bundle primary & community care committee 10 october 2018cwmtafmorgannwg.wales/docs/primary care...

Bundle Primary & Community Care Committee 10 October 2018

0 AGENDA1 Agenda Primary and Community Care Committee 10 October 2018.docx

1 PART 1 - PRELIMINARY MATTERS1.1 Welcome & Introductions1.2 Apologies for absence1.3 Declarations of Interest1.4 Unconfirmed Minutes of the meeting held on 27 June 2018

1.4 Unconfirmed minutes Primary and Community Care Committee 27 June 2018 PCCC 10 Oct 2018GR.doc

1.5 Matters Arising1.6 Action Log

1.6 Action Log PCCC 10 October 2018.docx

1.7 Chairs Report2 PART 2 - ITEMS FOR APPROVAL/ENDORSEMENT2.1 Baby Teeth Do Matter - 12 Month Evaluation Report

2.1 Baby Teeth DO Matter PCCC 10 Oct 2018 GR.docx

2.2 Organisational Risk Register2.2 Org Risk Register PCCC 10 Oct 2018 GRa.doc

3 PART 3 - GOVERNANCE, PERFORMANCE & ASSURANCE3.1 Report of the Director of Primary, Community & Mental Health

3.1 DPMH report PCCC 10 October 2018.doc

3.2 Primary & Community Care Internal Audit Report3.2 IA Report Governance Arrangements - Primary and Community Care Committee PCCC 10 Oct

2018.pdf

3.3 Inverse Care Law/Population Health Management Pilot Update3.3 Inverse Care Law and Population health management pilot report PCCC 10 October 2018.docx

3.4 Cluster Update3.4 Cluster update PCCC 10 October 2018.docx

3.5 Delivery Agreements3.5 Delivery Agreement Progress Updates Q 1 and 2 PCCC 10 October 2018.docx

3.5.1 Appendix 1 Composite Delivery Agreement Progress Update report PCCC 10 October 20183.5.1 Appendix 1 Composite Delivery Agreement Progress Update report PCCC 10 October 2018.pdf

4 PART 4 - FOR INFORMATION4.1 Primary Care Newsletter

4.1 Primary Care Newsletter (Welsh Government) Summer 2018 PCCC 10 October 2018.pdf

4.2 IMTP Monitoring Report4.2 IMTP Monitoring Report paper PCCC 10 October 2018.docx

4.2.1 Appendix 1 IMTP tracker quarterly report PCCC 10 October 20184.2.1 Appendix 1 IMTP tracker quarterly report PCCC 10 October 2018.docx

5 PART 5 - OTHER MATTERS5.1 To Review the Forward Look for 2018/19

5.1 Forward Look PCCC 10 October 2018.doc

5.2 Any other urgent business5.3 Date of Next Meeting

0 AGENDA

1 1 Agenda Primary and Community Care Committee 10 October 2018.docx

PRIMARY AND COMMUNITY CARE COMMITTEE

Wednesday 10 October 2018 Ynysmeurig House, Navigation Park, Abercynon

09.00 - 12.00

AGENDA

Lead / Attachment

PART 1 - PRELIMINARY MATTERS

1.1 Welcome and Introductions Chair / Oral

1.2 Apologies for Absence Chair / Oral

1.3 Declaration of Interests Chair / Oral

1.4 Unconfirmed Minutes of the meeting of the Primary

Care Committee held on 27 June 2018.

Chair

Attachment

1.5 Matters Arising Chair / Oral

1.6 Action Log Chair

Attachment

1.7 Chair’s Report Chair / oral

PART 2 - ITEMS FOR APPROVAL / ENDORSEMENT

2.1 Baby Teeth DO Matter – 12 month evaluation report

Director of Public Health

Attachment

2.2 Organisational Risk Register Director of Corporate Services

and Governance / Board

Secretary

Attachment

PART 3 - GOVERNANCE, PERFORMANCE AND ASSURANCE

3.1 Report of the Director of Primary, Community and Mental Health

Director of Primary,

Community & Mental Health

Presentation

3.2 Primary and Community Care Internal Audit Report (Substantial Assurance)

Director of Corporate Services

and Governance / Board

Secretary

Attachment

3.3 Inverse Care Law / Population Health Management Pilot update

Director of Public Health

Attachment

3.4 Cluster Update Locality Clinical Director

Attachment

3.5 Delivery Agreements Director of Primary,


Attachment

PART 4 - FOR INFORMATION (These items will only be discussed if related issues are raised with the Chair in

advance of the meeting)

4.1 Primary Care Newsletter

Director of Primary,


Attachment

4.2 IMTP Monitoring Report Director of Primary,


Attachment

PART 5– OTHER MATTERS

5.1 To review the Forward Look for 2018/19 Chair

Attachment

5.2 Any other urgent business Chair / Oral

5.3 Date of Next Meeting

Wednesday 9 January 2019 at 9.00am

Rhondda and Cynon Rooms, Ynysmeurig House, Abercynon CF45 4SN

1.4 Unconfirmed Minutes of the meeting held on 27 June 2018

1 1.4 Unconfirmed minutes Primary and Community Care Committee 27 June 2018 PCCC 10 Oct 2018 GR.doc

Agenda Item 1.4

Unconfirmed minutes of the Primary and

Community Care Committee

27 June 2018

Page 1 of 8

Primary and Community

Care Committee Meeting

10 October 2018

CWM TAF UNIVERSITY HEALTH BOARD

MINUTES OF THE MEETING OF THE PRIMARY AND COMMUNITY

CARE COMMITTEE HELD ON 27 JUNE 2018 AT YNYSMEURIG HOUSE, ABERCYNON

PRESENT:

Mrs M K Thomas − Vice Chair of the Health Board (Chair) Cllr R Smith − Independent Member

Mr K Montague − Independent Member

IN ATTENDANCE: Mr A Lawrie − Interim Director Primary, Community &

Mental Health Prof K Nnoaham − Director of Public Health

Dr S Hackwell − Assistant Medical Director for Primary Care

Mrs A Riley − Head of Finance for Primary Care Mrs S Scott-Thomas − Head of Medicines Management

Mrs A Davies − Assistant Director for Therapies and Health Sciences

Mr C Wilson − Assistant Director for Primary Care, Children and CAMHS

Mrs J Howard − Community Pharmacy Wales Mr I Jones − Optometry Wales

Mrs S Bradley − Head of Primary Care & Localities Manager Merthyr/Cynon, Merthyr and Cynon Locality

Mrs A Lagier − Locality Manager, Rhondda and Taff Ely Locality

Dr K Burkhardt − Clinical Director (Taff Ely Locality) Dr K Thomas − Local medical Committee Representative

Mrs K Clarke − Primary Care Dental Representative

Ms G Roberts − Head of Corporate Services Mrs J Gibbs − Secretariat

Ms K Rowe − Internal Audit - Observer

PCCC/18/038 WELCOME & INTRODUCTIONS

Mrs M Thomas (Chair) welcomed everyone to the meeting and members were invited to introduce themselves. The Chair also

apologised for the change of date at short notice.

PCCC/18/039 APOLOGIES FOR ABSENCE

Apologies for absence were received from Dr D Miller, Dr N Lewis, Mrs L Williams, Dr G Jordan, Ms S Thomas, Mr K Asaad, Mr R Williams, Ms

R Treharne and Mrs J Davies. Mrs M Thomas thanked Mrs L Williams

and Mrs K Clarke on behalf of the Committee for all their hard work and contribution to Primary Care on their respective retirements.

Agenda Item 1.4



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10 October 2018

PCCC/18/040 DECLARATIONS OF INTERESTS

Mr K Montague reminded the Committee that was a board member of

Merthyr & Valleys MIND organisation and Dr S Hackwell also reminded the Committee that he was a partner at the Morlais Medical Practice in

Merthyr Tydfil.

PCCC/18/041 MINUTES OF THE PREVIOUS MEETING

The minutes of the meeting held on 4 April 2018 were RECEIVED and APPROVED.

PCCC/18/042 ACTION LOG

Members RECEIVED and discussed the action log and the following

items were discussed:

• PCC/17/16 Baby Teeth Do Matter – end of year reports had not

yet been received, the final report would be received at the October meeting.

• PCC/17/57 Sexual Assault Referral Centre (SARC) – There was no update as Mrs L Williams had attended the set up meeting

27 June for SARC and an update would be received at the next meeting.

• PCC/17/61 – Inverse Care Law – Data would be available in

September 2018 and it is anticipated that feedback would be

received at October meeting

PCCC/18/043 MATTERS ARISING

There were none.

PCCC/18/044 COMMITTEE CHAIR’S REPORT

The Chair provided an oral update and the following areas were highlighted:

Vice Chairs meeting – Mrs M Thomas advised Members that the Vice

Chairs had met with the Cabinet Secretary in March and that Dr Andrew Goodall was also in attendance. The agenda had been primarily focused

on transformation work, the long term plan (which had now been published), current cluster funding as well as several discussions around

Out of Hours/General Practitioners contract negotiations and GP services/working together. Members NOTED that the Wales Audit

Office would be conducting an All Wales Review of Primary Care Services and that Mrs Sarah Bradley & Mrs Alison Lagier would feed

back to the Committee.

Agenda Item 1.4



27 June 2018

Page 3 of 8



10 October 2018

Mrs Suzanne Scott-Thomas explained that the issue surrounding cluster

funding affected recruitment as posts could not be offered on a permanent basis which was NOTED.

Members RESOLVED to:

• NOTE the Chair’s update.

PCCC/18/044 PRIMARY AND COMMUNITY CARE COMMITTEE ANNUAL REPORT

Ms G Roberts presented the Primary and Community Care Committee (PCCC) Annual Report. The aim of the report was to present the PCC

Committee’s draft Annual Report from 2017-2018, which provided an overview of the work undertaken during the year and set out how the

Committee it met its Terms of Reference. Members NOTED that the Terms of Reference had been slightly amended and that there was an

Independent Member vacancy (3rd sector) but the change had been

made to reflect that the committee would be quorate with 2 Independent Members in attendance.


• ENDORSE the annual report for submission to the Health Board for approval including the Terms of Reference.

PCCC/18/045 ORGANISATIONAL RISK REGISTER

Members RECEIVED and DISCUSSED a copy of the Organisational

Risk Register. The purpose of the report was to provide the Committee with the organisational risk register and to consider whether the

recorded risks were appropriately assigned.

Ms G Roberts presented the report and provided an update on the risk

register categories and the summary of the assessed risks. The Committee had 4 assigned risks and Members were asked to consider

the risk rating and any mitigating actions.

Members were asked to NOTE that since the last review the report had been presented to the Executive Board in March and the Quality

and Safety Committee in May where 4 risks associated to this Committee had been identified.

Risk 033 – The Chair felt that this did not sit with the Committee and

should be allocated to the Quality, Safety & Risk Committee (QSR). It was NOTED that this would be allocated to the QSR Committee for

scrutiny (Added to Action Log).

Risk 029 – it was agreed that the risk would be reviewed by Mr Alan

Lawrie & Mr Robert Williams in terms of wording (Added to Action Log).

Agenda Item 1.4



27 June 2018

Page 4 of 8



10 October 2018

Members RESOLVED to: • NOTE the report

• ENDORSE the allocated risks to the Committee subject to the amendments being done.

GOVERNANCE PERFORMANCE AND ASSURANCE

PCCC/18/046 PRESENTATION OF THE EARLY WORK IN RELATION TO THE

PRIMARY AND COMMUNITY TRANSFORMATION PLAN

Mr A Lawrie gave a short presentation on Transforming the Future Shape of Primary and Community Health Services – Influencing Whole

System Change.

Mr Lawrie gave an overview of the progress to date on several key

areas and highlighted: • The Transformational Plan

• Outputs from the Primary Care Workshops • The Long Term NHS Plan

• The Parliamentary Review • The new model

• Potential examples • The extended Community Resource Team

• Outcomes • The Next Steps………

Members RESOLVED, following discussion members NOTED the work

to date and agreed to RECEIVE an update at the next meeting (Added to Action Log)..

PCCC/18/047 REPORT OF THE DIRECTOR OF PRIMARY, COMMUNITY AND MENTAL HEALTH

Mr A Lawrie presented the report and the aim was to provide

information for the Committee to assure that progress against key areas was taking place and to provide high level information on a

range of services.

• Advanced Training Practice/Pacesetter initiative – Members NOTED that this was progressing well, although were

made aware that the activity of primary care nurses and in the locality team had not been captured within the report.

• Managed Practices – Mrs S Bradley advised the committee that there were currently 4 managed practices but from the 1

October 2018 the number would reduce to 2. The Members

NOTED that a report would be presented to Executive Board in relation to the proposed change and the consultation process

would begin with the other two practices.

Agenda Item 1.4



27 June 2018

Page 5 of 8



10 October 2018

• Welsh Government Delivery Agreement – Members NOTED

the project underspend at month 2 which would be closely monitored and refined over the next quarter. Any underspend

position would be reported to the Chair of the Committee prior to the next meeting.

• Welsh Community Care Information System – Mr A Lawrie advised that at present the system was not ready for live use

and further work was continuing with the national team.

Members RESOLVED to: • NOTE the report.

PCCC/18/048 POST PAYMENT VERIFICATION PROGRESS REPORT (FROM

AUDIT COMMITTEE)

Mr C Wilson presented the report which requested that the Committee

receive and NOTE the contents of the Post Payment Verification Year End Report for the period 1 April 2017 to 31 March 2018. Members

NOTED that where issues had been raised they should be aware of the mitigation in place to provide assurance. Members were aware that the

Audit Committee had referred the report to the Committee for ongoing monitoring.

Members NOTED that the report was prepared by staff from the NHS

Wales Shared Services partnership (NHSWSSP) with the aim to provide Cwm Taf with assurance that contractors had made

appropriate financial claims. Members noted that monies recovered was still relatively small in terms of the over-claim rate. In General

Medical Services (GMS) this was 4.70% and in General Ophthalmic Services (GOS) was 7.43%. The errors in GMS were in relation to

minor surgery; where inappropriate claims were made due to a lack of

clinical knowledge. Members NOTED that near patient testing, which was a relatively new service had proved to be a steep learning curve

for the GP Practices and ongoing work was in place to adapt the approach in the future.

Following discussion Members RESOLVED to:

• NOTE the report.

PCCC/18/049 CYNON VALLEY CLUSTER OVERVIEW

Mrs S Bradley presented the report. The purpose of the report was to

present Members with an update on work being undertaken by the Cynon Primary Care Cluster. The report highlighted areas of work

currently being delivered for patients using the Primary Care Cluster

funding. An update was provided on the key ongoing schemes.

Agenda Item 1.4



27 June 2018

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10 October 2018

The Committee was advised that the main change was a cluster re-

organisation whereby Cynon Valley Cluster had now split into 2 clusters but will continue to work as one. The GP practices had agreed

the re-grouping and there were no concerns identified in relation to the change. Members NOTED that the Cynon cluster meetings were very

well attended. The next step would be to inform Welsh Government and the Observatory of the change, it was also added that other health

boards in Wales also worked in smaller population based clusters.

Members RESOLVED to: • NOTE the report and the progress being made by the Cynon

Valley Primary Care Cluster and the reorganisation into two smaller clusters.

PCCC/18/050 PRIMARY CARE MEASURES

Mrs S Bradley presented the report which aimed to provide the

Committee with an update summary on the progress of Cwm Taf University Health Board against the current Primary Care Measures. In

presenting the report Mrs Bradley thanked Victoria Jeynes for her work on the report.

Mrs Bradley informed the Committee that there were issues within the

report and also limitations to the dashboard meaning that not all information was up to date and that further information would be

provided at the next meeting.

Following discussion Members RESOLVED to:

• NOTE the Primary Care Measures for Cwm Taf University Health

Board. • NOTE that the Directors of Primary Community and Mental Health

were working on 5/6 key measures for General Medical Services (GMS) which may give more valuable information.

PCCC/18/051 LOCAL ORAL HEALTH DELIVERY PLAN UPDATE

Mr C Wilson presented the report. The purpose of the report was to provide Members with an update on the progress of the National Oral

Health Plan and Oral Health Priorities. The national plan was completed in January 2018 and Cwm Taf received a positive response

from the Chief Dental Officer in February 2018 outlining several areas of progress this year including:

• Continued dental representation within cluster networks • Design to Smile/Baby Teeth do Matter highlighting the

engagement between the University Health Board and Rhondda

Cynon Taf County Borough Council and Welsh Water • Appointment of Restorative Consultant and Dental Nurse

Agenda Item 1.4



27 June 2018

Page 7 of 8



10 October 2018

• Continued engagement with the Post Graduate Medical and

Dental Education • The alternative pathway developed for oral surgery within a

primary care setting.

However, the response highlighted areas for action and these would be incorporated in the local oral health plan:

• Poor oral health in young children • General anaesthetic treatment for special care patients

• High incidences of late presenting cancer cases • Community Dental Service/Domiciliary Service.


• NOTE the report, action plan and progress to date. • Baby teeth DO matter would be presented at the October meeting.

PCCC/18/052 DIRECTOR OF PUBLIC HEALTH REPORT

Professor K Nnoaham presented the report which aimed to update the Committee of key areas within the portfolio of the Director of Public

Health. This report focussed on the Community Joint Care Programme. Due to key data not being available until September, a further report

focussing on the Inverse Care Law / Health Check programme would be presented to the next meeting.

Members NOTED that more recently access has been widened to

include referrals from health checks and sleep apnoea although we are still reflecting on the degree of uptake and whether the current

pathway is correct for those sources referrals.

Members NOTED the committee that the validated outcomes are

measured against other key benchmarks are very good and those who engage and complete the programme, however only 50% of those who

are referred actually complete the programme. Professor Nnoaham asked the committee to NOTE the uptake from the Merthyr Tydfil

locality was considerately lower than uptake in Rhondda Cynon Taf.

Mr C Wilson responded that feedback received suggested that referral into this scheme was quite complex and not straightforward. The

Primary Care team are looking into facilitating a better referral process and added that they are currently reviewing the whole Clinical

Musculoskeletal Assessment and Treatment Service (CMATS) process and have invited Public Health to be part of that process.


• NOTE the report.

Agenda Item 1.4



27 June 2018

Page 8 of 8



10 October 2018

FOR INFORMATION

PCCC/18/053 WALES AUDIT OFFICE DISCHARGE PLANNING REPORT

Members NOTED that the Audit Committee had referred the report to

the Committee for ongoing monitoring. The Report was RECEIVED and it was agreed to have a full response at a future meeting (Added

to the Action Log).

Members RESOLVED to: • RECEIVE the report.

PCCC/18/054 NATIONAL PRIMARY CARE BOARD

The minutes of the meeting of the National Primary Care Board which

was held on 16 March were received by the Committee.

PCCC/18/055 INTEGRATED MEDIUM TERM PLAN (IMTP) MONITORING

REPORT

Members RECEIVED the usual overview of the IMTP for information which linked closely with the ongoing transformation work.

Mr A Lawrie added that GP Out of Hours had not been discussed in

detail but a paper would presented at the Executive Board looking at a significant re-design.

PCCC/18/056 TO REVIEW THE FORWARD LOOK

The forward look was received and would be amended in line with the

agreed actions

PCCC/18/056 ANY OTHER URGENT BUSINESS

There was none.

PCCC/18/037 DATE OF NEXT MEETING

The next Primary and Community Care Committee meeting was

planned to take place 3rd October 2018, 9am to 12pm, Ynysmeurig House, Abercynon.

SIGNED …………………………………………………….

MARIA THOMAS, CHAIR

DATE ……………………………………………………

1.6 Action Log

1 1.6 Action Log PCCC 10 October 2018.docx

AGENDA ITEM 1.6

Action Log Page 1 of 1

Primary and Community Care Committee Meeting 10 October 2018

PRIMARY AND COMMUNITY CARE COMMITTEE ACTION LOG

No MEETING

DATE SUBJECT KEY ACTIONS/DECISIONS RESPONSIBLE

OFFICER COMPLETED/

updated PCC/17/16 & PCC/18/042

15 March

2017

Baby Teeth DO

Matter

Receive formal evaluation after 12

months

Dr Kelechi Nnoaham October 2018

On agenda

PCCC/17/057 & PCC/18/042

27 Sept

2017 & 4 April 2018

SARC The Executive Team to further discuss

SARC in Cwm Taf in relation to the new pathways and with Women’s Aid –

update on progress

Angela Hopkins Oral Update

PCCC/17/061 27 Sept 2017

Inverse Care Law

Obtain a copy of the data in Aneurin Bevan UHB for comparison with Cwm

Taf.

Kelechi Nnoaham June 2018 now

October

On agenda

PCCC/18/023 4 April 2018

GP Sustainability /

Out of Hours Service

Workshop held in February, Transformational plan developed,

discussed at Board. Presentation at the meeting – update agreed

Alan Lawrie October 2018 On agenda

PCCC/18/027 4 April

2018

Success

/evaluation criteria

Executive Team to discuss and develop a

proposal – update at a future meeting

Executive Team To be confirmed

PCCC/18/045 27 June

2018

Changes to risk

register

Risk 033 to be reallocated to the Quality

Safety and Risk Committee Risk 029 to be reviewed

Alan Lawrie and Robert Williams

Completed

PCCC/18/046 27 June 2018


Transformation plan

Update to be provided at the next meeting

Alan Lawrie On agenda Agenda item 3.1

PCCC/18/053 27 June

2018

WAO Discharge

Planning Report

Full response to the report Alan Lawrie Added to Forward Look for January

meeting

2.1 Baby Teeth Do Matter - 12 Month Evaluation Report

1 2.1 Baby Teeth DO Matter PCCC 10 Oct 2018 GR.docx

Baby Teeth DO Matter Page 1 of 7 Primary and Community Care

Committee Meeting

10 October 2018

AGENDA ITEM 2.1

10 October 2018

Primary and Community Care Committee Report

BABY TEETH DO MATTER

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

Author: Allison Green, Primary Care Development Manager

Contact Details for further information: 01685 351310 or email

[email protected]

Purpose of the Primary and Community Care Committee Report

The purpose of this report is to provide the Committee with an evaluation

of the first year of the ‘Baby Teeth DO Matter’ initiative. One of the actions being undertaken as part of the action plan to improve children’s oral health

across Cwm Taf.

Governance

Link to Health Board Strategic

Objective(s)

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 supports all of the Strategic Objectives.

Supporting evidence

N/A

Engagement – Who has been involved in this work?

Primary Care, General Dental Practices & GP practices


Committee Meeting

10 October 2018

Primary and Community Care Committee Resolution to:

APPROVE ENDORSE DISCUSS NOTE

Recommendation The Primary and Community Care Committee is

asked to • NOTE the ENDORSE the report.

Summarise the Impact of the Primary and Community Care Committee Report

Equality and diversity

To ensure that high quality oral health care is available to all children served by Cwm Taf

University Health Board.

Legal implications n/a

Population Health The initiative aims to promote the importance of oral health care in children.

Quality, Safety &

Patient Experience

The initiative aims to improve the quality, safety

and patient experience in oral health care.

Resources No additional resources required as managed from

within the existing GDS Contracts

Risks and Assurance Failure to increase the number of children

attending a general dental practice resulting in no

improvement to children’s oral health.

Health & 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

Workforce No additional UHB staff are required. Initiative is

delivered by general dental practices.

Freedom of

information status

Open


Committee Meeting

10 October 2018

BABY TEETH DO MATTER

1. SITUATION / PURPOSE OF REPORT

The purpose of this report is to provide the Committee with an evaluation of the first year of the ‘Baby Teeth DO Matter’ initiative. One of the actions being undertaken as

part of the action plan to improve children’s oral health across Cwm Taf.

2. BACKGROUND / INTRODUCTION

The Health Board introduced the initiative Baby Teeth DO Matter in April 2017 because

the latest epidemiology survey showed the levels of dental caries in Cwm Taf children under 5 years of age were the highest in Wales, i.e. 58.6% of 5 year old children in

Merthyr Tydfil and 43.1% of 5 year old children in Rhondda Cynon Taf have decayed, missing or filled teeth (dmft), compared to the Wales average of 34.5%.

The survey of 3 year-old children showed that 21% of Cwm Taf 3 year olds had tooth decay compared to the Wales average of 14.5%. Plus the end of year dental activity

data for 2015/16 showed that only approximately 40% of children under the age of 5 years of age had visited a dentist in the previous 2 years. As a result, improvement

of children’s oral health was identified as a local priority for Cwm Taf within the Local Oral Health Plan.

3. ASSESSMENT / GOVERNANCE AND RISK ISSUES

Baby Teeth DO Matter is based on a scheme that was trialled in Manchester and proved successful in increasing the number of children accessing routine dental

treatment.

There are two aspects to this pilot: • Getting the youngest children in our communities off to the best start with

regards to their dental health • Educating, informing and involving the community in improving their own health

and well being.

The pilot, which was offered to dental practices in Merthyr Tydfil, aimed to identify

children under 5 years old who had not attended a dentist in the last two years in order to deliver a simple evidence based oral health message and to encourage

regular attendance at a dental practice.

Initially 5 dental practices expressed an interest in participating in the pilot but 1 practice dropped out without taking part and another practice dropped out after 4

months so there are currently 3 dental practices participating in the Merthyr Tydfil area.

The dentist or dental therapist identifies children under 5 years of age by attending

baby clinics in GP practices and working with the Health Visitors and Practice Nurses.


Committee Meeting

10 October 2018

In order to take part and embed the Baby Teeth DO Matter project into the General

Dental Services Contract (GDS) Practices needed to deliver the following:

• Actively identify children age 0-5 years who have not attended a dental

practice in the previous two years and positively promote the initiative • Provide access to the eligible children

• Provide an assessment with advice and intervention according to protocols • Provide fluoride varnish application where appropriate

• Provide evidence based oral health messages which are reinforced using leaflets to promote tooth friendly routine for life

• Provide re-attendance opportunities.

The Health Board did not incur any additional costs as the initiative was managed within their existing GDS contract. Practices’ contracted Units of Dental Activity (UDA)

were reduced by 5% and instead of achieving UDAs, the funding was used to pay the dentist/dental therapist to attend the baby clinics.

Even though the pilot of Baby Teeth DO Matter, where dentists proactively identify

children to attend their practices, is only in the Merthyr Tydfil locality, a communication campaign to encourage children to come forward, has been

undertaken throughout Cwm Taf. Members may wish to note that access to general

dental services is not an issue in the area as every dental practice in Merthyr Tydfil is accepting new NHS patients (both adults and children).

OUTCOMES

The pilot did not work for everyone, with one practice deciding to stop participating

after 4 months because they were not seeing an increase in the number of children attending the practice.

From the evidence gathered to date, it would appear that for the initiative to be

successful the right person needs to provide the oral health messages; the Practice Nurse and the Health Visitor in the GP practice fully engage in the process and that

there is a separate room in the practice for the dentist/dental therapist to have a confidential conversation with the parent.

The initiative has not worked as well in some GP practices and this may be because there is no separate private consulting room and the oral health messages have to be

delivered in the corridor. As a consequence the dentist/dental therapist may not have been seen by the patient as being part of the wider baby clinic team.

When comparing the percentage of children attending a general dental practice (in

the last 24 months) in 2017/18 to 2016/17 the results are as follows:

Cwm Taf UHB Merthyr Tydfil

Children 0-17 years of age 4.48% 7.27%




Committee Meeting

10 October 2018

Encouragingly, an additional 1,570 children in Cwm Taf (0-17 years) attended a general dental practice compared to the same period in 2016/17.

As the initiative in Merthyr Tydfil is focussed on the dentist/dental therapist attending baby clinics to speak to parents, it is not surprising that the 0-2 year old age group

has seen the highest increase in patient numbers, compared to the previous year. The aim of the initiative is that as soon as the first tooth erupts the child should attend

a dental practice for routine dental care.

The number of under 5 year old children attending a general dental practice has also increased across the other localities where the UHB has been advertising the

awareness campaign. However, the numbers have not been as dramatic as in Merthyr Tydfil where the 3 dental practices are working with GP practices.

There has however also been a “ripple effect” as a consequence of the introduction of

Baby Teeth DO Matter. As can be seen in Graph 1, the number of children accessing dental services since April 2010 was fluctuating but in 2016/17 the UHB invested

additional UDAs into the Merthyr Tydfil locality. As a result the number of children attending a general dental practice in this locality gradually started to increase during

2016/17. However, since the introduction of Baby Teeth DO Matter in April 2017 the

numbers across Cwm Taf have continued to increase significantly and this trend has continued in 2018/19.

While the dentist/dental therapist is speaking to the parent to encourage attendance

of their 0-2 year old at the practice, they are also identifying the older siblings and the parents who have not attended a dental practice. As can be seen in Graph 2, the

consequence has been a significant increase in also in adult attendance since the introduction of the initiative.

The results of the pilot have been discussed at the Primary Care and Localities Clinical

Business Meeting with a recommendation that the Baby Teeth DO Matter initiative is rolled out to all interested dental practices in Cwm Taf. To date, 9 other practices

have expressed an interest in participating and discussions are ongoing regarding implementation. Only those practices accepting new NHS patients will be allowed to

participate in the initiative. There is no additional funding required for this initiative

as there will be a maximum 5% reduction in UDA target for each practice.

4. RECOMMENDATION

The Primary and Community Care Committee is asked to:

• NOTE the ENDORSE the report.

Freedom of information status

Open


Committee Meeting 10 October 2018

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l 20

10

Jun

e 2

01

0

Au

gust

20

10

Oct

ob

er

20

10

Dec

em

ber

20

10

Feb

ruar

y 2

01

1

Ap

ril 2

01

1

Jun

e 2

01

1

Au

gust

20

11

Oct

ob

er

20

11

Dec

em

ber

20

11

Feb

ruar

y 2

01

2

Ap

ril 2

01

2

Jun

e 2

01

2

Au

gust

20

12

Oct

ob

er

20

12

Dec

em

ber

20

12

Feb

ruar

y 2

01

3

Ap

ril 2

01

3

Jun

e 2

01

3

Au

gust

20

13

Oct

ob

er

20

13

Dec

em

ber

20

13

Feb

ruar

y 2

01

4

Ap

ril 2

01

4

Jun

e 2

01

4

Au

gust

20

14

Oct

ob

er

20

14

Dec

em

ber

20

14

Feb

ruar

y 2

01

5

Ap

ril 2

01

5

Jun

e 2

01

5

Au

gust

20

15

Oct

ob

er

20

15

Dec

em

ber

20

15

Feb

ruar

y 2

01

6

Ap

ril 2

01

6

Jun

e 2

01

6

Au

gust

20

16

Oct

ob

er

20

16

Dec

em

ber

20

16

Feb

ruar

y 2

01

7

Ap

ril 2

01

7

Jun

e 2

01

7

Au

gust

20

17

Oct

ob

er

20

17

Dec

em

ber

20

17

Feb

ruar

y 2

01

8

Ap

ril 2

01

8

Jun

e 2

01

8

Graph 1 - Number of Children attending a GDS practice in last 24 months to June 2018

Baby Teeth DOMatter commencedApril 2017


Committee Meeting 10 October 2018

128,000

130,000

132,000

134,000

136,000

138,000

140,000

142,000

144,000

Ap

ril 2

01

0

Jun

e 2

01

0

Au

gust

20

10

Oct

ob

er

20

10

Dec

em

ber

20

10

Feb

ruar

y 2

01

1

Ap

ril 2

01

1

Jun

e 2

01

1

Au

gust

20

11

Oct

ob

er

20

11

Dec

em

ber

20

11

Feb

ruar

y 2

01

2

Ap

ril 2

01

2

Jun

e 2

01

2

Au

gust

20

12

Oct

ob

er

20

12

Dec

em

ber

20

12

Feb

ruar

y 2

01

3

Ap

ril 2

01

3

Jun

e 2

01

3

Au

gust

20

13

Oct

ob

er

20

13

Dec

em

ber

20

13

Feb

ruar

y 2

01

4

Ap

ril 2

01

4

Jun

e 2

01

4

Au

gust

20

14

Oct

ob

er

20

14

Dec

em

ber

20

14

Feb

ruar

y 2

01

5

Ap

ril 2

01

5

Jun

e 2

01

5

Au

gust

20

15

Oct

ob

er

20

15

Dec

em

ber

20

15

Feb

ruar

y 2

01

6

Ap

ril 2

01

6

Jun

e 2

01

6

Au

gust

20

16

Oct

ob

er

20

16

Dec

em

ber

20

16

Feb

ruar

y 2

01

7

Ap

ril 2

01

7

Jun

e 2

01

7

Au

gust

20

17

Oct

ob

er

20

17

Dec

em

ber

20

17

Feb

ruar

y 2

01

8

Ap

ril 2

01

8

Jun

e 2

01

8

Graph 2 - Number of Adults attending a GDS Practice in last 24 months to June 2018

Baby Teeth DOMatter commencedApril 2017

2.2 Organisational Risk Register

1 2.2 Org Risk Register PCCC 10 Oct 2018 GRa.doc

Organisational Risk Register Page 1 of 17 Primary and Community Care Committee Meeting

10 October 2018

AGENDA ITEM 2.2

10 October 2018


ORGANISATIONAL RISK REGISTER

Executive Lead: Board Secretary / Director of Corporate Services and Governance

Author: Head of Corporate Services

Contact Details for further information: Gwenan Roberts 01443

744800 or [email protected]


The purpose of this report is for the Primary and Community Care 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 in August 2018, by

the Quality Safety and Risk Committee and the Health Board in September 2018 and has been updated to reflect related discussions.

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 mainly on providing strong governance and assurance.

Supporting

evidence

• There are a number of assessments that help inform

the content of the organisational risk register. • 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.


10 October 2018


APPROVE ENDORSE √ DISCUSS √ NOTE √

Recommendation The Primary and Community Care 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.


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


10 October 2018

ORGANISATIONAL RISK REGISTER


The purpose of this report is for the Primary and Community Care

Committee to review and discuss the organisational risk register and

consider whether the assessed and recorded risks are appropriately assigned. The Organisational Risk Register was last considered by the

Executive Board in August 2018, by the Quality Safety and Risk Committee (QSR) and the Health Board in September 2018. Changes made since are

identified in RED font.


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 in August and Quality, Safety & Risk Committee in September, the following changes to the register were


10 October 2018

agreed: 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


10 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,


10 October 2018

• Deprivation of Liberties Safeguards (DoLS) mainly associated 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 17 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

Sept 2018 Health Board

015

Reputational damage & potential legal

challenge on the decision making on

Funded Nursing Care (FNC). 16 12

Sept 2018 Health Board

029

Failure to sustain Primary Care

Services, across RCT and Merthyr

Tydfil but particularly in the Rhondda

Valleys.

16 16

Sept 2018 Primary & Community

Care

036 Primary Care Workforce - Recruitment

and sustainability 16 16


Care

030

Failure to continue to provide and

sustain GP Out of Hours Services as

currently configured.

16 16


Care

002 Failure to achieve Referral to

Treatment targets. 12 12

(was 20)

Sept 2018 Finance, Performance

& Workforce

003

Failure to achieve the 4 and 12 hour

emergency (A&E) waiting times

targets. 12 16

Sept 2018 Finance, Performance &

Workforce

013 Implementation of South Wales

Programme outcomes.

12 12 Sept 2018 Health Board

023

Failure to meet the timescale relating

to issuing concerns (complaints)

responses to patients and/or carers.

16 12

Sept 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

Sept 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 Sept 2018 Quality, Safety &

Risk

035 Failure to recruit sufficient registered

nursing staff. 20 20 Sept 2018 Quality, Safety

& Risk

008

Reduction in medical training posts

within various specialties & capacity to

meet workload demands.

20

20 Sept 2018

Quality, Safety &

Risk

027

Lack of control and capacity to

accommodate all hospital follow up

outpatient appointments.

20

20

(was 16)

Sept 2018 Finance,

Performance &

Workforce

032 Sustainability of a safe & effective

Ophthalmology Service.

20

16

Sept 2018

Quality, Safety

& Risk

005

Failure to sustain services as currently

configured to meet cancer targets.

20 16

Sept 2018 Finance,

Performance &

Workforce

033

Failure to sustain Child & Adolescent

Mental Health Services across the

Network

16 16

Sept 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

Sept 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

Sept 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 Sept 2018

Quality, Safety &

Risk

021

Failure to ensure all Staff obtain

competency/ compliance with

mandatory training requirements. 16 20

Sept 2018

Quality, Safety &

Risk

025 Failure to meet Fire Safety

Standards across the UHB. 16 16 Sept 2018 Quality, Safety &

Risk

018

Failure to achieve statutory and

mandatory planned preventative

maintenance (PPM) programme. 15 15 Sept 2018

Quality, Safety &

Risk

031

Failure to appropriately apply

Deprivation of Liberties Safeguards

(DoLS) legislation following the West

Cheshire court judgement.

16

(was 12)

12

Sept 2018

Quality, Safety &

Risk

016 Failure to comply fully with the

arrangements for managing Asbestos 16 12

Sept 2018

Quality, Safety &

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 Sept 2018

Quality, Safety &

Risk

040

(New)

Failure to fully comply with all the

requirements of the Welsh Language

Standards, as they apply to the

University Health Board.


Quality, Safety &

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 Sept 2018

Quality, Safety &

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.


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

Sept 2018

Health Board

012

Failure to Deliver Major &

Discretionary Capital programmes 12 12 Sept 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

Sept 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)

Sept 2018

Finance,

Performance

& Workforce


10 October 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


• 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


10 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 sustain 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


10 October 2018

Objective: Setting the Direction & Performance & Operational Delivery

Director Lead: Director of Primary, Community and Mental Health

(DPCMH)

Assuring Committee: Primary and Community Care Committee

Risk: Failure to sustain Primary Care services across RCT and Merthyr Tydfil

but particularly in the Rhondda Valley

Date last reviewed: September 2018

Risk Rating

0

5

10

15

20

25

Sep

-17

No

v-1

7

Jan

-18

Mar

-18

May

-18

Jul-

18

Sep

-18

Risk Score

Target Score

Rationale for current score:

(consequence x

likelihood):

Initial: 5 x 4 = 16

Current: 4 x 4 = 16

Target: 4 x 3 =12

The ongoing difficulties in recruiting staff for Primary Care reflects a

national problem

Rationale for target score:

There are ongoing and continuing problems in recruiting staff to

primary care areas but particularly within the Rhondda locality

There are a total of 16 practices within the Rhondda Valleys, (covering

65,000 approximate population) and over half are advertising for GP

sessions currently due to GP vacancies. Some have been advertising

for over a year.

Level of Control

=70%

Date added to the

risk register

December 2014

Controls (What are we currently doing about the risk?) Mitigating actions (What more should we do?)

• Where possible the Primary Care Team is working with practices to find

solutions for an exit strategy and are considering directly managing the

practices or recruiting on their behalf.

• The UHB has been successful following submission of bids against non

recurring Primary Care monies;

• The Board has developed its Strategy for Primary Care aligned with its

Integrated 3 Year Plan and National guidance. This includes milestones for

addressing some of the related reported risks. Progress in strengthening

the new IMTP. Board aware of the ongoing work and regular reports

received on progress.

• The good work developed as part of the Strategy is fully factored into

UHBs IMTP.

Action Lead Deadline

A report for additional investment in the

Primary Care Support Team has been

considered and taken forward.

Director of

PCMH

Oct 2017

Complete

Rhondda docs have developed a proactive

website to support recruitment

Director of

PCMH

Complete

Primary and Community Care Committee in

place to scrutinise IMTP delivery.

Primary Care Sustainability being discussed

with Clusters

Director of

PCMH

Director of

PCMH

Ongoing

Ongoing

Assurances

(How do we know if the things we are doing are having an impact?)

Gaps in assurance

(What additional assurances should we seek?)

Numbers of staff recruited; retention levels.

Current Risk Rating

Additional Comments

Ref No.

029

Current Risk Rating : 4 x 4 = 16

We are working closely with the Welsh Government on

the recruitment of staff – Train,Work,Live campaign


10 October 2018



(DPCMH)


Risk: Primary Care Workforce – recruitment and sustainability Date last reviewed: September 2018

Risk Rating

0

5

10

15

20

25

Sep

-17

No

v-1

7

Jan

-18

Mar

-18

May

-18

Jul-

18

Sep

-18

Risk Score

Target Score


(consequence x

likelihood):

Initial: 5 x 4 = 20

Current: 4 x 4 = 16

Target: 4 x 3 =12

An increasing number of practices across the UHB are advertising for

GP sessions currently due to (and other staff groups) vacancies.


Recruitment to Primary Care for GPs and some other professional

groups across Cwm Taf UHB remains challenging (reflecting a National

problem).

Level of Control

=60%

Date added to the

risk register

August 2016


• Where possible the Primary Care Team is working with the practices to find

solutions, which include practice mergers; considering where possible

directly managing solutions and/or working to recruit on behalf of the

practices.

• Primary and Community Care Committee in place to scrutinise delivery of

the IMTP.

• Local and National recruitment campaigns progressed, with some reported

success.


Development of the Cluster arrangements

maturing, working with Primary Care and

localities to develop solutions;

DPCMH Ongoing

The UHB has been successful following

submission of bids against non recurring

Primary Care monies;

DPCMH Complete

The Board has developed its Strategy for

Primary Care aligned with its Integrated 3

Year Plan and National guidance. This

includes milestones for addressing some of

the related reported risks.

DPCMH

Ongoing

milestones

being

monitored

Assurances


Gaps in assurance


Recruitment and retention data.

Current Risk Rating

Additional Comments

Ref No.

036


We are working closely with the Welsh Government on

the recruitment of staff – Train, Work, Live campaign


10 October 2018



(DPCMH)


Risk: Failure to continue to provide GP out of hours services as currently

configured


Risk Rating

0

5

10

15

20

25

Sep

-17

No

v-1

7

Jan

-18

Mar

-18

May

-18

Jul-

18

Sep

-18

Risk Score

Target Score


(consequence x

likelihood):

Initial: 5 x 4 = 20

Current: 4 x 4 = 16

Target: 4 x 3 =12

The Out of Hours team is encouraging GPs to fill shifts. However,

many sessions are filled via Locum Agency Doctors, which is

expensive and flexible sessions are offered. However, the fill rate

remains variable and is challenging to maintain services. The effect

of the HMRC tax implications is now having an impact.


There are ongoing and developing Primary Care recruitment

problems (reflecting a National problem). It is becoming increasingly

difficult to secure GP sessions for the GP Out of Hours Service and

many sessions especially on the weekend remain unfilled putting

additional demand on both existing A&E departments.

Level of Control

=60%

Date added to the

risk register

November 2014


• OOHs services reconfigured and number of centres reduced from 4 to 2 in

order to sustain services. An evaluation update considered by the Board

in July 2016, agreed to continue with the current service which is

scrutinized and monitored by the Primary and community Care Committee.

• There continues to be ongoing engagement and discussions with those

practitioners currently supporting the revised model.

• There continues to be engagement with key stakeholders including the

Community Health Council, GPs and patients.

• Further options are being considered in order to address ongoing

sustainability issues with the current service configuration


The out of hours team continuing to work

with GPs and other primary care staff, in a

flexible way for the best shift fill rates.

DPCMH Ongoing

All Wales approach being progressed to

mitigate variability of approaches across

NHS Wales Health Boards

Directors

of W&OD/

Directors

of PC&MH

Ongoing

(2017/18)

Regular dialogue with OOHs service and

Primary Care Clusters to ensure OOHs

cover is strengthened and supported.

DPCMH Ongoing

Assurances


Gaps in assurance


Shift fill rates; patient experience surveys The current service model is not sustainable and alternative solutions

are required.

Current Risk Rating

Additional Comments

Ref No.

030


Lack of an All Wales Approach results in HBs competing

with each other on GP sessional pay rates.


10 October 2018

Objective: To improve quality, safety and patient experience

Director Lead: Director of Primary Community and Mental Health


Risk: Inconsistent approach and arrangements in place for the management

and monitoring of patients requiring anticoagulation management within Cwm

Taf UHB


Risk Rating

0

5

10

15

20

25

Sep

-17

No

v-1

7

Jan

-18

Mar

-18

May

-18

Jul-

18

Risk Score

Target Score


(consequence x

likelihood):

Initial: 4 x 4 = 16

Current: 4 x 4 = 16

Target: 4 x 3 =12

Progress being made with influential clinical lead for the

anticoagulation service (Dr Stuart Hackwell – Assistant Medical

Director for Primary Care); Clarity regarding service provision and

variation being quantified and addressed.

Level of Control

=50%


Section 28 Reports received from HM Coroner in relation to the

variation in services and the risks of anticoagulation for patients –

risks cannot be completed eradicated but improvements can be made

to processes across the Health Board

Date added to risk

register

June 2017


• Linked also with HM Coroner Regulation 28 Report (s), a review overseen

by Dr M Page which concluded in 2016, provided a series of

recommendations directing improvement actions. Progress continues to be

made with the related taken forward and being led by Dr Stuart Hackwell.

• Discussions regarding Local and National Enhanced Service progressed;

• Planned lead from Primary Care to explore necessary support in order to

take the known and agreed improvement actions forward. Progress to be

routinely monitored via the Primary Care & Community Committee of the

Board and as necessary Executive Board

• Executive Board approved a pilot to implement phase 1 of the plan which

included capital investment etc


Progress being discussed and scrutinised at

the Primary and Community Care

Committee

Stuart

Hackwell

Ongoing

Action plan developed and agreed –

monitoring progress

DPCMH Ongoing

Ensure capital investment for DAWN

(dosing system in place) and actioned

across the health board through Executive

Capital Management Group

DPCMH /

Med

Director

Ongoing

Assurances


Gaps in assurance


Ensure evaluation takes place in 12 months from the start of phase 1. Ensuring investment required built into IMTP process across the

health board

Current Risk Rating

Additional Comments

Ref No.

038


Recognised as a major patient safety issue in Cwm Taf

3.1 Report of the Director of Primary, Community & Mental Health

1 3.1 DPMH report PCCC 10 October 2018.doc

Report of the Director of Primary Community and Mental Health

Page 1 of 12 Primary and Community Care Committee Meeting

10 October 2018

AGENDA ITEM 3.1

10 October 2018


REPORT OF THE

DIRECTOR OF PRIMARY, COMMUNITY AND MENTAL HEALTH

Executive Lead: Alan Lawrie, Director of Primary, Community and Mental Health

Author: Craige Wilson, Assistant Director of Primary Care, Children and

Community Services.

Contact Details for further information: [email protected]


The aim of the report is to update the Primary and Community Care

Committee on key areas within the portfolio of the Director.

Governance

Link to Health Board Strategic

Objective(s)




• 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 all of the above objectives.

Supporting evidence

Supporting information is provided where required throughout the report


The Primary and Community Care Team, independent contractors and

other community based staff.



10 October 2018


APPROVE ENDORSE DISCUSS √ NOTE √

Recommendation The Primary and Community Care Committee is

asked to: • DISCUSS and NOTE the report.


Equality and

diversity

There are no specific equality and diversity

implications identified

Legal implications There are no specific legal implications identified

Population Health The aim of the services identified within the report aim to contribute to improving the

population health

Quality, Safety &

Patient Experience

The aim of the services referred to in the report

aim to improve the quality, safety and patient experience.

Resources There are no specific resource implications

identified and the work is in line with Integrated Medium Term Plan and is reported by the

locality.

Risks and Assurance The specific risks are identified where

appropriate within the document.


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

The work reported in this summary supports

many of the health and care standards

Workforce Workforce implications are identified where

appropriate within the report


Open



10 October 2018

REPORT OF THE

DIRECTOR OF PRIMARY, COMMUNITY AND MENTAL HEALTH


This report provide a series of updates for the Committee to assure progress

against key areas and to provide high level information for a range of services. More detailed reports individual reports on topic areas can be provided as

required.


This reports gives an overview of the following areas:

• Community Dental Services Transfer from Cardiff

• The Cwm Taf Transformation Plan

• Eye Care plan update by exception • Oral Health Report update by exception

• GP Sustainability • Primary Care Measures

• Wales Audit Office – Primary Care Services (Cwm Taf UHB).


3.1 Community Dental Services Transfer from Cardiff

Following a detail review of the Community Dental Service delivered to the

Cwm Taf population by Cardiff & Vale UHB, a decision was taken to repatriate the service back to Cwm Taf with effect from April 2019.

A project structure has been established including staff from the Primary Care

Directorate, Finance, Human Resources and Clinical Systems. It is designed to ensure clear lines of responsibility at both strategic and operational level.

The overarching Steering Group was established in March 2018 and there are

four Task and Finish Groups, arranged to correspond with the work streams. In

addition a Project Manager commenced in June 2018, on a two year fixed term basis.

A general meeting with the Community Dental Staff (CDS) staff based in Cwm

Taf who will transfer as part of the arrangements was held on 12 September 2018. Staff were given the opportunity to ask any general questions regarding

the transfer and following this a frequently asked question (FAQ) document is being produced and will be made available to the staff. The general response

from staff to date with regards to the transfer of the service has been positive.



10 October 2018

A key risk has been identified within the Finance and Commissioning Task and

Finish Group. Following escalation to the Director of Finance at Cardiff and Vale UHB, there has been traction and improvement over the past two weeks. This

position will be monitored closely.

It has been noted that additional discretionary capital funding may be required

for equipment and / or vehicles. It is anticipated that the Steering Group will have an indication of any such costs following the next meeting to be held on

25 October 2018.

An alternative storage facility for ‘Designed for Smile’ may need to be identified within Cwm Taf. The Project Manager will undertake an assessment of this

requirement and the potential options and report back to the next Steering Group meeting.

The next steps are as follows:

• Following the receipt of the financial information for Cardiff and Vale, the cost of the staff proposed to transfer to Cwm Taf can be calculated

together with the other revenue requirements for the service. • Confirmation is required on the transfer of all equipment and vehicles to

Cwm Taf at no cost.

• Costs are required for the provision of an Service Level Agreement (SLA) for the maintenance of the Information Communication and Technology

(ICT) system • Confirmation is required on the ability of clinical engineering to support the

maintenance of dental equipment or the cost of this being provided externally.

• A management structure, including clinical lead, for the new service will be determined by the end of September 2018; this will also need to include

the service currently provided by ABMU in Bridgend. This will allow time for key appointments to be made to manage the service prior to April 2019.

• Group and one to one meetings, where necessary, to commence with staff in October 2018.

3.2 Update on Cwm Taf Transformation Plan

Alignment with ‘A Healthier Wales: Our Plan for Health and Social Care’

Cwm Taf University Health Board (UHB), Merthyr Tydfil (MT) County Borough Council and Rhondda Cynon Taf (RCT) County Borough Council were approved

‘Full Flexibility’ pathfinders, and as such a partnership transformation programme (proposal) has been developed and signed off by the Regional

Partnership Board. This programme is predicated on developing and delivering seamless services which are provided closer to home and transform outcomes

for individuals and communities.



10 October 2018

Our partnership track record of delivery has enabled us to be bold in developing

an ambitious long term model which, aligned to ‘A Healthier Wales: Our Plan for Health and Social Care’. It targets the necessary urgent change required to

deliver a whole system approach to the provision of health and social care

across Cwm Taf as outlined in Figure 1.

Figure 1

Applying the design principles of ‘A Healthier Wales: Our Plan for Health and

Social Care’ has led us as partners to the service strategy in Figure 2:

Figure 2

Prioritising our health and social care core funding differently, alongside non-

recurrent funding sources such as: the Primary Care Pacesetter Fund, Integrated Care Fund, Primary Care Delivery Plan funding, Mental Health

Transformation funding and others, has supported the piloting and evaluation1 of innovative service models such as: Inverse Care (CVD) Health Check, Cluster

led Virtual Ward, the integrated and award winning Stay Well@Home service.



10 October 2018

This evidence base of positive system change has lead the partnership to the

next phase of the transformation journey; scaling up and further integrating our out of hospital health and social care. Based on the whole system, Cwm Taf

Population Health and Social Care Service Model, above at figure 2, the

priorities for an initial tranche of Transformation Funding are for the following complementary components:

Integrated Community Care, Closer to Home

Multidisciplinary Anticipatory Care and Enhanced Routine Monitoring Services • Systematise practice, cluster and Health Board level, population health

segmentation and risk stratification. This segmentation will target the intervention of assistive technology, disease specific community teams and

the multi-agency Enhanced Community Cluster Team. • The further development, of a proactive outward facing assistive

technology model through utilisation of appropriate assessment, proactive calling, equipment and rapid response service, enabling people to maintain

their independence at home. • Scale up and further develop anticipatory support and care models, e.g.,

virtual ward and neighbourhood nursing. Cluster level, multi-agency, multi-professional Enhanced Community Cluster Teams.

Rapid Response Services

• To complement the 111 service, transform GP Out of Hours, into an Urgent Primary Care Out of Hours Service including the adoption of a prudent

workforce model and the development of a Machine Learning / Artificial Intelligence driven symptom checker application to reduce in and out of

hours demand on General Practice. • Roll out the next phase of the Integrated Stay Well@Home rapid

response service across Cwm Taf, to enable referral, via a single point of access, from community based health, wellbeing, pre-hospital and social

care professionals maintaining people for longer in their own homes.

Building on the knowledge of our transformation work to date it is likely that we would be able to demonstrate the following measurable benefits:

• The shift of interventions from clinical environments to an individual’s home environment where ever that may be

• Improved access to primary care services, i.e. reduced waiting times and patient satisfaction

• Increase in the number of people with an anticipatory care plan • Improved patient outcomes, experience and safety (based on defined clinical

need)

• A reduction in acute outpatient appointments • A reduction in medicines management costs

• A reduction in the demand for urgent primary care out of hours services • An increase in the range of community based services accessible out of

hours • A reduction in hospital conveyances by ambulance and admissions with a

reduced length of stay when someone needs acute care • Reduction on the reliance on acute care beds – reduction in Length of Stay /

Increase in time spent at home



10 October 2018

Overview of Multidisciplinary Anticipatory Care & Support and Enhanced Routine Monitoring Services

Objective(s)

• Population health segmentation, risk stratification and case mix analysis by practice, Cluster and Health Board

• Active engagement with Primary Care and wider multidisciplinary team to act on case-mix adjusted analysis by practice and Cluster

• Build on maturing Clusters by establishing an Enhanced Community Resource Team delivering multidisciplinary

anticipatory care and support at a cluster level across Cwm Taf, with the GP at the centre as an Expert Medical Generalist.

• Further develop the evidence base and test the assistive

technology model to support people to maintain their independence at home, underpinning the primary care

stratification and response. • Develop advanced training opportunities for multi-professionals

and multiagency staff within Primary, Community and social care settings.

Pace and Scalability

Aiming for implementation in early October across the existing Cwm Taf footprint. The pace of delivery will vary depending on the needs

and maturity of the locality and clusters. It is an evolving plan and

flexibility will be required.

Planned spend

2018-19 £k 2019-20 £k 2020-21 £k

£3,991 £8,652 £8,429

Overview of Rapid Response Services

Objective(s)

• To deliver a robust and responsive urgent care Out of Hours

service which will triage, advice, signpost, assess, see and treat patients in a timely manner meeting All Wales Standards.

• Integrated Stay Well@Home rapid response service, to enable referral, via a single point of access, from community based

health, pre hospital, wellbeing and social care professionals. • Avoid unnecessary conveyance/ attendance to hospital and

provide support to people to remain in their own homes – 12hrs, 7 days a week, 52 weeks a year (further evaluation will target the

12hrs to the correct window) • Provision of a range of temporary accommodation to avoid

admission. • Prevent the impact of long stay hospital admissions on people’s

self-care abilities.

Pace and Scalability

Aiming for implementation in early October across the existing Cwm Taf footprint. Recruitment and training will determine the detail of

the implementation, with the expectation that this services can only be delivered pan Cwm Taf.

Planned

spend

2018-19 £k 2019-20 £k 2020-21 £k

£1,350 £2,715 £2,715



10 October 2018

OVERARCHING PLANNED SPEND

Planned spend 2018-19 £k 2019-20 £k 2020-21 £k

Multidisciplinary

Anticipatory Care and Enhanced Routine

Monitoring Services

£3,991 £8,652 £8,429

Rapid Response Services £1,350 £2,715 £2,715

Integrated Transformation

Team £247 £493 £493

Total £5,588 £11,860 £11,637

Current Position

1. This plan was supported at the Regional Partnership Board in August 2018. 2. There are fortnightly partnership meetings developing the detailed proposal

to allow us to progress to advert for key posts. 3. The assumptions made within this proposal are based on the current

footprint of Cwm Taf. We are having constructive discussions with Bridgend

County Borough Council on the transformational opportunities provide by the recently announced boundary change.

3.3 Eye Care plan update by exception

Glaucoma

The lead consultant for glaucoma will shortly leave the UHB to take up a post in Abertawe Bro Morgannwg and prospects of recruiting a substantive replacement

in the short term are slim. As a consequence, a retired locum consultant has been appointed two days per week to undertake an urgent work and to support

a redesign of the service.

The new service model is likely to be less reliant on medical staff and will build on the skills that have been developed by both the hospital and community

optometrists, as well as developing an unqualified workforce to support these

staff.

New Outcomes Measures for Ophthalmology With effect from September 2018, the UHB is required to shadow report on the

next outcomes measure for ophthalmology. These are based on the patient’s condition and risk of harm; this is as well as reporting referral to treatment

times (RTT) for new referrals.

All patients on the ophthalmology waiting list will be categorised as R1, 2 or 3. R1 being the patients at greatest risk. The UHB will report monthly performance

to determine the percentage of R1 patients seen by their target date or within 25% in excess of their target date for care / treatment to the Welsh

Government.



10 October 2018

The Cabinet Secretary has announced additional investment of up to £4m

between now and the end of March 2020 to support health boards in the creation of sustainable services in support of the introduction of the new

measures. The eye care sustainability fund is non-recurrent and is available to

all NHS organisations to use between November 2018 and March 2020 to develop and implement processes which will support the implementation of the

new measure, sustainable services alongside the achievement of RTT for eye care patients. 3.4 Oral Health Report update by exception

Dental Contract Reform

Committee members will be aware that the UHB currently has three dental practices who have been part of Phase 1 of the Dental Contract Reform

programme since September 2017. Welsh Government has set each Health Board a target of having 10% of their dental practices part of the scheme from

October 2018. The UHB has received two expression of interest from practices in Taff Ely and the Dental Teaching Unit in Porth will also become a Dental

Contract Reform Practice. There are 35 dental practices in Cwm Taf and therefore the UHB will exceed the target with at least 5 practices in the scheme.

The UHB is currently reluctant to approve more dental practices as reducing contracted units of dental activity (UDAs) by 10% also reduces the amount of

patient charge revenue (PCR) the UHB receives; the dental allocation is given to Health Boards net of PCR and any shortfall in income has an impact on the

UHB’s financial position. However, additional funding (£45,000) has been agreed by Welsh Government should Health Boards approve a minimum of 10%

of dental practices.

Baby Teeth DO Matter The Health Board introduced the initiative Baby Teeth DO Matter in April 2017

because the latest epidemiology survey showed the levels of dental caries in Cwm Taf children under 5 years of age are the highest in Wales. An evaluation

of the first year of the scheme has now been undertaken and shows significant increases in the number of children accessing dental practices in Cwm Taf. The

report is detailed in full at Agenda item 2.1.

3.5 GP Sustainability

Two directly managed practices, Brookside Surgery in Troedyrhiw and Hillcrest Surgery in Mountain Ash (with a population of 3,000 and 1,730 respectively)

transferred back to independent status with effect from the 1st October. This leaves the Health Board with two directly managed practices. These are New

Tynewydd Surgery and Ferndale & Maerdy Medical Practice in the Rhondda with a combined patient list of 13,423.

The Primary Care team are also working with practices where there are single

handed GPs and discussing retirement and succession plans where appropriate.



10 October 2018

No new sustainability applications have been submitted but the Head of Primary

Care and the Assistant Medical Director (Primary Care) are working with two practices around clinical performance. Contingency plans are in place to deal

with possible outcomes following the Health Boards interventions and are in line

with strategic priorities.

3.6 Primary Care Measure The Directors of Primary and Community Care have commissioned the Primary

and Community Care Development and Innovation Hub to produce a National Primary Care Measures report by December 2018. This report will be a

comparative report and will show examples of good practice under each of the measures. In addition to this, the Directors have produced a high level key 5-6

indicators for Primary Care which are aligned to the recommendations within the Parliamentary Review of Health and Social Care. The information will be

collated from Health Boards and will be available via the NWIS Primary Care Portal.

3.7 Wales Audit Office Report

The UHB has recently received a report from the Wales Audit Office in relation to the provision of Primary Care Services. The key findings were that “the

Health Board has a sound plan for primary care and is making reasonable

progress towards implementing key elements of the national vision. Oversight arrangements are strong and performance against some indicators is above

average. However, there is further scope to raise the profile of primary care, shift more resources towards primary care and to address workforce

challenges.”

The report outlined as follows:

The Health Board has a strong primary care plan aligned to national priorities and whilst clusters are at an early stage of development, the Health Board is

taking steps to support their ongoing development. • The Health Board has a strong primary care plan aligned to national

priorities and it engages with a range of stakeholders in developing its plans. • Most clusters remain at a relatively early stage of maturity but cluster

development will be further supported through the Health Board’s new

strategic planning group. We found scope to strengthen cluster leadership, membership and to improve the evaluation of cluster projects.

Investment: The Health Board has some examples of resources shifting to

primary care but there are barriers to large-scale change and the available data make it difficult to accurately calculate the overall investment in primary care.

Workforce: Workforce challenges are threatening the sustainability of some

practices but the Health Board has begun workforce modelling and is in the early stages of testing solutions.



10 October 2018

Oversight and leadership: Strong leadership and monitoring arrangements

are in place and the Health Board is taking steps to improve primary care data; however, there is further scope to raise the profile of primary care.

Performance and monitoring: The Health Board is making reasonable progress in delivering its primary care and localities plan and some aspects of

performance are better than the Wales average, although a number of difficult challenges remain

The main recommendations were as follows:

Strategic planning:

• The Health Board commissioned the Primary Care Foundation to carry out demand and capacity assessments in GP practices but the take up from

practices has been variable. To maximise value from the commissioned work, the Health Board should centrally analyse and collate the messages

from the demand and capacity assessments and share the learning across all practices.

Investment in primary care

• While the Health Board recognises that it needs to shift resources from

secondary to primary and community settings, it cannot demonstrate that this shift is happening. The Health Board should:

a. Calculate a baseline position for its current investment and resource use in primary and community care.

b. Review and report, at least annually, its investment in primary and community care, to assess progress since the baseline position and

to monitor the extent to which it is succeeding in shifting resources towards primary and community care.

The primary care workforce

• The Health Board’s workforce planning is inhibited by having limited data about the number and skills of staff working in primary care, particularly

community dentistry, optometry and pharmacy. The Health Board should develop and implement an action plan for ensuring it has regular,

comprehensive, standardised information on the number and skills of staff,

from all professions working in all primary care settings.

New ways of working • Whilst the Health Board is taking steps towards implementing some new

ways of working, more progress is required to evaluate the effectiveness of these new models and to mainstream their funding. The Health Board

should: a. Work with the clusters to agree a specific framework for evaluating

new ways of working, to provide evidence of beneficial outcomes and inform decisions on whether to expand these models.

b. Centrally collate evaluations of new ways of working and share the learning by publicising the key messages across all clusters.



10 October 2018

c. Subject to positive evaluation, begin to fund these new models from

mainstream funding, rather than from the Primary Care Development Fund.

d. Work with the public to promote successful new ways of working,

particularly new alternative first points of contact in primary care that have the potential to reduce demand for GP appointments.

e. Evaluate the effectiveness of the Health Board’s new primary care communications officer role and share the learning with all health

boards in Wales.

Primary care clusters • We found variation in the maturity of primary care clusters, and scope to

improve cluster membership and leadership. The Health Board should: a. Review the relative maturity of clusters, to develop and implement

a plan to strengthen its support for clusters where necessary. b. Review the membership of clusters and attendance at cluster

meetings to assess whether there is a need to increase representation from local authorities, third sector, lay

representatives and other stakeholder groups. c. Ensure all cluster leads attend the Confident Primary Care Leaders

course.

The Primary Care Team have prepared a response to correct any matters of

factual accuracy and have prepared a management response to the recommendations; many of which have been or are being address currently.

The report and the management response will be shared at the next meeting and the progress will be monitored by the Committee to report to the Audit

Committee.

4. RECOMMENDATION

Members of the Primary and Community Care Committee are asked to:

• DISCUSS and NOTE the report


Open

3.2 Primary & Community Care Internal Audit Report

1 3.2 IA Report Governance Arrangements - Primary and Community Care Committee PCCC 10 Oct 2018.pdf

Governance arrangements - Primary & Community Care Committee

Internal Audit Report

2018/19

August 2018

NHS Wales Shared Services Partnership

Audit and Assurance Services

Governance arrangements - Primary & Community Care

Committee

Contents

NHS Wales Audit & Assurance Services Page 2 of 18

Contents Page

1. Introduction and Background 4

2. Scope and Objectives 4

3. Associated Risks 6

Opinion and key findings

4. Overall Assurance Opinion 6

5. Assurance Summary 7

6. Summary of Audit Findings 8

7. Summary of Recommendations 11

Review reference: CTU-1819-05

Report status: Draft Internal Audit Report

Fieldwork completion: 23 July 2018

Draft report issued: 31 July 2018 & 13 August 2018

Management response

received:

14 August 2018

Final report issued: 20 August 2018

Auditors: Emma Samways, Deputy Head of Internal

Audit

Kimberley Rowe, Principal Internal Auditor

Executive sign off: Robert Williams, Director of Corporate

Services and Governance/ Board Secretary

Distribution: Gwenan Roberts, Head of Corporate Services

Alan Lawrie, Interim Director of Primary,

Community and Mental Health

Committee: Audit Committee

Appendix A

Appendix B

Management Action Plan

Assurance opinion and action plan risk rating


Committee

Contents


ACKNOWLEDGEMENT

NHS Wales Audit & Assurance Services would like to acknowledge the time and co-operation

given by management and staff during the course of this review.

Disclaimer notice - Please note:

This audit report has been prepared for internal use only. Audit & Assurance Services reports

are prepared, in accordance with the Internal Audit Charter and the Annual Plan, approved by

the Audit Committee.

Audit reports are prepared by the staff of the NHS Wales Shared Services Partnership – Audit

and Assurance Services, and addressed to Independent Members or officers including those

designated as Accountable Officer. They are prepared for the sole use of Cwm Taf University

Health Board and no responsibility is taken by the Audit and Assurance Services Internal Auditors

to any director or officer in their individual capacity, or to any third party.


Committee

Final Internal Audit Report


1. Introduction and Background

In line with the 2018/19 Internal Audit Plan for Cwm Taf University Health

Board (the 'Health Board'), a review of the Health Board's governance arrangements of Board committees has been carried out. This review

focussed on the Primary & Community Care Committee (the ‘Committee’).

The Board functions as the corporate decision making body of the Health

Board, with Executive Directors and Independent Members sharing corporate responsibility for all decisions. The Board can formally approve

the delegation of specific executive powers to be exercised by committees, sub-committees, joint-committees or joint sub-committees that it has

formally constituted. The committee structure adopted by the Health Board should be determined on what best meets its own needs, taking account of

any regulatory, or Welsh Government, requirements.

The Health Board has chosen to constitute the following committees:

Academic Partnership Board

Audit Committee*

Charitable Funds Committee*

Finance, Performance & Workforce Committee

Integrated Governance Committee

Mental Health Act Monitoring Committee*

Primary & Community Care Committee

Quality, Safety & Risk Committee*

Remuneration & Terms of Service Committee*

*indicates the committee is required by Welsh Government.

There has been recent change within the Health Board at Board level with

four new Independent Members taking up post in the last year and a further two posts to be filled. In the same time, there has been some change within

the Executive Director cohort, with a new interim Director of Primary Community and Mental Health joining the team, while the previous Director

of Primary, Community and Mental Health has become the Interim Chief

Operating Officer (due to secondment of the previous post holder).

This review sought to provide assurance that committee structures and

their membership are being managed and operating as intended.

The relevant lead for the review is the Director of Corporate Services and

Governance/ Board Secretary.


Committee



2. Scope and Objectives

The overall objective of this audit was to evaluate and determine the adequacy of the systems and controls in place in relation to the Health

Board's governance arrangements of the Primary & Community Care Committee. The review sought to provide assurance to the Health Board's

Audit Committee that risks material the system's objectives are managed appropriately. The areas that the review sought to provide assurance on

are:

The terms of reference for the committee is up to date and documents the roles and responsibilities of the group, the Committee Chair and

other committee members.

Committee memberships appropriate in terms of size, skill mix, length

of tenure and attendance.

Meetings are scheduled at appropriate intervals throughout the year and

the agendas and forward work plans are in line with the terms of

reference of the Committee, with no gaps in coverage.

There is a clear information flow between the Board and the committee. Actions transferred to the Committee form other committees are

appropriately captured.

Risks owned by the Committee are appropriately considered and

monitored.

Consideration is given to commitments made in the IMTP that relate to

the work of the Committee.

Reports to the Committee are timely, clearly written, and the level of detail provided to members within reports is sufficient to allow members

to discharge their duties yet without being burdensome. There is clear purpose for presenting a particular report. For example, 'to note' or 'to

consider and approve'.

Decisions made are clearly recorded within minutes and an action where

appropriate.

Mechanisms are in place for reviewing the effectiveness of the

committee and its members on a periodic basis.

The Committee’s chair appropriately summarises and reports the

outcome and resolutions of meetings for the Board to clearly understand

the assurance obtained by the Committee.

There is an induction process for new members and continuing support

and development for those members on the Committee.


Committee



3. Associated Risks

The potential risks considered in the review were as follows:

Governance arrangements not properly discharged.

Ineffective decision making as a result of poor training and support.

Non-compliance with legislative requirements for Board committees as

set out in the Health Board's standing orders.

Inappropriate/ inaccurate decisions made where too little or too much

information is provided.

Lack of transparency in decisions made.

OPINION AND KEY FINDINGS

4. Overall Assurance Opinion

We are required to provide an opinion as to the adequacy and effectiveness

of the system of internal control under review. The opinion is based on the work performed as set out in the scope and objectives within this report.

An overall assurance rating is provided describing the effectiveness of the system of internal control in place to manage the identified risks associated

with the objectives covered in this review.

The level of assurance given as to the effectiveness of the system of internal control in place to manage the risks associated with the Governance

arrangements for the Primary & Community Care Committee is

Substantial assurance.

RATING INDICATOR DEFINITION

Substantial

Assurance

The Board can take substantial assurance that arrangements to

secure governance, risk management and internal control, within those areas

under review, are suitably designed and applied effectively. Few matters

require attention and are compliance or advisory in nature with low impact

on residual risk exposure.

Our audit fieldwork included: discussions with the Chair of the Committee; a review of key documentation, including the Terms of Reference and

Annual Report of the Committee; scrutiny of the agendas, minutes and other papers of the Committee; and an analysis of the interaction with the

Board and other relevant committees.

Overall, the Committee was found to be well managed which has enabled

its duties to be discharged as intended, appropriate issues discussed, and

relevant risks captured.


Committee



The overall level of assurance that can be assigned to a review is dependent

on the severity of the findings as applied against the specific review

objectives and should therefore be considered in that context.

5. Assurance Summary

The summary of assurance given against the individual objectives is

described in the table below:

Assurance Summary

1 Terms of Reference

2 Committee

membership

3

Meeting frequency

and forward work

plans

4 Information flow

5 Risk consideration

and monitoring

6 IMTP

7 Reports to the

Committee

8 Minutes and actions

9

Effectiveness of

Committee and

members

10 Board reports

11

New members

induction and

development

* The above ratings are not necessarily given equal weighting when generating the audit

opinion.


Committee



Design of Systems/Controls

The findings from the review have highlighted one issue that is classified as a weakness in the system control/design for the governance

arrangements of the Primary & Community Care Committee.

Operation of System/Controls

The findings from the review have highlighted three issues that are classified as weaknesses in the operation of the designed system/control

for the governance arrangements of the Primary & Community Care

Committee.

6. Summary of Audit Findings

In this section, we highlight areas of good practice that we identified during our review. We also summarise the findings made during our audit

fieldwork. The detailed findings are reported in the Management Action Plan

(Appendix A).

Objective 1: The terms of reference for the committee is up to date and documents the roles and responsibilities of the group,

committee chair and other committee members.

We note the following area of good practice:

The Terms of Reference are updated annually as required by the Health

Board's Standing Orders.

We identified the following finding under this objective:

There are minor duplication errors within the Terms of Reference.

Objective 2: Committee membership is appropriate in terms of size, skill mix, length of tenure and attendance.

We note the following areas of good practice:

The Committee was found to be of adequate size, with additional

attendees to provide detailed analysis, expertise and support as

required.

The Independent Members have a varied skill mix and relevant experience to enable them to execute their role. We also note that they

contributed widely to the meetings.


The Terms of Reference requires greater clarity in relation to

membership.


Committee



Objective 3: Meetings are scheduled at appropriate intervals

throughout the year and the agendas and forward work plans are

in line with the terms of reference of the committee, with no gaps

in coverage.

We note the following areas of good practice:

Meetings of the Committee were scheduled at regular intervals, and in

accordance with the Terms of Reference.

The Committee has a standard agenda template that covers all aspects

of responsibilities set out within the Terms of Reference and has built in

flexibility to ensure ad hoc reports can be tabled.

The ‘Forward Look’ plan of the committee is reviewed at each meeting to ensure that it is still targeted at the appropriate risk areas. An action

log captures all agreed actions.

We did not identify any findings under this objective.

Objective 4: There is clear information flow between the Board and the committee. Actions transferred to the committee from other

committees are appropriately transferred.


We read a sample of Board minutes in conjunction with Committee

papers. While no formal actions to be referred from the Board to the Committee were identified, we note that key issues that related to

Primary Care, and raised in Board meetings, also formed discussions in

Committee meetings, therefore, appropriately transferring information.


Objective 5: Risks owned by the committee are appropriately

considered and monitored.


The organisational risk register is a standard agenda item for the Committee. Our review of minutes confirmed that the four risks

delegated to the Committee were considered at each meeting.


Objective 6: Consideration is given to commitments made in the

IMTP that relate to the work of the committee.


Our review of the agenda and minutes of the committee confirmed that the Primary & Community Delivery Plan, which is a key element of the

IMTP, features at each Committee meeting.



Committee



Objective 7: Reports to the committee are timely, clearly written,

and the levels of detail provided to members within reports is

sufficient to allow members to discharge their duties yet without being burdensome. There is a clear purpose for presenting a

particular report, for example, 'to note' or 'to consider and

approve'.


Of the four reports to the Committee that we sampled, three were found

to be in a consistent format, presented to the Committee with a clear purpose and contained sufficient detail for members to discharge their

duties. The fourth report had originally been prepared for another committee and had been referred onto the Primary & Community Care

Committee.


For a small number of the reports sampled, there was a time delay in

the Committee receiving the report.

Objective 8: Decisions made are clearly recorded within minutes

and an action where appropriate.


The minutes of the Committee meetings were clear and all decisions made by the Committee are summarised for each agenda reference,

including actions to be tabled and included in the action log.


Objective 9: Mechanisms are in place for reviewing the

effectiveness of the committee and its members on a periodic basis.


The Committee has complied with the requirement to prepare an annual

report setting out its activities during the year and detailing the results of a review of its performance. Included in this is a review of the

Committee’s effectiveness.


Objective 10: The committee's chair appropriately summarises and

reports the outcome and resolutions of meetings for the Board to

clearly understand the assurance obtained by the committee.


The Committee provides the latest confirmed minutes and a summary

of discussions and activities of the Committee as part of the Committee

Chair's Report to the Executive Board each meeting.



Committee



Objective 11: There is an induction process for new members and

continuing support and development for those members on the

committee.

We identified the following finding:

There is no documentation on training and development included in the

Terms of Reference, which is a requirement of the Standing Orders.

7. Summary of Recommendations

The audit findings and recommendations are detailed in Appendix A

together with the management action plan and implementation timetable.

A summary of these recommendations by priority is outlined below.

Priority H M L Total

Number of

recommendations 0 0 4 4


Committee


Appendix A - Action Plan


Finding 1 - Induction and training (Operating effectiveness) Risk

The Health Board’s Standing Orders provide a list of the minimum requirements for each committee’s Terms of Reference, which includes training, development

and performance.

However, there is no reference to training and development included in the

Committee’s Terms of Reference. We acknowledge that the Terms of Reference

for another committee that we read, also did not make reference to training and

development.

Ineffective decision making as a result of poor training and support.

Recommendation Priority level

The Committee should ensure that training and development requirements are

documented in the Terms of Reference to satisfy the requirements of the Health

Board’s Standing Orders.

Low

Management Response Responsible Officer/ Deadline

Following discussion with the Committee Chair, the Terms of Reference will be

amended in line with Standing Orders.

Gwenan Roberts

Next meeting – October 2018


Committee




Finding 2 - Membership and quoracy (Operating effectiveness) Risk

The Committee’s Terms of Reference lists the Executive Directors as 'in

attendance' and does not specify if this requirement is mandatory.

For the meeting to be quorate two Independent Members must be present,

however, the Terms of Reference does not indicate whether this is inclusive of the Committee Chair, who is also an Independent Member. Other committee

Terms of Reference make this distinction.

For the last three meetings that we tested, they are deemed quorate if the

membership is inclusive of the Chair.

Governance arrangements not

properly discharged.

Non-compliance with legislative requirements for Board committees

as set out in the Health Board's standing orders


The Primary & Community Care Committee should clarify in their Terms of

Reference the required Members to be present at each meeting. Low


Following discussion with the Committee Chair, the Terms of Reference will be

amended in line with Standing Orders and will include specifically the requirement for executive directors to be present. The TOR will also be amended

to clarify that the Chair is included in the number of Independent Members at

the meeting.

Gwenan Roberts



Committee




Finding 3 – Terms of Reference errors (Operating effectiveness) Risk

We identified some minor duplication within the Terms of Reference:

'scope and duties':

1. Oversee the Primary & Community Care Delivery Plan in line with the IMTP.

3. Primary & Community Care Delivery Plan developing, implementing and

monitoring.

The following text on page 6 is written twice:

'The Director of Corporate Services & Governance/ Board Secretary, on behalf

of the Board, shall oversee a process of regular and rigorous self-assessment

and evaluation of the Committee's performance and operation.'

Governance arrangements not

properly discharged.

Non-Compliance with legislative requirements for Board committees

as set out in the Health Board's standing orders.


The Committee should review the Terms of Reference to correct any duplications

of responsibilities and text. Low


Following discussion with the Committee Chair, the Terms of Reference will be amended in line with Standing Orders and to correct the duplication of

responsibilities and text.

Gwenan Roberts



Committee




Finding 4 - Timeliness of reports (Operating effectiveness) Risk

During our review of the agenda and minutes of the Committee we made the

following observations in relation to the timeliness of reports taken to the

Committee:

Post Payment Verification Report

A Post Payment Verification (PPV) Progress Report was referred to the Committee

by the Audit Committee, the timeline was as follows:

Report issued - October 2017

Presented to Audit Committee - 13 November 2017 - referred to PCC

Committee for monitoring.

Committee meeting - 29 November 2017 (no PPV due to closeness of meeting

dates).

Committee meeting - 10 January 2018, PPV received by Committee but full

responses tabled for future meeting.

Committee meeting - 4 April 2018, PPV report not discussed.

Committee meeting – 28 June 2018, PPV report discussed.

Therefore there is a time delay between Audit Committee referral for monitoring

and the PPV report being discussed in detail. The members noted during the June 2018 Committee meeting that some of the findings in the report ‘lacked clarity

and confused understanding’.

Ineffective decision making as a

result of poor training and support

Inappropriate/ inaccurate decisions made where too little or too much

information is provided.


Committee




Interim District Nurse Guiding Staffing Principles

We also note a delay when reporting the District Nursing Staffing Principles document which was presented at the 4 April 2018 Committee meeting.

However, there were two Committee meetings between the issue of the original

document by Welsh Government in September 2017, and the April Committee.


The Committee should ensure timely receipt, review and monitoring of reports

referred and relevant documents. Low


The Primary and Community Care Committee has been in development and increasing its scrutiny of a large clinical area of the Health Board. At the end of

2017 the Chair (Donna Mead) came to the end of her tenure and Maria Thomas took over as the Vice Chair of the Health Board. The Post Payment Verification

Report on closer inspection following the meeting on 10 January was not in line with the Directorate Management’s understanding of the current position and as

a consequence it was decided to move to the next meeting.

Members at the meeting in June noted that the directorate management team

had not been part of the development of the report nor had an opportunity to

comment on the accuracy of the report. A previous iteration of the report had

also caused a lot of additional work.

The aim going forward is always to work with the Chair to ensure sufficient time

Gwenan Roberts

October 2018


Committee




is allocated for all matters to be considered by the Committee. The April meeting

was a particularly full agenda which then meant that the report was moved to June. I will work with the Chair of the Committee, using the Forward Look to plan

to receive reports as soon as practicable but there is a delay. In future, ensuring the reports are received at the earliest opportunity by the management team is

key to ensure accurate and comprehensive information.

Governance arrangements - Primary & Community Care Committee Internal Audit

Report

NHS Wales Audit and Assurance Services Page 18 of 18

Appendix B - Assurance opinion and action plan risk rating

Audit Assurance Ratings

Substantial assurance - The Board can take substantial assurance that arrangements

to secure governance, risk management and internal control, within those areas under review,

are suitably designed and applied effectively. Few matters require attention and are compliance

or advisory in nature with low impact on residual risk exposure.

Reasonable assurance - The Board can take reasonable assurance that arrangements

to secure governance, risk management and internal control, within those areas under review,

are suitably designed and applied effectively. Some matters require management attention in

control design or compliance with low to moderate impact on residual risk exposure until

resolved.

Limited assurance - The Board can take limited assurance that arrangements to secure

governance, risk management and internal control, within those areas under review, are suitably

designed and applied effectively. More significant matters require management attention with

moderate impact on residual risk exposure until resolved.

No assurance - The Board can take no assurance that arrangements to secure

governance, risk management and internal control, within those areas under review, are suitably

designed and applied effectively. More significant matters require management attention with

high impact on residual risk exposure until resolved.

Prioritisation of Recommendations

In order to assist management in using our reports, we categorise our recommendations

according to their level of priority as follows.

Priority

Level

Explanation Management

action

High

Poor key control design OR widespread non-

compliance with key controls.

PLUS

Significant risk to achievement of a system objective

OR evidence present of material loss, error or

misstatement.

Immediate*

Medium

Minor weakness in control design OR limited non-

compliance with established controls.

PLUS

Some risk to achievement of a system objective.

Within One

Month*

Low

Potential to enhance system design to improve

efficiency or effectiveness of controls.

These are generally issues of good practice for

management consideration.

Within Three

Months*

* Unless a more appropriate timescale is identified/agreed at the assignment.

3.3 Inverse Care Law/Population Health Management Pilot Update

1 3.3 Inverse Care Law and Population health management pilot report PCCC 10 October 2018.docx

Population Health Programmes update


10 October 2018

AGENDA ITEM 3.3

10 October 2018


POPULATION HEALTH PROGRAMMES UPDATE: INVERSE CARE LAW PROGRAMME

(CARDIOVASCULAR HEALTH CHECK PROGRAMME) AND THE POPULATION HEALTH MANAGEMENT PILOT

Executive Lead: Director of Public Health / Director Primary Care,


Authors: Consultants in Public Health

Contact Details for further information: Sara Thomas [email protected] (ICL Programme) and Kimberley Cann

[email protected] (Population Health Management Pilot Cwm Taf Local Public Health Team- 01685 351440


The purpose of this report is to inform the Primary Care Committee as to

the progress of the two Population Health Programmes in Cwm Taf

Governance

Link to Health


The programmes support the principles of ‘Cwm Taf

Cares’ with particular reference to the organisational objective of protecting and improving population health.

The Inverse Care Law Programme work underpins the Health Board’s commitment to reducing health

inequalities in Cwm Taf. The Health Check Programme links to the Heart Disease, Stroke and Diabetes Delivery

Plans. It has been identified as a priority in the Health Board’s Integrated Medium Term Plan.

The Population Health Management Pilot is a cornerstone of the Fifth Wave Cwm Taf Population Health Strategy

Supporting evidence

Programme development has been based on current evidence base and best practice.


Primary Care, Public Health, Welsh Government and a variety of community

partners are key stakeholders. Opportunity for patient feedback and engagement has been incorporated into ongoing programme evaluation.



10 October 2018


APPROVE ENDORSE DISCUSS NOTE √

Recommendation The Primary and Community Care Committee

is asked to • NOTE the on-going progress of the ICL

programme in Cwm Taf, locally reported outcomes and plans to revise the model going

forward • APPROVE that a more detailed report to include

the SAIL analysis and revised (post April 2019) delivery model be presented to the January

meeting of the Primary Care Committee. • NOTE the on-going progress of the Population

Health Management pilot.

Summarise the Impact of the Primary and Community Care

Committee Report


A population wide approach for those meeting the criteria for health check assessment is employed,

but with roll out prioritised initially into those areas with the highest levels of deprivation and

cardiovascular disease prevalence. The Population Health Management pilot will

identify population segments which will take account of these characteristics

Legal implications None

Population Health Deaths from circulatory disease account for around

25% of all premature (aged under 75 years) deaths each year in Cwm Taf. Although death rates are

falling, cardiovascular disease remains a major cause of premature morbidity and mortality, second

only to cancer1

The pattern of premature CVD mortality follows the

pattern of deprivation in Cwm Taf, with some of the highest rates in our more deprived valley

communities.

Cancer and cardiovascular disease are the main causes of years of life lost (YLL) and disability-

adjusted life years (DALYs) in Wales despite there being a significant drop for DALYs associated with

CVD in the last 15 years.2

1Public Health Wales Observatory (2014) Analysis of Annual District Death Extract & Mid Year Estimate (ONS) data for Cwm Taf population

2 Public Health Wales Observatory (2017) Health and its determinants in Wales- informing Public Health Wales Strategic Planning – Interim Report



10 October 2018

Population segmentation will enable evidence based interventions to be targeted to the need of sub-

populations.

Quality, Safety &

Patient Experience

Patient pathways and associated assessment and

management protocols have been developed in line with NICE guidance. Programme protocols are

included in a new service handbook. All patients are given the opportunity to feedback on their

experiences of the programme either by written questionnaire or online survey.

Resources The programme receives Welsh Government

funding.

Risks and Assurance The burden of illness related to cardiovascular

disease has consequences for individuals’ health, as well as healthcare and social costs. The ability to

target interventions will enable better outcomes.

Health & Care

Standards

Health and Care Standards (2015)

1.1 Health promotion, protection and improvement

2.1 Managing risk and promoting health and safety

3.1 Safe and clinically effective care 3.4 Information governance and communication

technology

7.1 Workforce

Workforce ICL Programme - Welsh Government funding has

supported recruitment and training of staff to undertake this programme with support and

leadership from existing resource within the UHB Primary Care and Public Health Teams.

Population Health Management Pilot – Health Board

(and PHW) funding has been secured to pilot this approach.


Open

POPULATION HEALTH PROGRAMMES UPDATE:

INVERSE CARE LAW PROGRAMME (CARDIOVASCULAR HEALTH CHECK PROGRAMME)



10 October 2018

AND THE POPULATION HEALTH MANAGEMENT PILOT


The purpose of this report is to inform the Primary and Community Care Committee (PCCC) of progress in relation to two population health programmes

in Cwm Taf - the Cwm Taf Inverse Care Law (ICL) Programme (Cardio vascular disease CVD Health Checks) and a Population Health Management feasibility

study in the Rhondda Primary Care Cluster.


The two programmes involve public health and primary care working together to improve population health in Cwm Taf. The Cwm Taf University Health Board

(CTUHB) Inverse Care Law Health Check Programme seeks to improve the health and wellbeing of adults aged 40-74 years through the early identification and

management of individual behavioural and physiological risk factors for cardiovascular disease and other conditions associated with these risk factors

e.g. cancer.

The Population Health Management pilot seeks to understand patient

populations, groups or clusters by characteristics related to their need and use of health care resources which can help Primary Care Clusters and GPs to decide

how best to use limited time and resources to deliver anticipatory and pre-emptive care for patients.


INVERSE CARE LAW PROGRAMME

Status summary (September 2018)

Members will recall a report received by the Committee in September 2017 which provided the background, logic model and early outcomes of this high profile

Welsh Government (WG) funded programme which started in January 2015 and uses CTUHB and Aneurin Bevan University Health Board (ABUHB) as its pilot

sites.

Situation

The Health Board continues to deliver this programme that focuses on primary prevention of cardiovascular disease (and cancer) and will by March 2019 have

been made available to all practices across Cwm Taf, with particular emphasis on offering a health check to eligible patients resident in our more deprived

communities.

A quarterly report is provided to Welsh Government as part of a delivery agreement which is attached as Appendix 1 and also reported under a separate

agenda item for this meeting.

The report for Quarters 1 and 2 for 2018 highlight that:



10 October 2018

• Overall approximately 40% of invited patients attend a health check. This

varies across practices with one practice achieving 85% uptake. • The programme is achieving a good attendance amongst middle-aged men, a

group that are generally difficult to reach.

• Uptake is lowest among the 40-44 age group, who have greatest capacity to benefit from adopting healthier lifestyles.

• Many patients are taking up offers of support to change lifestyles such as giving up smoking, increasing physical activity and reducing alcohol intake.

• At health check, a number of patients are triggering referral to their GP Practice team for further assessment leading to diagnoses of conditions such

as diabetes, high blood pressure (hypertension), and irregular heart rhythm (atrial fibrillation) that if not identified and treated would increase their risk of

a heart attack or stroke.

As part of the evaluation of the National Inverse Care Law Programme, a longitudinal study using the secure anonymised information linkage (SAIL)

database has been established which will provide a measure of short, medium and long term outcomes for the demonstrator sites in Cwm Taf and Aneurin

Bevan. A report informed by analysis of a SAIL data extraction was expected in September which would have enabled a more comprehensive update for the

committee. However, as mentioned in the delivery agreement report, this has

been delayed to December.

Key points • The programme continues to attract interest among politicians and WG officers

and the SAIL report is eagerly awaited • A different approach has been taken with Taf Ely Cluster whereby the Cluster

has been integral to shaping the way eligible patients are identified and prioritised and consequently how the ICL CVD Health Check Team resource is

deployed. It is envisaged that clusters will be encouraged to have greater ownership of the programme going forward.

• Conversations with Abertawe Bro Morgannwg University Health Board (ABMUHB) are on-going to learn more about their community based approach

to Health Checks piloted in the Bridgend North Cluster. • A workshop has been arranged for mid October to consider the future Inverse

Care Law delivery model in CTUHB. This will be informed by the uptake and

outcomes data together with feedback from patients, and clinicians and views of practices and clusters. Primary Care Colleagues in Bridgend have also been

invited to learn from their experience. • The future Cwm Taf model will need to consider key questions and challenges

raised including: o how to reach the >50% who do not take up the health check offer

including ▪ Who is and who is not having the Health Check?

▪ What are the factors that increase take-up among the population and sub-groups?

▪ Why do people not take up an offer of an NHS Health Check? ▪ The potential role of a workplace or community model



10 October 2018

o “Maintenance phase” - methods of picking up patients who become

eligible for the health check as they turn 40 years of age and frequency of repeat health check at practice and cluster level;

o optimizing the outcomes of the health check by improving access to

support available to patients to make lifestyle changes and where appropriate linking them to community assets by means of social

referral; o How is primary care managing people identified as being at risk of CVD

or abnormal risk factor results? o What is the effect of the CTUHB ICL Health Check on disease detection,

changing behaviours, referrals to local risk management services, reductions in individual risk factor prevalence, reducing CVD risk, statin

and/or antihypertensive prescribing compared to other programmes such as ABUHB and NHS Health Check in England?

o Use of predictive modelling approach to explore potential longer term outcomes and cost effectiveness of the intervention.

• A software provider will need to be secured to support the revised model post April 2019. This currently poses a risk to the programme, but can be mitigated

by timely support from the NHS Wales Informatics Service (NWIS).

Consideration of these queries and the key challenges above will form the basis

of an action plan, to take the programme forward locally.

POPULATION HEALTH MANAGEMENT

Status summary (September 2018)

Situation Population segmentation and risk stratification is being piloted across the

Rhondda primary care cluster to assess the feasibility of this approach to support population health management across Cwm Taf UHB. Primary care and secondary

care patient data are being linked and the Adjusted Clinical Groups model developed by the John Hopkins University is being applied, amongst others, to

predict individual patient’s risk of different health outcomes. We are also segmenting the population based on a range of factors to identify groups by their

holistic need. We will then identify which segments are most likely benefit from

anticipatory care, and work with healthcare professionals and patients to identify the most important outcomes for these segments of the population. We can then

identify and implement the most effective evidence-based interventions.

Background

The Population Health Management pilot seeks to understand patient populations, groups or clusters by characteristics related to their need and use of health care

resources can help Primary Care Clusters and GPs to decide how best to use limited time and resources to deliver anticipatory and pre-emptive care for

patients. Individuals in populations often share characteristics with others in the



10 October 2018

population. These characteristics can be quite different from the medical condition

they have and may, or may not, be seeking care for. By combining information on a range of acute and chronic conditions and healthcare usage, it is possible to

identify groups of patients based on their holistic need, rather than just disease

condition. Clustering individuals in this way can identify new segments of the population with similar needs. Their future risk and healthcare usage can then be

predicted and used to plan future care and resource needs for the population. This can help healthcare providers to take a person-centred, preventative

approach by providing the opportunity to intervene earlier and before a patient develops multiple conditions or their current condition worsens. We can also

target interventions at individuals who are the most likely to benefit from them, at the time they are most likely to be effective, taking preventative action before

further conditions develop. This would help to reduce demand for unscheduled, primary and secondary care and help to ease the pressure on appointments. It

would also help to prevent unplanned emergency admissions to secondary care and keep people healthy and at home for longer.

Action

We are currently in phase I of the pilot during which the GP practices have access to live reports on individual patients and their risk of future healthcare need for

a period of 3 months. The Local Public Health Team have access to aggregated

anonymous information on the pilot population. Population segmentation is also underway.

In addition, we are undertaking a process evaluation to inform potential roll out

of this approach across CTUHB in future. This includes an assessment of the usefulness of the approach to GP practise and its potential to inform the targeting

of interventions at population segments based on their holistic need.

Results Key findings from the initial population health overview

• 1% of patients account for 19% of costs across the cluster area. However, this cohort of patients may be frail or nearing the end of their life and not

amenable to standard interventions. • It is more common for individual to have multiple chronic conditions than just

one – 31% of patients had 2 or more chronic conditions compared to 22%

who had just one. • For example, of the patients with Chronic Obstructive Pulmonary Disease

(COPD) 94% also carry at least one other condition. And nearly 20% of patients with COPD also have a mental health diagnosis.

• Average cost and activity increases with multi-morbidity and the biggest cost is for patients who have 2-4 chronic conditions (total cost of around

£118,650,000). • While costs and resource use increase with a patient’s age, multi-morbidity is

a greater driver of cost than age. Patterns of multi-morbidity also vary across the cluster.

• The proportion of patients at risk of mortality in the next 12 months (Mortality Risk Score) varies by GP practice. Individual patient risk scores may help

clinicians identify patients who need end-of-life care.



10 October 2018

• Other risk models available for patients include: probability of emergency

admission; probability of in-patient hospitalisation in the next 6/12 months; probability of extended hospitalisation; current cost of healthcare use;

predicted cost of healthcare use; probability of high total cost; probability of

high pharmacy cost; and electronic frailty index.

Population segmentation

The initial iteration of the segmentation model has identified 36 different segments. We are working with Sollis Ltd. to adapt the model to make sure it is

adapted to our local population.

Next steps

Next steps will be to determine which of our segments are most likely to benefit from anticipatory care and to work with healthcare professionals and patients to

identify the outcomes which are most important to those segments. We will then use the evidence base to identify which interventions will be the most effective

in achieving these outcomes for the segments.

Phase II of the pilot will take place in May 2019 during which GP practices will be able to access the live reports for a period of 1 month. This allow any trends over

the 6-month intervening period to be identified. Measures of the accuracy of the model in predicting risk for the pilot population will also be available at this stage.

4. RECOMMENDATION


• NOTE the on-going progress of the Inverse Care Law (ICL) programme in Cwm Taf, locally reported outcomes and plans to revise the model going

forward • APPROVE that a more detailed report to include the SAIL analysis and revised

(post April 2019) delivery model be presented to the January meeting of the

Primary and Communty Care Committee. • NOTE the on-going progress of the Population Health Management pilot.

Freedom of

information status

Open



10 October 2018

Appendix 1

National Primary Fund 2018-19

Template for Reporting the Results from Delivery Agreement

Organisation:

Cwm Taf University Health Board

Delivery Agreement Name:

Cardiovascular Risk ‘Health Check’ (Inverse Care Law Programme)

Welsh Government Delivery Agreement Reference:

CWT003

Organisation Lead Contact:

Sarah Bradley

Period Covered in this Report:

Quarter 1+2

• Healthcheck activity and results are captured in the patient practice record using the Healthcheck + software

• The Audit + platform enables the activity to be monitored at practice level and project activity data is captured regularly and reported monthly

• Patient referrals and outcomes will be monitored as part of a Longitudinal Evaluation of

• All eligible patients living in deprived areas will have been offered a health check

• Extent of HC uptake in practice setting will have informed future model and decision to offer HC in alternative venues (workplace or community) or target groups

• Sustainable Model for HC developed

• Outcomes of patients having HC in both cohorts (Practice and community venues) will be captured and reported via SAIL allowing greater understanding of outcomes

• Ongoing capture and use of case studies

FROM APPROVED DELIVERY AGREEMENT

How results / benefits are measured Results / benefits planned by March 2019



10 October 2018

outcomes using data linkage (SAIL)

• Feedback is gathered from patients

• Feedback is obtained from GPs and Practice Staff

• There are other evaluation strands undertaken jointly with Aneurin Bevan as part of the National ICL programme board Research and Evaluation Framework including monitoring Trend of Premature CVD mortality and gap between most and least deprived

• Numbers of patients with disease identified through HC reported

• Impact on mortality trend is likely to take several years to demonstrate, but early signs in changes in lifestyle behaviours expected

• Understanding of the profile of patients attending and not attending for HC to inform efforts to improve uptake of HC offer

Outline progress with results/benefits expected by March 2019

Quarter 1+2 Cwm Taf is providing continued support to the National ICL Programme and implementation of the National Research and Evaluation Framework through the new programme lead and public health consultant. The final cluster of the initial programme will have a targeted approach to self-management follow up for patients who have undergone health check. This will involve an increased delivery of self-management education, awareness raising through a new communication approach utilising social media and partners along with social prescribing support in the postcode areas that are involved. Increasing flexibility, capacity and uptake is a priority for the team and appointments will now be offered out of regular working hours to increase attendance and meet the needs of the patients. A full service review is being undertaken by the new programme lead to ensure the objectives are being met and that the service is auditable, evaluated and effective. This is involving a variety of methods to maximise the opportunities available and improve the quality, prudence and sustainability of the service. The programme continues to roll out across Cwm Taf during these 2 reporting quarters with the final cluster of Taf commencing this Autumn. The delivery in Taf Cluster is being designed with the Cluster and will prioritise patients resident in areas of highest deprivation (WIMD quintiles 4 and 5). Activity data for quarter 1 & 2 is reported below: Headline Health Check activity for Quarter 1 & 2 (1/04-20/09/2018) The CVD Health Check Team has been active in 14 practices during the reporting period. 1973 people attended 179 people Did Not Attend a scheduled health check appointment 126 people declined the offer of an appointment



10 October 2018

Longitudinal Analysis It had been anticipated that a further extract of the SAIL longitudinal analysis would be available to report in September 2018. However this has been delayed and will now be available in November/ December. The following provides a local analysis of the programme during the period July 2017- June 2018 as captured by the software deployed to undertake the health checks in Cwm Taf. Uptake Trend Approximately 40% of people invited for a health check take up the offer. This varies across practices, with some achieving far in excess of 50% uptake. Uptake by age group and sex During the period July 2017- June 2018, the highest % uptake of health check has been in the over 65 age group and lowest in the 40-44 age group (Figure 1). Figure 1

Overall there are similar numbers of men and women attending for a health check; men aged 50 to 65 are well-represented (Figure 2).



10 October 2018

Figure 2

This along with other emerging data will be considered in how we target and design future delivery of the service to increase uptake in the groups which are more difficult to engage. Headlines from the local analysis The following preliminary data has been extracted from the Informatica Dashboard to support service planning, highlights from Quarter 1 (n=1178) include:

➢ 72% (844/1178) identified as obese or overweight ➢ 21% (250/1178) Identified as smokers ➢ 56% (139/250) of smokers accepted a referral to smoking cessation services ➢ 20% (157/770) patients recorded as inactive using GP-PAQ questionnaire were

referred to National Exercise Referral scheme ➢ 50% (587/1178) had a raised cholesterol >=5mmols/L ➢ 15% (17/111) of patients found to have a high blood sugar (HbA1c) during health

check were subsequently diagnosed by their GP to have diabetes within 3 months of health check

➢ 19% (229/1178) were recorded as having a high alcohol consumption (AUDIT C risk tool); 3% (6/229) accepted a referral to alcohol services

➢ 3% (31/1178) had irregular pulse of which 6% (2/31) were diagnosed by their GP with Atrial Fibrillation within 3 months of health check

➢ 27% (316/1178) were found to have a high BP ≥140/90 at health check; 4% (14/316 ) were diagnosed as having hypertension within 3 months of health check

Uptake and outcomes data will be used to inform future developments of the Inverse Care Law programme in Cwm Taf.



10 October 2018

Highlight any issues which have arisen since your last report and how you have, or plan to, address these.

The programme lead vacancy was filled with a new manager commencing in August 2018. This will improve the delivery and strategic approach of the programme and future development. There are planning workshops in place for October to identify the future delivery model from April 2019 to which the Health Board is totally committed. There is an aspiration that the new model will provide further support to patients to reduce their risk of CVD through behaviour change. This will involve an enhanced system of linking individuals to support in their community, including social prescribing and utilisation of community assets. Long term issues with the information data dashboard have continued to be challenging and work is ongoing with NWIS and Informatica to address this. It is essential that NWIS are able to progress this work in a timely manner, particularly since the dashboard contract with Informatica expires end March 2019. In addition the licences for the healthcheck + software used in practices expire in March 2019 and NWIS support is required to advise on the best contract arrangement from April 2019 onwards which best fits the future delivery model for the Inverse Care Law programme in Cwm Taf. The evaluation report informed by SAIL data has been delayed by 3 months, which is a further challenge to planning and developing the service and measuring outcomes. We intend to report the SAIL analysis as soon as it is available and it will be included in our next report together with our proposed future delivery model.

Planned full year spend £m

Spend to date £m Forecast end year spend £m

Any difference between planned and forecast spend £m

0.360m 0.120m 0.338m 0.022m

3.4 Cluster Update

1 3.4 Cluster update PCCC 10 October 2018.docx

Cluster Update Page 1 of 8 Primary and Community Care Committee Meeting

10 October 2018

AGENDA ITEM 3.4

10 October 2018


PRIMARY CARE CLUSTER INITIATIVES

Executive Lead: Alan Lawrie, Director of Primary, Community and Mental

Health

Author: Tess Raybould Primary Care Development Manager

Contact Details for further information: [email protected]


The purpose of this report is to present members of the Primary and Community

Care Committee with an update on work being undertaken by the Primary Care Clusters. The report highlights areas of work currently being delivered for

patients using the Primary Care Cluster funding.

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 2018-2021 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 largely on improving quality, safety, access and patient experience

Supporting

evidence

‘Our plan for primary care services in Wales’ Welsh

Government 2014 Cwm Taf UHB 3yr Integrated Plan

Cwm Taf Primary Care & Community Delivery Plan Cluster Plans for 2014-2017 & 2017-2020


10 October 2018


Primary Care & Localities Management Team, GP Cluster leads and wider Primary and Community Healthcare staff including GPs, Practice managers,

Dental, Optometry & Pharmacy Representatives, Local Authority & Third Sector

Partners.

Primary and Community Care Committee Resolution To:


Recommendation The Primary and Community Care Committee is asked

to:

• NOTE the report and progress that has been made by the Primary Care Clusters.

Summarise the Impact of the Primary and Community Care Committee

Report


Cluster plans are developed and any work attempts to address the deprivation and Inverse Care Law

implications for our population. It also recognises the specific needs of identified client groups.

Legal implications No legal implications have been identified.

Population Health The development of new services and initiatives within the Cluster areas will be tailored towards the needs of

the populations that it serves.

Quality, Safety &

Patient Experience

Governance structures are in place to ensure

development of any new service, models of care

consider the quality of our services to patients and enhancing the patient’s experience.

Resources The development and key delivery of any Cluster initiatives lies with Cluster Leads and other members

of network. This work is supported by dedicated UHB Cluster Development Managers. Cluster Network Plans

identify actions and highlight reports provided as part of the Welsh Government Delivery Agreements for

Primary Care.

Risks and Assurance Initiatives are implemented and piloted to determine benefits for the Cluster. Any risks will be identified

and assurances provided through regular Network plan updates, reports to the UHB and Welsh

Government.

Health & 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


10 October 2018

The work reported in this summary take into account many of the related quality themes

Workforce Clusters are working with the Health Board to determine future models and skill mix to provide

sustainable primary care services and deliver on the

ever growing needs of our population.

Freedom of

information status

Open


10 October 2018

PRIMARY CARE CLUSTER INITIATIVES


The purpose of this report is to present members of the Primary and Community

Care Committee with an update on work being undertaken by the Primary Care Clusters. The report highlights areas of work currently being delivered for

patients using the Primary Care Cluster funding.


In November 2014, Welsh Government launched ‘Our Plan for a Primary Care

Service for Wales up to March 2018’, which clearly sets out the work NHS Wales will do by March 2018 to further develop and improve Primary Care and

Community Services.

Cluster Network plans are developed and are considered as a key element of the UHB Primary and Community Services integrated medium term plans (IMTP) and

are funded through the Welsh Government Service Delivery Agreements.

The Clusters are required to set out a three year network action plan, which should complement the individual practice development plans, tackling issues

that cannot be managed at an individual practice level, or can be more effectively and efficiently delivered through collaborative action.

The network approach supports greater consistency of service provision across the Cluster and improved quality of care, whilst more effectively managing the

impact of increasing demand set against financial and workforce challenges.


This report provides a brief overview of the current work of the Primary Care

Clusters with the following focus: • Service sustainability

• Improved access • More services now available in the community.

The Clusters have development plans which have been informed by:

• Development plans produced by practices • Public health information on key health needs within the area

• Cwm Taf UHB information on current activity /referral patterns • Understanding of our localities baseline services (current service

provision) and identification of potential service provision unmet needs.


10 October 2018

Clusters are embedding the foundations to deliver a more robust workforce and meet local needs of patients. As such across the clusters there has been

investment in recruitment of multi -disciplinary professionals to extend skills and deliver the most appropriate care including:

Cluster Pharmacists – Taf Ely / Rhondda / Cynon

Cluster Pharmacists are now embedded in the Practices and actively engaged in face to face patient consultations and medication reviews. The Pharmacy

department is evaluating the scheme in terms of cost/benefit analysis and anecdotally from practice feedback the Pharmacists are increasing capacity for

the GP’s and promoting a mixed skills model. Some independent prescribing courses have now been completed adding value to these roles.

Cluster Physiotherapy Service – Merthyr Tydfil

Up to 30% of consultations are thought to be for musculoskeletal (MSK)

conditions. The Merthyr Tydfil Cluster physiotherapy service is now delivering 25 sessions, each week. The service is delivered in each practice and provides

assessment and advice for this cohort of patients offering early, often same day access to a muscular skeletal specialist.

Occupational Therapist – North Cynon

This pilot has been so successful that the post has been made permanent and is now working across the four practices that make up the newly established North

Cynon Cluster. Referral rates for Quarter 1 & 2 has increased by 63% when compared to the same time period last year.

Behavioural Change Workers (GPSO) – Merthyr Tydfil

This initiative has been developed in partnership with the Merthyr Tydfil Cluster and Merthyr Tydfil Social Services. The aim of this project is to change the

behaviour and culture of patients who frequently visit their GP’s who do not need

medical Intervention. The GPSO will engage with patients to: • Advise/assess service users and address social issues and offer support in

correlation with the Social Services and Wellbeing Act. • To promote independence and enable service users to take responsibility

for their own health and wellbeing. • Supporting the reduction of attendance within general practice for non-

medical intervention. This includes utilising appropriate services in the locality which may include, networking with other agencies the third sector

and other community resources.

Care Navigators – Taf Ely & Merthyr Tydfil Care Navigation/Care Co-ordination offers the potential to free up GPs

consultation time each day by sign posting patients that do not need to see a doctor to more appropriate healthcare professionals, within or outside of the

Practice. It facilitates the development of the role of the reception staff to suit a

more multidisciplinary practice culture.


10 October 2018

Third Sector Partnership Projects

Active Monitoring Practitioners – Taf Ely & Cynon

MIND Active Monitoring Practitioners are providing sessions from the practices offering brief interventions for early presentations of anxiety and depression.

Final evaluation will seek to demonstrate that the intervention has prevented the patient from re-presenting to the GP with the same issue thus preventing the

‘revolving door’ pattern of attendance. The impact on other mental health service referrals will also be considered. More recently, a process has been agreed to

allow the MIND practitioners to refer directly onto Primary Care Mental Health Teams when needed, rather than send this back to the GP.

Health & Wellbeing Community Coordinator - Rhondda

The Cluster agreed to recommission the service for a further 12 month period. The Wellbeing Co-ordinator is now in every practice for one day per week over a

two week period. A template has been developed to ensure that data is captured

in a structured way across all practices to aid with data collection and data analysis. The co-ordinator acts as sign poster and advocate.

Men and Women Sheds

Work is already underway to support these to become established ‘sheds’ in the Taf Ely area, namely:

• Weekly walking rugby, football and golf sessions • Gardening group and board game club

• Pontypridd canal group

• Weekly indoor bowling group • Community facility and gardening ‘grow for it’

Grow Rhondda

This is a community driven scheme in Upper Rhondda, where GPs in the area can ‘prescribe’ patients gardening activities with the goal of improving patients’

overall health and wellbeing. The gardening activities are delivered through local Men Sheds organisation and the gardens within one of our community hospitals

are used for the gardening activities. The scheme is aimed at patients who are over eighteen and experiencing social isolation/low self-esteem/mild anxiety &

depression.

Valley & Vale – Taf Ely Valley & Vale continue to deliver art based therapy sessions to specific individuals

& groups, through a joint funding arrangement. .

Drink Wise Age Well – Taf Ely

Drink Wise Age Well 3Cs in the Community (Companionship, Conversation and Creativity) sessions have continued in Ynysybwl. This group is being supported

by the Cluster with an aim of them to become a constituted group. The aim of these sessions is to boost the confidence of older people, encourage new

friendships, and find out about hobbies to help to improve their well-being.


10 October 2018

Hapi Project (Newydd Housing Association) – Taf Ely Hapi in partnership with the GP deliver weekly sessions to GP identified patients

on Healthy eating, cooking and physical activity. Indications are that this has had a positive impact on the participants and families – through use of questionnaires,

a focus group and health checks, the Taf Cluster can now formally evaluate this programme.

Parkrun Practices – Rhondda & Cynon

In an exciting and innovative initiative, the Royal College of General Practitioners (RCGP) is partnering with Parkrun UK to promote the health and wellbeing of

staff and patients. Under this initiative, GP practices across the UK are encouraged to develop close links with their local parkrun to become parkrun

practices.

Waun Wen Lyndsey Leg Club - Rhondda

The Lyndsay Leg Club concept is an evidence-based initiative providing community-based treatments, health promotion, health education and on-going

care for people of all age groups who are experiencing leg-related problems. The key emphasis of the Leg Club is to actively “empower members to participate in

their own care, in a social environment that eases loneliness by providing congenial surroundings where old friends can meet and new friendships be

formed”.

Care & Repair Partnership - Cynon The engagement with Care & Repair in the Virtual Ward pilot in the North clearly

evidences how multi-agency working across the sectors can assist organisations in achieving service delivery targets whilst improving outcomes for patients. Care

and Repair now have representation at both Cynon Cluster meetings.

Other initiatives

Electronic Consultations – Merthyr Tydfil

The e-Consult platform delivers better patient access via participating GP practices website. This service speeds up access to safe, efficient care, whilst at

the same time reducing practices workload. One practice has noted the success to date and anticipates a potential saving of 60-70 appointments per week in the

longer term and reports 100% patient satisfaction for feedback supplied during July-September 2018.

Nursing/Residential Home project - Rhondda

Residential homes are linked to just one or two practices depending on the number of residents in order to improve communication between the GP and the

home. Each home manager has received a survey monkey 6 months after the changes were implemented. 57% of the homes involved responded and key

themes were are follows:


10 October 2018

• Prior to the changes being implemented, 33% had patients registered with 6 different practices, 28% had patients registered with 5 different

practices, 22% registered with 4 different practices and 17% registered with 3 different practices. After the changes were implemented 67% had

patients registered at one practice and 33% had patients registered at 2 different practices.

• 75% felt that communication with the GP practice had improved as a result of the changes, 13% felt that communication had stayed the same and

12% felt that it had deteriorated. • 62% felt that the process for ordering repeat prescriptions felt there was

an improvement and 38% felt it was the same, none felt that this has deteriorated since the project.

• 37% felt their relationship with the GP practice had improved and 63% felt it was the same, none who responded felt their relationship had

deteriorated.

• 50% of respondents felt that the service to their residents had improved as a result of the changes implemented and 50% that the service remained

the same. None felt that the service to residents had deteriorated.

Workforce Planning – Cynon

Cynon is engaged in a pilot project with Skills for Health and the Workforce,

Education and Development Services (WEDS) to inform the design of a national

workforce planning tool specifically for Primary Care whilst producing two

workforce plans – one for North and one for the South. These plans will provide the Clusters with sustainable workforce models which will have considered

predicted population changes and local health needs.

Public Health – Rhondda and Taf Ely

Development of initiatives based on cluster specific health issues identified using

data and needs of the population e.g. Slimming World on Prescription (Rhondda),

Healthy Lifestyles programme (Taf).

4. RECOMMENDATION


• NOTE the progress being made by the Primary Care Clusters

Freedom of

information status

Open

3.5 Delivery Agreements

1 3.5 Delivery Agreement Progress Updates Q 1 and 2 PCCC 10 October 2018.docx

6 month Progress Updates

Primary Care Delivery Agreements

Page 1 of 5 Primary & Community Care

Committee Meeting

10 October 2018

AGENDA ITEM 3.5

10 October 2018

Primary & Community Care Committee Report

PRIMARY CARE INVESTMENTS: DELIVERY AGREEMENT 6 MONTH PROGRESS UPDATES

Executive Lead: Director of Primary, Community and Mental Health

Authors: Sarah Bradley, Head of Primary Care; Alison Lagier, Locality Manager; Lindsey Richardson, Head of Planning

Contact Details for further information: Lauren Morgan, 01443

443755 or email [email protected]

Purpose of the Primary & Community Care Committee Report

The purpose of this paper is to present the 6 month progress reports for the

Primary Care Delivery Agreements, covering 1 April to 30 September 2018. (Appendix 1).

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 mainly on – To improve quality,

safety and patient experience.

Supporting

evidence

‘Setting the Direction’ Welsh Government

‘Social Services and Wellbeing’ (Wales) Act 2014 ‘Our plan for primary care services in Wales’ Welsh

Government 2014 Cwm Taf UHB 3yr Integrated Plan

Cwm Taf UHB Primary & Community Care Delivery Plan




Committee Meeting

10 October 2018


Primary Care & Localities Management Team and wider Primary and Community Localities staff, Mental Health Directorate, Primary Care

Steering Committee of the Board, Local Medical Committee (LMC), Acute

Directorate Managers, Practice Managers, Executive Board, GP Cluster Leads.

Primary & Community Care Committee Resolution to:


Recommendation The Primary & Community Care Committee members

are asked to: • NOTE the first 6 monthly progress updates

against the Primary Care Delivery Agreements

Summarise the Impact of the Primary & Community Care Committee Report

Equality and Diversity

A key focus within these programmes of work attempts to address the deprivation and Inverse Care

Law implications for our population. It also recognises the specific needs of identified client groups.

Legal

Implications

None noted to date.

Population Health The programme of work is based on the health needs

assessment undertaken by Public Health Wales to support the Cluster Plan development.

Quality, Safety &

Patient Experience

The work centres on improving the quality of our

services to patients and enhancing the patient’s experience.

Resources The resources to develop the work are allocated form the dedicated Primary Care Investments as outlined

within the paper. The resource to deliver the work is within the Primary Care & Localities management

team.

Risks and Assurance

Any potential or actual risks in relation to the plan will continue to be monitored reported through the

mechanisms outlined within the report to Welsh Government and internally through our Clinical

Business Meeting, Executive Board and this Primary Care Committee of the board and would feature if

appropriate on our risk register.


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




Committee Meeting

10 October 2018

The work reported in this summary takes into account many of the related quality themes.

Workforce There are key workforce issues associated with this work in relation to demand on GP’s and practice staff

in general also the demand on acute services. The

intention is that this work will support alternative roles and skill mix to deliver on the ever growing

needs of our population. The workforce issues outlined within this work are reflected in detail within

our Integrated 3 yr plan.

Freedom of

Information Status

Open




Committee Meeting

10 October 2018

QUARTER 1 & 2 DELIVERY AGREEMENT PROGRESS REPORTS

1. SITUATION/PURPOSE OF REPORT

The purpose of this report is to present the first 6 monthly progress reports

for the Primary Care Delivery Agreements, covering the period from 1 April to 30 September 2018.

2. BACKGROUND/INTRODUCTION

Members will recall that the new Primary Care Investment Delivery Agreements for 2018/19 were shared with the Primary and Community

Care Committee in April 2018. Reporting to Welsh Government is now required on a 6 monthly rather than quarterly basis. The progress reports

attached as Appendix 1 will be submitted to Welsh Government by the deadline of 11 October 2018.


2018/19 Delivery Agreements Progress Updates 1 April to 30

September 2018

Detailed 6 monthly progress updates against each of the 2018/19 Delivery

Agreements are attached as Appendix 1. A summary of the spend to date is as follows, showing a forecast end of year underspend of £77k which will

be monitored and addressed over the coming months:

DA No. Project Name

£'000s

annual

£’000s

spend to date

£’000s

forecast year end

CWT001 Community Care Joint Plan 105 52

105

CWT002 Cluster Hub developments:

225 70 240

- MSK Taff Ely

- COPD Rhondda

- Diabetes Cynon

Cardiology Merthyr Tydfil

CWT003 Inverse Care Law & Risk

Stratification

360 120 338

Clusters Priorities

1,017 615

CWT004 · Taff Ely

· Rhondda 1,017

· Cynon

· Merthyr Tydfil




Committee Meeting

10 October 2018

DA No. Project Name

£'000s annual

£’000s spend

to date

£’000s forecast

year end

CWT005 Research, Evaluation & Development

97 45 97

CWT006 Multidisciplinary team

development 662 264 624

CWT007 Wound Care 356 130 330

CWT008 Older Persons Mental Health Redesign

480 240 480

CWT009 Out of Hours Redesign 550 212 550

CWT010 Training and development/ Primary care management

and leadership

702 249 777

CWT011 Advanced Training Practice

Hub & Spoke 382 43 301

Total 4,936 2,040 4,859

-77

The next progress updates will be the year end reports, to be submitted to

Welsh Government by 11 April 2019. These will be brought to the Primary & Community Care Committee meeting on 3 April 2019 for information prior

to submission.

4. RECOMMENDATION

The Primary & Community Care Committee members are asked to:

• NOTE the 6 monthly progress updates against each of the Primary Care

Delivery Agreements which will be submitted to Welsh Government on 11 October 2018 and the forecast year end spend.


Status

Open

3.5.1 Appendix 1 Composite Delivery Agreement Progress Update report PCCC 10 October 2018

1 3.5.1 Appendix 1 Composite Delivery Agreement Progress Update report PCCC 10 October 2018.pdf

Primary & Community Care Committee Item 3.5 Appendix 1

1

National Primary Fund 2018/19 Delivery Agreements 6 monthly Progress Updates

1st April to 30th September 2018

Scheme No.

Project Name Page

CWT001 Community Care Joint Plan 2

CWT002 Cluster Hub developments 4

CWT003 Inverse Care Law Programme 10

CWT004 Primary Care Clusters 15

CWT005 Research, Development & Service Evaluation 29

CWT006 Multi-Disciplinary Development – Recruitment & Retention

33

CWT007 Cluster Wound Clinics 34

CWT008 Older Persons Mental Health Redesign 37

CWT009 Out of Hours Redesign 38

CWT010 Training & Development/Management & Leadership

40

CWT011

PACESETTER - Development of Advanced Training Practice / Hub & Spoke networks

42


2

Organisation:


Delivery Agreement name:

CWT001 Community Joint Care Programme and MSK


Diane Gibbons, Principal Public Health Specialist on behalf of Kelechi Nnoaham, Director of Public Health

The primary outcome measures for this programme are Oxford Knee Score (OKS), Quality of Life (QoL) (using EQ-5D + EQ-VAS questionnaires), function (6 minute walk test (6 MWT) and 30 second sit to stand (30 sec s-s). Secondary measures include body weight, resting blood pressure (BP) and resting heart rate (RHR). Outcome data is collected at initial assessment and 12 weeks. Patients are followed up at 12 months.

It is intended that 420 patients will have engaged with the programme between April 2018 and March 2019 with over 50% fully completing the programme with positive outcomes.


Referral levels have continued to increase, particularly in the Taff locality where there is now a waiting list of 45 patients in the cluster area. Course timetabling is being explored to try and manage the waiting list effectively. Data is still outstanding for Groups 26 and 27 but average outcomes for group 25 across Cwm Taf remain very positive. Patients lost an average of 3.2 kg and experienced an average decreased waist measurement of 5.5cm over the 12 weeks. Improvements were reported in all aspects of quality of life and function testing. On average patients saw an improvement of 5.9 points in their Oxford knee scores and were able to walk an additional 83.8 metres during the 6-minute walk test. 24 of the 45 patients referred fully completed the Group 25 programme RCT are trialling the use of text reminders pre and post sessions to improve retention and increase additional independent exercise. The RCT team have also been undertaking work to improve and extend the range of exercise circuits used.




3

Merthyr are currently working with the physio team to pilot a back care programme which commenced in September. The Merthyr team are also linking in with physio in regards to developing their approach to pain management as part of the programme. Both JCP teams are trialling new venues according to demand.


The level of increased referrals in some areas may require changes in timetabling to accommodate and if necessary a review of patient criteria to ensure that patients do not have to wait for long periods.

Planned full year spend £k

Spend to date £k Forecast end year spend £k

Any difference between planned and forecast spend £k

105m 52m 105m 0


4

Organisation:



CWT002 Cluster Hub Locality Services

Diabetes Service

Musculoskeletal (MSK) Service

Chronic Obstructive Pulmonary Disease (COPD)

One Stop Cardiology Clinic


Sarah Bradley, Head of Primary Care Alison Lagier, Localities Manager



Diabetes Service

No of referrals per clinic.

No of patients seen per clinic (clinic slots available vs. clinic slots utilised).

DNA rate.

Referral to appointment time (community clinic).

Patient experience.

GP experience.

Outcome of clinic appointment (follow-up / discharge / refer to secondary care / refer to other specialty).

Impact on acute care waiting list and follow up activity. Activity data to be requested from secondary care

Diabetes Service

Practice nurses competent and confident in service delivery.

Shorter wait times from referral to first appointment

Positive patient experience reported by questionnaire results

Positive GP experience reported by questionnaire results

Third sector group service delivery established

Reduction in acute OP clinic waiting list

and waiting times for assessment, (%

targets to be set against baseline data

from service delivery period January –

March 2017)

Reduction in follow-up appointments in

secondary care, (% targets to be set

against baseline data from service

delivery period January – March 2017)

Improved national diabetic audit

achievements.

MSK Service The Clinical System Myrddin, CMAT database and Weekly Triage Clinic will be used to demonstrate:

Referral to appointment time

MSK Service

Reduction in acute OP clinic waiting

times for assessment. (to be measured


5

No of referrals MSK clinic


No of patients seen per clinic Impact on secondary care waiting list

Outcome of clinic appointment Patient experience - questionnaires will be used to determine not only experience but also outcomes for patients – with emphasis on self management and ongoing support e.g. through referrals to joint care programme. Number of re-referrals to CMATS triage within 6 months of appointment. Clinician experience - ongoing operational meetings and evaluation of service level agreements.

in the first quarter of the service

commencing and then % targets set)

Reduction in conversions for surgery

(to be measured in the first quarter of

the service commencing and then %

targets set)

Self evaluated reduction in pain by

patients

COPD Discharge Service

No of referrals per clinic

No of patients seen per clinic (clinic slots available vs. clinic slots utilised)

DNA rate

Referral to 1st telephone contact (community clinic)

No of patients who complete 6 week programme

No of patients re-admitted within 6 week programme

Number and type of referral to other services

Patient experience

GP experience

Impact on acute care follow up activity. Activity data to be requested from secondary care

COPD Discharge Service

Decrease in the number of patients being re-admitted following an exacerbation of COPD.

Patient evaluation of intervention re

confidence in managing own condition

Reduction in visits to GP – reduced

number of exacerbations for individual

patients

Reduction in acute follow- up

appointments

Reduction in re-admissions

Reduction in COPD attendances /

admissions to Secondary Care.

Reduction in ambulance call outs for

COPD indicators in the Rhondda and

conveyances to the hospital


No of referrals per clinic.

No of patients seen per clinic (clinic

slots available vs clinic slots utilised).

DNA rate.

No of referrals to open access

diagnostics (by diagnostic).


Reduced wait times for diagnostics and outpatients.

Improved access to cardiology diagnostics such as 24hr/7 day electrocardiogram, 24 hour ambulatory blood pressure monitoring.


6


Clinics are now fully established with the multi-disciplinary teams working together to deliver regular clinics to patients in the community settings of Dewi Sant, Keir Hardie Health Park, Ysbyty Cwm Cynon and Ysbyty Cwm Rhondda. There is initial information that shows where there has been a positive impact on referral to waiting times and more patients being seen in the community clinics in a timely manner. Data has been collected to demonstrate any impact for each specific area. All four schemes are currently going through a final evaluation which will be completed by June 2018. This will allow decisions to be made on future delivery and roll out of clinics. Diabetes Clinic Diabetes UK volunteers are now fully integrated with the delivery of services at the Cynon Diabetes Community Clinic and attend on a weekly basis to support patients and share information. Clinic data shows:

Number of patients seen January 2017 – January 2018 inclusive = 448

Impact on secondary care waiting list = 32 weeks ( November 2015), 6 weeks (November 2017).

82% of patients achieved a reduction in their HbA1c by between 2 to 83 mmol/l

39% of patients achieved an HbA1c < 64 where their baseline was > 64mmol/l

45% patients started treatment with an HbA1c > 90mmol/l, 97% reduced their HbA1c with 27% achieving < 64mmol/l

One patient reduced their HbA1c from 144 to 61mmol/l


(community clinic).


(diagnostics).

Outcome of clinic appointment (follow-

up/discharge/refer to cardiology/refer

to other specialty).

Outcome of diagnostic (discharge /

other).

Patient experience.

GP experience.

Impact on secondary care waiting list.

No of patients seen who were referred

to secondary care cardiology service

within 6 months of appointment.

No of patients who attended A&E for

cardiac related issue within 6 months

of appointment.

Diagnostic results should be returned to the GP within two weeks.


7

74% of patients achieved a reduction in their BMI by between 0.2 to 4.5

7% no change

52% of patients commenced with a BMI >35 with 87% achieving a reduction

50% of those who lost weight lost over 5% of their baseline weight with some losing as much as 12%.

96% of patients reported an increase in health literacy.

95% patients reported an increase in confidence in managing their condition.

Three practice Nurses and one GP have completed their training via the clinic. Patient Feedback

Excellent

Very Good

Satisfactory

Poor Very Poor

Information received before your appointment

21 (68 % )

4 (13%) 4 (13%) 2 (6%)

Information received during your appointment

29 (98%) 3 (2%)

Friendliness/courtesy of staff

27 (93%) 2 (7%)

Amount of attention paid to your needs

28 (90%) 3 (10%)

Efficiency with which the service seemed to operate

23 (74%) 8 (26%)

Follow up / discharge instructions

24 (88%) 3 (12%)

Overall rating given

27 (87%) 4 (13%)

Health Literacy No, not at all Yes, a little Yes, a lot


8

Has your understanding of your diabetes improved? 1(4%) 8 (26%) 21 (70%)

Has your confidence in managing your diabetes improved?

1 (4%) 7 (23%) 22 (73%)

Is there any way we can improve our services?

• ‘No’ x 2 • ‘Excellent service and nice people’ • ‘No everything is ok’ • ‘For me the service and staff are friendly and helpful’ • Very good appointment’ • ‘Not really, pleasant staff, personally I am happy’ • ‘Send us here sooner’ • ‘No. For me the service is very satisfactory’ • ‘Excellent service, very friendly and they listen to me’

The six months Primary Care Dietician pilot has now been evaluated: What were the main outcomes?

Little/no wait time to see the dietitian as part of the clinic; compared to usual practice of 7 weeks wait for a dietetic outpatient appointment

Reduction in G.P./Nurse time spent providing dietary advice, consultations kept to allocated time/reduction in clinics overrunning

64% of patients improved diabetes dietary knowledge, 17% mean % improvement from baseline

59% improved in confidence to self-manage diabetes, 21% mean % improvement from baseline

82% improved dietary intake, 40% Mean % improvement from baseline

46% had a BMI >35, 53% reduced their weight, mean % weight loss reduction of 2.4% (Half lost this weight in only 4 weeks as seen towards the end of the pilot)

Overall, 69% achieved reduction in HbA1c

56% had HbA1c >90mmol/mol at first appointment, 78% improved HbA1c at follow up with a mean reduction of 31mmol/mol (range 6-83mmol/mol)

69% increase in uptake of diabetes education during the pilot COPD Clinic

The report has been discussed at the Cwm Taf Respiratory Delivery group for consideration and recommendations.


9

It has been recommended, based on the outcomes detailed in the report, that Phase 1 of the COPD service continues to be delivered in the Rhondda and that the service is rolled out to another of the cluster areas.

The resources required to roll out the service to the three other cluster areas have been identified.

The Cynon has been identified as the next area in which the service will be implemented as they have the next highest prevalence of COPD. Discussions are ongoing with the respiratory team that serve the patients who live in the Cynon area as their service delivery model is slightly different to that in Rhondda, so some changes may be required in order to implement the service effectively .

Cardiology Clinic

The clinic has been running bi-weekly (excluding annual leave)

Vision 360 has now successfully proven the concept and clinicians have the ability to write directly into patients records within the Merthyr Cluster and all technical complications have been resolved.

Data is currently being collated to identify the benefits and impact the clinic is having on emergency attendance and the secondary care waiting list.

A meeting is taking place during September 2018 to agree a consensus on a health board wide model for community cardiology services


none

Planned full year spend £’000

Spend to date £’000

Forecast end year spend £’000

Any difference between planned and forecast spend £’000

225 70 240 15


10

Organisation:



CWT003 Cardiovascular Risk ‘Health Check’ (Inverse Care Law Programme)


Sarah Bradley

Healthcheck activity and results are captured in the patient practice record using the Healthcheck + software

The Audit + platform enables the activity to be monitored at practice level and project activity data is captured regularly and reported monthly

Patient referrals and outcomes will be monitored as part of a Longitudinal Evaluation of outcomes using data linkage (SAIL)

Feedback is gathered from patients

Feedback is obtained from GPs and Practice Staff

There are other evaluation strands undertaken jointly with Aneurin Bevan as part of the National ICL programme board Research and Evaluation Framework including monitoring Trend of Premature CVD mortality and gap between most and least deprived

All eligible patients living in deprived areas will have been offered a health check

Extent of HC uptake in practice setting will have informed future model and decision to offer HC in alternative venues (workplace or community) or target groups

Sustainable Model for HC developed

Outcomes of patients having HC in both cohorts (Practice and community venues) will be captured and reported via SAIL allowing greater understanding of outcomes

Ongoing capture and use of case studies

Numbers of patients with disease identified through HC reported

Impact on mortality trend is likely to take several years to demonstrate, but early signs in changes in lifestyle behaviours expected

Understanding of the profile of patients attending and not attending for HC to inform efforts to improve uptake of HC offer




11


Quarter 1+2 April – September 2018 Cwm Taf is providing continued support to the National ICL Programme and implementation of the National Research and Evaluation Framework through the new programme lead and public health consultant. The final cluster of the initial programme will have a targeted approach to self-management follow up for patients who have undergone health check. This will involve an increased delivery of self-management education, awareness raising through a new communication approach utilising social media and partners along with social prescribing support in the postcode areas that are involved. Increasing flexibility, capacity and uptake is a priority for the team and appointments will now be offered out of regular working hours to increase attendance and meet the needs of the patients. A full service review is being undertaken by the new programme lead to ensure the objectives are being met and that the service is auditable, evaluated and effective. This is involving a variety of methods to maximise the opportunities available and improve the quality, prudence and sustainability of the service. The programme continues to roll out across Cwm Taf during these 2 reporting quarters with the final cluster of Taf commencing this Autumn. The delivery in Taf Cluster is being designed with the Cluster and will prioritise patients resident in areas of highest deprivation (WIMD quintiles 4 and 5). Activity data for quarter 1 & 2 is reported below: Headline Health Check activity for Quarter 1 & 2 (1/04-20/09/2018) The CVD Health Check Team has been active in 14 practices during the reporting period. 1973 people attended 179 people Did Not Attend a scheduled health check appointment 126 people declined the offer of an appointment Longitudinal Analysis It had been anticipated that a further extract of the SAIL longitudinal analysis would be available to report in September 2018. However this has been delayed and will now be available in November/ December. The following provides a local analysis of the programme during the period July 2017- June 2018 as captured by the software deployed to undertake the health checks in Cwm Taf. Uptake Trend Approximately 40% of people invited for a health check take up the offer. This varies across practices, with some achieving far in excess of 50% uptake.


12

Uptake by age group and sex During the period July 2017- June 2018, the highest % uptake of health check has been in the over 65 age group and lowest in the 40-44 age group (Figure 1). Figure 1

Overall there are similar numbers of men and women attending for a health check; men aged 50 to 65 are well-represented (Figure 2). Figure 2


13

This along with other emerging data will be considered in how we target and design future delivery of the service to increase uptake in the groups which are more difficult to engage. Headlines from the local analysis The following preliminary data has been extracted from the Informatica Dashboard to support service planning, highlights from Quarter 1 (n=1178) include:

72% (844/1178) identified as obese or overweight

21% (250/1178) Identified as smokers

56% (139/250) of smokers accepted a referral to smoking cessation

services

20% (157/770) patients recorded as inactive using GP-PAQ

questionnaire were referred to National Exercise Referral scheme

50% (587/1178) had a raised cholesterol >=5mmols/L

15% (17/111) of patients found to have a high blood sugar (HbA1c) during

health check were subsequently diagnosed by their GP to have diabetes

within 3 months of health check

19% (229/1178) were recorded as having a high alcohol consumption

(AUDIT C risk tool); 3% (6/229) accepted a referral to alcohol services

3% (31/1178) had irregular pulse of which 6% (2/31) were diagnosed by

their GP with Atrial Fibrillation within 3 months of health check

27% (316/1178) were found to have a high BP ≥140/90 at health check;

4% (14/316 ) were diagnosed as having hypertension within 3 months of

health check

Uptake and outcomes data will be used to inform future developments of the Inverse Care Law programme in Cwm Taf.


14


The programme lead vacancy was filled with a new manager commencing in August 2018. This will improve the delivery and strategic approach of the programme and future development. There are planning workshops in place for October to identify the future delivery model from April 2019 to which the Health Board is totally committed. There is an aspiration that the new model will provide further support to patients to reduce their risk of CVD through behaviour change. This will involve an enhanced system of linking individuals to support in their community, including social prescribing and utilisation of community assets. Long term issues with the information data dashboard have continued to be challenging and work is ongoing with NWIS and Informatica to address this. It is essential that NWIS are able to progress this work in a timely manner, particularly since the dashboard contract with Informatica expires end March 2019. In addition the licences for the healthcheck + software used in practices expire in March 2019 and NWIS support is required to advise on the best contract arrangement from April 2019 onwards which best fits the future delivery model for the Inverse Care Law programme in Cwm Taf. The evaluation report informed by SAIL data has been delayed by 3 months, which is a further challenge to planning and developing the service and measuring outcomes. We intend to report the SAIL analysis as soon as it is available and it will be included in our next report together with our proposed future delivery model.




360 120 338 22


15

Organisation:



CWT004 Primary Care Clusters


Sarah Bradley

Primary care cluster name

Taff Ely Cluster Report

Health board


Please give brief outline of:

1 Your top 3 intended measurable results from your investment as a whole i.e. not per each element of investment plan

Service sustainability

Improved access

More services now available in the community

2 Delivery so far against your top 3 intended measurable results

Service sustainability

The Cluster have concentrated its efforts on some key areas to ensure patients get the right messages to allow them to ‘choose well’ and ‘take care of their own health & wellbeing’, these are:

o Development of Primary Care Cluster Website – to provide a one stop shop for the population of Taff Ely and information on services, support, classes and initiatives available in the area.

o Health, wellbeing & self care - engagement with 3rd sector organisations to delivery community based sessions to allow access to art based therapies, skills development and advice and support.

o Attendance at public events to promote health & wellbeing and choose well messages e.g. Big Bite event, Public Forum.

o Active promotion of Common Ailments Scheme and Welsh Eye Care Service.

o Care navigation training – which provides frontline staff with skills to inform patients on choices and access to available services. GP practices will signpost patients to appropriate services provided by primary care, social care and 3rd sector organisation.

All GP practices continue to work with Cwm Taf University Health Board to determine roles that are needed to develop sustainable Primary Care models and Multi-disciplinary teams. o #Your local team campaign – has profiled a range of our primary care

professionals including well-being co-ordinators, pharmacists, optometrists, occupational therapists and GP support officers, who explain who they are and how they can help.


16

Improved Access

Cluster Pharmacists are currently still in place across the practices. In addition to this a number of practices have employed pharmacists within their own teams.

Active Monitoring Programme has continued across all 8 GP practices Merthyr and the Valleys Mind provide quarterly reports for the Cluster to show access to the service, engagement and feedback from patients to demonstrate the difference this is making to patients. This also shows where individuals have been supported to manage their issues and improve their conditions, where appropriate, rather than attend for GP appointments. More recently a process has been agreed to allow the MIND practitioners to refer directly onto Primary Care Mental Health Teams when needed, rather than send this back to the GP.

More services now available in the community

The Cluster have worked with 3rd sector organisations to provide Community based sessions for identified groups or areas allowing access to community based information and support for the population of Taff Ely.

o Men and Women Sheds – the cluster have worked with ‘Shednet’ a local organisation set up to support development of sheds. This has allowed identification of groups and new activities, with work already underway to support these to become established ‘sheds’ in the area, namely:

Weekly walking rugby, football and golf sessions Gardening group and board game club Pontypridd canal group Weekly indoor bowling group Community facility and gardening ‘grow for it’

o Valley & Vale – continue to deliver art based therapy sessions to specific individuals & groups, through a joint funding arrangement. A report has been provided to the Cluster to show impact for participants. The sessions have recently moved to a new community run venue, to improve the links with an existing group who already uses the facility.

o Drink Wise Age Well 3Cs in the Community (Companionship, Conversation and Creativity) sessions have continued in Ynysybwl. This group is being supported with an aim of them become a constituted group. The aim of these sessions is to boost the confidence of older people, encourage new friendships, and find out about hobbies to help to improve their well-being.

o Hapi Project (Newydd Housing Association). Following the pilot which was developed by a GP in Parc Canol Practice and ‘Hapi’, this group have continued to meet and be supported. Hapi in partnership with the GP deliver weekly sessions on Healthy eating, cooking and physical activity. This is following identification of need by a GP in the practice as patients are presenting to her with health conditions such as diabetes, high cholesterol etc. – particularly in those considered to be obese. The next set of sessions are being delivered in partnership with Garth Olwg Lifelong Learning Centre. This will allow the Cluster to work with the Hapi Project and plan further roll out across Taff Ely.


17

Indications are that this has had a positive impact on the participants and families – through use of questionnaires, a focus group and health checks, the Cluster can now formally evaluate this programme.

Promoting the Choose Well and Health & Wellbeing messages to the population. Existing events and forums are being used to provide information to the population around their choices when they are considering which Primary & Community Care services they need. The cluster have recently attended the annual ‘Big Bite’ event in August and a Public Forum. The Pharmacy Common Ailment Scheme and Welsh Eye Care Service are actively being promoted.

The cluster hub at Dewi Sant Health Park is now being used for community clinics, voluntary sector sessions to allow delivery and access to central cluster wide support for the population. Through joint working with Community Co-ordinator and 3rd sector organisation this will continue to develop and allow delivery of services in the community ‘hub’.

3 Any issues for delivery and how these are being managed.

Care Navigation – the plans for the Cluster are to make this training available

for all Primary Care Contractors. This has not progressed as intended to this

point as it has been difficult to engage others. Therefore it was decided to

implement phase 1 to all GP practices and the 5 Pharmacists who attended the

training. It is hoped that the pharmacies can test this process within a setting

other than the GP practice to establish how this can be implemented in other

areas of primary care. Following a 6 month review, work will progress to move

towards further roll out and moving on to phase 2.

Supporting community ‘sheds’ – release of funds to individuals or recently

established groups is proving difficult due to the procurement and financial

processes of the heatlh board. To allow individuals to set up groups, they need

to purchase equipment – funds cannot be released until these have been

purchased. Development Manager is working with finance colleagues and

‘Shednet’ to find a solution.


18


Rhondda Cluster

Health board

Cwm Taf University Health Board CWT005



service sustainability; Up Skill workforce to enhance Primary Care Team and service provision

improved access; Promote working in Rhondda and improve upon recruitment and retention

more services available in the community Introducing New Models of Care to improve upon access to services for patients.


Parkrun practices

In an exciting and innovative initiative, the RCGP is partnering with

parkrun UK to promote the health and wellbeing of staff and patients.

Under this initiative, GP practices across the UK are encouraged to

develop close links with their local parkrun to become parkrun practices.

Involvement in this initiative will help practices:

Improve the health and wellbeing of practice staff

Improve the health and wellbeing of patients and carers, reducing the

need for lifelong medication.

Raise awareness amongst the parkrun community of services that

practices provide.

Contribute to the development of a local community and environment

that is centred around wellness generation.

Support the UK-wide movement to scale up social prescribing

activities.

All practices in the Rhondda cluster have agreed to sign up to become a

parkrun practice.

Waun Wen Lyndsey Leg Club The Lyndsay Leg Club concept is an evidence-based initiative providing community-based treatments, health promotion, health education and on-going care for people of all age groups who are experiencing leg-related problems. Leg Club staff work in a unique partnership with patients (members) and the local community. Working to best-practice guidelines the aim is to


19

provide a very high standard of care in a social and friendly setting that promotes understanding, peer support and informed choice. The key emphasis of the Leg Club is to actively “empower members to participate in their own care, in a social environment that eases loneliness by providing congenial surroundings where old friends can meet and new friendships be formed”. Transport to and from Leg Club is arranged and provided by local community volunteers. The Lindsay Leg Club concept has four key features that are different from conventional leg ulcer clinics:

they are community-based, held in a non-medical setting, e.g. a local community centre, church hall or meeting room;

members (patients) are clinically treated collectively; they operate on a drop-in basis (no appointments required); they incorporate a fully-integrated 'well leg' regime.

The Waun Wen community Centre in Porth, Rhondda has been identified as a venue. Volunteers have been recruited and a committee has been established. In conjunction with Deputy Head of Nursing the staff to provide the service at the leg club have been identified. Ellie Lyndsay OBE has visited the Waun Wen centre and spoken to the nurses and volunteers that will be involved. The first Leg Club is scheduled to take place on the 3rd October 2018. Health & Wellbeing Hub The Treorchy Arts festival took place on the 29th of June 2018. It was an event spread over multiple venues across Treorchy and incorporated many different activities. The Rhondda Cluster organised a health and wellbeing hub over two days. Over 20 organisations that are available to the community came along to provide information on how they can support health and wellbeing and educating the public on accessing the right professionals at the right time. Numerous third sector organisations available throughout the community attended including housing, public health as well as promoting health board initiatives such as the cardiovascular risk assessment. The community pharmacist who attends the cluster meetings attended and promoted the minor ailments scheme and one of the Optometrists from within the community also attended to promote the WECS scheme. Nursing/Residential Home project The cluster undertook a pilot to rationalise the number of GP practices that visit any one nursing or residential home. By allocating the whole home to just one or two practices depending on the number of residents, the clusters aim is to improve communication between the GP and the home as they will be dealing with less GP practices and variances in systems such as ordering repeat prescriptions. The benefit for the GP will be less time away from the practice visiting numerous homes that can be situated some miles away from each other, and so increasing upon the time that can be spent in surgery seeing patients and


20

undertaking other duties that impact on patient care. This will be particularly beneficial during the winter months when workload can increase dramatically. The community pharmacist who attends the cluster meeting also feels that the service that they provide to patients who reside within the homes will improve as they will have clearer lines of communication when dealing with fewer practices and a decrease in the number of differing prescribing systems. Each home manager has received a survey monkey 6 months after the changes were implemented. 57% of the homes involved responded

Prior to the changes being implemented, 33% had patients registered with 6 different practices, 28% had patients registered with 5 different practices, 22% registered with 4 different practices and 17% registered with 3 different practices. After the changes were implemented 67% had patients registered at one practice and 33% had patients registered at 2 different practices.

75% felt that communication with the GP practice had improved as a result of the changes, 13% felt that communication had stayed the same and 12% felt that it had deteriorated.

62% felt that the process for ordering repeat prescriptions felt there was an improvement and 38% felt it was the same, none felt that this has deteriorated since the project.

37% felt their relationship with the GP practice had improved and 63% felt it was the same, none who responded felt their relationship had deteriorated.

50% of respondents felt that the service to their residents had improved as a result of the changes implemented and 50% that the service remained the same. None felt that the service to residents had deteriorated.

Comments made in the feedback include:- “As there is the same GP’s in one surgery they have now developed a good relationship with the residents, staff and management”. “They have effectively communicated with the relatives when needed to ensure they feel a part of some difficult decisions or situations.”

“It’s is easier dealing with one surgery as opposed to many because we are familiar with their procedures and ways of working.”

“There has been discussions about ward rounds happening but nothing has happened yet. They are very responsive when a house call is requested”.


21

Cluster Pharmacist The cluster has continued to fund the 5 cluster pharmacists currently in post and working across all 13 practices for another 12 months up until March 2019. Rhondda Primary Care Cluster Community Network Co-ordinator Based on the evaluation of the Rhondda Primary Care Cluster Community Network Co-ordinator that was presented at the cluster meeting in January 2018, the Cluster agreed to recommission the service for a further 12 month period. The Wellbeing Co-ordinator is now in every practice for one day per week over a two week period. A template has been developed to ensure that data is captured in a structured way across all practices to aid with data collection and data analysis. Grow Rhondda. Grow Rhondda is a community driven scheme in Upper Rhondda, where GPs in the area can ‘prescribe’ patients gardening activities with the goal of improving patients’ overall health and wellbeing. The gardening activities are delivered through our local Men Sheds organisation and the gardens within one of our community hospitals are used for the gardening activities. The scheme is aimed at patients who are over eighteen and experiencing social isolation/low self-esteem/mild anxiety & depression. Weekly small group sessions are held with activities centred on the maintenance, planting and harvesting of a garden that incorporates a vegetable plot through the seasons. The scheme has been in operation for 6 months and evaluation is currently being undertaken. The Slimming World on prescription referral scheme 333 vouchers were purchased ad distributed to the practices based on practice list size. The Cluster agreed on the following referral criteria:-

Aged 18 year or over

Patients identified as obese (BMI ≥35) with or without a co-morbidity that is adversely affected by their weight. Or is of a South East Asian Ethnicity

Not attended or self-funded at any weight management service in the last 3 months (I.E Slimming World, Weight Watchers, Diet Doctor, Atkins or Cambridge diet)

To date 102 referrals have been made. 42 people had completed the 12 week programme. The others are still attending.

Of the 42, 32 have achieved 3% weight loss, 24 have achieved 5% weight loss and 8 have achieved 10% weight loss.

In the last cluster meeting the referral process was reviewed. Originally only GP’s could make a referral but this has now been opened up to Practice Nurses, Health Care Support Workers and also the Cardiovascular Risk Assessment team who are working within


22

Rhondda practices as it was felt that a cohort of patients were being missed.

Work experience week at Ysbyty Cwm Rhondda A work experience week was organised at Ysbyty Cwm Rhondda with the aim of engaging with year 10 pupils and promoting the various roles available within health. In line with the cluster work on recruitment and retention, primary care hosted a morning of the event with a GP from the cluster presenting and talking to pupils about becoming a GP and working in the Rhondda Valleys as well as representation from both community dental and community optometry.


The pharmacists take up over a third of the overall cluster budget and so this

limits the funding that is available for projects. The cluster now needs to make

decisions on cluster expenditure for 2019/2020 with regard to the

pharmacists and concentrate on identifying and planning cluster initiatives in

readiness for April 2019.


North and South CYNON Clusters

Health board

CWM TAF



Service sustainability The implementation of the ethos of prudent healthcare develops the workforce to ‘only do the work that only they can do’. The workplace should then become more rewarding and less pressured thus improving staff recruitment and retention rates. New models of primary care will be explored. Desired outcome is to create more cost effective and sustainable primary care services.

Improved access Improving access and increasing capacity: Exploring systems and mixed skills workforce to increase capacity and deliver appropriate services to meet patient need.

More services now available in the community Engagement with the Third Sector and other health & social care agencies. Commissioning of Cluster initiatives for service delivery.


23


Service sustainability Workforce Planning: both Clusters are engaged in a pilot project with Skills for Health and WEDS to inform the design of a national workforce planning tool specifically for Primary Care whilst producing two workforce plans – one for North and one for the South. These plans will provide the Clusters with sustainable workforce models which will have considered predicted population changes and local health needs. Training: there will be engagement in level 3 training for HCA’s and Diabetic foot check training which complements the Cluster Diabetic Community Clinic project in the up skilling and empowerment of clinicians in working in a specialist field thus improving confidence in and availability of care. Multi – skilled workforce: the piloting of the role of an Occupational Therapist in General Practice has been so successful that the post has been made permanent and is now working across the four Practices that make up the newly established North Cynon Cluster. The service is being expanded following the successful recruitment to Band 6 posts to further develop the model for Primary Care to ultimately replicate across the whole of Cwm Taf. The North Cynon Cluster are looking to recruit to an Advanced Nurse Practitioner position to do Nursing Home and |Home Visits. The South Cynon Cluster are looking to pilot a Health & Wellbeing Co-Ordinator post over the winter months to compare impact with their previous Community Nursing pilot 2017.18.

Improved access Cluster Pharmacists: Three full time Cluster Pharmacists are now embedded in the Practices and actively engaged in face to face patient consultations and medication reviews. The Pharmacy department is evaluating the scheme in terms of cost/benefit analysis and anecdotally from practice feedback the Pharmacists are increasing capacity for the GP’s and promoting a mixed skills model. Some independent prescribing courses have now been completed adding value to these roles. The South Cluster have committed Cluster funding to the same level of service for 2019.20. MIND active monitoring: MIND therapists are providing sessions from the practice base offering brief interventions for early presentations of anxiety and depression. Final evaluation will seek to demonstrate that the intervention has prevented the patient from re presenting to the GP with the same issue thus preventing the ‘revolving door’ pattern of attendance. The impact on other mental health service referrals will also be considered.


24

Care Navigation: this training is being considered by the Clusters as possible investment for next year to promote prudent health care and social prescribing.

More services now available in the community Care & Repair ‘Managing Better’ project: Care & Repairs ‘boilers on prescription’ continues to be hosted by a Practice in the Cynon; the District Nurses are supporting the identification of appropriate referrals. Evaluation is being progressed in partnership with Care & Repair; initial patient feedback has been extremely positive. The engagement with Care & Repair in the Virtual Ward pilot in the North clearly evidences how multi-agency working across the sectors can assist organisations in achieving service delivery targets whilst improving outcomes for patients. Care and Repair now have representation at both Cynon Cluster meetings. Community Co-ordinators: community co-ordinators attend all Cluster meetings and regularly deliver ‘clinics’ from Practices to engage with patients to assist in health promotion initiatives and signposting. The Community co-ordinators also input into the weekly multi – disciplinary ‘virtual’ ward in North Cynon. Optometry & Dentistry: The Health Boards Optometry advisor is an active member of the Cluster meetings thus promoting a ‘Primary Care’ focus to the group. A management and clinical representative for dentistry have recently been identified and will start to attend meeting is quarter four. Community Pharmacy: there has been positive engagement this year with Community Pharmacy colleagues who now attend the Cluster meetings and have been positive about the sharing of information and potential for improving joint working.


Practice capacity to manage some initiatives can be a challenge; time

needs to be invested in training and systems redesign before the

benefits of change can be evidenced. When a team is working at

capacity introducing such initiatives can prove challenging. The

outcomes of these plans are not usually evident in the short term and

the Cluster provides mutual support and encouragement to progress

initiatives in times of resistance.

Partnership initiatives with the third sector can be compromised by the

uncertainty of funding in that sector.

Projects where multi – skilled teams are central to delivery can be

jeopardised by the short supply of qualified and experienced

practitioners. Similarly the often short fixed term nature of the makes it


25

difficult to attract the calibre of candidate required to successfully

deliver in the pilots. As a result recruitment agencies may have to be

used resulting in inflated costs and less value for money. It has proved

impossible to recruit an Advanced Nurse Practitioner or Advanced

Emergency Paramedic due to shortages of supply and short term

contracts.

The year on year structure of Cluster funding impacts on the ability of

the Cluster to plan and commission to best effect. The lack of clarity

around the future funding of initiatives where concept has been

positively proven creates uncertainty and suspicion amongst some of

the Cluster membership. Large proportions of the Cluster budget

being committed to successful projects such as the Cluster

Pharmacists seriously restricts the scope for future innovation. The

inability to ‘carry over’ funds has also prevented the recommissioning

of successful services such as the MIND interventions due to

insufficient funds in each financial term whereas a cumulative fund

would make this affordable. The consequential reduction in the MIND

contract has resulted in ineffective provision which has impacted on

the positive view of the service by the Cluster as the service has

buckled under the pressure of demand outstripping supply. This

seriously threatens the recommissioning of this service by the

Clusters.

The different priorities and culture of the Cluster Practices escalated in

the first quarter of this year resulting in the split of the Cluster into

North and South. This has facilitated improved decision making and

increased momentum.


Merthyr Tydfil

Health board




Service Sustainability Develop the workforce and introduce new models of care to enhance quality, improve wellbeing and patient experience

Improved Access Introducing new systems and expanding the MDT to increase capacity

More services available in the community


26

Engage with Third Sector and other organisations to identify opportunities for shared working.


General Practice Support Officers(GPSO)

This initiative has been developed in partnership with, Merthyr Cluster and Merthyr Tydfil Social Services. 6 full time GPSO’s have been recruited, all of which are embedded within GP practices within the cluster locality. The aim of this project is to change the behaviour and culture of patients who frequently visit their GP’s who do not need medical Intervention. The GPSO will engage with patients to:

Advise/assess service users and address social issues and offer support in correlation with the social services and wellbeing act.

To promote independence and enable service users to take responsibility for their own health and wellbeing.

Supporting the reduction of attendance within general practice for non-medical intervention. This includes utilising appropriate services in the locality which may include, networking with other agencies the third sector and other community resources.

Progress this quarter GPSOs are collaboratively working with third sector organisations, Public Health and Community Coordinators. Service users are being referred and signposted and some examples include:

Care and Repair - The Warm Homes on Prescription scheme, will benefit people who have health conditions which are caused or made worse by living in cold housing

NERS - The Scheme targets clients aged 16 and over who have, or are at risk of developing, a chronic disease

Multiple Intervention Assistance (MIA) - MIA is available for families in Merthyr Tydfil with children aged 0 to 18 years, who need additional multiple support services

Valleys Steps – Teaching people to manage stress, anxiety levels and low mood.

Service user’s feedback has been highly positive. A full evaluation of the project is currently being undertaken by Public Health Wales and is due to be produced in October 2018. Active Signposting - Care Co-ordinators Active Signposting offers the potential to free up GP’s consultation time each day by referring patients that do not need to see a Doctor to more appropriate healthcare professionals, within or outside of the Practice. Receptionists from all practices across the cluster have completed seven core modules of training to become a Care Coordinator:

Exceptional Customer Service


27

Improving the Patient Experience

Succeeding with Difficult People

Managing Pressure at Work

Equality and Diversity

Understanding Information Governance

Active Signposting Course Progress this quarter Feedback continues to be positive and all practices are actively engaged as this has added value. The cluster has engaged in several Public Forums and the CHC to ensure patients are receiving the correct messages and explain the role and benefits of the care coordinator. Further work to promote the role is being undertaken.

Electronic Consultations e-Consult platform delivers better patient access and two practices in the cluster are using the service. Access to e-Consult is through each participating GP practices website. This service speeds up access to safe, efficient care, whilst at the same time reducing practices workload

Additional E Consult promotional material has been shared with all participating practices.

All participating practices are live and launched with the service.

Video presentations for Numed screens installed

Local promotion of service with patient participation groups – mother and toddler groups – CHC etc

Progress this quarter One practice has noted the success to date and anticipates a potential saving of 60-70 appointments per week in the longer term and reports 100% patient satisfaction for feedback supplied during July-September. The second practice does not feel the service has largely impacted a reduction in access and reports significantly lower numbers of appointments being saved. The two participating practices have fully engaged in promotion of the service and will both be evaluating during Q4. Cluster Physiotherapy Service Up to 30% of consultations are thought to be for MSK conditions. Merthyr Cluster physiotherapy service is now delivering 25 sessions, each week. The service is delivered in each practice and provides assessment and advice for this cohort of patients.

The service is delivered by two local providers to offer early, often same day access to a muscular skeletal specialist. The cluster feel this is proving to be instrumental in the effective use of clinical time and providing a more appropriate response to patients with muscular skeletal problems. The resource has worked extremely well across the cluster.


28

Progress this quarter Anecdotally, professionals within each practice feel they are seeing far less patients with muscular skeletal conditions and data is currently being collated as part of the formal evaluation to take place in December 2018.

3 Any issues for delivery and how these are being managed

Recruitment of clinicians/professionals to undertake cluster initiatives

problematic – in terms of availability and cost

MSK Pathway from Cluster into the Health Board need to be improved.

At present a patient that is assessed in the Cluster service cannot be

directly referred into the Health Board service due to governance

reasons.

Ongoing management of GPSO staff could prove difficult with Local

Authority internal HR policies which is being managed via a

commissioned SLA. There have been some ‘personality clashes’ in

some of the practices between staff and GPSO which has been

challenging to manage due to the line management structure. This is

will be picked up during the evaluation and hopefully provide some

recommendations.

During quarter three the cluster will be reviewing recommendations from each

of the evaluations currently being undertaken to inform any future decisions

about the continuation of the existing projects.

2018-19 Cwm Taf Cluster allocation £’000

£1,017

Spend to date

£615

Forecast end year spend

£1,107


29

Organisation:



CWT005 Research, Development and Service Evaluation


Professor John Geen


Primary Care R&D Infrastructure Professor Chris Butler continues to provide research expertise and Clinical Practice to the UHB as part of his retainer. Research Activity Please note: data is subject to change. Data extracted from the Open Data Platform on 19.09.18.

In the first half of the year (1st April 2018 – 30th September 2018) there were 7 active & recruiting non-commercial, primary and community care studies, recruiting a total of 61 participants.



Develop and progress the Research/ Evaluation work programme on each of the agreed themes.

Registration of each project through the appropriate approval (research / evaluation) process.

The number of patients enrolled onto research studies (commercial and non-commercial)

Increase the number of patient recruits participating in Primary care / Community related research.

The number of open research studies in Primary / Community care (commercial and non-commercial)

Increase the number of open research studies taking place within Primary / Community care.

Promote the PICRiS scheme amongst GP practices across Cwm Taf UHB.

Maintain / Increase the number of PICRiS GP practices and income from Health & Care Research Wales.

Submit applications for additional research / evaluation / innovation funding.

Successful applications submitted for research / evaluation / innovation funding in support of the programme of work.


30

CONDUCT – Collection Devices to reduce Urine Contamination (26)

P-PLAC – The (Primary-) Prescribing Lifestyle Adjustments for Cardiovascular Health Study (13)

ABACUS 3 – Antivirals for influenza like illness? Clinical and Cost effectiveness (5)

ARTIC-PC – Antibiotics for lower Respiratory Tract Infection in Children presenting in Primary Care (1)

PRIMUS – Primary care Management of lower urinary tract symptoms in men: Development and validation of diagnostic and decision-making aid (10)

Barack-D – Benefits of Aldosterone Receptor Antagonism in Chronic Kidney Disease (6)

CLASP: Cancer: Life Affirming Survivorship support in Primary care: Internal Pilot and randomised controlled Trial (0)

The following study was active and identified patients from Primary Care and recruited by a secondary care Consultant in Endocrinology. This study has recruited a total of 823 participants.

GENTHYR – Genetics of Thyroid Replacement Therapy (823) In the first half of the year (1st April 2018 – 30th September 2018) there were 2 active & recruiting commercial, primary and community care studies, recruiting a total of 2 participants.

GSK COPD: Post-authorisation Safety (PAS) Observational Cohort Study to Quantify the Incidence and Comparative Safety of Selected Cardiovascular and Cerebrovascular Events in COPD Patients using inhaled UMEC/VI Combination or inhaled UMEC versus Tiotropium (2)

The DECIDE Study: Pragmatic Randomised 104 Week Multicentre Trial to Evaluate the Comparative Effectiveness of dapagliflozin and Standard of Care in Type 2 Diabetes (0)

The following non-commercial study has been adopted onto the research portfolio (Cwm Taf CI) and obtained full ethical approval and is due to start recruitment shortly:

Community Digital INR Self-Testing Study The following non-commercial studies are in development:

Antibiotic Myth Busting

Urgent Eye Conditions in Primary and Secondary Care (Cardiff University)

The following non-commercial studies are closed to recruitment and in follow up:

P-PLAC: The (Primary-) Prescribing Lifestyle Adjustments for Cardiovascular Health Study.

GP Ability Study - Can the introduction of rapid and automatic Ankle Brachial Pressure and Pulse Volume measuring device into General Practice identify the presence or absence of Peripheral Arterial Disease in cardiovascular risk groups?

ALICE – Antivirals for influenza like illness? Clinical and Cost effectiveness


31

ARRISSA – At Risk Registers Integrated into primary care to Stop Asthma crises in the UK. A pragmatic cluster randomised trial with nested economic and process evaluations examining the effects of integrating at-risk asthma registers into primary care with internet based training and support

The following service evaluations are in development:

CRP testing in GP Out of Hours Services (GP)

Early Detection of Oral Cancer (Dentistry) R&D continues to send non-commercial study feasibility requests to Primary and Community Care:

“LQD study: A randomized pragmatic trial comparing the clinical and cost effectiveness of Lithium and Quetiapine augmentation in treatment resistant

Depression”

“AGE 39750: multi-country, multicentre, prospective, descriptive epidemiology cohort study on the burden of acute respiratory infection (ARI) due to respiratory

syncytial virus (RSV) during two consecutive RSV seasons in community dwelling and long-term care facilities (LTCF)/assisted living facilities adults ≥ 50 years of

age.”

“Urgent Eye Conditions in Primary and Secondary Care”

R&D continues to build partnerships with commercial companies to help increase commercial activity within Primary Care.

“INTREPID: Triple therapy treatment for COPD”

“Description and characterisation of asthmatics eligible for biologic therapy referral among primary and secondary care settings in Europe (RECOGNISE

Study)”

“Effect of semaglutide s.c. versus placebo on the progression of renal impairment in patients with type 2 diabetes and diabetic kidney disease”

“A 24-week multi-center, double-blind, placebo controlled dose-ranging study to

investigate the efficacy and safety of oral QBW251 in COPD patients on triple inhaled therapy (LABA / LAMA / ICS)”

PiCRIS The PiCRIS scheme will be promoted to GP Practices across Cwm Taf UHB over the coming months. Applications are expected to be submitted late Autumn (November) and R&D support will be provided to GP Practices to sign up to the scheme. There are currently 11 PICRiS practices across Cwm Taf UHB. Regular Primary Care Research stakeholder meetings are ongoing and in the calendar (August and November 2018).


32

Potential New Primary Care Projects (with potential funding source): Podiatry – Plan to submit a grant by end of 2018 (RfPPB) Dentistry – Earlier Detection of oral cancer (Tenovus) Dentistry – Dental Graduate Educational Intervention (TBC) Pharmacy – Antibiotics Resistance (1000 Lives) GP – CRP Out of Hours Services (Innovate to save or RCGP – for 2019. Support being given for service evaluation in 2018 to use as preliminary data for a larger project) GP – Weight/Scales (RCGP or Kershaw Family Bursary) Health Literacy - Working with citizens to co-produce solutions for hip and knee problems by improving health literacy (TBC) Hepatitis C / Drugs of Abuse / smoking cessation – Working with GP, Population Health researcher and Prof Butler to develop study design with view to submission for grant funding. May also involve working with ex-prisoners returning to the community.


No issues identified to date. Constantly reviewing resource requirements to build on current Primary and Community related research activity.




97 49m 97 0


33

Assessment of the number of practices reporting that they are experiencing workforce issues

Report on the placement of the PCSU workforce

Number of UHB directly managed practices

Evaluate PCSU workforce inputs into new developments of cluster working

Evaluate PCSU workforce inputs into core primary care sustainability

Recruitment of salaried GPs

Recruitment of nurses and

ANPs

Assessment of new roles,

outcomes and contribution to

the wider primary care team

Report on placement of

workforce and outcomes


Detailed Demand and Capacity assessments have been undertaken by the Primary Care Foundation to help inform practices as to their needs in respect of allocation of workforce and resources. Salaried GPs from the PCSU are currently supporting the directly managed practices and the vitual ward model. Two new GPs have been appointed to the PCSU and will commence posts in November and December 2018. They will be placed within the Directly Managed Practices in order to form a new clinical leadership team to drive forward the practice. Positive impact still being seen from the appointment of Occupational Health and Pharmacist into the virtual ward. Detailed evaluations have been undertaken on an individual role but also the impact of the virtual ward. One further Occupational Therapist (OTs)Band 6 has been recruited and a further 2 Band 6 OTs are in the process of being appointed. Two directly managed practices will be reverting back to independent status with effect from the 1st October 2018. This will leave two directly managed practices. Currently remodelling the physiotherapist team to ensure they are responsive to Practice needs.

Organisation:



CWT006 Multi Disciplinary Development – Recruitment and Retention


Sarah Bradley




34


No significant issues to report this at this time


Spend to date £k

Forecast end year spend £k


662 264 624 -38

Organisation:


Delivery Agreement name: Cluster Wound Clinics CWT007

Organisation Lead Contact: Lesley Lewis, Head of Nursing



Measure how quickly appropriate leg ulcer treatment is initiated

No. of patients on leg ulcer assessment waiting list

Measure referral to treatment time

Patient experience

GP experience

District Nurse experience

No. of patients being seen by Practice Nurses for complex wound care

No. of ambulant patients being seen by District Nurses for complex wound care

Duration of treatment, from first appointment to healing.

Treatment to be initiated at a quicker rate than current

A reduction in patients on waiting list

Positive patient experience, informed by patient questionnaires/feedback

Positive GP Practice experience, informed by GP questionnaires/feedback

Positive DN Practice experience, informed by DN questionnaires/feedback

Reduction in complex wound care delivery by Practice Nurses

Reduction in complex wound care delivery for ambulant patients by District Nurses

An average reduction in treatment duration, from first appointment to healing.


35


Positive qualitative feedback is being received from Service Users in the form of feedback forms, compliment letters & thank you cards.

A successful roll out of the service to the Merthyr locality in KHHP on 3rd September saw 35 ambulant patients referred from the District Nursing caseloads over the last 2 weeks.

Anecdotal evidence of feedback from the District Nursing teams in this locality suggest this has had a significant positive impact on the DN teams, which enables the DNs to provide quality care to the Housebound patients.

We have been successful in securing a treatment room for an additional day in YCR to open the clinic to accommodate the increasing demand for wound care in the Rhondda Locality.

The Wound Clinic staff have been involved in the set up and are going ‘Live’ with a new Lindsay Leg Club which will be based in Waun Wen Community Centre in the Rhondda Locality, this is will initially be manned the Wound Clinic staff however going forward a rota will include the neighbouring District Nursing Teams as the club grows. Leg Clubs aim to provide lower limb management in a social environment, where members (patients) are treated collectively and the emphasis is on social interaction, participation, empathy and peer support where positive health beliefs are promoted. The Model impacts positively on healing and recurrence rates and helps isolated older people reintegrate into their communities (Lindsay, 2018). This club aims to have a positive effect on the patients within the Rhondda locality including those who attend the wound clinic.

The long term aim is for Leg Clubs to be rolled out across all other localities, to provide an equitable service to all patients within CTUHB.

Due to the raising numbers of patients upon the Wound Clinics caseload awaiting Lymphoedema appointments for hosiery and assessments, a plan was devised for Lymphoedema Specialist Nurses to attend the clinics at regular intervals to carry out and complete assessments during their clinic appointment. This has reduced patient treatment delays and reduced the waiting lists for the Lymphoedema service.

All staff have completed Lymphoedema ‘Wet Leg Pathway’ training and new staff are due to attend in October. Then patients will be assessed and managed more effectively within the wound clinic service. The Lymphoedema Specialist Nurses are also providing education and support on the allocated dates within the Wound Clinics.

A standardised feedback form for DN teams and GP Practices is still in the process of being devised and distributed through appropriate channels in order to gain robust data around DN/GP experience. However preliminary anecdotal evidence suggests these partners are happy with the Service being delivered by Cluster Wound Clinics.

The first phase of expanding the Wound Clinic to the Taff Ely locality was successfully completed and the clinic is open five days a week. We now accept referrals from four GP practices within the Taff Ely cluster and are still awaiting the final surgeries to begin referrals by the end of October.

Following on from the previous report, when looking specifically at Leg Ulcer treatment, the average length of treatment episode continues to remain significantly lower. This continues to provide an excellent example of the


36

benefits of Cluster Wound Service staff receiving the training from the TVNs in relation to the management of Leg Ulcers, and the effective care that is being provided to patients with Leg Ulcers in the clinics.


The Final phase of Wound Cluster Clinic expansion involved opening a Wound Cluster Clinic in the Merthyr locality, which is based in the outpatient department in KHHP. The clinic is currently running 4 days a week and has taken over the ambulant patients from within the Merthyr Locality District Nursing Service. Rolling into the new month of October the clinic will be open 5 days per week and will be accepting Referrals direct from the Merthyr Cluster GP practices using WCCG following the introduction of a new electronic referral pathway. The development of the new referral method was reliant on NWIS and was significantly delayed.

In order to provide leg ulcer assessment and appropriate treatment of wounds within Cluster Wound Clinics, the nursing staff need to undergo an intense training package to allow this to proceed. It has been challenging to get all staff through the training package whilst maintaining the staffing of clinics and standards of care, so the achievement of this objective may be prolonged. However, a rolling rota is in place to ensure all registered nurses progress through this training and also the new HCSW’s will also attend TVN and Wound care training at a different level.

Currently six members of staff have undergone the full training by TVNs for the assessment and management of leg ulcers, with another member of staff due to commence training in the assessment process. The remaining qualified nursing staff have all completed parts of a robust competency assessment process with the TVNs and hope to complete the full competencies in the future, however this has proven difficult with part time staff and capacity issues within the clinics.

Capacity is presenting an issue across all localities given the successful roll out of the clinics and the uptake of patients. It would be beneficial to have two clinic lists across all localities, but current staffing doesn’t allow this at present.

Due to the increased referrals and limited capacity, a workforce review will be required to ensure adequate cover in all four sites. A model staffing plan will be developed in order to ensure optimal staffing levels within current budget resource.




330 130 330 -26,000


37

Number of inappropriate readmissions from EMI Care Homes to OPMH services.

Continued minimisation of readmissions.

Availability of 7 day access to CPN support and advice for patients and carers.

Patients and carers able to access CPN support and advice when needed, 7 days per week.

Time from referral to assessment and diagnosis.

Reduced time from referral to assessment and diagnosis.

Length of stay in hospital. Reduced average length of stay

Patient, carer and staff satisfaction. Improved patient, carer and staff satisfaction at quality and timeliness of support offered.


Occupancy levels within the Older Persons Mental Health wards remain constant, though there has been no need for any external transfers. Cambrian Ward closed early this financial year, and the new Health & Wellbeing Centre opened in May 2018 (a cornerstone of the Valley Life Project).

The seven days service (which runs in parallel to the Valley Life project) is a supportive service which provides a vital service to patients and carers preventing avoidable admissions. The Directorate’s long term aim of developing other seven day services to assist further continues, specifically around the Dementia Specialist Intervention Team, where it is anticipated that further improvements will be made this year.

The waiting times for OPMH are normally under 26 weeks with the significant proportion of patients still being seen under 11 weeks

The work undertaken with patients and families to ensure our service meet their needs continues. The model of individual meetings with families and carers and patients regarding the arrangements following the closure of

Organisation:

Cwm Taf UHB

Delivery Agreement name: CWT008 Older Persons Mental Health Redesign

Organisation Lead Contact: Phil Lewis




38

Fernhill Ward proved successful and was again utilised successfully during the closure of Cambrian Ward.

The Directorate, with the support of the Health Board, remains committed to a significant programme to support Valley Life, and both RCT and MT Local Authorities continue to contribute to our shared vision.


none




480 240 480 0

Shift fill rates will measured on a weekly basis with particular focus on PCH

Detailed analysis of complaints and compliments

Use of satisfaction surveys for both GPs working in the service

Use of satisfaction surveys for patients using the service

Assessment of achievement against the All Wales OOH Standards

Triangulate demand in A&E and OOHs and In Hours General Practice

Ensure that the fill rate for GP sessions is maintained and does not fall below 80%

Maintain uptake of the shift bundling package

Maintain a 2 site occupancy for the PCC

Change the skill mix within the service reducing the dependence on GP sessions

Achieve more integrated model between A&E and Out of Hours Service

Continue to undertake the 6 month review

Organisation:


Delivery Agreement name: CWT009 Out of Hours Redesign

Organisation Lead Contact: Sarah Bradley




39

Continue to measure the satisfaction from the GPs working in the OOH

Continue to measure the satisfaction of patients using the service

To achieve the OOH standards set by WG


Shift fill rates continue to be measured and reported on a weekly basis. The HMRC, pension issues and regional pay rate issues previously reported have impacted on the rota fill rate seeing a drop from regularly above 90% in 2017 to around 65-75% in the past 6-12 months. Further new supportive measures have been introduced in the form of the introduction of a 30 minute break after 6 hours of working. Work to expand the skill mix within the service to try and reduce the reliance on a GP workforce has been refocussed via new service model proposal which was endorsed at the September 2018 GP Out of Hours Peer Review. This new service model will be taken forward via a dedicated project over the As part of the this process the service will introducing a new Clinical Shift Lead role on weekends and bank holidays. The service will also be utilising the skills of a 111 Clinical Services Hub pharmacist commencing in the Autumn of 2018. The rota fill rate at PCH continues to be challenging. There is a renewed focus on sourcing an alternative location to deliver the OOHs service from at PCH. Complaints and compliments continue to be monitored. Complaints remain low at around 4 per month. Regular engagement meetings with the Director of Primary, Community, Mental Health, and the Clinical Lead take place with the OOHs GP workforce in order that their views are heard and they can help influence and shape the future of the service. The Clinical Lead is also in the process of establishing a new Clinical Reference Group. A Patient Satisfaction Survey is currently being undertaken and results will be published in the coming months. The service continues to report performance to WG against delivery of the WG standards for OOHs services.


40


The reduction in shift fill rates over the past year is being addressed by the development of a new service redesign model which was endorsed at the recent OOHs Peer Review. The new service model has a renewed focus on improved streaming of patients and modernisation of the workforce in order to expand the skill mix within the service and build clinical capacity. This work will be taken forward via a dedicated workstream.




550 212 550 0

Training and Redevelopment

Detailed analysis of the workforce via practice development plans

Detailed analysis of the workforce via cluster development plans

Numbers of staff completing independent prescribing qualification

Numbers of new nurses entering primary care for a career

Number of practice nurses completing the ANP qualification

Number of practice reporting sustainability issues as a result of recruitment and retention problems


Increased capacity within primary care as more staff are able to work autonomously

Increase in the number of practice nurses completing the ANP qualification

Increase in the number of practice nurses choosing Primary Care as a career choice

Decrease in numbers of individuals reporting problems with workforce issues

Increase in the number of patients receiving medication reviews

Increase in number of HCSWs completing the core skills

Organisation:


Delivery Agreement name: CWT010 Training and Development / Management & Leadership

Organisation Lead Contact: Sarah Bradley




41

Increase in the numbers of staff who hold the independent prescribing qualification

framework

Increase in numbers of staff being supported in mentorship roles

Management & Leadership

Evaluation of the new initiatives commenced by the clusters

Evaluation of new initiatives/service development in primary care

Measuring the shift in resource transferred from secondary care to primary care reflecting the shift in service delivery.


Robust cluster programmes across the four Localities delivering innovative and new service development.

Robust and legitimate use of the allocated cluster funds

Positive evaluation of Personal Development Plans

Delivery against the extensive work programme including workforce plan

Positive feedback/satisfaction from independent contractors

Positive feedback from stakeholders

Measure the shift in resource from secondary to primary care


Innovative cluster plans are already in place and full commitment to cluster expenditure. Evaluation report produced in respect of the cluster initiatives, e.g. GPSO, Health and Well Being Co-ordinator Assessment/evaluation has been undertaken of the new community cluster clinics in order to identify those which have provided to be cost and clinically effective. Two clinics, MSK and also Cardiology will be decommissioned in 2018 in order to support the scale up COPD and Diabetes clinic services. Appointment of clinical lead for Diabetes in order to support the additional work the Diabetes community clinic and to link with the wider strategic plans around diabetes. Dedicated experienced resource secured to provide the management and leadership to revert the Directly Managed practices back to independent status. 2 practices will transfer back to independent in October 2018. Continue to support the DSM role for various non medical staff to undertaken the independent prescribing qualification and mentorship. 4 ANP nurses appointed to commence advanced clinical practice Msc who will work across in-hours and OOH. Increase in the clinical practice educator hours in order to deliver the objectives against the HCSW education framework


42


There are no significant issues to report since the last report. All the individuals are in post.


Spend to date £k Forecast end year spend £m

Any difference between planned and forecast spend £m

702 249 777 +75

Organisation:



CWT011 PACESETTER - Development of Advanced Training Practice / Hub & Spoke networks


Sarah Bradley


Detailed analysis of the workforce via practice development plans

Detailed analysis of the workforce via cluster development plans

Numbers of staff completing independent prescribing qualification

Numbers of new nurses entering primary care for a career

Number of practice nurses completing the ANP qualification

Number of practice reporting sustainability issues as a result of recruitment and retention problems

Measuring the shift in resource transferred from secondary care to primary care reflecting the shift


Increase in the numbers of staff within each group who train and secure roles within Cwm Taf Primary Care

Increase in the number of practice nurses completing the ANP qualification

Number of Nurses completing the first year of the Masters Advanced Clinical Skills course

Increase in numbers of pharmacists training in primary Care in Cwm Taf

Increase in numbers of pre-registration nurses training in Primary Care in Cwm Taf

Increase in number of pharmacists working in practice in Cwm Taf


How results / benefits are measured

Results / benefits planned by March 2019


43

in service delivery as a result of an increase in these roles

Increase in the number of practice nurses choosing Primary Care as a career choice following qualification

Decrease in numbers of practices reporting problems with workforce recruitment and retention

Increase in the number of patients receiving appointments with the pharmacist

Increase in the numbers of staff who hold the independent prescribing qualification


Positive feedback regarding the training placements

Positive evaluation of Personal Development Plans

Delivery against the extensive work programme including workforce plan

Positive feedback/satisfaction from independent contractors

Positive feedback from stakeholders


Hub has been established Engagement with practices has taken place across Cmw Taf Identification of 8 spokes and signed up to the scheme. 5 have currently signed up. 27 nursing placements to be undertaken by the end of March 2019. Establishment of practice nurse mentorship group Engagement with WG colleagues and Swansea University in respect of the positive aspects and learning which could be extended across Wales as a model Appointment of Pharmacist Educator at Band 8a Appointment of 4 ANPs to commence the Msc in Advanced Clinical Practice ANP clinical skills and competency framework established To demonstrate that this is a model which can be adopted and rollout out across Cwm Taf, Bridgend and rest of Wales



44

No significant issues to report at this time.




382 43 301 -81

4.1 Primary Care Newsletter

1 4.1 Primary Care Newsletter (Welsh Government) Summer 2018 PCCC 10 October 2018.pdf

Topics this season:

A Healthier Wales

Indemnity

111

Free flu vaccinations for Wales’ care home workers

Community Pharmacy Con-tractual Framework 2018-19

Medicinal Cannabis

Expansion of medical edu-cation

Neighbourhood District Nursing pilots

Referral and Ongoing Care for Children with Suspected Diabetes

Picture of Oral Health 2018

Dental Digest Summer 2018

Funding announcements

Gender Identity Services

Wales eye care service up-lift

Liver Disease Toolkit

Primary Care Newsletter

Summer 2018

A Healthier Wales: Our plan for Health &

Social Care

Health and Social Services Secretary, Vaughan Gething, has

outlined major changes to the way NHS and social care is organised

in the future, bringing more care closer to home, with less reliance

on hospitals.

The proposals are set out in the Welsh Government’s long-term plan

for the future of health and social care in Wales, A Healthier Wales,

which focuses on providing more joined-up services, in community

settings - removing many of the current frustrations expressed by

those both using and working within the system.

In the future people will only go to a general hospital when it is

essential. The intention is to create even better care locally, with

support and treatment available across a range of community-based

services. This shift will mean that when hospital based care is

needed it can be accessed more quickly.

The changes will begin immediately, with a £100million

Transformation Fund to support the implementation of the plan. The

funding will be targeted at resources to speed up the process,

including the development of new integrated prevention services

and activities in the community.

You can read this plan here: https://gov.wales/topics/health/

publications/healthier-wales/

Health Secretary announces state-backed professional indemnity for GPs in Wales

The scheme, which is planned to come into

force from April 2019, will cover all contracted

GPs and other health professionals working in

NHS general practice.

The scheme, which was announced on 14

May will be aligned as far as possible to the

state backed scheme announced in England,

will ensure that GPs in Wales are not at a

disadvantage relative to GPs in England, and

that GP recruitment and cross border activity

will not be adversely affected by different

schemes operating in England and Wales.

Staff working in adult residential care and

nursing homes in Wales will be eligible for free

flu vaccinations through NHS community

pharmacies from this winter, Health and Social

Services Secretary, Vaughan Gething has

announced.

NHS healthcare staff are already offered flu

vaccination by NHS employers as part of

occupational health services. Sustained, year

on year progress has been made in increasing

uptake.

The Joint Committee on Vaccination and

Immunisation (JCVI) recommends that

healthcare and social care workers receive a

flu vaccination to help protect vulnerable

patients and residents in their care, from the

effects of flu.

Last winter, to the end of March 2018, there

were 71 reported flu outbreaks in Wales, of

which 42 (60%) happened in care homes.

Studies have shown that the uptake of flu

immunisation in staff in care homes is low, and

that they have an increased risk of catching flu.

Until now, responsibility for offering flu vaccine

to social care staff has rested with individual

employers. Despite having high flu vaccination

rates in residents, flu can spread easily within

care homes and can be passed from staff to

residents when the staff member has mild or

even no symptoms. This is partly because, as

people age, they do not produce as good an

immune response to vaccination. This makes

vaccination of staff caring for frail, older people

even more important.

Free flu vaccinations for Wales’ care home workers

111 service to be rolled-out nationally

111 is a free treatment and advice service,

managed by a team of professionals, who will

treat or direct users to the right health service

for their need. The service is available 24

hours a day, seven days a week.

Currently the service is only available in the

Abertawe Bro Morgannwg Health Board and

Carmarthenshire areas, where it was launched

as a pilot in October 2016 to test the

practicalities of combining NHS Direct Wales

and the GP Out of Hours services.

The service brings together NHS Direct Wales

and GP Out-of-Hours call handling and triage

into a single service. It differs from other UK

models by having a greater proportion of

clinical staff within it.

The decision to roll out follows an independent

evaluation of the pilot. It found the service

received over 71,000 calls in the first six

months of operation, with 95% or survey

respondents saying they were satisfied or very

satisfied with the service.

Although changes cannot be wholly be

attributed to 111. The evaluation found a 1%

decrease in Emergency Department

attendance in Abertawe Bro Morgannwg

during the first six months of service. There

was also a reduction in ambulance

conveyance to Emergency Departments. This

change was mainly seen in non-urgent

conveyances – down by just over 25% during

the evaluation period.

Community Pharmacy Contractual Framework Funding

Arrangements

2018-19

The Community Pharmacy Contractual

Framework for 2018-19 has now been finalised.

Total funding of £144.3m for 2018-19 includes

additional funding for enhanced services, the

Community Pharmacy

Quality and Safety

Collaborative Working

scheme and the

establishment of 20

Independent

Prescribing Pathfinder

sites by the end of

March 2019.

Enhanced Services

Funding to support

local commissioning of

enhanced services is

being increased initially

by £0.8m. As part of

the agreement, fees

payable for enhanced

services will be

increased in line with

any increase in NHS pay once details of any

pay deal are finalised.

Independent Prescribing Pathfinder sites

£0.2m is allocated to support health boards to

establish 20 pathfinder sites by 31 March 2019,

which utilise independent prescribing (IP) in

community pharmacy settings. Each pathfinder

site is being allocated £10,000 to meet

reasonable costs associated with establishing a

pathfinder site.

Community Pharmacy Quality and Safety

and Collaborative Working schemes

Funding available to the Community Pharmacy

Quality and Safety and Collaborative Working

schemes is being

doubled to £2.0m and

£1.0m respectively

alongside changes to

the schemes’ criteria.

Workforce

Development

Up to £0.35m is being

allocated to support

developing the

community pharmacy

workforce in 2018-19.

Funding (covering

course fees and a

contribution towards

expenses) will be

allocated to support up

to 50 community

pharmacists undertaking independent

prescriber training on courses beginning before

the end of March 2019.

Further funding will be available to encourage

up to 100 pharmacies to enter a new or existing

member of staff on an approved pharmacy

technician training programme.

If you have any queries regarding the

contractual framework for 2018-19, please

email us at [email protected]

Total funding for the Community Pharmacy

Contractual Framework of £144.3m, comprised

of the following elements:

£134.0m for dispensing and advanced

services;

£6.7m for local commissioning of enhanced

service;

£0.2m to establish 20 independent

prescribing pathfinder sites in community

pharmacies;

£2.0m for the Community Pharmacy Quality

and Safety Scheme;

£1.0m for the Collaborative Working

Scheme; and

£0.4m for workforce development

By 2019, through collaboration between Cardiff

and Bangor Universities, arrangements are

expected to be in place for students to be able

to study all of their medical degree in north

Wales.

This will be accompanied by an immediate

expansion of medical education in Wales, with

40 new funded medical places available from

September, 20 in each of Cardiff and Swansea

medical schools. Swansea University will also

collaborate with Aberystwyth University to

increase opportunities in west Wales.

Students will undertake as much of their

studies as possible in community based

settings to reflect Welsh Government policy

that care should be delivered as close to

patients’ homes as possible.

Expansion of medical education in Wales

Medicinal cannabis

Following recent media coverage about a

family’s use of illegal cannabis oil to treat their

epileptic child, the Home Secretary

announced a two-part policy review. The UK

Chief Medical Officer led the first part - a

review of the evidence for the therapeutic

benefits of cannabis-based medicines – and

has confirmed that the evidence is

robust. Based on the findings of the evidence

review, in the second part of the policy review

the Advisory Council on the Misuse of Drugs

(ACMD) will provide ministers with an

assessment of which cannabis products, if

any, should be rescheduled under the Misuse

of Drugs Act.

At the same time, a panel of clinical experts

has been established which will assess

requests from GMC registered clinicians listed

on the relevant specialist register to use

cannabis to treat a named patient. If the

panel accepts the request, the clinician will

retain sole responsibility for his/her prescribing

decisions, and will be required to arrange

supply. Any treatment involving a cannabis

based medicinal product will continue to

require a licence as issued by the Home

Office or the Department for Health in

Northern Ireland.

New British National Formulary (BNF) app

A new British National Formulary and BNF for

Children app has been launched, providing

NHS health care professionals with the latest

content.

The new app will replace the NICE BNF app.

However, unlike the NICE app, the BNF app

does not require an Athens password or a

constant data connection.

You need to download the content update

once per month but the app can then work

offline, even with your device in airplane

mode.

The new app can be downloaded for free from

the AppStore for iOS devices, and the Google

Play store for Android devices. To learn more

please visit:

https://www.bnf.org/products/bnfbnfcapp/

The 13 June 2018, saw the first joint workshop of the

three health board teams piloting neighbourhood

district nursing based on the Buurtzorg model. These

pilots have come about as part of the Plaid Cymru

financial compact with Welsh Government.

The three teams from Aneurin Bevan, Cwm Taf and

Powys were joined on the day by Sue Morgan,

National Director for Primary Care, Dr Sally Lewis,

National Clinical Lead for Value-Based and Prudent

Healthcare and from Welsh Government, Dr Andrew

Havers, Senior Medical Officer for Primary Care and

Paul Labourne, Nursing Officer for Primary and

Integrated Care.

The purpose of the workshop was to hear each health

board plans for taking forward a pilot of the Buurtzorg

model and also to explore ways of how the pilots could

work together. The afternoon was full of positive

discussion; a joint commitment was made by the pilots

to set up an Inter Pilot Forum. Through the forum the

pilots would take forward a joint approach to some

training activities and to measuring success and

evaluation of the pilot projects.

For further information on these pilots please contact

Paul at [email protected] or Rachel at

[email protected] who will only be too

pleased to help.

Neighbourhood District Nursing pilots

Examples of what the pilots are aiming to achieve

include:

A Population Health Focus

Caring for a designated population in line with

the District Nursing Staffing Principles.

Focussing in on sub group populations with long

term conditions within the neighbourhood for

targeted support. For example all three will

focus on palliative care, Cwm Taf have a focus

on respiratory disease, Aneurin Bevan have a

focus on frailty. This focus will look at

implementing improved and prudent skill mix to

maintaining people well within the

neighbourhood.

A Public Health Approach

Developing the neighbourhood district nursing

teams to have a public health making every

contact count approach. This may form part of

the Inter Pilot Forum actions with joint training

and development across the pilots.

A Person Centred Approach

Improving anticipatory and advanced care

planning within the neighbourhood and ensuring

this is well communicated to health and social

care colleagues including primary care, out of

hours services and WAST.

The National Paediatric Diabetes Audit reported in

July 2017 that around 23% of children with type 1

diabetes at the point of diagnosis are in diabetic

ketoacidosis (DKA). DKA requires intensive medical

intervention, is traumatising to the child and family,

and may cause long-term adverse effects on their

diabetes management. It made a number of

recommendations with regard to early diagnosis,

including awareness raising, prompt investigation

and referral.

Following the publication of the Diabetes Delivery

Plan for Wales 2016-2020; the Children and Young

People’s Diabetes Network developed a pathway

for the diagnosis of diabetes that has been

implemented in Cardiff and Vale University Health

Board. This pathway is now being shared with

health boards across Wales for local

implementation and paediatric diabetes services will

be helping to communicate the pathway in the

coming months. Any questions relating to the

pathway can be directed to the network at:

[email protected].

In addition, Diabetes UK Cymru has developed a

public awareness campaign highlighting the

common symptoms called “Know Type 1”, including

materials for primary care practices, which can be

found at: https://www.diabetes.org.uk/in_your_area/

wales/campaigning/know-type-1---wales.

Referral and Ongoing Care for Children with Suspected Diabetes

The Welsh Oral Health Information Unit (Cardiff

University) report, published in partnership with

Public Health Wales, shows that the

percentage of children experiencing obvious

tooth decay has dropped significantly from

45% in 2004/05 to 30 % in 2016/17.

The Welsh Government launched the

Designed to Smile campaign in 2008/09 to

improve children’s oral health and has been

piloting a preventive approach to care in dental

practices across Wales.

Between 2004 and 2017, there have been

continued reductions in the prevalence of

dental caries across all deprivation quintiles, as

classified by the Welsh Index of Multiple

Deprivation. Despite this, the ratios of dental

caries experience for the most deprived versus

the middle deprived groups appear to be

widening albeit slightly.

The series of surveys highlight considerable

improvements in oral health amongst 12 year

olds in Wales. In 2020/21 children who

participated in Designed to Smile prior to their

first adult teeth erupting into their mouth will be

surveyed in school year 7 for the first time. The

data collected in 2020/21 will inform the

estimation of the full impact of Designed to

Smile programme on the permanent dentition.

Picture of Oral Health 2018

The summer edition of the Wales Dental Digest has been published for 2018.

The purpose of the Dental Digest is to keep practitioners informed of current issues in NHS

dentistry.

This issue includes an update on contract reform; e-Referral to Specialist Dental Services; EU

Mercury Regulations and a new Clinical Dental Lead for Healthcare Inspectorate Wales.

https://gov.wales/topics/health/professionals/dental/publication/3digest/

Dental Digest—Summer 2018

Health Secretary, Vaughan Gething, has

confirmed almost £1.7million Welsh

Government funding to re-develop Tonypandy

Health Centre.

The funding will support the merger of two GP

practices in the area to create one new

integrated health and care centre, leading to

improved services for patients.

Today’s investment will allow the Health Board

to increase the number of clinical rooms and

create secure accommodation and private

space for clinical staff and patients.

The Cabinet Secretary has also confirmed

£646,000 funding to refurbish Fishguard Health

Centre.

The funding will support the merger of

Fishguard and Goodwick surgeries, updating

the facilities at the current Fishguard GP

practice to accommodate this service change

and lead to improved services for patients.

New funding announcements

From this autumn, people requiring gender

identity treatment will be able to access more

of their treatment in Wales.

The new Welsh Gender Team will start seeing

patients at the end of October, allowing

transgender people to access the care they

need closer to home.

Currently, all patients who present with gender

dysphoria are referred to the London Gender

Identity Clinic, where they are assessed and

provided with a treatment plan.

Patients in the Cardiff and Vale area who have

experienced difficulty in accessing the

medicines that have been recommended for

them by the London Clinic will be able to

access their prescriptions via a specialist GP

from next month. This development is targeted

towards the area of most need, with most

patients waiting for hormone replacement living

in the Cardiff area.

Work is continuing with Health Boards and the

General Practitioners Committee to develop a

fully integrated gender identity service in

Wales.

Adult gender identity services available in Wales this autumn

Welsh Government has reached

agreement with Optometry Wales

on a 1% payment uplift to

optometrists providing the Wales

Eye Care Services for 2018-19;

which include NHS sight test fees,

NHS optical voucher values,

payments for continuing education

and the training and pre-

registration supervisors grant. The

cost for these services will be

managed through the local health

boards.

After the uplift is applied,

payments for accredited Eye

Health Examination Wales

optometry practices will be:

£61.20 per Band 1

£40.80 per Band 2

£20.40 per Band 3

Wales Eye Care Service uplift

Other agreed payments include:

Accredited Low Vision Service Wales optometry practices

payments: £78.55 (rising from £77.77) for each low vision

assessment.

NHS Sight Test Fees/NHS Domiciliary Fee: the fee will remain at

the same level as 2017-18

NHS Optical Voucher Values: will remain at the same level as

2017/18.

Maximum Patient Charge within the Hospital Eye Service:

Maximum charges of £70.00 for single vision lenses and £113.80

in any other case will remain at the same level as 2017-18.

Payments for continuing education and training (CET): Payments

will be made in respect of claims made by optometrists and

ophthalmic medical practitioners relating to CET training

undertaken from 1 January to 31 December 2017. This year the

period during which optometrists and ophthalmic medical

practitioners may make their claims will be 1 July 2018 to 31

October 2018. Optometrists and OMPs can claim £550 compared

to £545 for the calendar year 2016.

Pre-registration supervisors grant: As of 1 April 2018 the

allowance paid to supervisors of pre-registration trainees will

increase to £3,549 from £3514. Claims from trainers taking on pre-

registration trainees on or after 1 April 2018 should be paid at this

new rate.

The British Liver Trust in conjunction

with the Royal College of GPs have

developed a liver disease toolkit. The

toolkit is part of a three year

programme of work running from 2016-

2019 that aims to support GPs and

primary care professionals in

identifying and delivering care to

patients with liver disease.

Its ultimate aim is to make liver disease

prevention, detection and treatment a central part of routine healthcare amongst the UK’s

43,000 GPs, practice nurses and other team members.

Progress on the project can be found here

Resources for practitioners can be found here

The toolkit is fully endorsed by the Liver Disease Implementation Group (LDIG). Andrew

Yeoman, Clinical Lead for Liver Disease in Wales commented: “Liver disease is on the

increase and the majority of people with cirrhosis do not know they have it because there are

few, if any symptoms. Consequently the early detection of liver disease in the community is of

fundamental importance to better patient outcomes. Therefore, the GP Liver disease toolkit -

produced by the British Liver Trust in collaboration with RCGP - is a hugely welcome

development and nicely complements the existing work of the LDIG around early detection. We

therefore wholeheartedly endorse this important initiative."

The programme aims to:

Improve early detection of all types of liver disease and ensure that patients receive appropriate

intervention and treatment

Raise awareness amongst GPs, primary care nurses and patients of the key risk factors for liver

disease, including alcohol misuse, obesity, and viral hepatitis

Provide practitioners with information on interventions to reduce risk factors and therefore prevent

liver disease developing

Develop and encourage the use of clear early identification, management and treatment pathways

and common GP systems for alcohol-related liver disease, viral hepatitis and non-alcohol related fatty

liver disease with the aim of using referral to secondary care in the most effective way

Disseminate clear guidelines, toolkits, resources and learning materials to GPs and provide e-learning

and workshops

Ensure that primary care clinical coding systems provide an effective means for the recording of liver

disease to facilitate both clinical care and data retrieval for audit and research

Welsh Government Climate Change Adaptation

Welsh Government has committed to publishing a new Climate Change Adaptation Plan in 2018. The

new plan is being developed in response to the UK Government’s latest Climate Change Risk

Assessment and the associated evidence report produced by the UK Committee on Climate Change.

July 2018 was one of the hottest and driest months on record in Wales, and our country has been subject

to several extreme floods in recent years. While these individual events can’t be directly linked to climate

change, projections indicate such events will be more frequent and severe in nature in future and will

affect all aspects of our economy, our environment and our lives. In addition, global impacts will affect

issues such as supply chains and the availability of imported food.

The Minister for Environment is, therefore, keen to ensure the involvement of stakeholders from across all

sectors in Wales, to provide the best opportunities and outcomes for Wales.

We have been working with a range of organisations to develop a set of draft actions for our new plan.

You are invited to workshops on 10 September in Cardiff, and on 12 September in Llandudno, to consider

our progress and contribute to the discussion.

https://wales.business-events.org.uk/en/events/p-86p4z9kxjl05mdn78l12we3yo7r8gvno/

In case you missed it...

Monthly Primary Care Updates

The primary care team at Welsh Government receive a large number of requests for briefings and advice on responses to correspondence, media enquiries and Assembly Questions. We recently launched a new process for gathering information on primary care issues that may affect patients, such as GP practices that are being supported under the Sustainability Assessment Framework, or are being managed directly by the health board. On 5th February we circulated two templates to directors and heads of primary care. One of which should be completed on a monthly basis. We hope it will cover most eventualities and allow us to respond to the majority of press queries and correspondence. However, we also circulated a “by exception” reporting template for those occasions where the unexpected happens which has not been captured on the latest monthly report and which is likely to lead to media and public interest. This could include a sudden practice closure, or an untoward incident that may attract political or press attention. Both templates explain who to contact for any queries and the e mail address for submission of the information. You should have received your blank templates by now, but if not, please email [email protected]

4.2 IMTP Monitoring Report

1 4.2 IMTP Monitoring Report paper PCCC 10 October 2018.docx

Primary and Community Care IMTP Monitoring Report

Page 1 of 5 Primary & Community Care Committee Meeting

10 October 2018

AGENDA ITEM 4.2

10 October 2018

Primary & Community Care Committee Report

PRIMARY AND COMMUNITY CARE IMTP MONITPRING REPORT

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

Author: Mrs Alison Lagier, Locality Manager

Contact Details for further information: Lauren Morgan, 01443 443755 or

email [email protected]


The purpose of this paper is for the Primary & Community Care Committee to receive and NOTE the Monitoring Report for the Primary and Community Care

Delivery Plan, IMTP (See attached as Appendix 1).

Governance

Link to Health Board Strategic Objective(s)




• 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 supports all of the Strategic Objectives.

Supporting evidence ‘Setting the Direction’ Welsh Government

‘Our plan for primary care services in Wales’ Welsh Government 2014

Cwm Taf UHB 3yr Integrated Medium Term Plan.


Primary Care & Localities Management Team and wider directorate staff, All Primary Care CD's and Assistant Medical Director for Primary & Community

services. Primary & Community Care Committee of the Board, Clinical Engagement with Secondary Care, Locality Leadership Group (LA & 3rd sector partners), Local

Medical Committee (LMC), Acute Directorate Managers, GP Practice Managers, Executive Board, GP Cluster Leads, UHB Directors.



10 October 2018

Primary and Community Care Committee Resolution To:


Recommendation The Primary & Community Care Committee is

asked to: • NOTE the Monitoring Report for the Primary and

Community Care Delivery Plan IMTP.

Summarise the Impact of the Primary and Community Care Committee

Report

Equality and Diversity A large part of the plan attempts to address the deprivation and Inverse Care Law implications for

our population. It also recognises the specific needs of identified client groups. Specific

components of the plan will be Equality Impact Assessed as necessary and mitigating actions will

be addressed.

Legal Implications None noted to date.

Population Health The plan is based on the health needs assessment undertaken by Public Health Wales ‘A profile of

health and lifestyle in Cwm Taf – Nov 2013’ produced to support Cluster Plan development.

Quality, Safety & Patient

Experience

The plan centres on improving the quality of our

services to patients and enhancing the patient’s experience.

Resources The resources to develop the plan currently all rest within the Primary Care & Localities management

team. The key delivery actions highlighted are

already identified within the Primary Care and Localities section of the UHB 3 year Integrated

Medium Term Plan and are prioritised against the Welsh Government primary care funding.

Risks and Assurance Any potential or actual risks in relation to the plan will continue to be monitored and featured in our

risk register and will be discussed at the Primary Care Committee of the Board.

Health & 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/10

64/24729_Health%20Standards%20Framework_2015_E1.pdf

The Primary & Community Care Delivery Plan reflects the related quality themes.



10 October 2018

Workforce There are key workforce issues associated with this work in relation to demand on GP’s and practice

staff in general and also the demand on acute services. The intention is that this work will support

alternative roles and skill mix to deliver on the ever growing needs of our population. The workforce

issues outlined within the Plan are again reflected in detail within our Integrated Medium Term Plan

which should be read in conjunction with this document.


status

Open



10 October 2018

THE PRIMARY AND COMMUNITY CARE IMTP MONITORING REPORT

1. SITUATION/PURPOSE OF REPORT

The purpose of this paper is to receive and NOTE the Monitoring Report on the

Action Plan for the Primary and Community Care Delivery Plan Integrated Medium Term Plan (IMTP). The full report is available online at:

http://cwmtaf.wales/Docs/Board_Papers/Legacy%202015-2016/15-11%20November%202015/AI%20%203%202%20Appendix%201%20Primary

%20and%20Community%20Care%20Delivery%20Plan%20UHB%204%20Nov%202015.pdf. The Monitoring Report is attached as Appendix 1

2. BACKGROUND/INTRODUCTION

In November, the 2014 Welsh Government launched ‘Our Plan for a Primary Care Service for Wales up to March 2018’, which clearly sets out the work NHS

Wales will do by March 2018 to further develop and improve Primary Care and Community Services.

Welsh Government require Health Boards to move more resources out of

hospital based care and support a clear shift of care into local communities. It is critical to ensure that there is sufficient capacity and investment in Primary

Care and Community Services to support the strengthening of prevention initiatives whilst better managing growing demand.

The development of the Integrated Medium Term Plan (IMTP) has provided the opportunity to align the planning and delivery of primary care services as an

integral part of the Health Board’s overall strategic direction. The Localities and Primary Care Team have developed a Primary Care and Community Plan with a

renewed emphasis on the changes required across the Health Care System detailing a vision for Primary Care. It is now a key feature of the Health Board’s

IMTP, along with emphasis on addressing health inequalities, strengthening prevention and building capacity and managing demand. We constantly aim to

secure and sustain progress made in the previous year, whilst refreshing our plan to reflect new national requirements, our local priorities and the desire to

‘fast track’ innovation/ modernisation and new models of delivery in Primary Care.

3. ASSESSMENT/GOVERNANCE AND RISK ISSUES

Governance The report as outlined in Appendix 1 is used by the directorate to track and

report on progress of all the key elements that are within the Primary and Community Care IMTP. The report is up-dated for each new financial year and

reflects the current priorities within the IMTP for 2018/19 along with the

refreshed Welsh Government Delivery Agreements.



10 October 2018

This is a live document that is up-dated quarterly by the directorate and used to report progress. Any key risks are also highlighted and are then included

within our own risk register for monitoring. Key elements of the plan would also feature via designated papers to the Integrated Quality and Safety Committee

within the directorate and any other committees within the UHB as appropriate.

Overview of Red and Amber Actions

There is one RED risk identified Out of Hours /111 Sustainability. This has been identified in our directorate Risk Register. The OOH service has faced a

few challenging months in respect of the shift fill rate. There has been weekly movement with the fill rate currently averaging at 70%. We are trying to reduce

and mitigate the risks both short term and long term by looking to alternative workforce to GP’s to pick up some of the capacity needed. Doctors in training at

Specialist Training year 2 and 3 (ST2s & ST3s), advanced nurse practitioners

(ANPs) and paramedics are being used currently with other workforce being explored and training programmes developed.

There is one AMBER risks identified:

Repatriation of Community Dental Service - The action for this quarter was

to work with and receive the data collection from Cardiff and the Vale University Health Board (C&VUHB) and to ascertain intentions of the transfer of

undertakings for prior employment (TUPE) as well as scope and cost IT systems, equipment, capital and workforce implications. Much of this work is very difficult

to progress currently as despite requesting the information there is a delay in receipt of any financial information from C&VUHB. This has been escalated by

the Director.

4. RECOMMENDATION

The Primary Care Committee is asked to:

• NOTE the Monitoring Report for the Primary and Community Care IMTP

Freedom of Information status

Open

4.2.1 Appendix 1 IMTP tracker quarterly report PCCC 10 October 2018

1 4.2.1 Appendix 1 IMTP tracker quarterly report PCCC 10 October 2018.docx

DIRECTORATE: PRIMARY CARE & LOCALITIES – 2018/19 PRIORITIES

1

The table below outlines the top 10 priorities for the Directorate in 2018/19 APPENDIX 1

Key Priority Quarter 1

Milestones

Quarter 2

Milestones

Quarter 3

Milestones

Quarter 4

Milestones

Risks RAG Rating

(Red, Amber, Green)

1. Out of

Hours/111

Sustainability

Maintain shift fill

rate ( 80% target)

Introduction of

shift breaks to

ensure max 6

hour shift

Set up clinical

reference group

Increase pay

rates to

harmonise with

neighbouring

HBs

Implement

regional working

overnight SE

Wales

Utilise clinical

services hub 111

pharmacist

Rebranding as

Urgent PC OOH

service

Evaluate

Clinical Service

Hub regional fill

rates

UHB lack of

agreement to

increasing pay

rates

Fill rate

decreases

RAG Red

Q1 & Q2

Fill rate can vary average

70% over last 4 weeks.

However the shift rate is in

reality lower as we are

reporting against a skeleton

rota.

30 mins shift break

introduced after 6 hours

max

Clinical Reference Group in

process of being set up

Harmonisation of pay not

yet progressed.

2. Pacesetter

Training Hub

Establish steering

group

Establish hub and

spokes

implementation

plan

Trainees in

placements

Recruit

pharmacist

trainer

Development of

mentorship

capacity and

available

placements

Share learning

on all Wales

basis

Evaluation and

student

feedback

Students

consolidation in

primary care/

job offers on

registration

Securing

continued

funding,

placements and

job

opportunities

RAG Green

Q1 & Q2

All milestones achieved,

positive interest from WG

who wish to use this as a

model to roll out across

Wales


2


Milestones

Quarter 2

Milestones

Quarter 3

Milestones

Quarter 4

Milestones

Risks RAG Rating

(Red, Amber, Green)

3. Development of

Primary &

Community Care

Estate

Identification of

key demand and

capacity issues

Mountain Ash –

establishment of

project board and

steering group;

Agreement for

land to transfer

directly from LA to

Apollo;

Development of

timeline

Tonypandy –

submission of

further

information to WG

to secure funding

Development of

P&CC Estates

Strategy

Mountain Ash –

Heads of Terms

agreed;

Revised

timeline;

Agreement on

accommodation

schedule;

Apollo liaise

with DV re

rental value;

Apollo instruct

initial design

architects

Tonypandy –

actions

dependent on

WG approval

Monitor

implementation

of Estates

Strategy

Mountain Ash –

Public

consultation

meeting

Pre-application

consultation

ADET and BREAM

pre-assessment

Business Case

submission

Tonypandy -

actions

dependent on

WG approval

Monitor

implementation

of Estates

Strategy

Mountain Ash –

Planning

permission

submitted

Detailed design,

RDS and

specification

Tonypandy -

actions

dependent on

WG approval

Planning

permission

Failure to

receive WG

funding

approval

RAG Green

Q1 & Q2

Mountain Ash - Green

Contract is being amended

to reflect the Heads of

Terms as agree. Building

costs still in negotiation

between the developer and

the District Valuer..

Engagement with the public

has commenced as per the

engagement plan.

Tonypandy - Green Yes on Track Funding approval now received from WG

4. Development of

MDT and

Transformation

Model

Development of

initial draft

transformation

plan

Submission of

Transformation

Plan

Recruitment

campaign

SLAs drafted

Appointment

into new roles

WG approval RAG Green

Q1 & Q2

All Actions Complete


3


Milestones

Quarter 2

Milestones

Quarter 3

Milestones

Quarter 4

Milestones

Risks RAG Rating

(Red, Amber, Green)

5. Development of

Eye Care

services

Promotion of

EHEW/low vision

SPECS – await

outcome of WG

review

Continue to

monitor upward

trend and

financial impact

Identification of

funding for

SPECS

dependent on

review

To be confirmed

depending on Q1

and 2 outcomes

To be

confirmed

depending on

Q1 and 2

outcomes

Insufficient

funding to

cover

increasing low

vision EHEW

claims,

potential cost

pressure

RAG Green

Q1 & Q2

Actions on track

6. Improvement of

Oral Health

Outcomes

Repatriation of

Community Dental

Service

Appointment of

CDS PM;

Establish Steering

Group;

Scoping of service

Baby Teeth Do

Matter

Evaluate

effectiveness and

improvements

shown;

Epidemiology

report for 12 year

olds

Repatriation of

Community

Dental Service

Data collection

from C&VUHB;

Ascertain

intentions of

TUPEs;

Scope and cost

IT systems,

equipment,

capital and HR

implications

Baby Teeth Do

Matter

Decision re

extension and

rolling out of

scheme, based

on evaluation

outcome

Repatriation of

Community

Dental Service

TUPE contracts;

Agree shadow

implementation

plan;

Agree

management

structure

Baby Teeth Do

Matter

Dependent on

outcome Q2

Repatriation of

Community

Dental Service

Appointment of

management

structure;

Agree full

implementation

plan;

Shadow

C&VUHB

service

Baby Teeth Do

Matter

Dependent on

outcome Q2

Failure to

receive

info/data from

C&VUHB

Lack of service

continuity if

staff do not

wish to transfer

C&VUHB failure

to agree to

equipment

transfer

Baby Teeth Do

Matter scheme

evaluation

outcomes – if

not effective

the scheme will

cease

RAG Amber

Q1 – Actions Complete

Q2 - Delay in receipt of

financial information.


4


Milestones

Quarter 2

Milestones

Quarter 3

Milestones

Quarter 4

Milestones

Risks RAG Rating

(Red, Amber, Green)

7. Development of

@Home service

and links to

SW@H

Contribute to

development of

business case of

SW@H 2

Review Health

@Home

requirements

with Therapies

to align with

SW@H 2

requirements

Review position

and potential

additional

resource or

redesign

requirements

Work with

partners to

develop SW@H2

implementation

plan should

funding become

available

Develop

investment

proposal for

Health @Home

if needed for

IMTP (or

Therapies)

If funding made

available,

commence

implementation

of plan

Funding RAG Green

Q1 & Q2

All actions complete

8. Palliative Care

service

development

New Y Bwthyn

Work with

planning team to

ensure build stays

on target

Establish Project

Group to develop

operational detail

for service

Service

Modernisation

3rd time-out

session to focus

on detailed service

spec

New Y Bwthyn

Work with

planning team

to ensure build

stays on target

Finalise name

of new unit;

Service

Modernisation

Draft service

spec to be

developed and

shared with

specialist team

New Y Bwthyn

Work with

planning team to

ensure build

stays on target;

details of artwork

to Project Board

Service

Modernisation

Refine service

spec and shared

with wider

partners

New Y Bwthyn

Work with

planning team

to ensure build

stays on target

for completion;

development of

de-

commissioning

and

commissioning

plans

Service

Modernisation

Progress

service spec

through

P&EOLC

Delivery Group

Potential risks

associated with

capital

development

RAG Green

Q1 & Q2



5


Milestones

Quarter 2

Milestones

Quarter 3

Milestones

Quarter 4

Milestones

Risks RAG Rating

(Red, Amber, Green)

9.

Community

hospital ward

development

Development of

Steering Group

Visioning paper

Point prevalence

audit

Shared Care Model

with Mental Health

developed and I2S

proposal outlined

Shared care –

capital support for

undertaking of

scoping exercise

for environment

Fortnightly

meetings with

key partners –

acute,

community, LA

Programme

plan developed

with key

timescales

Point

prevalence to

be undertaken

across all

hospital wards

(acute and

community)

Shared Care

I2S to be

submitted (if

approved,

implementation

plan to be

developed)

Capital scoping

to be completed

Draft model to

include rehab

pathway and

proposals around

choice

Shared care – if

agreed,

implementation

plan to

commence

Shared care –

engagement with

stakeholders

Implement new

rehab pathway

and choice

protocol

Shared care -

implementation

Political and

public concern

around formal

implementation

of choice

Sustained

engagement,

agreement and

implementation

of all partners

I2S not

approved in

which case

capital spend

would be

abortive

RAG Green

Q1 & Q2

All actions completed

however the Shared Care

scheme will not be

progressed this year as

despite rigorous work this I

not an I2S it is a service

development and will

therefore be the top priority

again for mental health and

localities in the IMTP for

2019/20. This will now be

taken out of this plan


6


Milestones

Quarter 2

Milestones

Quarter 3

Milestones

Quarter 4

Milestones

Risks RAG Rating

(Red, Amber, Green)

10.

Neighbourhood

Nursing Model

development

Establish Joint

Project Board

Confirm

agreement of

model

New JDs agreed

Recruitment of

staff

Engagement with

key stakeholders

Meet with

Buurtzhorg re

joint learning

and potential

workshop

Commissioning

of Malinko

software

Development of

communication

plan

Commencement

of model in 2 DN

teams

Implementation

of comms plan

Evaluation of

year 1 pilot

Potential

recruitment

IT

infrastructure

support

RAG Green

Q1 & Q2


11 Wound service

and Lindsay Leg

club

a) Wound Service

- Identify

additional

requirements for

roll out to Taff and

Merthyr

b) Lindsay Leg

club – develop

business case,

identify area and

commence

recruitment

a) Wound

Service - Roll

out to Taff

within resource

b) Lindsay Leg

Clubs – develop

operational

process and

commence

Steering Group.

Identify

community

chair for

steering group

and trustees

a) Roll out to

Merthyr with

identified

resource

b) Lindsay Leg

Club –

commence

delivery

a) Evaluate

activity across

all 4 clusters

b) Lindsay Leg

Club

operational

Capacity

Evaluate

Sustaining

community and

trustee

engagement

RAG Green

Q1 & Q2

a) Completed role out to

Taff Ely

b) The first Lindsay Leg club set up in Rhondda. Location Waun Wen Community Centre Trebanog to open on the 3rd October


7


Milestones

Quarter 2

Milestones

Quarter 3

Milestones

Quarter 4

Milestones

Risks RAG Rating

(Red, Amber, Green)

12. CHC cost

containment

Monitor and report

on spend and

achievement of

CRES at monthly

CBMs

Monitor and

report on spend

and

achievement of

CRES at

monthly CBMs

Work with

Finance to

develop a

tracker to

support the

work

Work with

procurement to

agree the

programme of

work for new

I2S resource

Monitor and

report on spend

and achievement

of CRES at

monthly CBMs

Review SLA with

Marie Curie for

end of life care

support

Monitor and

report on spend

and

achievement of

CRES at

monthly CBMs

Evaluate the

impact of the

I2S resource

and determine

any new actions

Unpredictability

of patient need

and costs

Lack of capacity

in community

care packages

Risk of costs

increasing in

sector

RAG Green

Q1 & Q2

All complete or on track.

Meeting in diary to agree

work programme with

procurement

5.1 To Review the Forward Look for 2018/19

1 5.1 Forward Look PCCC 10 October 2018.doc

Agenda Item 5.1

Forward Look Primary and Community Care Committee

Page 1 of 2

Primary and Community Care Committee 10 October 2018

PRIMARY & COMMUNITY CARE COMMITTEE: FORWARD LOOK 2018/19

10 October 2018 at 9am Ynysmeurig House Abercynon

Standard items

• Progress on Delivery Agreements (on agenda) Alan Lawrie

• Spotlight on Cluster Hub Development Progress on cluster plan (Locality to be confirmed) –

Rhondda or Taff Ely (on agenda)

Sarah Bradley

• Organisational Risk Register related to the Committee (on agenda) Robert Williams

• GP Sustainability Framework – any applications? (Director’s Report) Alan Lawrie

• Primary Care Indicators (Director’s Report) Alan Lawrie

Additional items

• Plan for update on Neighbourhood Nursing (move to next meeting) Angela Hopkins / Alan Lawrie

• Plan for WAO Primary Care review (move to next meeting) Alan Lawrie

• Update on the progress of anticoagulation services (Director’s report) Stuart Hackwell

• Primary Care Estate (new plan) (move to next meeting) Craige Wilson

• Palliative Care – overview report (move to next meeting) Craige Wilson

• Development plan for the OOHs service in particular with a focus on the multidisciplinary team approach and GP retention (on agenda)

Craige Wilson

• Update on Medicines Management (move to next meeting) Alan Lawrie

• Eye Care Plan Update (Directors Report) Alan Lawrie

• Econsult / web GP (Directors Report) Alan Lawrie

• Baby Teeth DO Matter Evaluation Report (on agenda) Kelechi Nnoaham

• Inverse Care Law (on agenda) Kelechi Nnoaham

• IMTP Monitoring report for information (move to next meeting) Alan Lawrie

Agenda Item 5.1

Forward Look Primary and Community Care Committee

Page 2 of 2

Primary and Community Care Committee 10 October 2018

Wednesday 9 January 2019 at 9am Ynysmeurig House Abercynon

Standard items

• Primary and Community Care Delivery Plan – Progress on Implementation Alan Lawrie

• Progress on Delivery Agreements Alan Lawrie

• Spotlight on Cluster Hub Development Progress on cluster plan (Locality to be confirmed) –

Rhondda or Taff Ely

Sarah Bradley

• Organisational Risk Register related to the Committee Robert Williams

• GP Sustainability Framework – any applications? Alan Lawrie

• Primary Care Indicators Alan Lawrie

Additional items

• Plan for update on Neighbourhood Nursing Angela Hopkins / Alan Lawrie

• Full response to WAO Discharge Planning Report Alan Lawrie

• Plan for WAO Primary Care review (moved from last meeting) Alan Lawrie

• Primary Care Estate (new plan) (moved from last meeting) Craige Wilson

• Palliative Care – overview report (moved from last meeting) Craige Wilson

• Update on Medicines Management (moved from last meeting) Alan Lawrie

• IMTP Monitoring report for information (moved from last meeting) Alan Lawrie

Items to consider • Links between the GMS Directly Enhanced Service (DES)

for Care Homes and the National Enhanced Service (NES) for Community Pharmacy for the same Sept 2019

Annual requirements • Annual Governance Statement Contribution

• Terms of Reference in line with the Standing Orders to take place in March 2019

• Committee Annual Report June 2019

Next meetings

Wednesday 3 April 2019

9.00am Rhondda & Cynon Rooms YMH

NB - Urgent items will be accommodated as required and

the Forward Look is subject to change.

Wednesday 10 July 2019

9.00am Rhondda & Cynon Rooms YMH

Wednesday 9 October 2019 9.00am Rhondda & Cynon Rooms YMH

bundle primary & community care committee 10 october 2018cwmtafmorgannwg.wales/docs/primary care...

Documents