agenda item 4.5 2 november 2016 health board report ... 2016-… · operational delivery report...

Operational Delivery Report

of 12 University Health Board Meeting 2 November 2016

AGENDA ITEM 4.5

2 NOVEMBER 2016

Health Board Report

OPERATIONAL DELIVERY REPORT

Executive Lead: Chief Operating Officer / Director of Therapies and Health Sciences and the Director of Primary Care, Community and Mental Health

Author: Head of Business Support (Operations)

Contact Details for further information: [email protected] or 01443 744800

Purpose of the Health Board Report

The purpose of this report is to update the Board on a number of key operational issues that are currently being taken forward and the associated

risks and contingency plans that are being managed.

Governance

Link to

Health Board Strategic

Objective(s)

The Board’s overarching role is to ensure its Strategy outlined

within ‘Cwm Taf Cares’ 3 Year Integrated Medium Term Plan 2015-2018 and the related organisational objectives aligned

with the Institute of Healthcare Improvement's (IHI) ‘Triple Aim’ are being progressed, these in summary are:

To improve quality, safety and patient experience

To protect and improve population health To ensure that the services provided are accessible and

sustainable into the future To provide strong governance and assurance

To ensure good value based care and treatment for our patients in line with the resources made available to the

Health Board. This report focuses on outlining the operational impact of all of

the objectives above.

Supporting evidence

Reports to Executive Board and Board sub-Committees, Chief Operating Officer Operational Board discussion, Strategic

Planning Group discussion, Executive Programme Board progress updates, discussion at Clinical Business Meetings

Engagement – Who has been involved in this work?

Assistant Directors of Operations - Scheduled Care, Unscheduled Care and

Mental Health & CAMHS, Locality Manager, Head of Primary Care, Head of Medicines Management, Directorate Managers, Assistant Director Therapies &

Health Sciences.

mailto:[email protected]



Health Board Resolution (insert √) To;

APPROVE ENDORSE DISCUSS √ NOTE √

Recommendation The Board is requested to: DISCUSS and NOTE the content of the report and the

current position in respect of a number of key areas.

Summarise the Impact of the Health Board Report

Equality and diversity

There are no specific equality and diversity issues highlighted within this report.

Legal implications

There are no legal implications highlighted within this report. However a number of indicators within the performance

information / dashboards monitor progress in relation to legislation, such as the compliance with national targets and

measures and compliance to statutory duties.

Population Health

A number of the indicators used to measure performance of the Directorates contribute to improvements in population

health.

Quality,

Safety & Patient

Experience

The clinical business meetings and the COO Operational Board

provide a forum for discussion in respect of quality and patient safety issues identified by the Executive Team and the

Directorates.

Resources The report highlights a number of financial and other resourcing issues which impact on operational delivery.

Risks and Assurance

The report highlights a number of risks related to the operational delivery for Directorates and Localities and the

actions being taken to mitigate these risks.

Health & Care Standards

The 22 Health & Care Standards for NHS Wales are mapped into the 7 Quality Themes:

Staying Healthy; Safe Care; Effective Care; Dignified Care; Timely Care; Individual Care; Staff & Resources

http://www.wales.nhs.uk/sitesplus/documents/1064/24729_Health%20Standards%20Framework_2015_E1.pdf

The work reported in this summary and related annexes take into account many of the related quality themes including safe

and effective care.

Workforce The report identifies a range of issues that will impact on workforce which include developing the workforce, realigning

staff numbers and using indicators to monitor progress in relation to workforce, such as sickness and Personal

Development Review rates.

Freedom of

information

status

Open





OPERATIONAL DELIVERY REPORT

1. SITUATION / PURPOSE OF REPORT

The purpose of this report is to update the Board on a number of key

operational issues that are currently being taken forward and the associated risks and contingency plans that are being managed.

2. BACKGROUND / INTRODUCTION

This joint operational delivery report from the Chief Operating Officer (COO) and Director of Primary, Community and Mental Health (DPCMH) provides an

overview of key activities including areas of joint working across the Directorates.

3. ASSESSMENT / GOVERNANCE AND RISK ISSUES

Acute Medical Service at the Royal Glamorgan Hospital

The above service continues to make good progress, with the appointment of a new Acute Care Physician, which will enable the extension of services into the

evening during week days. The advanced nurse practitioner workforce is

developing well with a number now able to work independently. ICT issues remain a challenge and this will be taken forward over the next few months.

Plans to co-locate the surgical assessment unit in the Royal Glamorgan Hospital

with the Ambulatory Emergency Care Unit (AECU), are being finalised and will require capital investment, this will optimise staffing resource and enable timely

cross specialty reviews.

Patient Flow Programme

Patient flow across the whole system improved during the summer months with lower levels of escalation being reported however, October has seen an

increase in the levels of escalation and a resultant reduction in achievement of the tier 1 targets.

A deep dive of patient flow issues across the whole system has been undertaken to determine the main areas of concern and an overview of the

main findings in three key areas is set out below.

1. Review of A&E practices through manager deep dives within the department

There are some process issues and areas where efficiencies can be made, however much of this is general housekeeping efficiencies and these actions will

be put in place immediately which should result in approximately 5% increase in 4 hour performance.



Space remains the biggest issue for the department at the Royal Glamorgan Hospital and this has a significant impact on the ability of the department to

function effectively.

Actions are being taken to mitigate the above and these include:

senior presence in the department

development of rapid assessment models revision of rotas

more robust escalation of specialty assessments close monitoring of waits

provision of additional minors space at the Royal Glamorgan Hospital - capital investment required

2. Review of issues in the supporting community hospital

There has been a down turn in the number of discharges from the Ysbyty Cwm

Rhondda site, this is not replicated on the Ysbyty Cwm Cynon site where discharges remain within the expected parameters. The issues relate to the

following areas:

Local authority delays in assessment due to social worker shortages in the

Rhondda area Local authority package of care delays over the past 3 months due to

changes in the commissioning arrangements with private care providers Care home availability is limited and is creating a number of delays

Availability of mental health assessment beds remains a key challenge in the community hospitals.

Actions are being taken to mitigate the above and these include: -

Further work to understand the impact of changes within mental health

Close working with local authority colleagues to highlight delays early in the process

Twice weekly patient flow meetings with local authority colleagues Recent appointment of a flow project manager to scope and improve

processes across the sites

Implementation of site based social worker model.

3. Review of inpatient mix on the acute site

The acute inpatient mix has not significantly changed however we have a higher than usual number of patients awaiting transfer to our community

hospital setting. Length of stay on the site does not indicate a deteriorating pattern and short stay numbers remain high. The senior nurses continue to

undertake deep dives with heads of nursing scrutiny.



Integrated Assessment and Response Service

The above service has been developed to improve communication and performance of health and social care services at the critical interface that

occurs during presentation at A&E departments and hospital admission through

to discharge

The pivotal functions of the service will be to:

Undertake initial assessments and commission / provide health, social care and third sector community support to facilitate safe and timely return home

from the A&E departments and the Clinical Decision Unit (CDU) to prevent unnecessary admission

For those patients who are admitted, integrated complex discharge assessments will be undertaken utilising the default position that individuals

are supported to return to a community setting.

The above will enable the connection of services, which will provide the foundation for the longer term vision of the development of an integrated

health and social care single point of access and corresponding community response, building upon and adding to the learning acquired during this first

phase of the integrated model.

The radical redesign of our integrated assessment and response services

represents transformational change and the first step in delivery of integrated @home services, which will be equipped to support older people to remain

living independently in community settings.

Full funding for the above service has been agreed on a recurring basis. Implementation of the above service model has therefore commenced with the

recruitment of additional community nurses, occupational therapists and therapy assistants. Social worker adverts are yet to be published and remain

the biggest recruitment concern.

Training for home care staff has commenced to ensure additional flexibility in the community service to support the new model. The service will focus on a

discharge to assess model, avoiding admission where appropriate and ensuring

complex patients are monitored and assessed at the earliest opportunity to facilitate timely discharge.

Redesign of Older People’s Mental Health Services

As part of phase 2 of the Older People’s Mental Health (OPMH) service redesign

(Valley LIFE) the Adult Mental Health Directorate completed an engagement exercise with staff, patients and the public on plans to release resources from

Dinas Ward in Ysbyty George Thomas into community settings. This is part of a wider Dementia Hub initiative to increase support for elderly people with mental

health problems and to support the process we have invested an additional



£198k into the Psychiatric Liaison Service to ensure that it can operate 7 days per week. The plan includes also the provision of additional resources into St

David’s Ward at the Royal Glamorgan Hospital to increase rehabilitation services and to improve patient flow across the mental health service.

Alongside this, positive discussions have opened with Treorchy Comprehensive

in relation to development of GCSE and A-level/Welsh modules that would connect the two institutions through structured volunteering (and potentially

apprenticeships).

Dinas Ward at Ysbyty George Thomas has closed and increased resources are now available in the community to support older adults with functional mental

health issues. This service redesign aligns with the recovery model of mental health care, where support and interventions are given in the least restrictive

environment to maximise the recovery of each individual.

Primary Care Mental Health Assessment

The mental health directorate has been working with the primary care assessment service to ensure that waiting times comply with the requirements

of the Mental Health Measure. Over recent weeks a number of evening and weekend clinics have taken place and this has given the team an opportunity to

review the way that it is delivering the service to meet the population needs

with services running outside of traditional 9am to 5pm pattern of working. This will have a significant impact on the Part 1 Assessment element of the

Mental Health Measure, which has been the most challenging part of tier 1 compliance in Mental Health.

Cardiac Catheterisation Laboratory Replacement Programme

As colleagues will be aware from previous reports, the Welsh Government

awarded the UHB £0.813m capital monies to progress the final phase of the cardiac catheterisation laboratory (the cath lab) replacement programme at the

Royal Glamorgan Hospital. The replacement programme has been completed and the replacement cath lab is now fully operational.

Primary Care & Communities

Cluster Development Plans Clusters are progressing their plans and spends against their allocations.

Practice pharmacists, social workers, communications, new roles and optimising skill mix are themes emerging to date.

In respect of the cluster hub development programme, the 4 new schemes,

MSK, respiratory, cardiology and diabetes are progressing well and largely on track with the outcomes and milestones identified in the delivery agreements.

These will be greatly supported by the implementation of Vision 360 which will enable the GPs with special interest to directly access patient records across

Cwm Taf. Information sharing protocols are currently being finalised.



Primary Care Dieticians

Two primary care dieticians have commenced and are now scoping the demands and needs within primary care supporting independent contractors,

chronic conditions management and cluster hub service development.

Redesign of @Home Service

The Health@home model has been implemented with a single point of access and triage function with one integrated team. The integrated assessment and

response service is in development in partnership with local authority colleagues and the Health@home nursing team will support this model. This

should strongly complement the @Home: IARS model.

Hep A Outbreak Following the sudden outbreak of Hep A in a Cynon Valley school, the school

nursing team was mobilised to undertake an intensive vaccination programme. The outbreak was closed in September with no new cases being reported.

Wound Clinics

Wound clinics continue to be delivered over 7 days a week. The skill mix has been reviewed and a team leader is currently being recruited and demand and

capacity is being assessed.

GP Out of Hours Service

Overall, our improved position is being maintained, with a GP shift fill rate averaging 93%. There are still however a few pinch points, especially at

holiday periods and particularly some challenges to fill shifts in Prince Charles Hospital at weekends, which are mitigated by double booking of shifts and

additional ST2 and 3s in A&E being resourced by the OOHs service. Other options for improving the PCH weekend shift fill are under consideration such as

revising the workforce model or commissioning regular shifts from an external provider. Ongoing concerns with HMRC and pension thresholds pose a key risk

for the service going forward and expert advice has been sought from KPMG and Deloittes – despite these disincentives GP numbers in the service remain at

circa 70, in line with the average since redesign.

111 Preparedness

The first workshop to introduce the 111 model took place on 20 October 2016. Richard Bowen, Director for the National Project introduced the session and

shared learning from the pilot project in Aneurin Bevan UHB. There was good representation from clinicians and a series of ongoing monthly meeting will now

be scheduled. Discussions need to take place in respect of Cwm Taf’s position in the all Wales pilot programme, with a strong desire for us to join the

programme after ABMU and Hywel Dda, given our levels of service capability.



Post Operative Cataract Scheme

This scheme is fully in place and the latest results show that approximately 65% of patients are now seen post operatively by their community optometrists

this includes patients who have received their surgery outside of the health

board. In 2015/16 less than 5% of patients were being seen in the community so there has been a dramatic increase since March 2016 and good progress

against the Ophthalmology Planned Care Board’s target of 80%.

Should any patients need to come back to the hospital service because of the complex nature of their surgery or any post operative complications, this facility

is still available.

Alternative Pathways of Care for Minor Oral Surgery (MOS)

As reported previously, the UHB established a pilot within a General Dental Practitioner (GDP) practice to provide Minor Oral Surgery (MOS) services in

primary care.

An informal assessment of the first five months of the pilot suggests that more than up to 90% of approximately 500 patients referred to the two practices

have being treated in primary care i.e. a referral to secondary care is avoided.

The impact of this new pathway has been demonstrated with a reduction in the

number of patients referred from General Dental Practitioners (GDPs). As can be seen below, the number of referrals has dropped from 1300 to 872 in the

first 5 months of the scheme being introduced.

2015/16 Apr May Jun Jul Aug Total

Oral Surgery 248 250 275 293 234 1300

2016/17 Apr May Jun Jul Aug Total

Oral Surgery 164 179 186 168 175 872

In addition, a comparison of the outpatient waiting list shows a reduction from 1319 at this point last year to 1020 this year.



Similarly the treatment cohort of patients has reduced from 1000 in September 2015 to 791 this year.

Key Risk Areas

Facilities Issues at Prince Charles Hospital The drainage system at Prince Charles Hospital continues to present operational

challenges in respect of the inpatient areas and theatre capacity. Theatre activity recently needed to be curtailed whilst a drainage issue was resolved. It

is expected that the refurbishment of the ground and first floor at Prince Charles Hospital will alleviate this problem.

Sustainability of tier 1 A&E performance targets There are key risks in respect of maintaining the tier 1 A&E department targets

during the winter period. October has been a particularly challenging month with a corresponding reduction in performance for 4, 8 and 12 hour waits. It is

hoped that the work identified within this report in respect of patient flow and the more stable commissioning arrangements within the local authorities will

help to ease the pressure over the coming weeks. However if performance remains unchanged in the forthcoming weeks a gold command will be mobilised

to put in place additional senior management support for the site based teams.

RTT Position The RTT position at the end of September was 1035 patients waiting over 36

weeks. Whilst this is a slight improvement on the end of March position it is above the expected 50% reduction target agreed with the Welsh Government.

Whilst there has been an improvement in the number of breaches across a

range of surgical specialities, most notably orthopaedics and ophthalmology, there has been a deterioration in the position across a number of medical

specialities. This is particularly the case in dermatology with 187 patients breaching 36 weeks at the end of September – a plan is in place to address this

position.



Surgical Waiting List Trend

0

100

200

300

400

500

600

700

800

General Surgery

Orthopaedics

Urology

Total

Head and Neck Directorate Waiting List Trend

Medicine Waiting List Trend

0

50

100

150

200

250

300

350

400

Cardiology

Dermatology

Gastroenterology

General Medicine

Respiratory Medicine

Rheumatology

Total

The majority of patients waiting over 36 weeks are still in ophthalmology but this position has improved from just over 600 at the end of March to 422 at the

end of September 2016; there were over 1,500 this time last year.

The key to delivering an end of year position of zero 36 week breaches is

further improvement in ophthalmology and this can only be achieved through further outsourcing together with addressing the current situation in

dermatology.

Two additional nurses have been employed to facilitate the provision of nurse led clinics in dermatology and the UHB has also commenced tele dermatology



clinics, led by medical photographers, in the Royal Glamorgan Hospital; the same is planned in Prince Charles Hospital. These both form part of the plan for

a sustainable service solution.

However, the plans for additional internal surgical activity over the remaining 5

months will be need to balanced with the emergency pressures during this period; in the same period last year 1022 elective procedures were cancelled

due to lack of available beds.

Diagnostic and Therapies Waiting Times There were approximately 3,000 patients who breached their waiting time

target at the end of March 2016, at the end of September this has reduced to 2410. The modality with the greatest number of patients breaching their target

date in Non Obstetric Ultrasound (NOUS) with 1247; there are just over 500 patients awaiting endoscopic investigations; 141 cystoscopies; 185 MRI and

139 CT scans.

A mobile MRI van is in place and will assist in clearing the outstanding patients and a mobile CT van will also be in place around mid December. Additional

locum sonographers have been employed to help reduce the NOUS waiting times and there are also plans in place to outsource 700-800 patients.

A reorganisation of resources in endoscopy has already resulted in 50 patients being seen within target and additional sessions are planned to reduce this

further and the potential for outsourcing is also being explored.

Despite all of these actions achieving a zero position for diagnostics and therapies will be a significant challenge.

Nurse staffing levels

Nurse staffing levels remain a key risk for operational services particularly for the Royal Glamorgan site. Overseas European recruitment has not been as

successful as first anticipated, however recruitment from the Philippines is ongoing. New graduates took up post in early April and this has slightly

improved the overall picture.

GMS Sustainability

General practice remains under significant pressure from a number of changes over recent years – increased workload volume, increased complexity of work

in an ageing population but also recruitment challenges for both GPs and the nursing professions. Many GPs are choosing not to take up traditional

partnerships but are instead opting to work abroad or to take up locum work. Four GP Practices continue to be directly managed by the Health Board. The

Primary Care Team continue to work with the GP practices and a Practice Sustainability Group has been established to look at various options going

forward.



CAMHS Operational pressure remains in all three delivery areas, Cwm Taf, Cardiff &

Vale and Abertawe Bro Morgannwg UHBs. Trajectories have now been completed for all Waiting List Initiatives and service redesign and workforce

plans are being put in place, but the ongoing operational pressure generated by

an increase in genuine and complex referrals has not relented during the first part of the new financial year. This area of work remains under significant

scrutiny and requires constant focus from the directorate management and local operational teams. Given the intensive waiting list activities underway,

each of the Health Boards in the network, now have performance trajectories tracking towards achievement of the new 28 day target by April 2017 – this is a

significant achievement by the directorate. This progress will allow all parts of the network to consider initiating the CAPA model from April 2017 and the

other Health Boards to adopt the shared care model in primary care prescribing; and the development of neuro developmental services in

community paediatrics.

4. RECOMMENDATION

The Board is requested to:

DISCUSS and NOTE the content of the report and the current position in

respect of a number of key areas.

Freedom of information status

Open

agenda item 4.5 2 november 2016 health board report ... 2016-… · operational delivery report...

Documents