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SUMMARY REPORT ABM University Health Board

Quality & Safety Committee Date: 25th June 2015

Agenda item: 3.7

Subject Primary Care Governance Report

Prepared by Locality Management Teams

Approved

and

Presented by

Hilary Dover- Locality Director, Bridgend and Neath Port Talbot

Jan Worthing- Locality Director, Swansea

Karl Bishop- Associate Medical Director (Dental Services)

Alex Gibbins- Head of Medicines Management , Bridgend

Locality

Lindsay Davies- Head of Primary Care and Planning, Neath Port

Talbot Locality

Zoe Wallace- Head of Primary Care and Planning, Bridgend

Locality

Purpose

This report provides members of the Quality and Safety Committee with assurance on the following areas of Primary Care governance

General Dental Services across the Health Board, particularly improvements made and planned since the previous report to the Committee in May 2014

Following publication of the General Pharmaceutical Services Audit Review of March 2015 clarity on the accountability and responsibilities for clinical governance and contract monitoring processes in place in ABMU

The outcome of the Community Pharmacy Clinical Governance and Contract Monitoring Review Process for 2013/14 and 2014/15, as requested following the previous report to the May 2014 Committee meeting.

A description of the achievements of the Health Board in relation to the Welsh Government, Robbie Powell, Learning for the Future Action Plan and how any areas of unresolved risk will be taken forward by the Health Board.

Decision

Approval X

Information X

Other

Corporate Objectives

Excellent Population Health

Excellent

Population Outcomes

Sustainably

& Accessible

Service

Strong

Partnerships

Excellent

People

Effective

Governance

X X X

Executive Summary

This paper summarises the arrangements for governance within General Dental

Services within the Health Board including the Quality Assurance system, Health

Inspectorate Wales programme, performance and contract monitoring systems.

Additionally it summarises action being taken to improve patient experience in several

areas of General Dental Services and the information being used to inform this.

It updates the Quality and Safety Committee on the internal arrangements and

associated responsibilities for monitoring of the General Pharmaceutical Contract and

the actions identified for 2015/16 that address the recommendations highlighted in the

internal audit report.

Additionally following the paper received by the Quality and Safety Committee in

December 2014 it was agreed to provide an update report in June into the progress

being made against the Robbie Powell Learning for the Future action plan.

Key Recommendations

The Quality and Safety Committee are asked to

Note the systems and processes in place to provide the Board with assurance on standards of governance in dental practices

Note the current status of practices in relation to the QAS and actions being taken to provide assurance.

Note the current processes that are in place to identify performance issues and outliers among dental contractors across ABMU

Note the high level of performance cases which are currently ongoing across ABMU Health Board

Support the service plans being progressed to improve quality, governance and the patient experience.

Note the accountability and governance framework that are in place within ABMU and be assured that it will receive reports, at least annually, on contractual monitoring review process and outcomes that aim to ensure community pharmacy contractor compliance with the General Pharmaceutical Contract.

Note the content of the report,

Endorse the proposed actions to address any areas requiring improvement

Endorse the current contract monitoring process to provide assurance that compliance is scrutinised and managed

Accept the report for the Learning for the Future Action Plan and note the work

that the Locality will be undertaking with other Directorates to ensure that

areas of unresolved risk are taken forward through their performance and risk

management systems

To note the summary of activity for General Medical Service Governance.

Assurance Framework

Assurance on the Governance arrangements is provided to Locality Management teams through their Primary Care Governance structures.

Next Steps

Areas of on-going risk will be taken forward through the Locality teams and be incorporated into the risk and governance arrangements of the new Operational Delivery Unit

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Main Report ABM University Health Board


Agenda item: 3.7(a)

Subject Governance Arrangements in Primary Care Dental Services

Prepared by Locality Teams

Approved by Locality Management Boards

Approved and Presented by

Karl Bishop, Assistant Medical Director (Dental Services); Lindsay Davies, Head of Primary Care & Planning, NPT Locality;

PURPOSE This report updates the Quality and Safety Committee on the Governance arrangements in place within General Dental Services, following a previous paper presented by the Localities in May 2014 prior to the introduction of new practice inspection programme by Health Inspectorate Wales. INTRODUCTION Under the General Dental Services 2006 Regulations LHBs are the Statutory Bodies that hold NHS GDS contracts with general dental and orthodontic practitioners (dental contractors) and governance within NHS primary denta306l care is a responsibility of LHBs. Providers of NHS primary care dental services contracted with an LHB are expected to co-operate with such governance requirements as the LHB establish. The regulations also state that the contractor will establish, and operate a practice based quality assurance system. In addition these regulations state that the contractor will ensure that there are appropriate arrangements for infection control and decontamination in place within their practices. GENERAL DENTAL SERVICE PROFILE As of June 1st 2015 there are 79 dental practices and 306 individual dental performers working across the Health Board area. These include three special orthodontic practices and three locally recognised Dentists with Enhanced Skills [DES]. In addition Neath Port Talbot has the post graduate dental training Unit who also provide services to patients. ASSURANCE STRUCTURES The quality, safety and governance of primary care dental services is provided from three main sources, namely:-

1. Professional quality assurance self-assessment 2. National practice inspection programme 3. Performance management of individual contracts by Locality Primary Care teams.

This work is supported by two part-time Dental Practice Advisors [DPAs] who transferred to (each) Health Board’s employ from Public Health Wales in September 2014, accountable to the Associate Medical Director (Dental Services), and the Dental Reference Service [DRS]. Although the DRS no longer undertakes a regular inspection

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programme, it produces reports on specified practices’ clinical activity reporting on a per patient basis.

A summary of the governance arrangements and reporting structures for General Dental Services is outlined in the following diagram.

General Dental Practitioner

Dental Clinical Governance

Group

Locality Management Board

Quality Assurance Self

Assessment

Patient Experience Contract Monitoring

Locality Governance Groups

Quality and Safety Committee

Assurance and

Learning

Group

QUALITY ASSURANCE SELF ASSESSMENT NHS Dental Practices are required to complete the online Quality Assurance Self- Assessment (QAS) questionnaire on an annual basis. The QAS is designed to ensure that General Dental Practices comply with the statutory requirements, guidance and best practice for governance, thereby providing the assurance that dental staff are working within high quality, safe environments. All completed questionnaires are then reviewed by the Health Board’s Dental Practice Advisor (DPA). The DPA produces a report for each practice which highlights any required actions and the timescales for these actions. Practices are allocated green, amber or red status depending on the actions identified. The following table reports on the status allocated to each practice.

Locality Number of practices completing QAS

% of all practices completing QAS

Number of practices with green status

Number of practices with amber status

Number of practices with red status

Bridgend 23 100 23

Neath Port Talbot

17 100 17 0 0

Swansea 43 100 39 1 3

Total 83 79 1 3

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In 2014/15 the vast majority achieved ‘green’ status with the remainder taking appropriate action to address any issues identified. Whilst reviewing the QAS reports with each practice, the DPAs identified a number of common themes:

Information Governance

Decontamination and Cross Infection Control

Radiation Protection and Ionising Radiation (Medical Exposure) Regulations (IRMER) Compliance

Policy Guidance and Procedures

These have been shared through the Health Board’s governance mechanisms and through Health Board/Local Dental Committee Liaison Group. The Locality primary care teams will ensure all actions highlighted in the individual practice reports are carried out by the practice within the stated timescales, and also review at year-end practice visits or share ABMU-wide at the ‘dashboard’ discussions as appropriate. HIW INSPECTIONS Following the cessation of the Dental Practice Board inspection programme in 2014 Health Inspectorate Wales (HIW) commenced a programme of dental inspections in 2014-15, focussing on those practices who had not been visited for more than three years under the previous inspection arrangements. This ‘catch-up’ series of visits has now concluded and the Welsh Government commissioned a three year rolling programme will commence in 2015/16

During the inspection HIW consider and review the following areas;

Patient experience,

Delivery of Standards for Health Services in Wales,

Management and leadership,

Quality of environment.

At the end of each inspection, HIW provide an overview of their findings to representatives of the dental practice to ensure that they receive appropriate feedback. Any urgent concerns that may arise from dental inspections will be notified to the dental practice and to the Health Board via an immediate action letter. Any such findings will be detailed, along with any other recommendations made, within Appendix A of the inspection report.

Once an agreed practice inspection report and improvement plan has been produced it is the responsibility of the contract provider to take forward any actions identified by HIW. Following receipt of the completed improvement plan the Health Board Dental Practice Advisor and Dental Contract Manager are responsible for ensuring that actions have been fully implemented and within the required timeframe. The following inspections have been undertaken:

Locality Number of practices inspected

Reports published

Reports awaited

Bridgend 3 3

Neath Port Talbot 4 2 2

Swansea 5 3 2

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Through the national implementation group for the HIW inspection programme, on which ABMU is represented, it has been noted that a number of the areas which are identified as concerns in HIW reports relate to areas where the GDPs may have self-assessed themselves as having achieved through the QAS. Where these instances occur individual health boards will be addressing the concerns with the relevant GDPs and will report back through the established governance mechanisms. It is however, important to note that the QAS tool is reviewed and revised on an annual basis and therefore with regular refinement both processes should become more aligned. CONTRACT PERFORMANCE REPORTING AND MONITORING The Health Board’s Locality Primary Care Teams review exception reports available on-line from NHS Dental Services on a quarterly basis which are compiled from activity data from General Dental Practices. All General and Personal Dental Services contracts in the LHB are compared by NHS Dental Services, with all other general contracts in England and Wales to highlight discrepancies in recorded activity for which payment has been claimed. The quarterly Contract Exception Report and the accompanying Summary Exception Report present a set of contract risk indicators for each individual dental contract (including multiple claims for the same patient, free replacements and returns and continuations). These indicators may be associated with risks to the successful delivery of contracts, or to the quality of services or ‘best value’ associated with the contract. These exception reports are monitored across the three localities in line with the locally produced exception report protocol. However, it has emerged that where a number of performers are working to one contract the Exception Report’s picture of ‘average’ performance data may not be sufficiently accurate eg bringing together Band 2 and Band 3 claims and reporting as a single line can mask potential splitting of courses of treatment and inappropriate claiming patterns. Health Board primary care team staff have therefore, in the past year, produced an addendum to the Exception Reporting Protocol which sets out how to conduct more comprehensive analysis of the activity that is undertaken on a patient by patient basis by dental performers where the Health Board may have cause for concern, e.g. more than three performers working to a single contract number or an individual dentist who is allocated to perform more than 8000 Units of Dental Activity.

Where the LHB has significant concerns relating to the performance of a contract, in-depth investigations may need to be carried out with the support of the Dental Reference Service via the Dental Practice Adviser. Examination of patient records, claims information, patient questionnaires and examination of patients may be undertaken. Decisions on the level and depth of examination required are always made by Locality management teams with the advice of the aforementioned professionals and the Associate Medical Director as soon as potential professional concerns are involved.

It should be noted that occurrence of some exceptions, irrespective of level of risk, may lead to the contract holder being issued with a notice of breach of contract, that may require them to, amend their performance over one of a wide range of issues (e.g. including opening times or type of care provided) within a set timeframe. PERFORMANCE CONCERNS

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ABMU Locality Teams, working with the Dental Practice Advisors and the Associate Medical Director (Dental Services) are currently reviewing a number of performance concerns which have arisen through a mixture of contract performance monitoring, patient concerns reported to the Health Board or General Dental Council and ‘whistle blowing.’ These concerns are being addressed in line with the Welsh Government Model Operating Procedure for the Management of Dentists on the Dental Performers List whose Performance is of Concern (2012). Lessons learned from cases continue to be shared anonymously across the organisation and will be shared formally with Local Dental Committee in an anonymised format. In order to support performers in understanding the dental contract fully the Health Board continues, with Local Dental Committee support, to encourage all performers to attend the regular local courses provided by senior Professional Dental Advisors and Wales’ Deanery on the regulations and associated expectations of financial claims that underpin the dental contract. Within the Health Board, Locality and professional staff are confident, through comparison of practice performance against an ABMU ‘dashboard’ (available for examination if required) of issues that might indicate cause to be concerned that dental performers are not investigated without due cause and lessons continue to be shared to ensure a consistent, ABMU-wide approach. ANTI- MICROBIAL PRESCRIBING To ensure appropriate and effective dental treatment is being provided and guidelines for the issue of antibiotic/antimicrobial prescribing are followed, a process for identifying concerns has, since April 2015, been developed by the Locality Primary Care and Medicines Management teams in conjunction with the Health Board’s Dental Practice Advisor (DPA). Any concerns are reported to the DPA who will provide support and guidance to identified providers. Concerns will be escalated through the appropriate channels by DPA as and when necessary PATIENT EXPERIENCE Local Oral Health Plan [LOHP] The Health Board’s Oral Health Plan (December 2014), which was developed to support the National Oral Health Plan contains 20 objectives and associated actions to be taken over the subsequent five years to improve the oral health of the population for which ABMU is responsible. These objectives, cover prevention activities such as Designed to Smile, primary, community, secondary and tertiary care dental and oral health services. Improving contract management in order to improve governance and increase both the quality and capacity within General Dental Health Services is an explicit objective within this plan. An Integrated Impact Assessment was undertaken on the LOHP led by Swansea Locality as part of the Healthy City Programme. Access The following table illustrates the increased dental access rates for the year 2013/14 in comparison with the previous year that results from continual monitoring of contracts, eg non-recurrent and recurrent commissioning of activity in areas of high need utilising

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monies recovered for under-performance or inappropriate claiming and recommissioning), particularly the major additional activity commissioned in April 2013 The Localities are currently working together with Procurement and Internal Audit colleagues to supplement the Health Board’s formal procurement rules and standing orders with commissioning guidelines that reflect the primary care context to ensure a consistent commissioning of dental services is adopted. .

Number of patients receiving treatment

% of population receiving treatment

% change of previous year

Bridgend 78869 57 +5

Neath Port Talbot

59319 42

0*

Swansea 141342 59 +2

Total 279530 54 2

*NB the improved position for NPT residents is reflected within the Swansea and Bridgend data which is based on practice rather than patient postcodes: additional activity for NPT residents was commissioned from practices in Pontardawe and Llynfi Valley

With over 40% of its adult population and 71% of children accessing dental services over the past two years, the Health Board is considered one of the highest performers in Wales. However, access continues to be a problem for residents in many areas, with only 12 of the Health Board’s 79 NHS contracted practices accepting all patients, ie all adults as well as children (14 accept children only). Health Board staff have also worked to increase access to mainstream General Dental Services through reminding GDPs of NICE recall guidelines thus potentially reducing the number of patients recalled inappropriately by their GDP for 6 month check up appointments. A further major piece of work that is intended to improve effectiveness and, ultimately, enhance in-hours general dental services, is the recent and ongoing work to review and revise the two urgent dental access systems that are currently in operation in ABMU. The first stage has been to review and revise the in-hours urgent access scheme to improve its utilisation. A new model was implemented on the 1st April 2014 which, with the inclusion of a Health Board Dental Services coordinator making direct appointments for patients triaged by NHS Direct, improved both access for patients to in-hours urgent dental care and provided the Health Board with valuable data on service demand and patient requirements. A service review, which included patient consultation, was undertaken in November 2014 and based on these findings a revised service specification was developed and issued on 1st June, focusing on

value for money

one appointment system being adopted by all providers to maximise the use of appointments

ensure the service continues to meet patient demand. The revised service will be commissioned from September 2015. As soon as possible thereafter, the Out-of-Hours service will be remodelled and re-located to reflect service demand and easy access, eg in one or two central locations. The remodelling will be progressed as an integral part of the Health Board’s planned pilot of a 111 system. As

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indicated above, the revisions to the urgent access systems summarised above are intended to improve the patient experience and release resources for re-investment in core, in-hours, general dental services. Complaints During the period 1st April 2014 to 31st March 2015 the Health Board received the following number of patient concerns in relation to GDS services.

Locality Bridgend Neath Port Talbot

Swansea Out-of- Hours Provision

Total

Number of Concerns

9 16 19 6 50

The Health Board currently has 1 Ombudsman investigation ongoing in relation to General Dental Services. This case relates to the clinical care provided and is currently under investigation. No Ombudsman’s cases have been closed in the previous financial year. Key themes emerging from concerns are:-

Clinical treatment provided

Charges for work

Access to out of hours services. The complaints regarding access to the Out-of-Hours Dental Service have been upheld and have been examples of poor patient experience, with patients experiencing significant difficulty in having calls answered in order to book emergency appointments and also if they get through patients experience further problems with the availability of appointments. As indicated earlier in this report, a programme of work is now progressing at speed (phase 1 being changes to the in-hours access system) to resolve these issues in 2015. KEY RECOMMENDATIONS The Quality and Safety Committee is asked to note:

The systems and processes in place to provide the Board with assurance on standards of governance in dental practices

The current status of practices in relation to the QAS and actions being taken to provide assurance.

The current processes that are in place to identify performance issues and outliers among dental contractors across ABMU

The high level of performance cases which are currently ongoing across ABMU Health Board

The service plans being progressed to improve quality, governance and the patient experience.

General Dental Practitioner

Dental Clinical Governance

Group

Locality Management Board

Quality Assurance Self

Assessment

Patient Experience

Contract Monitoring

Locality Governance Groups

Quality and Safety Committee

Assurance and

Learning

Group

Governance Structures

Annual on-line self assessment to ensure good governance within each dental practice

Reviewed by Dental Practice Advisor

Red/Amber/ Green status allocated to practices depending on actions identified- 95% of ABMUHB practices were given a green status

Themes emerging from the QAS include:-

• Information Governance

• Decontamination and Cross Infection Control

• Radiation Protection and IRMER Compliance

• Policy Guidance and Procedures

The programme commenced in 2014 and the areas

reviewed are:-

Patient experience,

Delivery of Standards for Health Services in

Wales,

Management and leadership,

Quality of environment.

Exception reports provided through NHS Dental

Services on a quarterly basis, these show potential

risk indicators for each contract. Exceptions and

outliers are the investigated further.

Dashboard information used to monitor and compare

practice performance.

Concerns that are raised through patients’ concerns,

the General Dental Council or whistle-blowing are

investigated by the Health Board, working with the

Dental Practice Advisor and Associate Medical Director.

Concerns are reported directly to practices as well

as to ABMUHB.

Key themes from concerns include:-

Access

Access to the Out of Hours dental services

Charging

Clinical care provided

ABMU Quality and Safety Committee

Locality Management Boards

Locality Quality and Safety Groups

ABMU Pharmacy Operational Group

Trends identified from returns include :-

Needing to ensure that staff have annual appraisals and personal development plans

Waiting times for medication

Privacy for discussing issues

The comfort of waiting areas

Needing to ensure that there are processes for dealing with concerns and complaints

Needing to have systems in place to deal with incidents regarding controlled drugs

The need to develop whistle blowing policies

Trends identified:-

Having a named Caldicott Guardian,

Keeping an asset and information register.

Awareness of the NHS Wales Acceptable Use

policy for internet use

Small number of pharmacies where staff work

offsite,

Staff awareness of business continuity plans

Excellent, effective

and efficient

services meeting

standards

Organised for

excellence and

improvement

Always being as

safe as possible

Services planned

with our

communities

•Contract monitoring

visits across Dental and

Community Pharmacy

•HIW inspections

•Self assessment and

analysis systems

•Financial scrutiny

•Robust governance

systems and

arrangements

•Supporting community

pharmacies in annual

appraisals, PDRs and

whistle-blowing policies

•Learning from

concerns

•Improved access to

General Dental

Services

•Working with

community pharmacies

to improve concerns

management

•Performance

management systems

•Improving information

governance in


•Improving controlled

drugs management in


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MAIN REPORT ABM University Health Board


Agenda item: 3.7(b)

Subject General Pharmaceutical Contract- Arrangements for provision of assurance of compliance with contractual requirements within ABMU Health Board.

Prepared by Locality Management Teams, Medicines Management Team

Approved and presented by

Lindsay Davies- Head of Primary Care and Planning, Neath Port Talbot Locality

Alex Gibbins- Heads of Medicines Management, Bridgend Locality

PURPOSE Following publication of the General Pharmaceutical Services Audit Review of March 2015 this paper seeks to clarify the accountability and responsibilities for clinical governance and contract monitoring processes in place in ABMU. INTRODUCTION The report outlines the current roles and responsibilities in place to support the clinical governance and contract monitoring of the General Pharmaceutical Contract. The report responds to the findings of the internal audit conducted in September 2014 (published March 2015) which reported that the framework that is in place to oversee and manage General Pharmaceutical Services and communicate assurance on these to the Board needed to be documented and formally reported. KEY ISSUES Internal Structures When the General Pharmaceutical contract, was introduced in March 2005 management responsibility for its implementation and management rested with the Primary Care Directors of the former 22 Local Health Boards [LHBs]. Accountability to the LHBs was clear, and supported by representation from all independent contractors including Community Pharmacy. Following the creation of the new integrated Local Health Boards, including ABMU, in 2009 the responsibility for the management of the contract was placed with the three Locality Heads of Primary Care and Planning, reporting to their Locality Directors. The Locality Directors were in turn accountable to the Executive Director for Primary and Community Care and, thence the Health Board. Any contractual or governance issues of note would have been raised by the Locality Directors via the performance review process

__________________________________________________________________________________________

The Heads of Primary Care and Planning have within their teams, identified primary care managers with responsibility for the operational management of the Community Pharmacy Contract including an annual programme for monitoring and visiting. Professional support and advice is provided to the Primary Care Teams by the Medicines Management Team via a Lead Locality Head of Medicines Management along with Medicines Management Technicians who support the visiting programme as well as meetings involving pharmacy contractors.

Pharmacy Liaison Group The formal involvement of community pharmacy contractors that was in place in the former LHB structure was not continued in the integrated Health Board structure that was introduced in 2009. The Pharmacy Liaison Group comprises Health Board Locality manager, including those from Medicines Management and meets quarterly with Community Pharmacy representatives. The internal audit highlighted that the group’s terms of reference indicate that it has a formal reporting mechanism to the Health Board Primary Care Development Group [PCDG]. This, however, is not the case and would, in any event, be inappropriate as the PCDG is a discussion forum, chaired by the Director of Primary, Community Care & Mental Health/Chief Operating Officer to support and direct ABMU-wide consideration of primary care matters that are for Locality and/or Executive level or Health Board decision. The Pharmacy Liaison Group therefore, whilst providing a valuable opportunity to strengthen the interface between the Health Board and community pharmacies, does not form part of the mechanisms for providing assurance on the monitoring and management of the contract. The Pharmacy Liaison Group has a remit similar to the Local Medical Committee and Local Dental Committee Liaison Groups n that it provides a vehicle for discussion between the parties to inform Locality/Health Board service development and contractual matters.

Executive Director for Primary and Community Care

Locality Directors

Locality Heads of Primary Care

and Planning

Head of Medicines Management –

Community Pharmacy Lead

Primary Care Managers

__________________________________________________________________________________________

The terms of reference for this group will be updated to reflect its status as a Health Board/contractor professions discussion forum. Pharmacy Operational Group This group comprises representatives from the three locality primary care and medicines management teams. It was established as an informal forum in which contractual matters and processes that needed to be pursued consistently ABMU-wide could be discussed in order to be taken forward via the three locality management teams. This group reports to locality quality and safety groups and locality management team and will continue to meet and will develop formal terms of reference to support the new operational Delivery Unit.

RECOMMENDATION The Quality and Safety Committee is asked to note:

the accountability and governance framework that is currently in place within ABMU

the actions that will be taken to formalise these as an integral element of designing and implementing the new operational management structure

the further assurance that will come from receiving annual reports – supplemented where necessary - on contractual monitoring review process and outcomes that aim to ensure community pharmacy contractor compliance with the General Pharmaceutical Contract.

ABMU Quality and Safety Committee

Locality Management Boards

Locality Quality and Safety Groups

ABMU Pharmacy Operational Group

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Agenda item: 3.7(c)

Subject General Pharmaceutical Contract- Analysis of Clinical Governance and Information Governance Questionnaires. Report on the contract monitoring processes for 13/14 and 14/15.

Prepared by Locality Teams

Approved and Presented by

Lindsay Davies- Head of Primary Care and Planning, Neath Port Talbot Locality

Alex Gibbins- Head of Medicines Management, Bridgend Locality

INTRODUCTION The Pharmaceutical Service (Wales) Regulations 2013 require Community Pharmacies to complete an online Clinical Governance and Information Governance questionnaire at the end of each financial year. Locality Teams have analysed these returns to seek assurance that pharmacies are compliant with the regulations and to identify key areas in which pharmacies may require support to develop. This report:

Updates the Quality and Safety Committee on the results of the questionnaires completed in the 2013/14 financial year

Highlights common key issues across the Health Board

Provides a summary report of the last two years’ Community Pharmacy visiting programme

BACKGROUND Schedule 4, part 4, of the Pharmaceutical (Wales) Regulations 2013, states that an NHS pharmacist must participate in an acceptable system of clinical governance, with assurance provided to the Health Boards by an annual self assessment of compliance. All pharmacies in Wales must complete a standard clinical governance online self assessment and an information governance questionnaire at the end of each financial year. The questionnaires are “locked down” at the end of April and Health Boards are provided subsequently with the results from NHS Wales Informatics Services (NWIS). As the online questionnaires only cover clinical governance and information governance, ABMU Health Board has developed its own paper- based Self- Assessment Questionnaire (SAQ) which is sent to contractors for return each July. The responses to these and the online SAQs are used to inform the visiting schedule by Primary Care teams with Medicines Management support, this visiting programme forms a core part of the contract performance review process .

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KEY ISSUES

The Regulations in England, but not Wales, support the withholding of payments to contractors who fail to submit the questionnaires or whose response is not deemed to show compliance with the regulations. Primary Care and Medicines Management leads will continue to recommend a Wales-wide approach is agreed to tackle this at appropriate all-Wales fora.

The practice visiting schedule is determined through analysis of both the online and paper based Self-Assessment Questionnaires that are submitted. In addition, consideration is given as to whether there has been a change in ownership or management within a pharmacy as this will trigger a visit. Any other pertinent information about the pharmacy and its operation will also be taken in to account to determine if a visit is required. This process has been agreed across ABMU and adopted in each locality area. The Locality Teams, in discussion with Medicines Management Colleagues as the Pharmacy Operational Group will document the proposed criteria for Locality Management Board approval.

CLINICAL GOVERNANCE AND INFORMATION GOVERNANCE QUESTIONNAIRES Analysis of 13/14 Responses

94% of the (117 out of 125) pharmacies in ABMU submitted their responses on line as opposed to using a paper based system

Although 100% of pharmacies submitted questionnaires, some failed to fully answer all the questions.

Some themes emerged from the responses which indicated where support to contractors, e.g. formal learning sessions, may help secure improvement. Currently, community pharmacies do not have access to protected learning time in the same as other Primary Care contractors do. However, the Wales Centre for Pharmacy Professional Education (WCPPE) provides all registered pharmacists, pharmacy technicians and support staff in Wales the provision of learning and development opportunities, to enhance their competence to deliver high quality patient services. WCPPE is an operational unit of the School of Pharmacy and Pharmaceutical Sciences, Cardiff University.

OUTCOMES OF CONTRACT MONITORING VISITS 2013/14 AND 2014/15 2013/14 Contract Monitoring

Locality Responses received (%)

Number whose submissions were complete and provided adequate assurance (%)

Number visited (%)

Number of pharmacies given action plans (%)

Bridgend 32 (97) 18 (54) 3 (9) 15 (46)

Neath Port Talbot

33 (100) 5 (15) 6 (18) 26 (79)

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Swansea 59 (100) 40 (68) 6 (10) 17 (29)

All completed plans and actions reviewed as part of the 2014/15 monitoring programme. 2014/15 Contract Monitoring

Locality Responses received (%)

Number whose submissions were complete and provided adequate assurance (%)

Number visited (%)

Number of pharmacies given action plans (%)

Bridgend 33 (100) 2 (6) 10 (30) 31 (94)

Neath Port Talbot

33 (100) 4 (12) 9 (27) 29 (88)

Swansea 59 (100) 41 (69) 17(28) 29 (49)

The number of pharmacies asked to complete action plans within Bridgend Locality increased significantly from 2013/14 to 2014/15 the reason for this is improvements made within the Locality to the processes for reviewing submissions and judging whether the assurances given are adequate. The Committee are also asked to note that since April 2015 community pharmacies have provided the Health Board with assurance through the return of completed actions plans, which will be reviewed as part of the 2015/16 monitoring programme. ANALYSIS OF RESPONSES An analysis of the responses has been made against the previous Healthcare Standards and the self-assessment fields themselves to identify key themes. Issues identified include:-

Annual appraisal, personal development plans and performance management

Evidence of learning from audits

Clear indication in the pharmacy of which services are funded by NHS Wales

The physical environment of pharmacies including waiting areas

The needs for pharmacies to have up to date complaints policies

Not all pharmacies have NHS email addresses

Awareness of controlled drugs policies

Whistle- blowing policy containing contact for concerns regarding controlled drugs

Having a named Caldicott Guardian

Keeping an asset and information register.

Awareness of the NHS Wales Acceptable Use policy for internet use

Small number of Pharmacies where staff work offsite,

Staff awareness of business continuity plans

RECOMMENDATIONS

The Quality and Safety Committee is asked to note:

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the analysis of the online questionnaires recognising the areas where contractors may need further support to develop

the outcomes of the visiting programme for 2013/15 and 2014/15 and agree this provides assurance that pharmacies are robustly monitored and performance managed where necessary.

that Locality Teams, including Medicines Management staff, will, as the ABMU Pharmacy Operational Group, be making formal recommendations to the Locality Management Teams on the following as part of their work programme for 2015/16:

documenting the review and outcomes from the SAQs.

pharmacy visit criteria feasibility and benefits of providing protected time for formal learning

opportunities in conjunction with WCPPE for contractors to further improve governance and compliance with contractual requirements.

Clinical Governance Questions 1-10

Common themes: Annual appraisal, personal development plans and performance management.


Common themes: Summary of audit results, Action taken as a consequence of results. The gaps in the chart represent a free typed response. They types of aids provided in the main are Non CRC tops, large print labels


Common themes: Clear indication in the pharmacy of which services are funded by NHS Wales. Areas of best practice identified via the patient questionnaire include: Service provided, Performance of staff, Areas od worst

performance include Waiting time, privacy for discussing issues, comfort of waiting areas. All Pharmacies identified action to undertake to address their worst areas of performance.


Common themes: Having a documented complaints and concerns procedure, having and NHS email, records of actions in response to ENAS.


Common Theme: does the Pharmacy have a documented procedure for ensuring stock is sold by retail in a safe and effective manner.


Common Themes: Small number of Controlled drug incidents reported. Still a lack of awareness of who to contact regarding incidents with Controlled drugs.


Common Themes: Whsitle blowing policy containing contact for concerns regarding controlled drugs.

Information Governance Questions 1-10

Common Themes:

Having a named Caldicott Guardian, Keeping an asset and information register.



Common Themes: Awareness of the NHS Wales Acceptable Use policy for internet use


Common Themes: Small number of Pharmacies where staff work offsite, Staff awareness of business continuity plans

Appendix 2

1



Agenda item : 3.7(d)

Subject Primary Care Governance Report- Learning for the Future

Prepared by Locality Management Teams

Approved

and

Presented by

Zoe Wallace- Head of Primary Care and Planning, Bridgend

Locality

PURPOSE

To describe to the Quality and Safety Committee the ABMU Health Board position

with regard to actions in response to the Welsh Government Robbie Powell enquiry

and to outline how any areas of unresolved risk will be taken forward by the

Localities and Operational Delivery Unit.

INTRODUCTION

The Learning for the Future- Taking Forward and building on the recommendations

from the Robert Powell Investigation report (WG:2012) contains a number of

recommendations for Health Boards in Wales and the Welsh Government, ABMUHB

completed an action plan based on these recommendations and this report provides

a summary position of the actions which are the responsibility of Health Boards.

ASSESSMENT OF RESPONSE TO ACTIONS

The following actions were identified within the report as being the responsibility of

Health Boards to take forward.

Action 3

The General Medical Services Contract requires contractors to ‘keep adequate

records of attendance on and treatment of patients’ and ‘shall include in the record

clinical reports from any other health professional who has provided clinical services.

The existing GP systems are currently being upgraded and the new systems have

the ability to scan electronically all documents received by the GP as part of the

individual’s record. LHBs must assure themselves that all practices are able to

demonstrate that robust and comprehensive record keeping is in place.

ABMU Health Board Response

2

The relevant Quality Outcomes Framework (QOF) indicators were reviewed in all 77

practices in 2012/13, where practices were found to be deficient improvement plans

were put in place and completed.

In 2013/14 the QOF indicators relating to records management were removed,

however the relevant sections of practices’ Clinical Governance Self Assessment

Tool assessments were scrutinised and formed part of the Practice Visiting

Programme for that year. During the practice visiting programme 26 practices were

visited by the Clinical Directors. Scrutiny of records remains a part of the Practice

Visiting Programme for 2015/16 with explicit guidance to clinical directors on the

review of records.

Following completion of a questionnaire by practice on arrangements for managing

information and communication undertaken in 2013-14 additional training and

support was provided in the Protected Learning Time sessions for practices in the

same year, including a specific session held by the Medical Defence Union.

The Individual Health Record is now in place in all Health Board practices, with the

roll out having been completed earlier this year. Technical issues within the Out of

Hours service have been raised directly with NHS Wales Informatics Service

(NWIS).

Since April 2015 the DATIX incident reporting system has been piloted in all

practices in Bridgend and Neath Port Talbot and a small number of practices in

Swansea. The DATIX system allows practices to report incidents including poor

discharge arrangements from secondary care, poor communication from secondary

care and any other incidents or learning within the practice. This information will

improve communication regarding concerns from Primary to Secondary care and

allow for improved data capture for analysing trends. The risk of poor communication

between secondary and primary care regarding discharge features on each locality

risk register and through using information from incident reporting it will enable

individual services to investigate any potential failures on their part.

Action 6

Aside from technological support systems. Doctors must be satisfied that when they

are off duty, suitable handover arrangements have been made for their patients’

medical cover to ensure continuity. The introduction of personal care plans for

individuals with chronic conditions, cancer and mental health will also improve

integration and continuity of care. Tools such as the Clinical Governance Self

Assessment toolkit are available to practices to review and develop their internal

communication systems. LHBs must seek assurance that such safeguards are in

place


3

In 2013/14 and 2014/15 CGPSAT self assessment scores were compared with

Health Board suggested minimum standards for fields which related to actions from

the Learning for the Future report including communication systems. Where

practices did not meet the suggested scores they were contacted individually and

offered additional support to address any areas of concern. As noted previously

analysis of these scores also informed the Practice Visiting Programme with

practices who did not complete the self assessment or whose assessment raised

concerns, being prioritised for a visit by the Clinical Director.

From April 2015 the Clinical Governance Practice Self Assessment Toolkit

(CGPSAT) has formed part of the QOF process therefore all practices within the

Health Board will be required to complete the CGPSAT.

A review of the QOF indicator for transfer of information was undertaken in 2012/13

in all 77 practices and all were found to have a policy in place to send and receive

information from the Out of Hours service. The Out of Hours Service is required to

provide information to practices by 9 a.m. the following day and compliance with this

target is reported to the Quality and Safety Committee. A small number (1%) of

transfers of information occur after 9 a.m. and this is due to problems with practices’

fax machine. NWIS are leading on a national programme of upgrade to practice

systems, to enable them to move to the Data Transfer Systems (DTS) which is more

robust and has a failsafe mechanism of transferring information directly into patients’

records.

Arrangements are in place to exchange information between GP practices and Out

of hours for patients who have a particular need, particularly those at end of life. This

information is communicated between professionals via a ‘special note.’ In 2013 use

of special notes was checked through QOF monitoring and no issues were identified

in any of the Health board practices, however subsequent audits of the use of

special notes have identified that these are not used routinely within Primary Care.

All practices were written to in 2013 reminding them of the importance of using

‘special notes’ and the issue has been discussed within Locality Primary Care

governance forums. The issue is being taken forward through Cluster Networks who

will be managing it through their governance and risk management structures.

Action 7


Welsh Government will commission a review of the existing arrangements for

accessing and storage of records, taking into account technological advance. This

will include updating the existing regulations during 2013/14 if this is required. In the

meantime all LHBs need to satisfy themselves that robust processes are in

place to deal with any issues of non-compliance in the retrieval and handling

of medical records from GP practice following a patient’s death in line with

existing requirements.

4

Localities receive monthly compliance reports from Share Services and have

processes in place to identify and address any areas of non compliance.

Action 8


By March 2013 all LHBs must undertake a review of their governance

arrangements for assuring the quality of primary care. This should include the

effectiveness of the interface with secondary care and communications

systems.

A rolling programme of practice visits are undertaken within the Health Board with

the framework and methodology reviewed regularly. As noted previously, these visits

are informed by practices’ assessment using the CGPSAT tool in addition to other

intelligence such as issues raised via concerns or Ombudsman reports. The practice

visits are led by the locality Clinical Directors and provide an opportunity for

monitoring and dialogue between the Clinical Director and practice.

Additionally each Locality host governance forums, be that on a locality or cluster

level. These forums include opportunities to share lessons learnt, to raise any

concerns and to review and monitor incident themes and trends. These forum report

into Locality governance and management groups.

Across the Health Board there is a Primary Care Governance forum which is chaired

by the associate Medical Director and whose membership includes, Clinical

Directors, Heads of Primary Care and Governance Managers. This is a formal group

which supports the development of governance systems across Primary Care

through:-

- Sharing lessons learnt

- Learning opportunities

- Implementation of shared actions to support cohesive working across the

Health Board

- Providing a discussion forum for shared risks.

As noted previously the piloting of DATIX within primary care will strengthen the

interface between primary and secondary care through identifying and investigating

incidents as they occur.

A summary of the governance activities for Primary Care is included in Appendix 1,

which describes the range of locality and Health board wide tools used to ensure

robust governance arrangements.

5

Action 9

The outcome of each LHB review will be shared with Healthcare Inspectorate

Wales who will test out the effectiveness of these arrangements through

undertaking a rolling programme of reviews during 2013/14


The Healthcare Inspectorate Wales (HIW) reviews have been completed and the

findings of a national report will presented to Locality management Boards in July

2015. Within its findings HIW found that communication systems within practices

were adequate to provide continuity of care for patients, but that communication

between secondary care and primary care with regard to discharge of patients needs

to be improved.

RECOMMENDATION

The Quality and Safety Committee is asked to:-

-Accept this report for the Learning for the Future Action Plan and note the work that

the Locality will be undertaking with other Directorates to ensure that areas of

unresolved risk are taken forward through their performance and risk management

systems.

- Note the framework for General Medical Service Governance included as Appendix

1.

6

Appendix 1

General Medical Services Assurance Activities

Analysis of the Clinical Governance Self Assessment Tool (CGSPAT) based

on the standards for health care in Wales (51 matrices) and identification to

practices of additional support available.

Implementation of the Practice Visiting Programme (one third of practices

annually) utilises the CGSPAT results aswell as discussion on post payment

verification, HIW and CHC reports, patient involvement and any general

points relating to for example access, arrangements for carers.

Analysis and Monitoring of complaints - trends and themes arising

Annual contract monitoring return confirming compliance with a range of

contractual and statutory requirements.

Annual Quality and Outcome Framework returns

Cluster Network Annual Report, Risk Registers and key learning points from

National Pathway work on cancers, end of life and polypharmacy

Review and action on Health Inspectorate Wales - practice inspection reports

Implementation of the performance procedures for doctors on the

performance list and associated processes including screening, and reference

panels and resulting action plans

ABMU wide primary care performance database – overview of any current /

previous concerns

Performance list regulations including processes to gain entrance to list and

requirements to notify change of circumstances

Locality Primary Care Governance Forum/ Governance Boards

ABMU wide Primary care governance forum (chaired by Assistant Medical

Director Primary Care) oversees consistency and identifies good practice.

Regular liaison meeting with GMC ( medical director and assistant medical

director primary care)

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