delivering through partnership - whssc.wales.nhs.uk annex (ii) a… · delivering through...

Delivering through partnership

This report is the property of Cwm Taf University Health Board; it must not be copied in

whole or in part without the express permission of the author:

Shane Mills Clinical Lead for Collaborative Commissioning & Head of the NHS Wales Quality Assurance & Improvement Team West 3a Whitchurch Hospital Cardiff CF14 7XB By telephone on 029 20336278 By e-mail at [email protected]

The NHS Wales Collaborative Commissioning Leads and NHS Wales Quality Assurance & Improvement Team are hosted by Cwm Taf University Health Board on behalf of NHS Wales.

The National Framework was developed and is monitored in partnership between NHS Wales Quality Assurance & Improvement Team and NHS Wales Shared Services Partnership: Procurement Services on behalf of NHS Wales.

The Commissioning Care Assurance & Performance System was developed in partnership between NHS Wales Quality Assurance & Improvement Team and NHS Wales Informatics Services on behalf of NHS Wales.

mailto:[email protected]

NHS Wales National Collaborative Framework for Adult MH & LD Hospitals Annual Report 2014-2015

Foreword

The NHS Wales National Collaborative Framework for Adult Mental Health &

Learning Disability Hospitals provides demonstrable evidence that employing a „once

for Wales‟ approach creates the ability to apply such frameworks as an improvement

mechanism for increasing quality whilst reducing cost.

Through this annual report the Clinical Lead for Collaborative Commissioning has

enabled Local Health Boards to understand the mechanisms and outcomes of the

oversight regime involved in delivering the National Framework on their behalf.

I commend the 2014/15 annual report as it demonstrates that since approval by the

Minister for Health & Social Care in April 2014 the new National Framework has:

Delivered robust scrutiny and performance management of providers which has

enabled real assurance that patients are cared for in safe and effective

environments, demonstrated through 111 provider assurance reviews undertaken;

Established an intolerance of sub-standard care demonstrated by the termination

of several units from the National Framework and the issuing of 94 improvement

notices with circa 1200 separate improvement actions;

Proven the usefulness of the innovative Quality Assurance Rating system that

presents NHS Wales with an uncomplicated yet robust performance yardstick

demonstrated through 75% of patients being placed with a „3Q‟ provider, although I

am aiming for this number to be higher;

Provided information systems that allow patients to be „in-sight and in-mind‟ even

where the placement is some distance from the Local Health Board and I am

encouraged by the 92% attendance at care & treatment reviews; and

Enabled real cost financial savings to be realised for patients which have remained

in services, and where new patients have been placed it allows quality assured

lower cost providers to be commissioned. Activity cost reductions have now

exceeded £9m since the launch of the framework in 2012

Yours sincerely

Stephen Harrhy

June 2015

Mr Stephen Harrhy Chief Ambulance Services Commissioner & Director responsible for NHS Wales Quality Assurance & Improvement Team


About this Annual Report

This section explains the context and assumptions made to support the reader in

understanding, interpreting and positively using this annual report.

The NHS Wales National Collaborative Framework for the Provision of

Medium secure, Low Secure, Controlled Egress and Uncontrolled Egress

Adult Mental Health and Learning Disability Services shall be referred to

as the „National Framework‟ within this annual report.

The terms medium and low secure are used within the National

Framework to denote a unit that has secure entrance and perimeter and

high degree of relational and procedural security. Medium secure units

normally care for patients with a higher risk profile.

The term controlled egress is used within the National Framework to

denote a unit (usually termed locked rehabilitation) that has a restricted

exit/entrance.

The term uncontrolled egress is used within the National Framework to

denote a unit (usually termed open rehabilitation) that has an

unrestricted exit/entrance during working hours.

This report covers those patients receiving assurance under the National

Framework it does not cover any patient placed with a provider not

providing services under the National Framework.

This annual report is based on activity between 1st April 2014 and 31st

March 2015.

The pathway through hospital care can take several years and this is the

third annual report of the National Framework, therefore caution should

be taken when attempting time based comparisons.

Activity savings are estimated as savings to hospital care and will be

available to offset possible incurred costs in non-hospital settings.

The following abbreviations will be used for Local Health Boards (LHBs)

Abertawe Bro Morgannwg University Health Board (ABMUHB)

Aneurin Bevan University Health Board (ABUHB)

Betsi Cadwaladr University Health Board (BCUHB)

Cardiff and Vale University Health Board (C&VUHB)

Cwm Taf University Health Board (CTUHB)

Hywel Dda University Health Board (HDUHB)

Powys Teaching Health Board (PTHB)

https://www.wales.nhs.uk/ourservices/directory/LocalHealthBoards/866


Section A

Overview of National Framework services

Background

Overview of National Framework services

Section B

Providing Assurance & Improving the Quality of Care

Section C

Ensuring Safe, Effective & Efficient Providers

Section D

Delivering Better Value whilst Improving Quality

Appendices A-Providers B-Trends by LHBs

Supplemental

Building on success i-National Framework refresh ii-CAMHS National Framework

iii-Integrated Collaborative Commissioning Programme


For clarity this background is presented in the form of frequently asked questions

“Data remains the single most important motivator and tool for

a clinical leader: high quality, comparative, unit-level and individual-level clinical and

financial data”

Public Health Wales (2014) Achieving Prudent Healthcare in NHS Wales

“The possession of accurate, relevant, and useable information from which the safety and quality of services can

be ascertained is the vital key to effective commissioning”

Francis, R. (2013). Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office.


Background

1. Why do we have a National Framework?

Prior to 2012 non-NHS Wales mental health and learning disabilities hospital services

were commissioned separately by each Local Health Board or through the Welsh Health

Specialised Services Committee. These commissioning arrangements led to disparity in

costs, contractual obligations, standards and performance management across NHS

Wales. Oversight of these hospitals was the remit of individuals or small teams within

Local Health Boards with little or no collaboration. An independent review in 2012

stated that the use of the independent sector by NHS Wales prior to the development of

the National Framework was “inefficient, ineffective and inconsistent”1.

In March 2012 a National Framework for medium and low secure care was launched

and was successful in improving quality assurance and reducing costs. Subsequently the

Chief Executives of the NHS Wales Local Health Boards considered that a broader suite

of services required the assurance of a national collaborative framework and developed

the NHS Wales National Collaborative Framework for Adult Mental Health & Learning

Disability Hospitals, commenced in April 2014.

2. What is the National Framework?

The NHS Wales National Collaborative Framework for Adult Mental Health & Learning

Disability Hospitals is a formal agreement and mechanism developed by the NHS Wales

Collaborative Commissioning Leads and Shared Services Partnership that enables the

National Health Service in Wales to procure and performance manage services under

the pre-agreed standards, costs, terms and conditions of a contract in a compliant

manner in accordance with EU and UK Procurement Regulations and LHB Standing

Orders and Financial Instructions.

3. What are the benefits of the National Framework?

The National Framework was developed to enable:

An approved list of suitably qualified, financially viable providers to meet NHS

Wales‟ quality, service and cost criteria;

The establishment of bespoke NHS Wales‟ care standards, standard contract

terms/conditions and a transparent pricing framework;

Access to management information and the provision of clear and consistent patient

level data to underpin a performance management framework; and

Consistent and sustainable high quality service provision and improved patient

outcomes.

1 Tayside Centre for Organisational Effectiveness (2013). Review of the NHS Wales Mental Health & Learning Disability Secure Services Procurement

Project, a retrospective view. Cardiff: NHS Wales

7


4. What is the scope of the National Framework?

The scope of services covered by the National Framework are-

Independent and NHS England hospitals providing the following services:

Medium secure, mental health, male;

Medium secure, mental health, female;

Medium secure, learning disabilities, male;

Medium secure, learning disabilities, female;

Low secure, mental health, male;

Low secure, mental health, female;

Low secure, learning disabilities, male;

Low secure, learning disabilities, female;

Controlled egress, mental health, male;

Controlled egress, mental health, female;

Controlled egress, learning disabilities, male;

Controlled egress, learning disabilities, female;

Uncontrolled egress, mental health, male;

Uncontrolled egress, mental health, female;

Uncontrolled egress, learning disabilities, male; and

Uncontrolled egress, learning disabilities, female.

5. What has changed with the National Framework since 2012

In February 2012 the first National Framework covered medium and low secure

services provided by 11 provider companies/organisations with a total of 37 separate

hospital sites and 84 individual units.

In April 2014 the second National Framework covered medium secure, low

secure, controlled egress and uncontrolled egress services provided by 22 provider

companies /organisations with a total of 88 separate hospital sites and 290

individual units.

6. How are services commissioned under the National Framework?

The National Framework provides the enacting mechanism for the commissioning

of services. These services are provided once a patient is placed through the

National Framework process and an individual patient placement agreement is

generated, and therefore a contract enacted, between the placing organisation and

provider. As of 31st March 2015, 20% of patient placement agreements are generated

by the Welsh Health Specialised Services Committee for specialist hospital services

and 80% by Local Health Boards for non-specialist hospital services.

8


Section A

Overview of National Framework

7. National Framework Patient Overview 2015 11 8. National Framework Overview Trends 2014-2015 11 9. National Framework Overview by Local Health Board 12 10. National Framework Overview Trends 2014-2015 by LHB 12 11. Learning Disabilities/ Mental Health split 13 12. Male/Female split 14 13. Age profiles 14 14. Patient placement by country 15 15. Length of stay (completed and continuing) 15 16. National Framework Activity – Admissions 17 17. National Framework Activity – Discharges 18


Overview of the National Framework

“Data should be kept by health and social care commissioners, on all [Out

of Area Placements], in order to inform service and system development and to

monitor progress over time”

Royal College of Psychiatrists. (2005). Out of area treatments for working age adults. Faculty Report

Welsh Government, (2012) Together for Mental Health: A Strategy for Mental Health and Wellbeing in Wales. Cardiff: Welsh Assembly Government.

“Service user experience is improved, with safety, protection

and dignity ensured and embedded in sustainable services”


Overview of National Framework

7. National Framework Patient Overview 2015

On 31st March 2015 there were 342 adult patients of NHS Wales receiving assurance

under the National Framework, shown in the graphic below by tier of care.

8. National Framework Overview Trends 2014-2015

On 31st March 2015 there were 342 adult patients of NHS Wales receiving assurance

under the National Framework compared to 339 on 1st April 2014 and denotes an

increase of 1%, with specific adjustments in the following areas:

Number of patients cared for by medium secure providers increased by 6%;

Number of patients cared for by low secure providers reduced by 4%;

Number of patients cared for by controlled egress providers increased by 19%;

Number of patients cared for by uncontrolled egress providers reduced by 25%.

The chart below compares the number of patients receiving assurance under the

National Framework by tier of care on 1st April 2014 (342) and 31st March 2015 (339).

Medium Secure

69 patients (20%)

Low Secure

151 patients (44%)

Controlled Egress

95 patients (28%)

Uncontrolled Egress

27 patients (8%)

65

158

80

36

69

151

95

27

0

20

40

60

80

100

120

140

160

180

Medium secure Low secure Controlled egress Uncontrolled egress

Nu

mb

er

of

pat

ien

ts

Tier of care

2014 2015

11


9. National Framework Overview by Local Health Board

In terms of the 342 patients receiving assurance under the National Framework

on 31st March 2015:

ABMUHB had 19% (65) of the total patients;

ABUHB had 18.7% (64) of the total patients;

BCUHB had 18.4% (63) of the total patients;

C&VUHB had 16.1% (55) of the total patients;

CTUHB had 12.6% (43) of the total patients;

HDUHB had 9.6% (33) of the total patients; and

PTHB had 5.6% (19) of the total patients.

The proportion of LHB patients by tier of care is detailed in the chart below.

10. National Framework Overview Trends 2014-2015 by LHB [Appendix B provides details on the number of patients by tier of care on April

1st 2014 and March 31st 2015 by LHB]

Between 1st April 2014 and 31st March 2015 the overall number of patients of

NHS Wales receiving assurance under the National Framework varied by LHB

specifically:

ABMUHB had 16% more patients;

ABUHB had 7% less patients;

BCUHB had 2% more patients;

C&VUHB had 6% more patients;

CTUHB had 2% less patients;

HDUHB had 3% less patients; and

PTHB had 14% less patients.

4

4

6

14

14

10

17

6

20

20

25

25

33

22

8

8

17

12

16

9

25

1

1

4

8

12

1

0 10 20 30 40 50 60 70

PTHB

HDUHB

CTUHB

C&VHB

BCUHB

ABUHB

ABMUHB

Number of patients by tier of care

Medium secure Low secure Controlled egress Uncontrolled egress

12

The chart below details the number of patients receiving assurance under the National

Framework by LHB between 1st April 2014 and 31st March 2015.

11. Learning Disabilities/Mental Health split [Note that figures denote patients admitted per classification of unit not diagnosis]

Of the 342 patients receiving assurance of the National Framework on 31st March 2015,

those cared for in mental health units make up 79% of the total (271), whilst those cared for

in learning disabilities units make up the remaining 21% (71).

Of the 21% cared for in learning disabilities units, 8% are female (28) and 13% male (43).

The chart below displays the percentage of patients receiving assurance under the National

Framework on 31st March 2015 in mental health or learning disability units as a percentage

of the overall number within a specific tier of care.

56

128

64

23

13

23

31

4

0% 20% 40% 60% 80% 100%

Medium secure

Low secure

Controlled egress

Uncontrolled egress

% of overall patients

MH LD

56

69

62

52

44

34

22

65 64 63

55

43

33

19

0

10

20

30

40

50

60

70

ABMUHB ABUHB BCUHB C&VHB CTUHB HDHB PTHB

Nu

mb

er

of

pat

ien

ts

April 1st 2014 March 31st 2015

13


Females31%

Males69%

12. Male/Female split

As of 31st March 2015 of the 342 Welsh

patients receiving assurance under the

National Framework, 69% (237) were

male and 31% (105) were female as shown

in the graphic to the right.

13. Age Profiles

The age of patients receiving assurance under the National Framework on 31st March

2015 ranged from 18 years old to 76 years old.

Grouping both male and female patients together across all types of care

demonstrated that:

18% (61) of patients were aged between 18-24 years old;

41% (141) of patients were aged between 25-40 years old;

31% (106) of patients were aged between 41-59 years old; and

10% (34) of patients were aged between 60-76 years old.

The table below details the age (in ranges) by tier of care and sex of patients receiving

assurance under the National Framework on 31st March 2015.

8

20

13

67

15

18

46

38

1012

18

97

17

21

11

7

20

11

12

4

9

6

1

5

0

5

10

15

20

25

30

35

40

45

50

Ma

le A

ge

18-2

4

Ma

le A

ge

25

-40

Ma

le A

ge

41-

59

Ma

le A

ge

60

+

Fem

ale

A

ge

18-2

4

Fem

ale

A

ge

25

-40

Fem

ale

A

ge

41-

59

Fem

ale

A

ge

60

+

Nu

mb

er

of

pat

ien

ts w

ith

in a

ge g

rou

p

Medium Secure Low Secure Controlled Egress Uncontrolled Egress

14


14. Patient placement by country [Note that placement by country is subject to quality of suitable providers at the time

of placement, provider‟s ability to meet specific patients needs and bed availability]

Mapping patients receiving assurance under the National Framework within the

borders of either England or Wales shows that overall 68% of patients of NHS Wales

were cared for in hospitals within Wales and 32% in hospitals within England

The chart below details the percentage (of overall LHB number) of patients receiving

assurance under the National Framework on 31st March 2015 by LHB and per country.

15. Length of stay (completed and continuing)

Length of stay can vary enormously depending on response to treatment, complexity

and/or risk. Patients can be subject to assessments that take weeks or be subject to

hospital treatment that takes many years.

Of the 197 patients receiving assurance under the National Framework and discharged

between 1st April 2014 and 31st March 2015:

43.6% (86) had a length of stay of less than a year;

15.2% (55) had a length of stay of between 1 and 2 years;

23.3% (46)had a length of stay of less of between 2 and 5 years; and

5% (10) had a length of stay of greater than 5 years.

41 49

45

2537

27

15

12 13

41

920

5

10

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

ABMUHB ABUHB BCUHB CTUHB C&VUHB HDUHB PTHB

% o

f p

atie

nts

pla

ced

in W

ale

s o

r En

glan

d

Wales England

15


The length of stay is shown in the chart below.

The table below details the length of stay of patients continuing to receive assurance

under the National Framework within their current provider (i.e. not

discharged) as at 31st March 2015 by type of care.

The table below demonstrates that:

43% (146) of patient‟s length of stay was between 1-3 years;

39% (134) of patient‟s length of stay was between 3-5 years;

14% (47) of patient‟s length of stay was between 5-7 years; and

5% (15) of patient‟s length of stay was beyond 7+ years.

<6 mths

6 mths -1 yr

1-2 yrs 2-3 yrs 3-5 yrs 5-7 yrs 7-10 yrs

10> yrs

Medium secure

13 17 22 9 6 2 0 0

Low secure

33 32 47 12 17 9 1 1

Controlled egress

18 23 30 6 9 2 6 0

Uncontrolled egress

3 7 5 3 2 0 5 2

Total 67 79 104 30 34 13 12 3

7

9 9

3 3 3

26

15

29

15

8

3

1

9

1211

3

5

2

5

3

65

4

0

5

10

15

20

25

30

35

<6 months 6 month-1 year

1-2 years 2-3 years 3-5 years 5-7 years 7-10 years 10+ years

Nu

mb

er

of

pat

ien

ts

Completed length of stay on discharge


16


16. National Framework Activity- Admissions

Between 1st April 2014 and 31st March 2015 there were 199 patient admissions

into a National Framework provider.

The chart below details the where the patient was recorded (through the Care

Assurance & Performance System- see section 26) as being admitted from

(admission source), and into a National Framework provider between 1st April

2014 and 31st March 2015

Where there was an identifiable main admission source (excluding unknowns) for

each tier of care it was:

21.1% (8) of patients in Medium Secure care were admitted from Prison;

24.5% (22) of patients in Low Secure care were transferred from another

low secure facility;

29.4% (17) of patients in Controlled Egress were admitted from

independent sector low secure; and

17


17. National Framework Activity- Discharges

Between 1st April 2014 and 31st March 2015 there were 197 patients discharged

from a National Framework provider.

The chart below details the where the patient was recorded (through the Care

Assurance & Performance System- see section 26) as being discharged to

(discharge destination), after receiving care from a National Framework

provider between 1st April 2014 and 31st March 2015.

Where there was an identifiable main discharge destination (excluding unknowns)

for each tier of care it was:

42.9% (15) of those discharged from medium secure stepped down to

independent sector low secure;

23.6% (22) of those discharged from low secure were transferred to

independent sector low secure;

21.3% (6) of those discharged from controlled egress were repatriated to

a NHS MH rehabilitation units; and

20.6% (4) of those discharged from uncontrolled egress stepped down to

a home address.

18


Oth

er

Section B


18. Role of NHS Wales Quality Assurance Improvement Team 21 19. Hospital Assurance Reviews 21 20. Meeting the standards of care 22 21. Improving the quality of care 23 22. Putting quality first 24 23. „Quality then cost‟ – Prioritising high quality providers 25 24. Communication and Connectivity 27 25. National Framework Secure File Sharing Portal 28 26. Commissioners Care Assurance & Performance System 29 27. Attendance at Care & Treatment Plan reviews 30


“Commissioners must have the capacity to monitor the performance of every

commissioning contract on a continuing basis during the contract period”


“Commissioners responsible for funding placements should be proactive in ensuring that

patients are safe.”

Flynn, M. (2012). Winterbourne View Hospital- Serious Case Review. South Gloucestershire Council



18. Role of NHS Wales Quality Assurance Improvement Team

The NHS Wales Quality Assurance & Improvement Team is a national team serving the

seven Local Health Boards and WHSSC. The team performance manages National

Framework providers by:

Challenging substandard provider performance and advising on improvement through

hospital assurance reviews;

Collating and analysing performance management information in line with the National

Framework specifications, standards and contract conditions through the

Commissioning Care Assurance & Performance System;

Ensuring providers reduce risk and dependency and promote hope, recovery and

rehabilitation;

Ensuring all procured services are provided and present value for money;

Ensuring provider quality and safety concerns are raised, discussed and disseminated

with commissioners and statutory agencies; and

Facilitating collaborative working between providers and commissioners to ensure safe,

effective and high quality care that improves patient experience.

19. Hospital Assurance Reviews

Hospital assurance reviews are undertaken by the NHS Wales

Quality Assurance & Improvement Team and involve obtaining

assurance that the provider is maintaining the required clinical

standards, ensuring good clinical practice underpins clinical care

and that providers were reducing risk and dependency and

promoting hope, recovery and rehabilitation.

The team undertook 111 full provider hospital assurance reviews

at individual units between 1st April 2014 and 31st March 2015

including 100% of units where Welsh patients were receiving

services. The team also undertook 41 focused hospital assurance reviews at individual

units in response to concerns raised by performance data, local safeguarding teams,

whistleblowers, LHBs or regulators.

During each assurance review a „provider assurance report‟ is completed and

published on the Commissioning Care Assurance Performance System (see section

26).

21


20. Meeting the standards of care

It is a requirement of providers to maintain the standards set out within the

National Framework. There are 76 bespoke Welsh standards based on best

evidence, experiential learning and good clinical practice across 22 areas of care

delivery within the current National Framework. 111 providers were audited across

all 22 care areas/76 standards between 1st April 2014 and 31st March 2015.

The average number of standards verified as being maintained on the annual

provider hospital assurance review, across all 111 provider units, was 82.8%.

Individual provider units were verified as maintaining between 47.4% and 100% of

the 76 standards through hospital assurance reviews.

The table below details the average achievement for each of the 22 care areas

across 111 provider units audited between 1st April 2014 and 31st March 2015. The

lowest average achievement is listed first (and the lowest scoring three are coloured

red and highest scoring three are coloured green);

98.8

94.9

94.9

91.4

89.6

89.2

87.6

87.3

86.4

84.8

84.6

84.5

83.6

83.2

82.7

82.6

81.9

79.6

79.5

75.0

57.4

54.2

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0

Robust Emergency Planning & Response

Adequate Patients Engagement & Satisfaction

Fit for Purpose Environment

Maintenance / Use of Medical Devices

Effective Leave/community Presence

Assessing and Addressing Nutritional Needs

Respecting Equality, Diversity & Human Rights

Safe & Minimal Physical Interventions

Safe & Effective Patient Observations

Safe Medicines Management

Reporting of Serious & Untoward Incidents

Effective Health Promotion

Adequate & Effective Workforce

Robust Governance & Accountability

Safeguarding vulnerable adults

Satisfactory Patient Information

Accurate & Complete Patient Records

Managing & Addressing Complaints

Effective Care & Treatment Interventions

Effective Risk Assessment & Risk Management

Effective Multi-Professional Team

Robust Care and Treatment Planning

% of provider units maintaining standards in this area

22


The 5 specific standards of the total 76 that measured the lowest compliance rate

within the 111 provider units is detailed in the table below (ranked with the standard

achieving lowest compliance rate ranked first).

21. Improving the Quailty Of Care

After the NHS Wales Quality Assurance & Improvement Team has undertaken either a

full or focused hospital assurance review (see section 19) an improvement notice is

issued if one or more areas of substandard care are identified.

There were a total of 94 improvement notices issued between 1st April 2014 and 31st

March 2015. Each improvement notice details the justification for identifying none-

attainment of the required standard and a series of actions to be completed by the

provider in order to provide assurance the National Framework requirement can be

met. All improvement notices and progress reports are published on the Commissioners

Care Assurance Performance System (see section 26).

Of the improvement notices issued between 1st April 2014 and 31st March 2015 there

were between 1 and 42 actions, with an average of 13 actions per improvement notice

and circa 1200 improvement actions in total issued between 1st April 2014 and 31st

March 2015. An example of a section of an improvement notice is below.

During the improvement notice period the provider is subject to enhanced performance

management, and regular updates on progress towards completion of the improvement

notice are required by the NHS Wales Quality Assurance & Improvement Team. The

improvement notice is concluded once the team has verified that all requested actions

have been completed.

Standard maintained

by 34% of providers

A multi-professional team meeting is convened monthly for each patient to review the care and treatment plan, treatment effectiveness and Patient personal outcomes/goals, and all discussions and agreed actions must be documented in the patient‟s contemporaneous notes.

Standard maintained

by 50% of providers

Each patient‟s mental health, physical health and wellbeing needs are identified through

appropriate assessment

Standard maintained

by 53% of providers

Care and treatment plan(s) must be reviewed at a maximum interval of one month via the

multi-disciplinary team meeting.

Standard maintained

by 56% of providers All identified care and treatment interventions are undertaken.

Standard maintained

by 60% of providers

Patients must be appropriately supported to take as much responsibility for developing the

care and treatment plan as they are able.

Assessment Outcome Assurance required

AREA: Patient engagement and satisfaction-Care planning

The provider must ensure they engage with the patient regarding their care and treatment. All discussions should be clearly recorded in the patient‟s contemporaneous notes.

Core Service Requirement not maintained. There was no evidence that care and treatment

plans are discussed at MDT. Care plans are written in the third person with little

evidence of patient involvement in their development.

Some patients refused to sign care plans or get involved in development but no reasoning documented or any evidence of attempts to re engage following initial refusals.

No discussions with patients, in relation to care and treatment, were evidenced in the plans.

The provider will review all care plans to ensure that all patients are encouraged to engage in their own care and treatment planning and discussions and development

The provider will evidence continuous engagement with each patient to understand the importance of the care plan in the patient‟s clinical records.

The provider will evidence that a system is in place to ensure all care plans are discussed in the MDT at least monthly.

23


22. Putting quality first

The NHS Wales Quality Assurance & Improvement Team has developed a

bespoke „Quality Assurance Rating System‟.

This system is designed to ensure that providers provide care in safe and

high quality environments that promote rehabilitation and recovery, which

use treatments that are evidence-based and effective, whilst ensuring public

protection and value for money.

The system works by making it a contractual obligation for providers to

make every effort to maintain a „rating‟ of 3 quality assurance marks

(represented by 3 „Q‟s). This rating is then periodically revalidated

throughout the contractual term by the NHS Wales Quality Assurance &

Improvement Team.

If a provider fails to meet part of the specification it will constitute a performance

issue and be docked one or more „Qs‟ depending on the consequences or possible

consequences of the failure. The three „Q‟s‟ are re-established after the NHS Wales

Quality Assurance & Improvement Team is satisfied the performance issue is

rectified.

The Quality Assurance Rating System allows as „real time‟ as possible representation

of current provider quality to inform Local Health Boards at the point of patient

placement and throughout the patients stay.

The table below demonstrates the Quality Assurance Rating of providers at the point

of each of the 199 patient placements between 1st April 2014 and 31st March 2015 by

LHB:

75% (149) patients were placed with a provider maintaining 3Qs;

22% (43) patients were placed with a substandard provider validated at 2Qs; and

4% (7) patients were placed with a critically substandard provider validated at 1Q.

0

5

10

15

20

25

30

35

ABMUHB ABUHB BCUHB C&VUHB CTUHB HDHB PTHB

30

20

29

22

31

10

778

10

53

5 5

23

1 1Nu

mb

er

ofn

pat

ien

ts p

lace

d t

hro

ugh

th

e

Nat

ioan

l Fra

me

ork

e-p

lacm

en

t p

roce

ss

QQQ

QQ

Q

24


23. ‘Quality then cost’- prioritising high quality providers

The National Framework uses a „quality then cost‟ ranked provider model; with each

of the 290 provider units within the scope of the National Framework given a quality

assurance rating (see section 22 above) and ranked with other units who provide the

same service (across 16 service types –see section 4).

The provider units are ranked by quality first: ensuring that those units maintaining

the 3 quality assurance marks are ranked above all those achieving 2 quality

assurance marks and those achieving 2 quality assurance marks are ranked above all

those achieving 1 quality assurance mark, and those suspended being illegible to

receive placements.

The providers all achieving the same quality assurance mark are then ranked by cost,

with the lowest cost provider ranked above those with higher cost. An illustrative

listing is shown in the table below.

As can be seen in the example, since it has the lowest quality assurance rating

„Example Unit D‟ is ranked below all other units even though it has the lowest cost.

In order to ensure that providers are incentivised to maintain quality and offer best

value the process of the National Framework encourages commissioners, where

clinically appropriate to do so, to place patients with the highest ranked provider.

The Commissioning Care Assurance & Performance System (see section 26)

provides a national electronic patient placement function where commissioners, at

the point of placement, are supplied with all the information and intelligence to

make an informed choice on the most suitable provider to meet the clinical, social

and geographical needs of the patient.

The process for the national electronic patient placement function is;

1. Commissioner identifies most suitable service type to meet the clinical needs

of the patient;

2. Commissioner is presented with the ranked list of provider units (see above),

who have beds available supported by the most recent intelligence on each

provider and, in order to support care „closer to home‟ when appropriate, an

Service type-

LOW SECURE-MENTAL HEALTH-MALE

Unit Name Quality Assurance Rating Cost

Example Unit A QQQ £400

Example Unit B QQQ £500

Example Unit C QQ £300

Example Unit D Q £200

25


ability to see the distance to each potential provider and travelling route and

(if necessary) a satellite picture of the provider unit;

3. Commissioner identifies highest ranked and most suitable provider to meet

the clinical, social and geographical needs of the patient;

4. Contact details of the provider unit is supplied including ability to send email

directly to a specific providers referrals manager;

5. Clinical telephone discussion occurs between commissioner and provider to

discuss needs of the patient and if agreed that the provider can meet the needs

of the patient agrees admission date; and

6. Post admission, CCAPS generates a specific contract between commissioner

and provider.

The screen shot pictures below demonstrate these functions.

Providers are ranked by Q rating then price

Providers are arranged service type

Choose a postcode important to patient and the distance to each provider is displayed to promote

care closer to home

Location of provider is displayed and route by road. Satellite

image of provider can be shown

26

Providers intelligence can be examined (complaints,

incidents, POVAs, Patient Care Indicators and Q rating history)


24. Communication and Connectivity

NHS Wales Informatics Service and the NHS Quality Assurance & Improvement Team

have worked in partnership to develop and maintain systems to deliver contractual

rigour, performance management and clinical oversight to support the National

Framework.

The two systems in use are the Commissioning Care Assurance & Performance System

and the National Framework Secure File Sharing Portal as detailed in section 25 and

26.

The benefits of these systems are delivering outcomes at three levels:

Macro level-Value for National Collaboration

Enables integrated commissioning across organisations

Enables integrated commissioning across tiers of care

Promotes good quality providers and deters poor quality providers

Meso level- Value for an organisation

Enables transparent commissioning decisions

Improves clinical commissioning (outcome focused)

Enables LHBs to refocus from data to patient management

Enables timely response to failing services

Micro Level-Value for a patient

Enables choice of care provision

Supports transparent quality rating system

Enables timely alerts to complaints/incidents/POVA concerns

Enables measuring & supports improving patient level outcomes

Promotes the drive for transition from hospital to community care

Value for national

collaboration

Value for an organisation

Value for a patient

National Collaborative Commissioning and

Commissioners Care Assurance &

Performance System

27


25. National Framework Secure File Sharing Portal

The National Framework Secure File Sharing Portal is a secure way of sharing

information through an online application.

Managed and facilitated by the NHS Wales Quality Assurance & Improvement

Team and hosted by NHS Wales Informatics Service, the portal „connects‟ each

provider of National Framework services with each commissioner (LHB) to

safely transfer and receive clinical, contractual and patient identifiable

information.

There were circa 240 users of the portal with 11,000 folders at 31st March 2015,

the biggest portal in use by NHS Wales.

The main objectives of the National Framework Secure File Sharing Portal are

to:

Support a „paperless NHS‟;

Ensure sensitive data cannot be intercepted, corrupted or misplaced;

Enable the sharing of sensitive information such as Person Identifiable

Information and commercially sensitive information;

Enables sharing of large volume information;

Enable information to be shared instantly; and

Eliminate postage costs.

28


26. Commissioning Care Assurance & Performance System

The Commissioning Care Assurance & Performance System (CCAPS) has been

developed through a partnership between the NHS Wales Quality Assurance &

Improvement Team and NHS Wales Informatics Service (with funding from a

successful Welsh Government Healthtech bid and with cooperation from Local

Authorities).

CCAPS is an informatics resource for use by NHS and LA to enable the

commissioning of integrated long term publicly funded care and support the

performance management of care providers to deliver beneficial outcomes for

citizens.

CCAPS is an enhanced version of the NHS Wales performance system that has been

in place for the performance management of National Framework providers.

The graphic below illustrates the functionality of CCAPS in 2015.

By July 2015 CCAPS can be accessed by:

Care coordinators for each patient receiving assurance of the National Framework

from health and social care organisations;

Local commissioning Teams (i.e. Continuing Healthcare Teams or gatekeepers);

Strategic commissioners (i.e. planners, finance, directors);

Quality, complaints or safety leads; and

Providers.

Commissioning Care Assurance & Performance System (CCAPS) Functionality

Records POVA/ Complaints/

Incidents at a patient level

Patient level performance

indicators (care plans, risk assessments etc)

Instant electronic intelligence sharing

between commissioners

(alerts)

Comparisons across providers/commissioners (benchmarking by patient/

ward/ hospital/provider)

Seamless commissioning

(across tiers of care and organisations)

Single all Wales electronic placement process (quality first)

Supports collaboration between

regulators and commissioners

Records each patients last and next care

planning meeting and attendance

Identification of service pressures and opportunities

National and local market analysis

Provider bed availability

Providers quality reports and improvement plans

29


27. Attendance at Care & Treatment Plan (CTP) reviews [Please note: Attendance at the CTP review by the designated care coordinator/ Local

Health Board representative complies with the Mental Health (Wales) Measure 2010

and is considered good clinical practice, although non-attendance at the CTP review

does not signify a complete absence of patient contact as professionals may have

visited the patient at other times other than the CTP review]

The NHS Wales Quality Assurance & Improvement Team monitors the

attendance at CTP reviews in order to ensure that no patient is „out of sight and

out of mind‟. Between 1st April 2014 and 31st March 2015 a total of 299 patients

receiving assurance under the National Framework were recorded as being in

receipt of a CTP review.

The average percentage attendance at a CTP review by a designated care

coordinator or a Local Health Board representative (including social services)

for all LHBs was 92% with specifically, by individual LHB:

ABUHB 89% (50) of CTP reviews attended by care coordinator or representative

ABMUHB 79% (44) of CTP reviews attended by care coordinator/representative;

BCUHB 87% (48) of CTP reviews attended by care coordinator/representative;

C&VUHB 94% (46) of CTP reviews attended by care coordinator/representative;

CTUHB 100% (37) of CTP reviews attended by care coordinator;

HDUHB 94% (29) of CTP reviews attended by care coordinator/representative;

PTHB 100% (15) of CTP reviews attended by care coordinator.

The table below demonstrates the attendance by either a care coordinator/

representative or non attendance at a CTP held for a patient receiving assurance

under the National Framework between 1st April 2014 and 31st March 2015.

Secu

re C

are

44

37

4642

37

28

15

6

7

2

4

1

6

127

3

2

0

10

20

30

40

50

60

ABUHB ABMUHB BCUHB C&VHB CTUHB HDUHB PTHB

Nu

mb

er

of

pat

ien

ts in

re

ceip

t o

f C

TP r

evi

ew

CTP attended by Care Co-ordinator CTP attended by other LHB representative CTP NOT attended

30


Section C


28. Data, Information, Knowledge and Wisdom 33 29. Providers under the National Framework 34 30. Patient Care Indicators 35 31. Incidents 37 32. Incidents by type of service 38 33. Complaints 39 34. Complaints by type of service 40 35. Protection of Venerable Adults 41 36. Equality and diversity 42


“Commissioners funding placements should ensure that they have up to

date knowledge of services e.g. adverse incidents/serious untoward

incidents...safeguarding investigations etc”

Flynn, M. (2012). Winterbourne View Hospital- Serious Case Review. South Gloucestershire Council

“Metrics need to be established which are relevant to the quality of care and

patient safety across the service, to allow norms to be established so that

outliers or progression to poor performance can be identified and

accepted as needing to be fixed”




28. Data, Information, Knowledge and Wisdom

Through the Commissioning Care Assurance &

Performance System (see section 26), the NHS Quality

Assurance & Improvement Team gathers a substantial

quantity of data on patients receiving assurance under

the National Framework directly from providers.

In order to adhere to the values of patient-centered care, the data gathered by the

NHS Wales Quality Assurance & Improvement Team is not anonymous data on

provider‟s performance (average length of stay, total number of complaints over the

year etc) but prudently chosen data to create an „information picture‟ on each

individual patient receiving assurance under the National Framework, for example

for each patient the following information is collected:

NHS number, name, age, sex and predominant need;

E-CAARE process record including why current provider was chosen for patient

and that providers Quality Assurance Rating level at time of patient placement;

Current patient placement agreement (LHB-Provider patient contract);

Every serious and non-serious incident concerning the patient including incident

type, date, time and whether investigation report is available;

Every Protection of Vulnerable Adult (POVA) incident concerning the patient

including date, name of the local safeguarding person the incident was reported to

and when it was reported;

Every complaint made by patient including date and complaint category;

Patient‟s admission source and discharge destination;

Care and Treatment Planning meeting dates & recorded attendance from local

services;

Length of stay in current provider and whole patient pathway (all previous

admissions);

Cost per day of current placement, cost of whole patient pathway and additional

services (staff) required costing.

This allows the NHS Wales Quality Assurance & Improvement Team to have

knowledge of a provider (or individual ward or hospital) constructed or

deconstructed from individual patient‟s information.

This knowledge allows the effective and efficient deployment of the NHS Wales

Quality Assurance & Improvement Team clinical assets in order to fully understand,

performance manage and improve (wisdom) care delivery within National

Framework providers.

33


29. Providers under the National Framework [Appendix A provides details on providers as of April 1st 2014]

At the commencement of the new National Framework in April 2014 there were

22 distinct providers with a total of 88 hospital sites and 290 individual units

(wards).

On March 31st 2015 there are 279 individual units with 11 units withdrawing

or being terminated over the first year of National Framework operation.

Reasons for withdrawal or termination are reconfiguration of units, closure of

units and inability to meet required standards within the National Framework.

The map below displays the general location of the National Framework provider‟s

hospitals as at March 31st 2015.

34


30. Patient Care Indicators

In place of numerous Key Performance Indicators measuring organisational

data the NHS Wales Collaborative Commissioning Leads have developed

patient-level outcome measures in order to align with the patient-centred values

of NHS Wales.

These „Patient Care Indicators‟ are collated, analysed and verified by the NHS

Wales Quality Assurance & Improvement Team for each patient receiving

assurance under the National Framework every quarter (changing to monthly

in October 2015) in order to:

Compare performance across National Framework providers;

Provide a detailed account of the National Framework providers

attainment of the required patient-level performance targets;

Provide an indication of issues that may require remedial action; and

Indicate where there is potential to improve the effectiveness of care.

There are currently six Patient Care Indicators in place covering: care and

treatment planning; risk assessment and management; physical healthcare;

health promotion and well being; therapeutic interventions; meaningful and

culturally appropriate activity.

Each Patient Care Indicators has three or more „achievement guidelines‟

(directions given to providers on attainment of the Patient Care Indicator). As

an example two of the six Patient Care Indicators are shown in the box below.

Patient Care Indicator Achievement

guidelines

Physical Health

Improvement in the physical

health of all patients will be

an integral part of their care

and treatment.

a) Personalised physical health care plan present and

contemporary. b) All identified physical health care interventions have been

undertaken. c) Patient monitored for possible side effects of prescribed

medication. d) Physical health care plan has been reviewed at least 3

monthly via MDT.

Care & Treatment Plan Patients will have a personalised care plan in place that meets the requirements of the Mental Health Measure (2010)

a) Care and Treatment Plan present and contemporary b) Care and Treatment Plan has been developed in

collaboration with the Patient. c) All Patient needs are identified within the Care and

Treatment Plan d) All identified needs have corresponding identified

outcomes. e) Outcomes are personalised to Patient f) Care and Treatment Plan has been evaluated monthly via

the Multi Disciplinary Team.

35


There were 7009 assessments of Patient Care Indicators for patients receiving

assurance under the National Framework between 1st April 2014 and 31st March

2015.

Of these 7009 assessments, the range of achievement (meaning the Patient Care

Indicator has been recorded as having been achieved by the provider and verified by

the NHS Wales Quality Assurance & Improvement Team) was between 42.9% and

100% with the average achievement across all Patient Care Indicators for eligible

patients being 97.8%.

The table below displays the Patient Care Indicator, the number of instances of that

Indicator being measured between 1st April 2014 and 31st March 2015 and the

percentage of patients receiving assurance under the National Framework recorded

by the provider as having achieved the Patient Care Indicator.

The lowest level of achievement was against the Patient Care Indicator measuring

effective and personalised care and treatment planning at 94.2%.

Patient Care Indicator

Number of instances that Patient Care

Indicator was measured

Number in % of patients that

PCI was recorded as

being achieved

Care & Treatment Plan

Patient will have a personalised care plan in place that meets the requirements of the Mental Health Measure (2010)

1129 94.2%

Risk assessment & Management

Patient will have a risk assessment in place which exposes current and historical risks and that all risks identified have corresponding documented mitigating/ management actions

1175 98.7%

Physical Health

Improvement in the physical health of all patient will be an integral part of their care and treatment

1175 97.7%

Health Promotion & Well Being

Patient will have a personalised Health Promotion Plan in place that identifies their health promotion needs and set out interventions to address those needs

1169 97.4%

Therapeutic Interventions

Patient will be enabled to receive personalised evidence based therapy interventions using a multi-disciplinary approach. Therapeutic interventions will achieve measurable outcomes and be delivered by appropriately qualified and experienced Staff

1183 99.3%

Meaningful & Culturally Appropriate Activities

Patients are enabled to access to a broad range of meaningful and culturally appropriate activities

1178 99.3%

36


31. Incidents

All incidents involving patients receiving assurance under the National

Framework are monitored by the NHS Wales Quality Assurance & Improvement

Team to highlight areas requiring intervention, remedial action or improvement.

The incidents are monitored against a bespoke 60 point matrix of 12 care areas

and 5 levels of severity. An example of one section of the incident matrix is shown

in the table below.

A total of 8288 incidents involving patients receiving assurance under the

National Framework occurred between 1st April 2014 and 31st March 2015:

4949 or 59.7% were classed as negligible;

2646 or 31.9% were classed as minor;

571 or 6.9% were classed as moderate;

111 or 1.3% were classed as severe; and

11 or 0.1% were classed as critical.

The table below demonstrates the incident type and severity level of incidents

involving patients receiving assurance of the National Framework reported

between 1st April 2014 and 31st March 2015.

The table above demonstrates that the most frequent incident type was

„disruptive/aggressive behaviour or violence‟ at negligible severity at 42% (3494) of

all incidents.

Incident Type

OUTCOME

Negligible Minor Moderate Severe Critical

Medication

An error in the prescribing or Dispensing of

medication to a Welsh patient which is not

administered or results in no

harm.

An error in the administration

of medication to a Welsh patient which results in minimal or no

harm.

An error in the prescribing,

Dispensing or administration

of medication to a Welsh patient

requiring medical

monitoring.

An error in the prescribing, Dispensing

or administration of medication to a Welsh patient which requires

medical treatment. An event involving

Controlled Medication.

An error in the prescribing,

Dispensing or administration of

medication to a Welsh patient which results

in actual or potentially life threatening Harm

or Death.

Negligible Minor Moderate Severe Critical Total

Disruptive/ aggressive behaviour or violence

3494 1452 382 66 9 5403

Self-harming behaviour 831 714 92 29 1 1667 Sexual abuse 89 190 15 2 0 296 Access, admission, transfer, discharge (inc missing patient) AWOL

88 10 21 7 1 127

Medication 76 52 5 1 0 134 Environment/ service disruptions 34 12 2 0 0 48 Infection control incident 4 1 0 0 0 5 Patient injury resulting from an accident or is unexplained

193 82 29 1 0 305

Patient harm resulting from any act or omission relating to treatment/ clinical procedure/ intervention

32 9 3 0 0 44

Documents, data & legal 14 9 12 1 0 36 Substance use/ abuse 12 22 5 0 0 39 Controlled items 82 93 5 4 0 184

TOTAL 4949 2646 571 111 11 8288

37


32. Incidents by Type of Service

Incidents involving patients receiving assurance of the National Framework are

monitored by the NHS Wales Quality Assurance & Improvement Team at a patient,

unit, hospital and provider and service type level.

Although allowances must be made for individual patient‟s clinical presentations,

behaviours and employee abilities; by calculating the number of occupied bed days

(number of days in which a providers bed was in use by a welsh patient receiving

assurance of the National Framework) by service type and cross referencing with

incident data it is possible to determine the types of services where incidents are

more likely to occur.

In respect of National Framework providers: on average across all service types there

were 81.7 incidents per 1000 occupied beds days or 0.08 incidents per patient, per

day.

In order to demonstrate a reasonable comparison the table below has been listed by

the number of incidents per 1000 occupied beds days recorded as involving patients

receiving assurance of the National Framework reported between 1st April 2014 and

31st March 2015. The service type with the highest total is listed first and the three

service types with highest number of incidents per 1000 occupied beds days of are

coloured red and the three with the lowest number are coloured green.

38

Number of incidents per 1,000 occupied bed days per severity level

Service type (LD=Learning Disabilities &

MH=Mental Health)

Negligible Minor Moderate Severe Critical

Total

Controlled Egress-LD-Male 126.9 118.6 34.4 2.0 0.2

282.1

Controlled Egress-MH-Female 137.4 47.8 14.1 3.2 0

202.5

Controlled Egress- LD –Female 127.0 39.3 5.5 0.6 0

172.3

Low secure- MH –Female 78.8 51.7 3.9 0.5 0

134.9

Uncontrolled Egress- LD-Male 46.0 64.4 10.5 5.3 0

126.1

Low secure- LD-Female 71.9 40.4 5.2 0.5 0

118.0

Controlled Egress- MH–Male 54.1 20.1 4.9 2.7 0

81.8

Uncontrolled Egress- MH-Female

28.5 27.2 9.5 3.8 1.9

70.8

Medium secure- MH-Female 33.4 30.8 5.9 0.5 0

70.6

Medium secure- LD-Female 45.2 3.4 0.9 0.0 0.0

49.4

Low secure- MH–Male 28.9 11.9 2.4 0.5 0

43.8

Medium secure- LD-Male 15.6 15.6 5.5 2.2 1.1

40.0

Medium secure- MH-Male 15.7 7.5 2.0 0.1 0

25.3

Low secure- LD –Male 7.7 7.2 2.4 1.0 0.5

18.8

Uncontrolled Egress- MH-Male 12.1 4.4 2.2 0 0

18.7


33. Complaints All complaints involving patients receiving assurance of the National Framework

are monitored by the NHS Wales Quality Assurance & Improvement Team to

highlight areas requiring investigation or improvement.

Complaints made by patients

receiving assurance of the

National Framework are

categorized against a bespoke

54 point matrix of 1o

complaints areas with at least

4 sub-categories in each. An

example of two sections of the

complaint matrix are shown

to the right

A total of 257 complaints were made by patients receiving assurance of the

National Framework between April 1st 2014 and March 31st 2015. The table below

details the number of complaints (as a percentage of total complaints) received

between 1st April 2014 and 31st March 2015 for each complaint area.

The top three areas of complaint made by patients receiving assurance of the National

Framework between 1st April 2014 and 31st March 2015 were:

Poor staff communication skills (10.1% of total complaints)

Behaviour of other patient (8.9% of total complaints)

Food quality, quantity or availability (7% of total complaints)

Complaint area Sub-category

Hotel Services

A. Food (quality / quantity / availability) B. Accommodation (Facilities / maintenance) C. Accommodation (cleanliness) D. Lack of privacy / dignity E. Accommodation (other)

Clinical Treatment

A. Relating to any act or omission B. Relating to Physical Health C. Relating to talking therapies D. Side effects (effects / discussion of) E. Physical interventions F. Discontent / disagreement with treatment plan G. Includes Section 17 leave / community sessions. H. Therapeutic sessions cancelled I. Poor access to staff for treatment / care purposes J. Clinical treatment (other)

1.2

1.2

2.7

3.5

4.3

9.3

14.0

14.4

17.9

31.5

0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0

Legal

Equity and diversity

Other

Communication

Hospital Protocols

Patient property

Hotel services

Clinical treatment

Behaviour of other patient(s)

Attitude/behaviour of staff

% of total complaints made by patients receiving assurance of the National Framework

39


34. Complaints by type of service

Complaints involving patients receiving assurance of the National Framework are

monitored by the NHS Wales Quality Assurance & Improvement Team at a patient, unit,

hospital and provider and service type level.

Although allowances must be made for individual patient‟s tolerances, attitudes, clinical

presentations and behaviours; by calculating the number of occupied bed days (number

of days in which a providers bed was in use by a welsh patient receiving assurance of

the National Framework) by service type and cross referencing with complaint data it is

possible to determine the types of services where complaints are more likely to be

received.

In respect of National Framework providers: on average across all service types there

were 2.5 complaints per 1000 occupied beds days or 0.003 complaints per patient, per

day.

The table below details the number of complaints received between 1st April 2014 and 31st

March 2015 by service Type. In order to demonstrate a reasonable comparison the table

below has been listed by the number of complaints per 1000 occupied beds days, with the

service type with the highest total listed first (and highest three coloured red) and the

lowest total listed last (and lowest three coloured green).

Service type

Medium secure- Learning Disabilities –Female 6.8

Controlled Egress-Learning Disabilities-Male 5.9

Controlled Egress- Learning Disabilities –Female 5.0

Uncontrolled Egress- Mental Health –Female 4.4

Low secure- Mental Health –Female 3.2

Low secure- Mental Health –Male 2.9

Controlled Egress- Mental Health –Male 2.3

Medium secure- Mental Health –Female 2.2

Low secure- Learning Disabilities –Female 1.6

Medium secure- Learning Disabilities –Male 1.5

Low secure- Learning Disabilities –Male 1.3

Uncontrolled Egress- Learning Disabilities –Male 1.3

Medium secure- Mental Health –Male 1.3

Controlled Egress-Mental Health-Female 0.9

Uncontrolled Egress- Mental Health –Male 0.7

Number of complaints per 1,000 occupied bed days per severity level

40


35. Protection of Vulnerable Adults The Protection of Vulnerable Adults (POVA) is a section within the Care Standards

Act (2000). The act states when an issue of care needs to be reported as a concern.

The act of potential abuse can take many forms including: physical abuse; sexual

abuse; psychological abuse; financial or material abuse; discriminatory abuse; neglect

and acts of omission2.

All potential POVA incidents involving patients receiving assurance of the National

Framework are monitored at a patient, unit, hospital and provider and service type

level by the NHS Wales Quality Assurance & Improvement Team to highlight areas

requiring investigation, intervention or improvement. The data includes date POVA

incidents occurred, date reported, name and contact number of person reported to.

A total of 439 POVA incidents involving patients receiving assurance of the National

Framework occurred between 1st April 2014 and 31st March 2015.

Although allowances must be made for employee abilities the table below

demonstrates the number of POVA incidents received by service type and includes

percentage of overall POVA incidents and is listed by the number of POVA incidents

per 1000 occupied beds days with the highest total listed first (and highest three

coloured red) and the lowest total listed last (and lowest three coloured green).

2 Department of Health (2000) No secrets: guidance on developing and implementing multi-agency policies and procedures to protect vulnerable adults from abuse, London: The Stationary Office.

Service type Number of PoVA

incidents

% of total PoVA

incidents

Number of PoVA incidents per

1,000 occupied bed days

Uncontrolled Egress- Learning Disabilities –Male 19 4.3% 25.0

Low secure- Learning Disabilities –Female 20 4.6% 10.3

Controlled Egress- Learning Disabilities –Female 31 7.1% 8.6

Controlled Egress-Mental Health-Female 46 10.5% 7.8

Controlled Egress-Learning Disabilities-Male 33 7.5% 6.8

Controlled Egress- Mental Health –Male 76 17.3% 6.2

Medium secure- Mental Health –Female 30 6.8% 5.1

Low secure- Learning Disabilities –Male 26 5.9% 4.4

Medium secure- Learning Disabilities –Male 10 2.3% 3.6

Medium secure- Learning Disabilities –Female 4 0.9% 3.4

Low secure- Mental Health –Male 90 20.5% 3.2

Low secure- Mental Health –Female 26 5.9% 2.7

Medium secure- Mental Health –Male 21 4.8% 1.7

Uncontrolled Egress- Mental Health –Male 2 0.5% 1.3

Uncontrolled Egress- Mental Health –Female 5 1.1% 1.2

41


36. Equality and diversity

An important requirement of the National Framework is to ensure providers respect

equality, diversity and human rights.

The National Framework sets out a three specific requirements to be maintained by

providers.

The average achievement across all 111 units for the standards in the area of

Respecting Equality, Diversity & Human Rights was 87.6%.

The specific achievements against each of the three specific requirements are shown

in the table below.

These achievements demonstrates that the National Framework has a positive impact

on compliance with the equality policies and national legislation, and potentially

supports the legal requirement to foster good relations between protected

characteristic groups.

Despite the positivity of the National Framework promoting equality, diversity and

human rights and integrating these principles into the provider‟s activities,

inequalities continue to exist in healthcare services for different groups of people. In

view of this each provider is required to formulate an annual equality statement

validating the requirement that all patients irrespective of their ethnicity or lifestyle

receive high quality care.

These reports are available on the Care Assurance & Performance System (see section

26)

Standard maintained

by 84% of providers

A Providers must ensure that any patient‟s needs in respect of race,

disability, gender, sexual orientation, age, relationships and family life,

religion or belief, gender identity pregnancy and maternity, are identified

within 7 days of admission.

Standard maintained

by 88% of providers

Provider must ensure patient‟s needs in respect of race, disability, gender,

sexual orientation, age, relationships and family life, religion or belief,

gender identity pregnancy and maternity, are addressed.

Standard maintained

by 87% of providers

Providers must ensure that the promotion of equality, diversity and human

rights is part of the staff induction programme and annual training

programme.

42


Section D


37. Average cost of care 45 38. Total spend on National Framework 45 39. Activity costs 46 40. National Framework cost reductions 46


“We will require safe, effective and efficient services to provide value for money”

Welsh Government, (2012) Together for Mental Health: A Strategy for Mental Health and Wellbeing in Wales. Cardiff: Welsh Assembly Government.

“Prudent healthcare [ensures] that healthcare fits the needs and circumstances of the citizen and actively avoids waste and harm”

Public Health Wales (2014) Achieving prudent healthcare in NHS Wales



37. Average cost of care

The average cost of care for a patient receiving assurance under the National

Framework equals £149,351 per annum.

The table below details the average cost per day per patient placed in each of

the service types as at March 31st 2015 - the list is ordered by highest cost first.

38. Total spend on National Framework

The total annualised spend by NHS Wales based on patients receiving assurance

under the National Framework as at 31st March 2015 equalled £51.077m per annum

- the table below details this cost across each LHB.

£9

,77

8,4

08

£9

,22

6,9

23

£9

,60

4,6

94

£8

,45

7,1

85

£6

,29

7,5

35

£4

,94

6,0

97

£2

,76

6,4

81

£0

£1,000,000

£2,000,000

£3,000,000

£4,000,000

£5,000,000

£6,000,000

£7,000,000

£8,000,000

£9,000,000

£10,000,000

ABMUHB ABUHB BCUHB C&VUHB CTUHB HDHB PTHB

Spe

nd

by

LHB

on

Nat

ioan

l Fra

me

wo

rk o

n M

arch

3

1st

20

15

Medium secure- Learning Disabilities –Female £530

Medium secure- Learning Disabilities –Male £503

Medium secure- Mental Health –Female £502

Medium secure- Mental Health –Male £466

Low secure- Learning Disabilities –Female £451

Controlled Egress-Learning Disabilities-Male £449

Controlled Egress- Learning Disabilities –Female £439

Low secure- Mental Health –Female £428

Uncontrolled Egress- Learning Disabilities –Male £428

Low secure- Learning Disabilities –Male £422

Controlled Egress-Mental Health-Female £387

Low secure- Mental Health –Male £379

Controlled Egress- Mental Health –Male £355

Uncontrolled Egress- Mental Health –Female £351

Uncontrolled Egress- Mental Health –Male £312

45


39. Activity costs Since the launch of National Frameworks in 2012 the potential savings over a 3 year

period from 2012-2015 equates to £9.8 million, which is detailed across the seven

LHB and WHSSC in the table below over each of the years the National Framework

has been operational („-„and green colour denotes decrease in activity costs, red

colour denotes increase in activity costs).

40. National Framework cost reductions [Note that cost reductions do not include additional staffing costs which historically

cost several £m and which the National Framework includes within the daily cost]

Based upon the patient placement profile as at 1st April 2012, the National

Framework has delivered potential cost reductions of £6.262m for LHBs across

providers since this date by: reductions in providers‟ daily costs; and price „refresh‟

exercises (permitted periodic revised price submissions by providers).

The table below details the potentially recurrent cash savings by each LHB between

1st April 2014 and 31st March 2015 with the key dependency being patient activity and

profile.

£9

06

,86

1

£9

67

,27

0

£8

63

,411

£6

70

,95

8

£8

77

,02

0

£5

68

,55

4

£13

1,5

53

£1,2

75

,89

7

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

ABMUHB ABUHB BCUHB C&VUHB CTUHB HDUHB PTHB WHSSC

46

Activity costs

2012-2013 Activity costs

2013-2014 Activity costs

2014-2015 Total activity

costs 2012-2015

ABMUHB -£838,187 £384,946 £1,340,955 £887,714

ABUHB -£3,352,747 £0 -£389,335 -£3,742,082

BCUHB £419,093 -£1,347,310 -£928,524 -£1,856,741

C&VUHB -£628,640 -£1,154,837 £937,707 -£845,770

CTUHB £209,547 -£1,732,256 -£183,460 -£1,706,169

HDUHB £628,640 -£962,364 -£362,482 -£696,206

PTHB -£419,093 £0 -£427,714 -£846,807

WHSSC £210,848 -£1,768,878 £535,685 -£1,022,345

Total -£3,770,539 -£6,580,699 £522,833 -£9,828,405


Appendices A-Providers

B-Trends by LHBs

41. Providers 48 42. Abertawe Bro Morgannwg University Health Board 49 43. Aneurin Bevan University Health Board 49 44. Betsi Cadwaladr University Health Board 50 45. Cardiff and Vale University Health Board 50 46. Cwm Taf University Health Board 51 47. Hywel Dda University Health Board 51 48. Powys Teaching Health Board 52


Appendix A-Providers

41. Providers

The table below details in the first/ third column the trading name of the provider

and in the second/fourth column the name of their managed hospitals able to provide

services under the National Framework on 31st March 2015.

Acorn Care (Welshpool) Limited

Phoenix House Hospital Partnerships in Care (cont)

Arbury Court

Acorn Care Limited The Woodhouse Oaktree Manor Ballington House Burston House

Calderstones Partnerships NHS Foundation Trust

Whalley Hazelwood House

Cambian Healthcare Limited

St Augustines Hospital Kemple View The Fountains Suttons Manor Sedgley Lodge Annesley House Cambian Churchill Lombard House Delfryn House Abbey House St Teilo House Aderyn Aspen House Elm Park Raglan House The Willows Appletree House Pelham Woods

Cambian Learning Disabilities Limited

Cedars Pastoral Cymru (Cardiff) Limited

Ty Catrin

Fairview Pastoral Cymru Limited Ty Cwm Rhondda Cambian Learning Disabilities Midlands Limited

Cambian Manor Pinetree Care Services Limited

Pinetree

Care UK Mental Health Partnership Limited

Litchfield House Priory Healthcare Limited

Aberdare

Cygnet Health Care Stevenage Hayes Grove Derby Dewsbury Blackheath Church Village Bierley Bristol Kewstoke St Neots Wyke Recovery F1rst Lewisham Highbanks Centre Brighouse Roehampton Ealing Market Weighton Westlands Cheadle Royal

The Huntercombe Group

Market Drayton Ty Gwyn Market Weighton Priory Secure Services

Limited Cefn Carnau

Roehampton Thornford Park Heatherwood Court Limited

Heatherwood Court Farmfields

Mental Health Care Limited

New Hall Chadwick Lodge Plas Coch Rushcliffe Independent

Hospital Ltd Rushcliffe Hospital

St Davids St Andrews Healthcare Northampton Partnerships in Care St Johns Birmingham

Stockton Hall Nottingham Kneesworth Essex Calverton Hill St George Healthcare

Group St Marys

Llanarth Court All Saints The Spinney St Cyrils The North London Clinic Ludlow Street

Healthcare Group St Peters Hospital

The Dene

48


Appendix B-Trends by LHBs

This Appendix will provide a breakdown in the use of the National Framework

between 1st April 2014 and 31st March 2015 by LHB and by tier of care.

42. Abertawe Bro Morgannwg University Health Board (ABMUHB)

The number of ABMUHB patients receiving assurance under the National Framework

increased by 16% (56 to 65), with specific adjustments in the following areas:

The number of patients cared for by medium secure providers remained constant;

The number of patients cared for by low secure providers remained constant;

The number of patients cared for by controlled egress providers increased by 56%;

The number of patients cared for by uncontrolled egress providers remained constant.

43. Aneurin Bevan University Health Board (ABUHB)

The number of ABUHB patients receiving assurance under the National Framework

decreased by 7% (69 to 64), with specific adjustments in the following areas:

The number of patients cared for by medium secure providers decreased by 9%;

The number of patients cared for by low secure providers decreased by 3%;


The number of patients cared for by uncontrolled egress providers decreased by 25%.

17

22

16

1

17

22

25

1

0

5

10

15

20

25

30


Nu

mb

er

of

pat

ien

ts


11

34

8

16

10

33

9

12

0

5

10

15

20

25

30

35

40


Nu

mb

er

of

pat

ien

ts


49

https://www.wales.nhs.uk/ourservices/directory/LocalHealthBoards/866


44. Betsi Cadwaladr University Health Board (BCUHB)

The number of BCUHB patients receiving assurance under the National Framework


The number of patients cared for by medium secure providers increased by 100%;


The number of patients cared for by controlled egress providers decreased by 11%;


45. Cardiff and Vale University Health Board (C&VUHB)

The number of C&VUHB patients receiving assurance under the National Framework



The number of patients cared for by low secure providers increased by 19%;


The number of patients cared for by uncontrolled egress providers increased by 33%.

7

26

18

11

14

25

16

8

0

5

10

15

20

25

30


Nu

mb

er

of

pat

ien

ts


18

21

10

3

14

25

12

4

0

5

10

15

20

25

30


Nu

mb

er

of

pat

ien

ts


50


46. Cwm Taf University Health Board (CTUHB)

The number of CTUHB patients receiving assurance under the National Framework






47. Hywel Dda University Health Board (HDUHB) The number of HDUHB patients receiving assurance under the National Framework




The number of patients cared for by controlled egress providers decreased by 11%;


2

21

9

2

4

20

8

1

0

5

10

15

20

25


Nu

mb

er

of

pat

ien

ts


7

25

11

1

6

20

17

0

5

10

15

20

25

30


Nu

mb

er

of

pat

ien

ts


51


48. Powys Teaching Health Board (PTHB)

The number of PTHB patients receiving assurance under the National Framework




The number of patients cared for by controlled egress providers remained constant;


3

9

8

2

4

6

8

1

0

1

2

3

4

5

6

7

8

9

10


Nu

mb

er

of

pat

ien

ts


52


Supplemental

Building on success i-National Framework refresh ii-CAMHS National Framework

iii-Integrated Collaborative Commissioning Programme

49. CAMHS National Framework 54 49. National Framework refresh 55

50. National Collaborative Commissioning:

Integrated Health & Social Care Programme 55


Supplemental-Building on success

49. CAMHS National Framework

In June 2014 WHSSC sponsored the creation of a National Framework for CAMHS

Low Secure & Acute Hospital Services, through the use of the CAREMORE®

methodology and building upon the processes involved in the development of the

adult National Framework.

The CAMHS National Framework services are available for the small number of

Welsh patients who are deemed to be at increased risk of rapidly declining mental

health or serious self harm and/or who require a period of intensive, comprehensive,

multi-disciplinary, evidenced based treatment and care by qualified and experienced

staff for the purposes of assessment and/or treatment and for which there is no

equivalent service accessible in NHS Wales at the point in time it is required.

There were three aims for the development of this National Framework Agreement as

follows:

to improve the experience of Welsh children and young people in hospital care;

to improve the quality of the care provided by such hospitals; and

to ensure value for money is demonstrated by these hospitals.

The development of the National Framework Agreement has enabled NHS Wales to

have, for the first time, a comprehensive suite of 161 bespoke care standards that will

promote care with due regard to individual social and clinical needs and through

holistic, evidence based interventions underpinned through a therapeutic alliance of

child/young person, their family staff within a culture of therapeutic optimism and

positive regard.

Six „Required Care Outcomes‟ have also been developed and will be measured for all

patients every month, an example of one of the six Required Care Outcomes is shown

in the table below.

Improved mental health, well-being and Patient experience through effective and minimum use of pharmacological Interventions

a) The Provider ensured that all medications were available and offered as prescribed to the Patient and was at the minimum required level to achieve the identified clinical outcome(s).

b) The Provider ensured that on each occasion of, and reasons for, the failure to provide or for the Patient failing to accept/receive any individualised prescribed medication is clearly documented.

c) The Provider ensured that the effectiveness and side effects of the prescribed medication regime was reviewed (at a maximum interval of 1 month) via the multi-disciplinary meeting.

Ministerial approval was obtained for the Framework Agreement to become

operational on the 1st April 2015.

54


50. National Framework refresh

The National Framework structure allows for a refresh at the 1st October 2015 which

permits new providers to apply for inclusion on the framework as well as provide an

opportunity for standards to be reviewed and revised.

Preparatory work began in April 2015 and (as at June 2015) has shown:

A probable net increase in units is expected;

Standards have been updated;

„Patient Care Indicators‟ have been renamed „Required Care Outcomes‟ and

modified to be more outcomes focused.

Information requirements have been updated to reflect the introduction and

functionality of the Commissioners Care Assurance & Performance System.

51. National Collaborative Commissioning: Integrated Health & Social Care Programme

“The expectation for effective collaborative working across NHS and with partners is clear. Solutions to the challenges we face will be found in the opportunities of regional and national approaches with health and other partners” 3

The Welsh Government have awarded Invest to Save funding 2015/16 for the

establishment of an integrated commissioning programme across health & social

care. The intention is to build upon the creation by NHS Wales of National

Framework Agreements and the partnership with Local Authorities enabled by the

Healthtech 2014/15 funded CCAPS Project (see Section 26).

The scope of the first project under the programme is being finalised together with

the collaborating organisations which are presently all seven LHBs and thirteen of the

22 Local Authorities.

The strategic objectives for the project are shown in the table below

3 Dr Andrew Goodall, Chief Executive of NHS Wales, NHS Wales Planning Framework 2015/16 page 2

Objectives Potential Benefits

To improve service quality.

Improved access to services Improved meeting of resident needs. Improved resilience of services. Improved evidence of clinical/care decision making. Improved measurement of outcomes for residents. Improved risk assessment and management.

To improve value for

money

Greater awareness and benchmarking of costs between service providers. Cost of service provision identified to standard units of measurement. Reduced cost through competitive market pressure and economies of

scale through NHS and Social Care in Wales acting in collaboration. Improved understanding and balancing of future demand against

required capacity


Thank you for taking time to read this annual report; I

have made every effort to ensure all the information

within this report is correct at the time of going to

print, however if errors have occurred please let me

know.

If you have any queries about this annual report, the

National Frameworks or the work of the NHS Wales

Quality Assurance & Improvement Team in general

please contact us on 029 20336278 and we will be

happy to answer any queries.

Kind regards

Clinical Lead, NHS Wales Collaborative Commissioning &

Head of the NHS Wales Quality Assurance & Improvement Team


This report is the property of Cwm Taf University Health Board; it must not be copied in whole or in part without the express permission of the author: Shane Mills, Clinical Lead for NHS Wales Collaborative

Commissioning contactable on Tel: 029 20336278 or by e-mail at [email protected]

Winner 2012 Government Opportunities Award

Winner 2013 Welsh Public Sector Procurement Awards

Winner HSJ Efficiency Awards 2013

Finalist Patient Safety and Care Awards 2014

Finalist* HSJ Value in Healthcare awards 2015

*winner announced Sept 15

mailto:[email protected]