care and treatment for our patients in line with the resources made available to the

Health Board. This report focuses on all of the above objectives.

Supporting evidence

N/A


The data and information contained within the dashboard originates from a variety of sources which have a number of engagement processes associated

with them.


25 October 2018

Finance, Performance & Workforce Committee Resolution (insert √) To;

APPROVE ENDORSE DISCUSS √ NOTE √

Recommendation The Finance, Performance & Workforce Committee is asked to:

• DISCUSS and NOTE the Urology Service Deep Dive and the associated performance actions

to support the achievement of cancer targets.

Summarise the Impact of the Finance, Performance & Workforce

Committee Report

Equality and

diversity

There are no directly related Equality and

Diversity implications as a result of this report.

Legal implications None.

Population Health A number of indicators monitor progress in relation to Population Health and the impact of

cancer diagnosis and treatment upon it.


A number of indicators monitor progress in relation to Quality, Safety and Patient

Experience.

Resources There are no directly related resource

implications as a result of this report.

Risks and Assurance The Urology Service Update lists where performance is not compliant with national or

local targets.

Health and Care

Standards

The 22 Health & Care Standards for NHS Wales

are mapped into the 7 Quality Themes: Staying Healthy; Safe Care; Effective Care;

Dignified Care; Timely Care; Individual Care;

Staff & Resources http://www.wales.nhs.uk/sitesplus/documents/1

064/24729_Health%20Standards%20Framework_2015_E1.pdf

The work reported in this summary and related appendices take into account many of the related

quality themes.

Workforce A number of indicators monitor progress in

relation to Workforce.


Open.


25 October 2018

UROLOGY SERVICE DEEP DIVE RELATING TO CANCER BREACHES


The purpose of this report is to provide the Finance, Performance & Workforce

(FPW) Committee with a Deep Dive update on the Urology service provision at Cwm Taf UHB, focussing on the achievement of the Welsh Government’s Cancer

Waiting Time Targets.


The Finance, Performance and Workforce Committee has received a number of

reports providing updates on urology as part of performance reporting in the

normal course of FPW business over recent months. In particular, a decline in urology performance was identified at the July FPW meeting and Members

requested that a report be brought back to the Committee outlining initial improvement activities that had been completed. This report provides an

update on progress across a number of key quality and performance targets, specifically:

• the ability to achieve compliance with the 31 and 62 day Cancer

Targets and progress towards the implementation of the Single Cancer Pathway

• Sustained delivery of the Referral to Treatment (RTT) 36 week target; and

• Service delivery issues affected by the reconfiguration of services other than Urology.


3.1 Service Profile

The Urology service sits within the portfolio of the Assistant Director of Surgery and within the Directorate of Surgery that covers Urology, General Surgery and

Trauma & Orthopaedics. The department provides services across our two District General Hospital’s (DGHs) (outpatient clinics, diagnostics and inpatient

and daycase surgery), and on three community hospital sites (outpatient clinics only). The following services are provided:

• Core urology

• Percutaneous and laparascopic surgery • Andrology, including a tertiary level service; and

• Oncology.

3.2 Workforce

The service remains challenged by its current workforce profile, particularly in

relation to the medical workforce. The profile of the workforce is outlined below.


25 October 2018

Table 1 – Current workforce model

Staff

Group

Establishment Vacancies

Consultants

• 5 WTE Consultants covering:

Core Urology Percutaneous and

Laparoscopic Surgery

Andrology Oncology.

• 2 WTE

vacancies currently

covered by

locum Consultants.

Middle

Grades

• 2 WTE Registrars

• (2 training ST and 1 specialty doctor)

• 1 WTE SHO (CT2)

• 1 x CT2 from

August (locum is now covering

this post)

Juniors • 1 WTE F1

Nursing • 1 WTE ANP

• 3 WTE NP • 1 WTE SCP

• 1 WTE Urology team assistant

Admin Support

• 4.5 WTE band 4 • 1.5 WTE band 3

• 0.6 WTE band 2

• 1.9 WTE band 4

The main area of concern relating to the medical workforce is its long term

reliance upon locum consultants; although the service is currently relatively stable with three permanent and two long-term locum consultants in situ. This

provision is at a relatively high cost and outside of the current allocated medical staff budget. A recent recruitment drive to attempt to put in place a

substantive workforce structure attracted interest from some potentially appointable medical staff, however, unfortunately all of the potential applicants

withdrew their applications prior to interview. Informal feedback from the candidates on the reasons for withdrawing applications included:

• Concerns around the provision of a 1:5 consultant rota across two (and

after April 2019 potentially three) hospital sites • Lack of a robust middle grade tier rota; and

• Concern about the pending integration with Princess of Wales (POW)

Hospital, given the fragility of its urology service.

Work is progressing through the Transition programme clinical work streams to provide more clarity on the future service, with the aim of providing a

compelling vision of the service that will secure further substantive consultants to join our current team (which is generally acknowledged as containing

outstanding individuals).


25 October 2018

3.3 Performance

The service currently delivers services that feature in the target reports for both

Referral to Treatment (RTT) and Cancer Waiting Times.

Referral to Treatment (RTT)

As can be seen from the table below, the service delivered the zero breach position required at the end of the financial year. This was for the second year

in a row and is expected to also be delivered for 2018/19.

Table 2 – RTT Performance Apr 2017 – Aug 2018

RTT Performance 2017/18

Apr 17 May 17 Jun 17 Jul 17 Aug 17 Sep 17 Oct 17 Nov 17 Dec 17 Jan 18 Feb 18 Mar 18

Breached 15 32 38 39 56 54 40 54 61 51 19 0

RTT Performance 2018/19

Apr 18 May 18 Jun 18 Jul 18 Aug 18

Breached 16 19 46 43 51

The demand and capacity plans developed for the service are balanced overall.

However, due to the small consultant numbers, the sub-specialty element of the service continues to pose a significant month on month challenge, even

though patient numbers are also relatively small.

The capacity available within the service is impacted considerably by high suspected cancer demand. This is the case for outpatient, diagnostic and

surgical capacity. In addition, the sub-specialism in Andrology has further impact due to the relatively high levels of out of area referrals into the service.

Work is ongoing with Commissioning colleagues to ensure that any tertiary elements of the service are appropriately monitored and that tariffs are

proportionate to the impact on the service.

Cancer 62 day Target

The graph below outlines the Health Board’s overall performance against the 62

day cancer target. The further detail relates specifically to Urology.

As can be seen and is reflected to the Committee on a monthy basis, the Health Board performance against the 62 day target since January 2017 has fluctuated

between 81% and 94%. The average number of monthly breaches has been 8 (range 3 to 14).


25 October 2018

Graph 1 – Urgent Suspected Cancer (USC) Monthly Performance

The same graph below shows the performance in Urology only where performance ranges between 30% and 80% with average breaches of 5.2

(range 2 to 10).

Graph 2 – Urology monthly performance

As already noted above, there remains a high demand on the service for patients referred with symptoms that are suspicious for urological cancers.


25 October 2018

Although the number of patients receiving a positive cancer diagnosis remains consistent with an average of 14 per month via USC and 17 per month Non-

Urgent Suspected Cancer (NUSC), the volume of patients referred into the

service with cancer symptoms is showing an upward trend since January 2017. Our internal referral data shows the average referred into the service from Jan-

2017 to September 2018 is 1,037 per month, with a range between 916 and 1,221 (as shown in Graph 3 below). This gives an overall detection rate for

cancer referrals of between 2.4% and 4.7%, the lowest detection rate of all tumour sites.

3.4 Performance improvement

Although performance against the 62 day Cancer Target across Wales is

problematic within Urology, the Health Board acknowledges that performance in Cwm Taf UHB over the last 12 months has been a particular issue. This was

raised appropriately via the Finance Performance and Workforce Committee and an improvement plan has been put in place.

That improvement plan focused on the two main pathways within the Urology Cancer service; Haematuria (bladder cancer) and Prostate.

Within both pathways the primary cause of breaches within the Health Board

was delays for diagnostic investigation and the subsequent reporting of results:

• Flexible cystoscopy • CT

• MRI • TRUS biopsy

• Histology.

Graph 3 – Urology Urgent Suspected Cancer (USC) referrals

900

950

1000

1050

1100

1150

1200

1250

Urology Suspected Cancer Referrals


25 October 2018

One of the main elements of the Directorate’s plan to improve the patient

pathway within Urology was the development of the Treatment Centre at the

Royal Glamorgan Hospital (RGH). This facility houses the Urology clinical team with dedicated diagnostic rooms to facilitate the one-stop pathways within a

single unit. The implementation of this facility has been challenging, and it became fully functional in October 2018.

Haematuria

In March 2018 the Health Board implemented a six month pilot of a one-stop

haematuria pathway, which is included at Appendix 1 for information. The service had previously implemented what was originially considered to be a

“one-stop” pathway but this included only the initial USS and flexible cystoscopy. Patients continued to experience further delays for CT scans. In

addition, the new one-stop service includes:

• A designated Ultrasound machine within the one stop haematuria clinic

• All patients with visible haematuria requiring a CT scan will have this following their flexible cystoscopy (on the same day); and

• If a renal tumour or invasive bladder cancer is detected on USS, it is intended the necessary staging investigation are carried out on the same

day.

The implementation of this pathway required considerable collaborative working between the urology and radiology departments. The six month pilot has now

completed and although a formal report is yet to be produced, initial findings are positive in that:

• Of the active patients referred post July 2018, there are no breaches on this

pathway, with 45 days being the current longest wait and this patient has surgery booked imminently; and

• The average wait for these patients to get to clinic was 12 days.

Prostate

The pathway for suspected and confirmed prostate cancer patients has

historically been problematic, which is replicated across both NHS Wales and NHS England. Within Cwm Taf UHB, the pre-diagnosis pathway is delivered

locally but for patients with a positive diagnosis the surgical treatment is delivered within the tertiary unit at the University Hospital of Wales. Both sides

of this pathway have had inherently long delays for patients. In addition, the nationally agreed pathway has seen changes in recommended clinical practices,

which has posed further challenges.

The Health Board has had a one-stop prostate pathway in place since 2016. However, due to fluctutations in capacity, particularly for the radiology

elements of the pathway, it has struggled to be delivered consistently within

the 62 day target.


25 October 2018

Over the last 4 years the number of confirmed prostate cancers has remained relatively constant, however the number of trans-rectal ultrasound (TRUS)

guided biopsies undertaken has increased by 37% (443 in 2011/2012 to 609 in

2015/2016). The National Institute for Health and Care Excellence (NICE) recommendations for repeat biopsies on active surveillance patients; the

lowering of age related Prostate-Specific Antigen (PSA) reference ranges; and requirement for repeat biopsies when an abnormality is identified on MRI scan,

have all contributed to a substantial increase in prostate biopsy numbers.

The original prostate pathway required patients to undergo a standard TRUS biopsy prior to MRI (undertaken in separate outpatient appointments).

Depending on the MRI results, some patients are then required a repeat (targeted) biopsy.

In March 2018, a revised pathway was developed, with first phase

implementation in July 2018. The pilot pathway realised centralisation of the Royal Glamorgan Hospital (RGH) Prostate pathway into the Treatment Centre

with all patients deemed clinically suitable for a one-stop process, receiving

their consultation, counselling, and both MRI and TRUS biopsy at the same visit. There are some patients who, due mainly to medication regimes, are not

able to have investigations on the same day as their consultation and they are treated via a 2-stop pathway.

It was anticipated that patients referred in from 1 July 2018 onwards would

follow the designated pathway which is included at Appendix 2 for information. However, this proved difficult to achieve due to summer annual leave and

although the pathway improved from this point, it is only for patients referred from 1 September 2018 onwards that we are seeing the overall

improvements anticipated. It should be noted however that there are still patients in the system who were referred before 1st July 2018 which may

breach the pathway once treated.

The most recent review of the prostate pathway is showing:

• There are currently 26 active urgent suspected cancer (USC) patients who

were referred in prior to July 2018. Currently 24 of these look likely to breach the 62 day path pre-validation. The average wait to date is 97 days

with the longest wait at 170 days

• There are 11 active USC patients who were referred in during July 2018. Unfortunately six of these are likely to be considered breaches pre

validation. The average wait to date is 51 days with the longest 84 days. This was prior to any change in capacity

• There are 129 active USC patients who were referred in from August 2018

onwards. There are no patients who are likely to breach to date. The longest wait to date is 60 days. This is a significant improvement on the pre August

position


25 October 2018

• Although the average wait for OSPBC improved to 14 days maximum it has plateaued at around 22 days maximum since early September. (This figure

also includes a number of patients who previously would have attended two

stops.) This compares to the average wait of 35 days and the maximum wait of 45 days pre August 2018.

• The largest impact on pathway improvement, however is the reduction in

patients who had to attend for separate TRUS and biopsy (BX) and MRI. These patients made up over 50% of the breach numbers we have seen in

2018. There are now significantly less patients missing a one stop service due to capacity, which has reduced the delays in pathways.

The table below illustrates the anticipated net result of these issues and

improvements:

Forecast for next 3 months

September 18 October 18 November 18

USC Best Case

82% USC Best Case

88% USC Best Case

90%

No Treated

60 No Treated

60 No Treated

60

No

Breaches

11 No

Breaches

7 No

Breaches

6

USC

worst Case

80% USC

worst Case

85% USC

Worst Case

87%

No

Treated

60 No

Treated

60 No

Treated

60

No

Breaches

12 No

Breaches

9 No

Breaches

8

NUSC

estimate

98% NUSC

estimate

98% NUSC

estimate

98%

As noted, the main issues that will impact on performance are:

• We are still managing Urological patients and reporting patient breaches

through to their treatment pathways, which were delayed at diagnostics between March and June

• We are expecting a drop in performance in September’s reporting as we continue to clear the backlog of those patients delayed at the front end

earlier in the year • The position regarding USC patients commencing their pathway from August

2018, shows a significant improvement in performance and expected breach

numbers going forward • There are no main issues identified in other tumour sites, aside from a

general issue in radiology capacity with timely CT reporting. A cancer pathway coordinator is also shortly to be appointed in radiology to improve

the timeliness of appointments and reporting of patients on cancer pathways.


25 October 2018

The following actions are being taken to mitigate the impact of the above:

• Enhanced scrutiny for the whole Urological pathway by the Urological cancer pathway coordinator, who has worked with the urological Clinical Nurse

Specialist (CNS) to manage the pathways and escalate these patients on a daily basis

• Increased capacity for the two main Urological pathways from 1st July onwards; this will be reflected in those patients being treated from

September onwards • Continous monitoring of one stop diagnostic capacity to ensure delays are

not recurring at the front end of the pathway.

It should also be noted that the pathways being implemented within Cwm Taf UHB are considered to be best practice across NHS Wales and England. A

recent national Single Cancer Pathway workshop focussed on Urology pathways and we were able to show that we were among the first to have implemented

them successfully. The challenge is to sustain delivery in an area of increasing

demand and with consistently challenging workforce issues.

It should also be noted that the pathway improvements implemented ensure that patients can be referred for tertiary treatment in a timely manner.

Unfortunately once a patient is referred to the tertiary unit we relinquish an element of control on the pathway and there remains a risk that patients will

breach the pathway. The cancer service team continue to work closely with colleagues in tertiary centres to highlight patients at risk of breaching and to

develop innovative treatment pathways acorss the full spectrum of the service.

3.5 Resources

In addition to the physical pathway changes implemented in these two pilots, non-recurrent investment has also been made into a cancer pathway co-

ordinator. This is a crucial resource requirement if we are to sustain and

further improve these clinical pathways. As the initial funding was non-recurrent, there is a need for a band 4/5 cancer pathway co-ordinator role to be

appointed on a substantive basis and this will therefore be included in the Integrated Medium Term Plan (IMTP) for 2019/20.

3.6 Future Changes

As has been noted previously, Health Boards are now required to report against

Welsh Government’s new Cancer target; the Single Cancer Pathway. Under this target all patients with symptoms suspicious of cancer will be expected to

receive a first definitive treatment within 62 days of the suspicion being noted. The majority of Urology patients diagnosed with cancer are reported under the

current 31 day target, which poses a further challenge for the diagnostic elements of the service. However, the Welsh Cancer Network is working closely

with Health Boards to identify demand and capacity needs for implementation

of the Single Cancer Pathway (SCP) and we continue to be at the forefront of this work.


25 October 2018

4. RECOMMENDATION

The Finance, Performance & Workforce Committee is asked to:

• DISCUSS and NOTE the Urology Service Deep Dive and the associated

performance actions to support the achievement of cancer targets.


Open


25 October 2018

APPENDIX 1


25 October 2018

APPENDIX 2

2.5 Update report on cancer breaches- FPW 25 Oct 2018

1 2.5 Update report on cancer breaches- FPW 25 Oct 2018 GR.doc

Update Report Cancer Breaches Page 1 of 4 Finance, Performance and Workforce Committee

25 October 2018

AGENDA ITEM 2.5

25 October 2018


UPDATE ON CANCER PERFORMANCE

Executive Lead: Kamal Asaad, Medical Director / Balan Palaniappan, Lead Cancer Clinician

Author: Wayne Jenkins, Lead Cancer Manager

Contact Details for further information: Wayne Jenkins, Lead Cancer

Manager [email protected]

Purpose of the Finance, Performance and Workforce Committee

Report

The purpose of the report is to provide the Finance, Performance and

Workforce Committee with an update on the latest performance for Urgent Suspected Cancer (USC) and Non Urgent Suspected Cancer (NUSC)

cancer targets which are a tier 1 priority for Health Boards.

Governance

Link to Health Board Strategic

Objective(s)

The Board’s overarching role is to ensure its strategic objectives, and the related organisational objectives

outlined within the 3 Year Integrated Medium Term Plan 2018-2021, are being progressed. Aligned with

the ‘Quadruple Aim’ described within ‘A Healthier Wales’ (Welsh Government, June 2018) these

objectives are: • To improve quality, safety and patient experience.

• To protect and improve population health. • To ensure that the services provided are accessible

and sustainable into the future. • To provide strong governance and assurance.

• To ensure good value based care and treatment for

our patients in line with the resources made available to the Health Board.

This report focuses on all of the above objectives.

Supporting

evidence

Welsh Government Referral to Treatment (RTT) Times

management rules.


-


25 October 2018


APPROVE ENDORSE DISCUSS NOTE √

Recommendation The Finance, Performance and Workforce Committee is asked to:

• NOTE the report and the issues raised in

the achievement and sustainability of the target delivery.

Summarise the Impact of the Finance, Performance and Workforce Committee Report

Equality and

diversity

No implications have been highlighted from an

equality and diversity perspective

Legal implications No known legal implications

Population Health There are no known population health

implications

Quality, Safety &

Patient Experience

Urgent Suspected Cancer (USC) and Non Urgent

Suspected Cancer (NUSC) cancer targets are a tier 1 priority for Health Boards.

Resources There are no further resource issues

Risks and Assurance The attached reports outline any issues of risk

and assurance for the Committee.

Health and Care Standards

The 22 Health & Care Standards for NHS Wales are mapped into the 7 Quality Themes:

Staying Healthy Safe Care

Effective Care Dignified Care

Timely Care Individual Care

Staff & Resources

http://www.wales.nhs.uk/sitesplus/documents/1064/24729_Health%20Standards%20Framework

_2015_E1.pdf

Workforce n/a

Freedom of

information status

Open


25 October 2018

UPDATE ON CANCER PERFORMANCE


The purpose of the report is to provide the Finance, Performance and Workforce Committee with an update on the latest performance for Urgent Suspected

Cancer (USC) and Non Urgent Suspected Cancer (NUSC) cancer targets which are a tier 1 priority for Health Boards.


There are two cancer targets:

• 31 days to treatment for 98% of patients not referred in as USC, • 62 days to treatment for 95% of patients referred in as USC. (A local

delivery target of 90% has been agreed with Welsh Government due to

the low treatment numbers within Cwm Taf UHB)

A number of Cwm Taf residents receive the treatment part of their pathways at tertiary centres at Cardiff and Vale UHB and Velindre. If Cwm Taf refers a case

within half of the pathway then the delivery responsibility passes to the treating centre. Otherwise responsibility remains with the originating health board. (We

reflect this as ‘True Performance’ in the table below.)

The Health Board has managed to deliver the NUSC target on a sustained basis over time.

The table below shows the performance against both targets for the last 3

months.

Month NUSC True Performance

USC True Performance

Target 98% 90%

August 2018 100% 86.25%

July 2018 100% 86.25%

June 2018 100% 88%

The latest report prepared for Welsh Government is attached at Appendix 1

for information.

The report highlights that the main challenge facing the Health Board in achieving and sustaining the USC target is with Urological Cancers. The report

clarifies the actions taken to address the issues raised.


25 October 2018


This report provides an assurance that the Health Board has effective processes in place to manage and monitor performance across a range of indicators and

key issues, in particular where there are current organisational challenges.

4. RECOMMENDATION

The Finance, Performance and Workforce Committee is asked to:

• NOTE the report and the issues raised in the achievement and

sustainability of the target delivery.

Freedom of

information status

Open

2.5.1 Appendix 1 - Monthly Cancer Performance Report Aug 18wj

1 2.5.1 Appendix 1 - Monthly Cancer Performance Report FPW 25 Oct 2018 GR.docx

1

2.5.1 Appendix 1

Monthly Cancer Performance Report – Cwm Taf

August 2018

Main reasons cancer targets not met this month and actions taken to mitigate harm

Non Urgent Suspected Cancer (NUSC) – 97% achieved with 4

breaches. 2 breaches were Urological, treated at Cardiff and Vale UHB and had date of decision to treat (DoDT) and the whole wait at

Cardiff and Vale. 2 breaches were Upper Gastrointestinal treated at Velindre and had DoDT and whole wait there. Cwm Taf true

performance is 100%.

Urgent Suspected Cancer (USC) – 85% achieved with 12 breaches, although 1 breach (Lung) was referred on within 31 days,

therefore Cwm Taf true performance is over 86%.

Urology accounted for 9 of the USC breaches, which reflects the

recent challenges reported over the last few months in this tumour site. We have addressed the main issue, which is capacity for One

Stop Prostate Biopsy Clinic and one stop haematuria clinic this will be reflected in improved performance from October onwards as

patients reach the main diagnostic events earlier in the pathway.

Forecast for next 3 months

September 18 October 18 November 18

USC Best

Case

82% USC Best

Case

88% USC Best

Case

90%

No

Treated

60 No

Treated

60 No

Treated

60

No

Breaches

11 No

Breaches

7 No

Breaches

6

USC worst

Case

80% USC worst

Case

85% USC Worst

Case

87%

No

Treated

60 No

Treated

60 No

Treated

60

No Breaches

12 No Breaches

9 No Breaches

8

NUSC estimate

98% NUSC estimate

98% NUSC estimate

98%

Reasons for not achieving target in next 3 months

Issues and challenges

We are still managing Urological patients and reporting patient breaches through to their treatment pathways, which were delayed

at diagnostics between March and June.

2

We are expecting a drop in performance in September’s reporting

as we continue to clear the backlog of those patients delayed at the front end earlier in the year.

The position regarding USC patients commencing their pathway

from August 2018, shows a significant improvement in performance and expected breach numbers going forward.

There are no main issues identified in other tumour sites, aside from a general issue in radiology capacity with timely CT reporting.

A cancer pathway coordinator is also shortly to be appointed in radiology to improve the timeliness of appointments and reporting

of patients on cancer pathways.

Actions to be taken in next few months to improve performance

We have implemented enhanced scrutiny for the whole Urological

pathway by putting in place a Urological cancer pathway coordinator, who has worked with the urological CNS to manage

the pathways and escalate these patients on a daily basis.

We have put in place increased capacity for the two main Urological pathways from 1st July onwards and this will be reflected in those

patients being treated from September onwards.

We are continuing to monitor one stop diagnostic capacity and ensure delays are not reoccurring at the front end of the pathway.

Number of cancelled cancer operations due to emergency

pressures or other for this month (please detail whether they have since been rescheduled and the reason for the

cancellation)

None

2.6 INNU update report FPW 25 Oct 2018 GR

1 2.6 INNU update report FPW 25 Oct 2018 GR.docx

Interventions Not Normally Undertaken (INNU) update

Page 1 of 11 Finance, Performance & Workforce Committee

25 October 2018

AGENDA ITEM 2.6

October 2018


INTERVENTIONS NOT NORMALLY UNDERTAKEN (INNU) UPDATE

Executive Lead: Director of Public Health

Authors: Consultant in Public Health

Contact Details for further information: Kimberley Cann [email protected] Cwm Taf Local Public Health Team


The purpose of this report is to inform the Finance, Performance and Workforce Committee as to the progress of the Interventions Not Normally

Undertaken (INNU) workstream within the Value-Based Healthcare cross-

cutting theme.

Governance

Link to Health


The Board’s overarching role is to ensure its Strategy

outlined within ‘Cwm Taf Cares’ 3 Year Integrated Medium Term Plan 2015-2018 and the related

organisational objectives aligned with the Institute of Healthcare Improvement's (IHI) ‘Triple Aim’ are being

progressed, these in summary are: • To improve quality, safety and patient experience.

• To protect and improve population health. • To ensure that the services provided are accessible

and sustainable into the future.

• To provide strong governance and assurance. • To ensure good value based care and treatment for

our patients in line with the resources made available to the Health Board.

This report focuses on all of the above objectives.

Supporting

evidence

Identified within the report


Local Public Health Team



25 October 2018

Finance, Performance & Workforce Committee Resolution To:

APPROVE ENDORSE √ DISCUSS NOTE √

Recommendation The Finance, Performance & Workforce Committee is asked to:

• NOTE the proposed process for ensuring policy accuracy, compliance, and identifying and

realising and cost-savings, and • ENDORSE the implementation of this process

by Directorates and incorporation into Integrated Medium Term Plans (IMTPs).

Summarise the Impact of the Finance, Performance & Workforce Committee Report

Equality and

diversity

A population wide approach for those meeting the

criteria for INNU is employed.

Legal implications None

Population Health Cwm Taf University Health Board (CTUHB) has a

policy which sets out INNU procedures which are

available within the Health Board and the criteria which must be met for the procedure to take

place. There are 30 INNUs in total available where appropriate for the population of CTUHB.


INNUs are procedures which are not normally undertaken because: (i) there is currently

insufficient evidence of clinical and/or cost-effectiveness; (ii) the intervention has not been

reviewed by the National Institute for Healthcare and Clinical Effectiveness (NICE) or the All Wales

Medicines Strategy Group (AWMSG); and/or (iii)

it is considered to be of relatively low priority for NHS resources.

Resources This work has formed part of the Value-Based Healthcare cross-cutting theme.

Risks and Assurance The undertaking of INNUs has consequences for

individual’s health, as well as healthcare resource and opportunity costs.

Health and Care Standards

Health and Care Standards (2015) 1.1 Health promotion, protection and

improvement 3.1 Safe and clinically effective care

Workforce Health Board funding has supported staff resource

to undertake this work.

Freedom of Information Status

Open



25 October 2018

INTERVENTIONS NOT NORMALLY UNDERTAKEN (INNU) UPDATE


The purpose of this report is to inform the Finance, Performance and Workforce Committee as to the progress of the Interventions Not Normally Undertaken

(INNU) work stream within the Value-Based Healthcare cross-cutting theme.


INNUs are procedures which are not normally undertaken because: (i) there is currently insufficient evidence of clinical and/or cost-

effectiveness; (ii) (ii) the intervention has not been reviewed by the National Institute

for Healthcare and Clinical Effectiveness (NICE) or the All Wales

Medicines Strategy Group (AWMSG); and/or (iii) it is considered to be of relatively low priority for NHS resources.

Cwm Taf University Health Board (CTUHB) has a policy which sets out these INNU

procedures and the criteria which must be met for the procedure to take place.

Recent work has suggested that there may be cost-savings available from ensuring that these procedures are only performed in line with policy criteria. It

has also highlighted that there is an ongoing need to ensure accurate coding and monitoring of activity levels to provide accurate estimates for comparisons at a

local and national level, ensuring the guidance is kept up to date with latest evidence, and engaging with clinicians to enable them to stay informed and

supported when adhering to the policy.


Status summary (October 2018) The Local Public Health Team (LPHT) within CTUHB have developed a clear,

replicable process by which Directorates can ensure policy accuracy, compliance, and identify and realise and cost-savings. It is recommended that this process is

incorporated into the Integrated Medium Term Plan (IMTP). It has been tested

with two INNUs (grommets and tonsillectomy) to date and found to be effective but may vary between INNUs.

This process is set out for the relevant Directorates with INNUs in Appendix 1.

The LPHT will provide ongoing support to the Directorates to help implement the process and adapt to their individual needs, including identifying ongoing plans

to reduce activity (where appropriate), and ongoing monitoring of activity.

4. RECOMMENDATION

The Finance, Performance & Workforce Committee is asked to: • NOTE the proposed process for ensuring policy accuracy, compliance, and

identifying and realising and cost-savings, and • ENDORSE the implementation of this process by Directorates and

incorporation into Integrated Medium Term Plans (IMTPs).

Freedom of

Information Status

Open



25 October 2018

Appendix 1: Report for Directorates on implementation of the INNU process

Interventions Not Normally Undertaken (INNU):

Establishing a process for ensuring INNU policy accuracy, compliance and identifying and realising cost-savings

October 2018

Contents

1. Purpose of this paper ................................................................... 4 2. Background ................................................................................ 4

3. Aims and objectives ..................................................................... 5 4. Proposed methodology ................................................................. 6

5. Potential benefits to the Directorate ............................................... 7

Purpose of this paper

This papers sets out a process by which Directorates can ensure policy accuracy, compliance, and identify and realise and cost-savings relating to Interventions

Not Normally Undertaken (INNUs).

Background

INNUs are procedures which are not normally undertaken because: (i) there is currently insufficient evidence of clinical and/or cost-effectiveness; (ii) the

intervention has not been reviewed by the National Institute for Healthcare and Clinical Effectiveness (NICE) or the All Wales Medicines Strategy Group

(AWMSG); and/or (iii) it is considered to be of relatively low priority for NHS resources. Cwm Taf University Health Board (CTUHB) has a policy which sets out

these INNU procedures and the criteria which must be met for the procedure to

take place.

Recent work has suggested that there may be cost-savings available from ensuring that these procedures are only performed in line with policy criteria. It

has also highlighted that there an ongoing need to ensure accurate coding and monitoring of activity levels to provide accurate estimates for comparisons at a

local and national level, ensuring the guidance is kept up to date with latest evidence, and engaging with clinicians to enable them to stay informed and

supported when adhering to the policy.

The Local Public Health Team (LPHT) within CTUHB have developed a clear, replicable process by which Directorates can ensure policy accuracy, compliance,

and identify and realise and cost-savings. It is recommended that this process is incorporated into the IMTP. It has been tested with two INNUs (grommets and

tonsillectomy) to date and found to be effective but may vary between INNUs.



25 October 2018

The LPHT can provide ongoing support to the Directorates to help implement the process and adapt to their individual needs, including identifying ongoing plans

to reduce activity (where appropriate), and ongoing monitoring of activity.

Aims and objectives

Aim: to ensure ongoing INNU policy accuracy and compliance, identifying and realising cost-savings to the Directorate where available

The table below shows the INNUs which occur within your Directorate:

Area INNU

Surgery & Urology

1. Treatment for erectile dysfunction 2. Scar revision

3. Female breast enlargement (augmentation mammoplasty)

4. Breast prosthesis removal or replacement 5. Breast lift (mastopexy)

6. Botulinum toxin 7. Correction of nipple inversion

8. Haemorrhoidectomy 9. Circumcision

10. Varicose veins (asymptomatic and mild/moderate cases)

11. Vascular skin lesions

12. Other skin conditions (benign) – removal of

Trauma &

Orthopaedics

13. Hallux valgus (bunion) surgery

14. Ganglia – surgical removal

Obstetrics &

Gynaecology

15. Elective caesarean section

16. Reversal of sterilisation (male and female)

Area INNU

Head & Neck 1. Correction of prominent ears (pinnaplasty) 2. Face or brow lift (rhytidectomy)

3. Rhinoplasty 4. Laser therapy for myopia

5. Blepharoplasty 6. Xanthelasma palpebrum (fatty deposits on the eyelids)

7. Soft palate implants for obstructive sleep apnoea 8. Apicetomy

9. Wisdom teeth 10. Orthodontic treatment

Area INNU

Therapies 1. Skin hypo-pigmentation

Area INNU

Unclassified 1. Fibromyalgia in adults



25 October 2018

The objectives of this work are to: a. Provide a mechanism to support clinicians in identifying whether a

procedure should take place and provide reasoning for not undertaking

a procedure on an individual basis b. Identify and realise any cost-savings from reductions in procedures

which do not fit policy criteria c. Identify and amend any errors in the coding or definitions in the

current policy, to support accurate estimates of local activity and national comparisons

d. Keep the INNU policy up-to-date to reflect current procedure guidance and coding practice

e. Ensure clinical engagement to inform any needed changes to policy and to raise awareness of policy criteria

f. To support ongoing monitoring of INNU activity.

Proposed methodology

Figures 1-3 show an overview of the proposed process. The order of the steps

within each stage is not prescriptive but should be flexible to take advantage of availability of the range on individuals who can contribute to this process. Full

details of the implementation of this process for the two piloted INNUs and the resulting recommendations on the most effective approach are available from the

LPHT who can advise Directorates on each stage.

It is recommended that where possible the process is undertaken for groups of similar INNUs (e.g. requiring input from the same clinical team) conjointly to

save time and duplication of work.

Figure 1: Establish current situation



25 October 2018

Figure 2: Identify any action required

Figure 3: Embed compliance with policy and monitoring of activity

Potential benefits to the Directorate

Undertaking this process will provide Directorates with ongoing oversight of

policy adherence by: (i) ensuring activity levels are interpreted consistently over time; (ii) providing a baseline for comparison and expected activity levels; and

(iii) ensuring clinical agreement over the criteria for undertaking the intervention.

The use of run charts can be used to highlight activity levels which are outside of those expected due to change fluctuations. Which can then prompt further

exploration through audit of patient notes and clinical engagement.



25 October 2018

Until policy accuracy and compliance (in particular around coding and interpretation of codes) is ensured via stages 1-2, it is difficult to estimate

potential cost-savings related to individual INNUs as activity estimate can vary

widely. The process was piloted on tonsillectomy and the findings are shown below. Currently reported activity levels for the INNUs in this Directorate are also

shown below and estimate a total of 1,445/293/0 excess procedures.

Key findings for tonsillectomy Outcome

Coding agreed F34.1>5, F34.7>9

Data interpretation

caveats agreed

Filter by diagnosis code: J03, J35-36

All diagnosis fields should be searched (not just primary)

Filter by procedure code: F34.1>5,

F34.7>9

Only need to search primary procedure field

Current annual activity

level

(April 2017 – March

2018)

165 FCEs per 100,000 population (494 in total)1

Comparators HDUHB: 68.2 per 100,000 population (262)

C&VUHB: 84.5 per 100,000 population (417)

ABUHB: 75.9 per 100,000 population (446)

ABMUHB: 105.3 per 100,000 population (560)

BCUHB: 88.3 per 100,000 population (615)

Figures not available for PTUHB

HB peer comparator rate (excluding HDUHB & PTUHB): 97.1

FCEs per 100,000 population (507 in total)2,3

Year-on-year variation for CTUHB was not outside of expected

random fluctuations (statistical process control)

Current costing

estimate

Fully absorbed cost per procedure (including overheads):

£1,598

Fully absorbed cost for 498 procedures: £789,412

Direct releasable cost saving opportunity per procedure: £538

Potential number of FCEs saved if peer rate applied: 204

Potential cost savings if peer rate applied: £109,752

New guidance identified Royal College of Surgeons (2016). Commissioning Guide:

Tonsillectomy. NICE accredited evidence.

Recommended changes

to policy

Policy to refer to ‘Tonsillectomy for recurrent tonsillitis and its

complications (adult and child)‘ in future (instead of

‘Tonsillectomy (adult and child)’)

No policy criteria changes

No coding changes

Estimated impact on

activity levels

None4

Estimated impact on

costing estimate

None4

Scoping audit of patient

notes findings

It is not well documented in patient notes how the policy

criteria are met to enable accurate audit

Recommendations Further exploration of whether outsourcing of tonsillectomy is

conducted by other Health Boards and incorporation into peer

comparisons

Feedback on these findings to clinicians at the ENT audit

session to: (i) further raise awareness of policy criteria; (ii)

agree how reductions in activity can be achieved; and (iii)

improve reporting of how policy criteria are met in patient

notes. Ongoing monitoring of activity.



25 October 2018

1. Based on mid-year population estimate for 2017 by Stats Wales (BCUHB: 696,284; PTUHB: 132,515; HDUHB: 384,239; ABMUHB: 531,858; CTUHB:

299,080; ABUHB: 587,743; C&VUHB: 493,446)

2. It has not been explored whether any outsourcing is undertaken within the other Health Boards

3. Sensitivity analysis: assuming HDUHB is not under-reporting, the peer value is 466.

4. Please note that whilst there is no change in activity and cost, there is improvement on data interpretation which may make figures appear different to

previous reports.

The table below shows the estimated activity for INNUs within your Directorate, comparisons against other Health Boards, and potential cost-savings. It is

important to note that until coding and interpretation of activity is agreed for these INNUs these estimates may not be accurate.



25 October 2018

Area INNU Coding Rate per

100,000 (activity)

(Apr 17 – Mar 18)*

Peer com-parator rate per

100,000 (activity)**

Excess activity (expec-

ted) [tbc]

Surgery & Urology

Treatment for erectile dysfunction

N29.1 1.0 (3) 0.8 (23) 1 (2)

Scar revision S06.5 or

S06.9; S23.1>4

122.0 (365) 37.8

(1,131)

252

(113)

Female breast enlargement (augmentation mammoplasty)

B30.1; B31.2 0 (0) 1.6 (23) 0 (5)

Breast prosthesis removal or replacement

B30.- 7.4 (22) 1.4 (33) 18 (4)

Breast lift (mastopexy) B31.3 1.3 (4) 0.5 (24) 2 (2)

Botulinum toxin X85.1 1.7 (5) 2.8 (85) 0 (8)

Correction of nipple inversion

B35.6 0 (0) 0 (0) 0 (0)

Haemorrhoidectomy H51.1>3;

H51.8>9; H52.1>4;

H52.8>9

26.7 (80) 4.8 (144) 66 (14)

Circumcision N30.3 53.2 (159) 7.7 (230) 136 (23)

Varicose veins (asymptomatic and

mild/moderate cases)

L84.1>6; L84.8>9

L85.1>3; L85.8>9 L86.1>2; L86.8>9 L87.1>9; L88.1>3 L88.8>9

66.5 (199) 5.1 (153) 184 (15)

Vascular skin lesions I99 (ICD-10) 2.0 (6) 0.2 (10) 5 (1)

Other skin conditions (benign) – removal of

S04.1>3; S04.8 S05.1>5;

S05.8>9

S06.1>5; S06.8>9 S09.1>5; S09.8>9 S10.1>5; S10.8>9 S11.1>5;

S11.9>9

133.7 (400) 43.4 (1298) 270 (130)

Trauma & Ortho-paedics

Hallux valgus (bunion) surgery

W79.1 1.7 (5) 1.6 (49) 0 (5)

Ganglia – surgical removal T59.1>4; T59.8>9

T60.0>4-; T60.8>9

13.7 (41) 2.3 (68) 34 (7)

Obstetri

cs & Gynae-

cology

Elective caesarean section R17.1, 17.2,

17.8, 17.9

178.2 (533) 20.2 (604) 473 (60)

Reversal of sterilisation (male and female)

N18.1; Q29.1>2 Q29.8>9; Q37.1 Q37.8>9;

0.3 (1) 0 (0) 1 (0)

Total 1,445

*Based on primary procedure only; **Based on only those Health Boards for

which figures are reported.



25 October 2018


100,000

(activity)

(Apr 17 –

Mar 18)*

Peer com-

parator

rate per

100,000

(activity)**

Excess

activity

(expec-

ted)

[tbc]

Head &

Neck

Correction of prominent

ears (pinnaplasty)

D03.3 5.0 (15) 0.6 (16) 13 (2)

Face or brow lift

(rhytidectomy)

S01.- 1.7 (5) 1.6 (33) 0 (5)

Rhinoplasty E02.1>9;

E07.1>3;

E07.8>9

24.4 (73) 1.5 (46) 69 (4)

Laser therapy for

myopia

C46.1 0 (0) 0 (0) 0 (0)

Blepharoplasty C12.1>6;

C12.8>9

C13.1>4;

C13.8>9

C15.1>5;

C15.8>9

49.8 (149) 10.9 (327) 116

(33)

Xanthelasma palpebrum

(fatty deposits on the

eyelids)

C12.1>3 7.0 (21) 5.0 (149) 6 (15)

Soft palate implants for

obstructive sleep

apnoea

F32.8 0.3 (1) 0 (0) 1 (0)

Apicetomy F12.1 0 (0) 0.8 (8) 0 (2)

Wisdom teeth F09.3 32.8 (98) 3.3 (99) 88 (10)

Orthodontic treatment F14.1>3;

F14.8 >9

F15.1>4;

F15.9

0.7 (2) 1.1 (21) 0 (3)

Total 293




100,000

(activity)

(Apr 17 –

Mar 18)*

Peer com-

parator

rate per

100,000

(activity)**

Excess

activity

(expec-

ted)

Therapies Skin hypo-

pigmentation

L81.9 (ICD

10)

0 (0) 0 (0) 0 (0)

Total 0

*Based on primary procedure only; **Based on only those Health Boards for which figures are reported.


100,000

(activity)

(Apr 17 –

Mar 18)*

Peer com-

parator

rate per

100,000

(activity)**

Excess

activity

(expec-

ted)

Un-

classified

Fibromyalgia in adults M7909

(ICD10)

0 (0) 0 (0) 0 (0)

Total 0



3.1 To review the Forward Look for 2018/19

1 3.1 Forward Look FPW 25 October 2018 GR.doc

Agenda item 3.1

Forward Look FP&W

Page 1 of 1 Finance, Performance & Workforce Committee Meeting 25 October 2018

Finance, Performance and Workforce Committee: Forward Look 2018/19

25 October 2018 1.00pm – YMH

• To receive a quarterly update on CAMHS Performance – to include Primary Care CAMHS Alan Lawrie

• To receive an update on the Deep Dive undertaken in Facilities John Palmer

• To receive a quarterly update on the organisational risks assigned to the Committee Robert Williams

• To receive a Clinical Deep Dive into Urology John Palmer

• To receive an update report on Cancer Breaches Kamal Asaad

• To receive an update report on Interventions Not Normally Undertaken (INNU) Nov 2018 Kelechi Nnoaham

22 November 2018 1.00pm – YMH

• Finance Dashboard Steve Webster

• Performance Dashboard Ruth Treharne

• Workforce Dashboard Jo Davies

• To receive an update on Demand & Capacity Planning – Ophthalmology John Palmer

24 January 2019 1.00pm – YMH

• Finance Dashboard

• Performance Dashboard

• Workforce Dashboard

• To receive an update on Follow Up Outpatients Not Booked (now January 2019) John Palmer

2018/19 • Detailed update on Delayed Transfers of Care – Operational Director (s)

• Committee Assigned Organisational Risks Quarterly Update - to be added to Forward Look for January 2019. • Annual Report for 2017/2018 – to include Annual Self-Assessment and Updated Terms of Reference –October

2018 • To receive an update on Frequent Attenders – to be confirmed

NB - No meeting will be held

in August or December. Urgent items will be

accommodated as required and the Forward Look is

subject to change. Quarterly items

• CAMHS Performance

Annual review of the Terms of Reference in line with the Standing Orders – each October

Principles • Anything that has improved for 3 months consecutively will be placed on the Agenda

(Good news) for Info • Anything that has declined for 3 months consecutively will be placed on the Agenda

(Improvement Plan) • Any area where we have a Delivery Unit intervention will be reviewed at every

meeting until intervention is withdrawn

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