meeting of the powys teaching health board

MEETING OF THE POWYS TEACHING HEALTH BOARD BOARD MEETING WEDNESDAY 27 JUNE 2012, 1.30PM - 5.00PM, TRAINING ROOMS 1&2, BRONLLYS HOSPITAL NO ITEM ENC PRESENTER PRESENTATION: CHIEF MEDICAL OFFICER’S ANNUAL REPORT 1 PRELIMINARY MATTERS 1.1 Welcome and Apologies for Absence 1.2 Declarations of Interest All

1.3 Minutes of meeting held on 18 April & 06 June 2012 1.3 Chairman

1.4 Action Review from Previous Meetings 1.4 Chairman

1.5 Chairman’s Report Verbal Chairman

2 ITEMS FOR APPROVAL / ENDORSEMENT

2.1 Financial Plan 2012/2013 2.1 Director of Finance

2.2 Section 33 Agreement with Powys County Council 2.2 Director of Finance

2.3 Business Case: Renal Unit, Welshpool 2.3 Director of Planning 2.4 Business Case: Mansion House Decant 2.4 Director of Planning

2.5 Strategic Equality Objectives 2.5 Director of Workforce & OD

2.6 Workforce Plan 2012/13 2.6 Director of Workforce & OD

2.7 Powys Public Health Strategic Framework 2.7 Director of Public Health

2.8 Options Review of Sexual Health Services for Powys 2.8 Director of Public Health

2.9 Board Scheme of Delegation 2.9 Chief Executive

2.10 Proposal for Board Associate Member 2.10 Chief Executive

2.11 NHS Shared Services Governance Framework 2.11 Director of Finance ITEMS FOR DISCUSSION 3 STRIVING FOR EXCELLENCE 3.1 Annual Plan 2012/13 3.1 Chief Executive

4 ENSURING THE RIGHT ACCESS 4.1 Bridging the Gap: Action Plan 2011/12 4.1 Director of Therapies & HS 4.2 Mental Health Measure 4.2 Director of Nursing 4.3 Business Case: Builth Wells 4.3 Director of Planning 5 IMPROVING HEALTH AND WELLBEING

5.1 Director of Public Health Update Report 5.1 Director of Public Health

6 MAKING EVERY POUND COUNT

6.1 Financial Performance 2012/13: Month 1 Month 2

6.1a 6.1b

Director of Finance

7 GOVERNANCE & ASSURANCE

7.1 Board Committee Reports:- Audit Committee Integrated Governance Committee

7.1a 7.1b

Committee Chairs

7.2 Quality and Safety Annual Report 2012 7.2 Q&S Committee Chair

7.3 Governance and Accountability Module 7.3 Director of Therapies & HS

8 OTHER MATTERS

8.1 Any Other Urgent Business Verbal Chair

8.2 Date of Next Meeting: 1.00pm, 05 September 2012, Training Rooms 1&2, Training Department, Bronllys Hospital

KEY: Annual Plan Themes Improving Health and Wellbeing Involving the People of Powys Ensuring the Right Access Making every Pound Count Striving for Excellence Governance & Assurance Motion to Exclude Members of the Public and the Press To approve a motion under Section 1(2) Public Bodies (Admission To Meetings) Act 1960: “Representatives of the press and other members of the public shall be excluded from the remainder of this meeting having regard to the confidential nature of the business to be transacted, publicity on which would be prejudicial to the public interest”.

FOR APPROVAL

Board Minutes Meeting held 18 April 2012 & 06 June 2012 Status: Awaiting Approval

Page 1 of 16 Board Meeting27 June 2012

Agenda Item 1.3

BOARD MEETING 27 JUNE 2012

AGENDA ITEM 1.3

DRAFT MINUTES OF BOARD MEETING HELD 18 APRIL 2012 & 06 JUNE 2012

Report of

Chairman

Paper prepared by

Corporate Governance Manager

Purpose of Paper

To provide the Board with the draft minutes of the Board Meetings held on 18 April 2012 and 06 June 2012, for approval.

Action/Decision required

The Board is asked to APPROVE the draft minutes of the Board Meetings held on 18 April 2012 and 02 June 2012.

Link to ‘Doing Well, Doing Better: Standards for Health Services in Wales’:

1. Governance and Accountability

Link to Health Board’s Annual Plan

Improving Health & Well-Being Ensuring the Right Access Striving for Excellence Involving the People of Powys Making Every Pound Count

Acronyms and abbreviations

N/A

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MINUTES OF THE MEETING OF THE POWYS TEACHING HEALTH BOARD

HELD AT 11.00 AM ON WEDNESDAY 18 APRIL 2012, IN CLYWEDOG ROOM, LADYWELL HOUSE, NEWTOWN HOSPITAL

Present: Mel Evans (ME) tHB Chair (Chair of Meeting) Andrew Cottom (AC) Chief Executive Alan Austin (AA) Associate Member (SRG Chair) Mark Baird (MB) Independent Member Joanna Davies (JD) Director of Workforce & OD Roger Eagle (RE) Independent Member Gareth Jones (GJ) Independent Member Gloria Jones Powell (GJP) Independent Member Andrew Leonard (AL) Independent Member Brendan Lloyd (BL) Medical Director Jo Mussen (JM) tHB Vice Chair Gyles Palmer (GP) Independent Member Jeremy Patterson (JP) Associate Member (CEO, Powys CC) Chris Potter (CP) Director of Public Health Amanda Smith (AS) Director of Therapies & HS Jackie Walters (JW) Independent Member In Attendance: Les Bence (LB) Head of Financial Planning Rani Mallison (RM) Corporate Governance Manager Andrew Powell (AP) Locality General Manager (Mid & South) Public Attendance: 2 members of the public were present. Apologies: Paul Dummer (PD) Independent Member Rosemarie Harris (RH) Independent Member Rebecca Richards (RR) Director of Finance Carol Shillabeer (CS) Director of Nursing Bruce Whitear (BW) Interim Director of Planning

tHB/12/15

Declarations for Interest There were no declarations of interest received for noting.

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tHB/12/16

Minutes of Previous Meeting held on 29 February 2012 The minutes of the previous meeting held on 29 February 2012 were agreed as a true and accurate record, with the inclusion of the following paragraph:- tHB/12/11: Corporate Risk Register - Discussion was held regarding a risk in relation to Information Governance and the Board was assured that action was in hand to address this.

tHB/12/17

Action Review from Previous Minutes The Board received an Action Review Grid which provided a summary of actions arising from previous Board meetings held during 2012, as at with progress outlined against the outstanding actions. The Board noted that options regarding the future service model for sexual health services was being developed and would be presented to the Board in June 2012.

tHB/12/18 Chairman’s Report Following a formal welcome to Board Members, the Chair:-

had attended an all-Wales meeting of Health Board Chairs with the Minister for Health, Social Services and Children where debate had been held regarding NHS Wales financial position and Health Board Service Plans;

had undertaken a Powys-wide visit of GP practices and hospitals; and met with all Board Committee Chairs to discuss governance

arrangements in light of proposed changes to the Board structure

tHB/12/19 Annual Plan 2012/13 AC presented the previously circulated paper, providing the Board with the proposed Annual Plan for 2012/2013 for discussion and approval. AC advised the Board that the Annual Plan should be seen as a dynamic process which provided the key components through which the Health Board articulated its high-level objectives for delivery and the organisational development necessary for achieving that delivery. AC outlined to the Board the proposed priorities for 2012/13 which were focussed around the Welsh Government’s Together for Health Strategy: Improving health and well-being (health); Ensuring the right access (services); Striving for excellence (delivery); Involving the people of Powys (people); and Making every pound count (money). AC advised the Board that the document included a section ‘making it happen’ which outlined the actions necessary to ensure that the organisation could provide the capacity and capability required to deliver the Plan.

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Following detailed discussion, the Board APPROVED the organisation’s Annual Plan 2012/13, noting that there was a need for pace to ensure its implementation.

tHB/12/20 Interim Financial Plan 2012/13 LB presented the previously circulated paper, providing the Board with the 2012/13 Interim Financial Plan for approval. LB advised that the Board was required to produce a balanced financial plan for the year, setting out how the Board would contain costs to live within the annual revenue resource limit from the Welsh Government. LB advised that the Board has a clear strategy to reduce costs and improve quality but in preparing the financial plan for 2012/13, the Board had to date, been unable prepare a plan which would ensure the organisation lived within the resources available. LB asked the Board to note that the Interim Plan identified a shortfall in savings and/or cost avoidance measures of £8.1M in order to secure a fully balanced plan. LB advised the Board that it was essential for the Board to set delegated budgets as clear targets for budget holders at the start of the financial year as delegated budgets would enable robust performance management of the organisation’s financial position to take place on a routine basis. Therefore, LB asked the Board to approve an interim financial plan in order to set delegated budgets in April 2012. LB outlined to the Board the risks and assumptions made in developing the Interim Plan and also outlined several steps being taken in order to secure an improved financial position in 2012/13 and for the longer term. The Board held detailed discussion regarding the Interim Financial Plan and sought assurance from the Chief Executive measures were being taken wherever possible to ensure a balanced financial plan could be developed and delivered. Following discussion, the Board APPROVED the Interim Financial Plan 2012/13 and REQUESTED that a balanced Financial Plan 2012/13 be presented to the Board for approval in June 2012.

tHB/12/21 Board Assurance Framework 2012/13 AC presented the previously circulated paper, providing the Board with proposed arrangements for the development, oversight and use of the Board Assurance Framework. AC advised the Board that the Board Assurance Framework would set out the key strategic risks to achieving the Board’s objectives, the controls in place to prevent those risks from materialising and the assurances that the Board

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receives regarding the effectiveness of those controls. AC advised that, the Board was to consider its Annual Plan 2012/13 at its meeting in April 2012, and this would articulate the Board’s vision and ambitions, underpinned by its strategic objectives (key aims). AC asked the Board to note that the approval of the Board’s Annual Plan 2012/13 was the first key step in being able to determine the key risks that threaten the achievement of the organisation’s strategic objectives. AC also asked the Board to note that it committee structure would also need to be finalised and approved in advance of the Board Assurance Framework being fully populated. In light of the need for these key developments to take place, AC proposed that the Audit Committee, on behalf of the Board, receive the Board Assurance Framework at its meeting on 01 May 2012, to ensure that there was an appropriate spread of strategic objectives and that the main inherent/residual risks had been identified, as well as any that are newly arising (as outlined within the Committee’s Terms of Reference). AC suggested that this would then allow the Board, at its meeting on 27 June 2012, to take assurance from the Audit Committee regarding the adequacy of the Board’s Assurance Framework and that identification of the Board’s key risks to achievement of its objectives have been fully determined. The Board welcomed the work underway to ensure development and completion of its Assurance Framework and APPROVED the proposal for the Audit Committee to receive the document at its meeting on 01 May 2012.

tHB/12/22 Board Committee Structures AC presented the previously circulated paper, providing the Board with proposed arrangements for the Board’s Committee Structure and Membership, following a review of Corporate Governance by internal review by Internal Audit. AC outlined the proposed Board Committee Structure as follows:-

Quality & Safety Committee o Mental Health Act sub-Committee o Information Governance sub-Committee

Audit Committee Integrated Governance Committee Charitable Funds Committee Remuneration & Terms of Service Committee

AC advised the Board that the proposal suggested that the sub-Committees of the Quality & Safety Committee within the existing structure (Risk Management, Improving Patient Involvement & Experience, Safeguarding, Clinical Effectiveness, Infection Prevention and Control & Environment of Care) be stood down. AC asked the Board to note that, whilst reviewing the roles of these sub-Committees, it was apparent that the workplan of each sub-Committee was based on operational/management actions and decisions and so it was therefore proposed that these sub-Committees move into the

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Agenda Item 1.3

executive function of the organisation, reporting to the Board of Directors The Board discussed and APPROVED the revised Board Committee structure, to be effective from 01 May 2012. Membership for each Board Committee was discussed and the following AGREED:-

Quality & Safety Committee Chair Independent member of the

Board Gloria Jones Powell

Vice Chair Independent member of the Board

Paul Dummer

Members At least two other independent members of the Board, to include the Chair of the Audit Committee and the Vice Chair of the Board.

Jo Mussen (tHB Vice Chair & Chair of sub-Committee) Gareth Jones (Chair of Audit Committee) Mark Baird (Chair of sub-Committee) Jackie Walters

Information Governance sub-Committee Chair Independent member of the

Board Mark Baird


TBC

Members At least one other independent member of the Board

Gyles Palmer Jackie Walters

Mental Health Act sub-Committee Chair Independent member of the

Board Jo Mussen


TBC

Members At least one other independent member of the Board

Andrew Leonard Roger Eagle

Audit Committee Chair Independent member of the

Board Gareth Jones


Roger Eagle

Members At least one other independent member of the Board (one of which should be a member of the Q&S Committee)

Andrew Leonard Gloria Jones Powell Mark Baird Rosemarie Harris

Integrated Governance Committee Chair Independent member of the

Board Roger Eagle


TBC

Members Chair of Audit Committee Chair of Quality & Safety Committee tHB Vice Chair

Gareth Jones Gloria Jones Powell Jo Mussen

Charitable Funds Committee Chair Independent Member Andrew Leonard

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Agenda Item 1.3

Vice Chair Independent Member TBC Members 1 other Independent Member

Director of Finance Director of Nursing

Gyles Palmer Gareth Jones

Remuneration and Terms of Service Committee Chair Chair of the Board Mel Evans Vice Chair Independent Member TBC Members At least two other Independent

Members (the chair of the Audit committee to be included)

Jo Mussen Roger Eagle Gareth Jones

tHB/12/23 Gwent and South Powys Partnership Mental Health Strategy AC presented the previously circulated paper, providing the Board with the an outline of the strategic direction for mental health services for the people of South Powys, developed as part of the Gwent and South Powys Integrated Partnership. AC advised the Board that the Gwent and South Powys Partnership Mental Health Strategy was an opportunity to improve the mental health and mental health services for the people of South Powys. AC asked the Board to note that the Strategy fit with the Welsh Government (draft) Strategy for Mental Health and with the direction of travel of the Local Delivery Plans. AC advised the Board that implementation of the Strategy would focus on the specific needs of the rural communities and as such provided an opportunity to utilise a wide range of partnership expertise for application locally. The Board welcomed and APPROVED the Gwent and South Powys Partnership Mental Health Strategy.

tHB/12/24 Strategic Outline Case: Llandrindod Wells Scheme AP presented the previously circulated paper, providing the Board with the Strategic Outline Case (SOC) for the reconfiguration of Llandrindod Wells Hospital for approval. AP advised the Board that comprehensive service and capital modelling had been undertaken and a SOC prepared for the redevelopment of facilities at Llandrindod Wells Hospital and associated properties. It was noted that this redevelopment was essential to the delivery of service and financial plans of the tHB. AP advised the Board that the proposed reconfiguration of the hospital comprised of three related but distinct phases of capital works and so, following advice from the NHS Wales Shared Services Partnership, the tHB had prepared a SOC as a framework that described the three phases as a single capital scheme. AP asked the Board to note that preparing a SOC in this case allowed the tHB to make an analysis of the entirety of the scheme through the business case modelling process.

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Agenda Item 1.3

AP advised the Board that, if approved by Welsh Government, the intention was that the delivery of the SOC would be achieved through the preparation of individual Business Justification Cases (BJC) for the each of the proposed 3 phases. The Board discussed the proposed reconfiguration of Llandrindod Hospital and APPROVED the Strategic Outline Case for submission to Welsh Government.

tHB/12/25 Financial Performance: Month 11, 2011/12 LB presented the previously circulated paper, informing the Board of the outturn financial performance of the tHB against the 2011/12 Financial Plan, approved by the Board in April 2011, at Month 11. LB advised that:- The tHB was reporting an overspend of £3.5M to month 11 The tHB was currently profiling an overspend of £3.9M to month 12 with

associated risks identified The tHB was on track to achieve its capital resource limit target The tHB was on track to contain cash within its cash limit, The tHB was on track to achieve the Public Sector Payment Policy target The tHB was projecting savings of £12.287M against a plan of £13.3M The tHB was subject to an external review of its 2012/13 financial plan in

order to secure an advance in funding to ensure break even in 2011/12 The Board NOTED the outturn financial performance of the tHB against the 2011/12 Financial Plan at Month 11.

tHB/12/26 Director of Public Health Update Report SA presented the previously circulated paper, providing the Board with an updated of Public Health developments. SA outlined to the Board, work currently being carried out by the Powys Public Health team in respect of Flu Vaccination and Alcohol Brief Intervention training. SA advised that, vaccinations had been targeted to frontline health care staff and any staff who requested the vaccination is offered it. Planning was already underway for increasing vaccination uptake in 2012-13. The Board held a detailed discussion regarding flu vaccination access and the importance of GP involvement. It was noted that further work was needed to understand the reasons for staff not accessing the vaccination, for future planning. SA updated the Board, in respect of intervention training across Powys to tackle alcohol misuse and confirmed the involvement of Community Health Council and Social Care staff including Primary Care Nurses across Powys to assist Phase 3 Alcohol brief Intervention course.

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Agenda Item 1.3

The Board NOTED the work undertaken in respect of the approach taken in vaccinating Powys tHB staff and the SUPPORTED the Alcohol Brief Intervention training currently underway.

tHB/12/27 Corporate Plan 2011/12: End of Year Report AC presented the previously circulated paper, providing the Board with an end of year report against delivery of the Organisation’s Corporate Plan 2011/12. AC advised that, whilst the Board had received routine reports in respect of the organisation’s performance against delivery of the Corporate Plan, via the Integrated Governance Committee, the purpose of this report was to provide the Board with the detail of the progress made and to also outline where objectives hadn’t been achieved as originally anticipated. AC provided the Board with a detailed end of year position in respect of the five key aspirations articulated in the Plan: Promoting Health and Wellbeing; Continuously Improving Safety, Effectiveness and Patient Experience; Capturing the Benefits of Integration; Empowering Our Staff; and Living Within Our Means. AC also provided detail with a summary of those objectives not delivered within year and the reasons associated with the delay. AC assured the Board that were objectives had not been delivered within year; these would be included within the Annual Plan 2012/13, to ensure delivery. AC asked the Board to note that, in terms of the Making it Happen section of the Corporate Plan 2011/12, progress in delivery the priorities identified had been slow in some areas which may have impacted upon some objectives within the Plan not being delivered within the year. AC assured the Board that the priorities identified in respect of Making it Happen would be included within the Annual Plan 2012/13 to ensure delivery of the Board’s 2012/13 objectives. The Board welcomed the end of year report and acknowledged the progress achieved within the year in respect of the five aspirations articulated by the Board, however the Board also acknowledged that there was further work required in respect of Making it Happen to ensure delivery of the organisation’s Annual Plan 2012/13 (as discussed earlier in the meeting).

tHB/12/28 Standards for Health Services in Wales AS presented the previously circulated paper, providing the Board with an update on the process through which Standards for Health Services had been embedded throughout the tHB during 2011/12 and into 2012/13. AS outlined to the Board requirements to use the Standards for Health Services in Wales to plan, design, develop and improve services across all health services and in all healthcare settings. AS advised that, the continuation of the self-assessment tool to determine what areas were doing well and those areas which require improvements would remain a key source of assurance.

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Agenda Item 1.3

AS advised that, a Governance and Accountability module would provide a framework for determining how well Powys tHB was governed. The module was framed around three key theme; Setting the direction, Enabling delivery, Delivering results, achieving excellence. AS also advised that an Action Plan 2012/13 would also assist the next steps forward and identify key actions to ensure the standards continued to be embedded and developed as a service improvement tool throughout the organisation. The Board held a brief discussion in respect of the process around the standards and it was suggested that a future development session be arranged to explore this issue. The Board NOTED the update and work undertaken on the Standards for Health Services in Wales for Powys teaching Health Board.

tHB/12/29 Capital Bid: Orthopaedic Theatres AP presented the previously circulated paper, providing the Board with an update in respect of the submission of a capital bid for Orthopaedic laminar flow at Brecon and Llandrindod Wells Hospitals. AP advised that, in November 2011, Powys tHB submitted a capital bid to the Welsh Government to fund the replacement of the ventilation systems and replace UCV systems at Brecon and Llandrindod Wells theatres. AP advised that submission of the bid was made following recommendations from the Annual Validation reports undertaken in September 2010 by Welsh Health Estates. It was noted that the report had highlighted key health and safety concerns within the existing plant in Brecon and Llandrindod Theatre and the completion of this work was subsequently identified as a priority within the Discretionary Capital programme for 2011/12. AP advised that the value of the scheme exceeded what could be covered from discretionary capital and subsequently a bid was submitted. It was noted that the capital bid also included the purchase of orthopaedic equipment for use in Brecon and Llandrindod theatres, which was a key enabler to achieve the Localities vision to repatriate patients requiring orthopaedic day case procedures. The Board NOTED the submission of a capital bid for Orthopaedic laminar flow at Brecon and Llandrindod Wells Hospitals.

tHB/12/30 NHS Wales Shared Services AC presented the previously circulated paper, providing the Board with an update in relation to the ongoing developments in respect of NHS Wales Shared Services. AC advised the Board that the Welsh Government had recently undertaken a consultation (15 February to 11 April 2012) on the proposed amendments to Velindre NHS Trust (Establishment) Order 1993 and proposed new regulations to establish a Shared Services Committee of Velindre NHS Trust.

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Ac advised that in light of these proposed changes, a Shared Services Transition Project Board had been established and was working through the practicalities of ensuring the timely and effective transition of staff and assets to Velindre NHS Trust under clear hosting and governance arrangements to be effective from 1st June 2012, in accordance with appropriate legal advice and the guidance of the Minister for Health, Social Services. The Board NOTED the update in respect of proposed changes to arrangements in respect of NHS Wales Shared Services.

tHB/12/31 Draft Annual Audit Report 2011 AC presented the previously circulated paper, providing the Board with the Wales Audit Office Annual Audit Report 2011. AC advised the Board that the Report concluded that:-

the Auditor General for Wales had issued an unqualified opinion on the 2010/11 financial statements of the tHB;

progress was being made in addressing the areas for development indentified in the 2010 Structured Assessment, although some specific challenges remained;

that there were firm foundations in place to make best use of theatre resources but accelerated action, including development of a performance management framework, was needed to realise its full potential;

the tHB does not have sufficiently robust ICT disaster recovery and business continuity arrangements but it is aware of these risks and is currently taking improvement action; and

the tHB has taken action to address the issues identified in a number of performance audit reviews, although further progress was needed to address increasing challenges in some areas.

AC assured the Board that the actions required to make improvements in response to the Report had been considered when developing the Annual Plan 2012/13. The Board NOTED the Wales Audit Office Annual Audit Report 2011.

tHB/12/32 Board Committee Reports The Board received and noted for information:-

an update from the Audit Committee Chair which outlined key developments via the Audit Committee in March 2012;

an update from the Quality & Safety Committee Chair which outlined key developments via the Quality & Safety Committee in March 2012; .

No issues of concern were raised by Committee Chairs. The Board RECEIVED the reports from the: Audit Committee Chair; Quality &

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Agenda Item 1.3

Safety Committee Chair.

tHB/12/33 Date and Time of Next Meeting 06 June, 2012, 1.00pm, Training Rooms 1&2, Training Department, Bronllys

MINUTES OF THE MEETING OF THE POWYS TEACHING HEALTH BOARD HELD AT 10.00 AM ON WEDNESDAY 06 JUNE 2012,

TRAINING ROOMS 1&2, BRONLLYS HOSPITAL

Present: Jo Mussen (JM) tHB Vice Chair Andrew Cottom (AC) Chief Executive Mark Baird (MB) Independent Member Roger Eagle (RE) Independent Member Rosemarie Harris (RH) Independent Member Gareth Jones (GJ) Independent Member Gloria Jones-Powell (GJP) Independent Member Andrew Leonard (AL) Independent Member Brendan Lloyd (BL) Medical Director Gyles Palmer (GP) Independent Member Rebecca Richards (RR) Director of Finance Jackie Walters (JW) Independent Member Bruce Whitear (BW) Interim Director of Planning In Attendance: John Dwight (JD) Wales Audit Office Emily Games (EG) Corporate Governance Support Officer Rani Mallison (RM) Corporate Governance Manager Sarah Pritchard (SP) Head of Financial Control Anthony Veale (AV) Wales Audit Office Public Attendance: There were no members of the public were present. Apologies: Alan Austin (AA) Associate Member (Chair of SRG) Mel Evans (ME) tHB Chair Paul Dummer (PD) Independent Member Jeremy Patterson (JP) Associate Member (CEO, Powys CC) Carol Shillabeer (CS) Director of Nursing

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Agenda Item 1.3

Amanda Smith (AS) Director of Therapies & HS Joanna Davies (JD) Director of Workforce & OD

tHB/12/34 Audit Committee Annual Report 2011/12 GJ, as Committee Chair, presented the Board with the Audit Committee Annual Report 2011/12, providing the Board with assurance in respect of the adequacy and effectiveness of the organisation’s functions and systems to maintain a sound system of internal control. GJ advised the Board of elements for development moving forward, which included: the development of the Board Assurance Framework; improved assurance arrangements in respect of risk management and improvements in respect of the tHB’s Internal Audit Service. GJ thanked Audit Committee members for their high level of attendance and support throughout the year. The Board RECEIVED the Audit Committee Annual Report.

tHB/12/35 Internal Audit Annual Report 2010/11 AC presented the Board with the Internal Audit Annual Report 2011/12, including the Head of Internal Audit’s Opinion. AC advised the Board that based on the work undertaken in 2011/12, internal audit had concluded that the Board could take some assurance that the arrangements upon which the organisation relies to manage risks, controls and governance within those areas under review, and the operational compliance noted, are suitably designed and applied effectively. However, management need to address the exposure to significant risk in several areas. AC further asked the Board to consider the overall Opinion in the context of the overall ratings as outlined within the Annual Report. AC also asked the Board to note that the Opinion should be considered in a context of managing risk and not eliminating risk. GJ endorsed this positive view to the Board and recognised that the 2011/13 Opinion would act as a baseline from which the Organisation can make improvement. The Board RECEIVED the Internal Audit Annual Report 2011/12 and NOTED the Head of Internal Audit’s Opinion.

tHB/12/36 Financial Position: Month 12, 2011/12 RR presented the previously circulated paper, informing the Board of the outturn financial performance of the organisation against the 2011/12 Financial Plan, which had been approved by the Board in April 2011. RR advised that:-

• the tHB was reporting a balance outturn position following receipt of

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Agenda Item 1.3

£3.9M (repayable) advance funding against 2012/13 allocation. As a result, the tHB was reporting the achievement of meeting its revenue resource limit;

• the tHB had achieved its capital resource limit target; • the tHB had achieved its cash limit; • the tHB had achieved the Public Sector Payment Policy target; • the tHB had identified savings of £12.525M against a plan of £13.3M.

GJ commented that the consistent reporting of the financial position to the Board throughout the year had been beneficial for assurance purposes. The Board NOTED the outturn financial performance of the organisation against the 2011/12 Financial Plan at Month 12.

tHB/12/37 Presentation of Annual Accounts 2011/12 RR presented the Board with the Annual Accounts 2011/12 which had been audited by Wales Audit Office as required. RR advised that the tHB had achieved its financial targets and statutory duties for 2011/12, including:-

• operational financial balance, reporting a small surplus of £0.030M; • cash contained within cash limit; • capital financial balance; and • the 95% target for prompt payment of invoices.

RR asked the Board to note that the achievement of operational financial balance had included the additional funding of £15M, provided by Welsh Government which was not repayable and a further amount of £3.9M received as an advance against the 2012/13 Resource Limit repayable in 2012/13 RR advised that, during the audit of the accounts, the Wales Audit Office had not requested any corrections to the accounts which had not been made. It was noted that two issues had been identified by Wales Audit Office and discussed with the Director of Finance:-

1. calculations for provisions and contingent liabilities relating to Continuing Healthcare claims;

2. non-signed Long Terms Agreements RR advised the Board that the Audit Committee had considered the final Annual Accounts 2011/12 at its meeting on the 31 May, 2012, and no recommendations for amendments were received. The Board APPROVED the Annual Accounts 2011/12.

tHB/12/38 Wales Audit Office: Audit of Financial Statements Report (ISA 260) JD presented the Board with the Audit of Financial Statements (2011/12) Report. JD advised that it was the intention of the Auditor General for Wales to issue an unqualified certificate and report on the financial statements.

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JD outlined the main findings within the report, which included the issues noted above (minute 12/37) and that balances relating to the Welsh Health Specialised Services Committee had yet to be audited. JD confirmed that there were no misstatements identified in the Financial Statements which remained uncorrected. JD outlined to the Board two matters arising from consideration of the qualitative aspects of the accounting practices and financial reporting but overall, the information provided was relevant, reliable and easy to understand and a good quality of the draft financial statements had been maintained during 2012. AV advised the Board of the additional substantive report requested by the Auditor General in respect of, the additional resource of £3.9M from WG. The substantive report would provide further details in relation to the financial position of Powys tHB, and noted that other HB’s across Wales where, finances had exceeded financial resource limit would be subject to the same narrative reporting. AV confirmed to the Board that the final phase of the substantive report would be submitted to AC for final comments. The Vice Chair (JM) thanked SP and RR, and staff within the Finance Department for their assistance in completing the audit of financial statements 2011/12. JM also thanked JD and AV and the Wales Audit Office Team for the completion of this work. The Board RECEIVED the Audit of Financial Statements (2011/12).

tHB/12/39 Letter of Representation RR presented the Letter of Representation, which was a standard template for completion, outlining that this would be provided to the Wales Audit Office in connection with the audit of the financial statements of the tHB for the year ending 31 March 2012. RR advised that the Letter stated that the annual accounts were the responsibility of management and that management’s statements to the auditor during the audit process were true. GJ, Audit Committee Chair, advised the Board that the Audit Committee had considered the Letter of Representation at its previous meeting and confirmed that it was not aware of any amendments that would need to be made. The Board APPROVED the Letter of Representation.

tHB/12/40 Remuneration Report RR provided the Board with the remuneration figures 2011/12 for approval. RR advised that the remuneration figures 2011/12 had been audited by the Wales Audit Office as part of the audit of financial statements and no issues had been identified. It was noted that the remuneration figures for 2011/12 would be published as

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part of the organisation’s Annual Report 2011/12. RR advised the Board that the Audit Committee had considered the remuneration figures 2011/12 at its previous meeting and, recommended that the Board formally approved the remuneration figures 2011/12. The Board APPROVED the remuneration figures 2011/12 for inclusion in the organisation’s Annual Report 2011/12

tHB/12/41 Recommendation from the Audit Committee to the Board GJ, Audit Committee Chair, outlined to the Board that the following reports had been considered by the Audit Committee, in accordance with its Terms of Reference, at its meeting on 31 May, 2012. GJ, on behalf of the Audit Committee, recommended to the Board that its APPROVED the following reports;

the Annual Accounts 2011/12, including the Annual Governance Statement;

the Letter of Representation; the Remuneration Report; and AUTHORISED the Chairman, Chief Executive and Director of Finance to

sign them where required.

tHB/12/42 Date of Next Meeting Wednesday 27 June 2011, 1.00pm, in the Training Rooms 1&2, Training Department, Bronllys Hospital

FOR DISCUSSION

Action Review 18 April 2012


Agenda Item 1.4


AGENDA ITEM 1.4

ACTION REVIEW FROM PREVIOUS MEETINGS 2011/12 - 2012/13

Report of

Chairman

Paper prepared by


Purpose of Paper

To provide the Board with a summary of actions arising from previous Board Meetings held (2011/12 – 2012/13), as at 18 April 2012.


The Board is asked to DISCUSS progress against the actions arising from previous Board Meetings (2011/12 – 2012/13).






N/A

FOR DISCUSSION



Agenda Item 1.4

BOARD MEETINGS ACTIONS ARISING

OUTSTANDING

Board Minute Board Date Action Responsible Progress Completed tHB/12/19 Annual Plan 2012/13

18 April 2012 An update report in respect of Setting the Direction (including the maturity matrix) to be presented to the Board in September 2012.

Director of Strategic Planning/Director of Therapies & Health Sciences

COMPLETE Board Minute Board Date Action Responsible Progress Completed

tHB/12/07 Integrated Performance Report

29 February 2012

A paper regarding the delivery of sexual health services to be brought to a future meeting for discussion to ensure that improvements were delivered in this area.

Director of Public Health

18/04/12: Options regarding the future service model being developed for consideration by the Executive Team, prior to presentation to the Board in June 2012. 27/06/12: Options included on agenda for approval

tHB/11/31 Public Health Update Report

15 April ‘11 Board to hold discussion at a future meeting regarding the investment in Public Health, ensuring that it receives the resources required.


08/12/11: Capacity and capability of all Teams, including Public Health, to be considered as part of the development of the 2012/13 Annual Plan. 15/06/11: Discussions ongoing. Further Update to be provided to the Board in October 2011. Additional resources have been

FOR DISCUSSION



Agenda Item 1.4

secured by the Public Health Team.

tHB/11/44 Stakeholder Reference Group

15 April ‘11 Proposed appointment of SRG Chair to be sent to Minister for final approval, subject to guidance from WG.


10/08/11: Minister approval received. Alan Austin appointed as SRG Chair. 15/06/11: Request for approval submitted to Minister. Response is awaited.

Discussion to be held with PCC Chair regarding County Council representation on the Group.

tHB Chair

10/08/11: Discussion held with PCC and representative identified. 15/06/11: Discussion held with Council and position re-no Board member on SRG clarified. Awaiting nomination

tHB/11/32 Corporate Plan 2011/12

15 April ‘11 Specific Action Plan to be developed in response to the concerns highlighted in the WAO Annual Audit Report 2009/10.

Chief Executive 15/06/11: Approved Corporate Plan reflects concerns. Detailed actions/ individual actions to meet the Corporate Plan currently being populated for completion 16th June 22/06/11: Completed. On agenda for Board Meeting 10/08/11

tHB/11/50 Chairman’s Report

15 June ‘11 tHB position against Manifesto Commitments to be circulated to Board


Complete. E-mail sent to Board Members

FOR DISCUSSION



Agenda Item 1.4

Members for information. 20/06/1

tHB/11/54 Workforce Plan

15 June ‘11 Board to formally approve Workforce Plan at Development Session on 26 July 2011.

Director of Workforce & OD

Complete. On agenda for Board Meeting 10/08/11

tHB/11/56 Public Health Update Report

15 June ‘11 Board to receive Sexual Health Strategy for formal approval in August 2011.


Complete. On agenda for Board meeting 10/08/11

tHB/11/61 Financial Performance: Month 1, 2011/12

15 June ‘11 Financial Position at Month 2 to be circulated to Board Members, outside of the meeting.

Director of Finance Complete. E-mail sent to Board Members 07/07/11

tHB/11/30/3 Matters Arising: New Directions for Powys

15 April ‘11 Dates of engagement events to be circulated to Board Members, once available.

Director of Planning Members will have received all dates by June 15th 2011.

tHB/11/37 Financial Position and Outlook 2010/11

15 April ‘11 Month 12, 2010/11 Financial Position to be circulated to Board Members, once available.

Director of Finance Month 12, 2010/11 financial position presented to the Board on 02 June 2011.

tHB/11/07 Public Health Quarterly Update Report

16 Feb ‘11 Update regarding the reduction in capacity within the PH Team to be presented to the Board at its next meeting.


Update Report presented to Board on 15 April 2011.

tHB/11/09 Integrated Performance Report

16 Feb ‘11 Future Reports to include WAST performance data on a locality basis.

Director of Performance

Complete. Integrated Performance Report presented to Board on 15 April 2011 included the data requested.

tHB/11/14 tHB Response to SaTH Consultation

16 Feb ‘11 Final response to be developed following discussions held by the Board on 16 Feb 11 and signed off by CEO, on behalf of the Board.

Chief Executive tHB response submitted and copies shared with Board Members.

tHB/11/81 10 August ‘11 Board Members asked to provide All Board Members 06/10/11: Complete. Included on

FOR DISCUSSION



Agenda Item 1.4

One Powys Plan

comments directly (by 26 August 2011) or to the Director of Planning (by 15 August 2011) with regards to the One Powys Plan consultation.

Board agenda.

tHB/11/44 Stakeholder Reference Group

15 April ‘11 Mechanisms for the SRG to link with stakeholders and communities to be determined.

Director of Planning 06/10/11: Complete. Included on Board agenda. 10/08/11: Mapping to be presented to the Board in October 2011 as part of the first update from the SRG Chair. 15/06/11: An early ‘mapping’ of stakeholders is complete. The SRG will receive this at their July meeting. It is proposed that this will be brought to the Board at its meeting in August 2011.

FOR APPROVAL

Interim Financial Plan 2012/13 Page 1 of 7 Board meeting27 June 2012

Agenda Item 2.1


AGENDA ITEM 2.1

INTERIM FINANCIAL PLAN 2012/13

Report of

Director of Finance

Paper prepared by Director of Finance

Purpose of Paper

The purpose of this paper is to present the updated 2012/13 Interim Financial Plan for Board approval.

Action/Decision required The Board is asked to APPROVE the tHB’s updated Interim Financial Plan for 2012/13.

Link to ‘Doing Well, Doing Better: Standards for Health Services in Wales’

Ensure sound financial engagement and accountability in the use of resources (27.2)

Link to Health Board’s Corporate Plan

Living within our means


AWMSG – All Wales Medicines Strategy Group DGH – District General Hospital GDS – General Dental Services GMS – General Medical Services GPs – General Practitioners HCHS – Hospital and Community Health Services HQ – Headquarters IHI – Institute for Healthcare Improvement NHS – National Health Service NICE – National Institute for Clinical Excellence PbR – Payment by Results tHB – Teaching Health Board WG – Welsh Government WHSSC – Welsh Health Specialist Services Committee

FOR APPROVAL


Agenda Item 2.1

INTERIM FINANCIAL PLAN 2012/13

Purpose The purpose of this report is to present to the Board the updated Interim Financial Plan for 2012/13 for approval. Background The Board is required to establish a balanced financial plan for the year which sets out how the organisation will contain costs to live within its revenue resource limit from the Welsh Government. The board received and approved an interim financial plan in April 2012 and in doing so, noted:-

The financial strategy by which the financial plan has been developed is founded on improvements in service design and delivery

the process and approach to the financial plan’s development includes reference and response to costing and financial analytical work undertaken during the previous financial year

the residual risks and the proposed approach to treatment the process for budget setting, and the next steps to developing a longer term solution to our financial position

The Financial plan could only be approved as interim because it did not demonstrate how the tHB would fully meet the requirement to breakeven by the end of March 2013. The board noted that the remaining financial challenge within the plan was £8M. At the board meeting of 18th April, the board were also advised that the tHB had been requested by the Welsh Government to produce a supplementary plan, identifying how the tHB will meet the breakeven requirement, thereby closing the £8M challenge. This paper will set out the revised plan that was submitted to Welsh Government on 9th May 2012. Updated Financial Plan The supplementary financial plan, as submitted to WG is appended to this report at appendix 1. In summary, the plan identifies that the Health Board’s previous financial plan has been updated on the following basis

• Utilising balance sheet opportunities arising from 2011/12 year-end negotiations with external providers

• Managing our system to limit growth and thereby utilising contingencies / reserves set in the original plan to offset the position

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Agenda Item 2.1

• Creating extended opportunity through the “Making it Happen” Programme lead by the Nurse Director

These three items are wholly reliant upon the full delivery of the savings programme already established for the year. The supplementary plan also recognizes that these items alone will not bring the health board to full financial balance. The residual risk will remain at approximately £4M, which is the value of the early draw down from 2011/12 resulting in a reduction in income in 2012/13. The Health Board has recommended to the Welsh Assembly via the supplementary plan that the £3.9M reduction in income in 2012/13 is instead staged over a 3 year period, subject to a revised and satisfactory 3 year financial plan being developed and presented. At the time of writing this report, no response has been provided from Welsh Government on this submission. We will advise the board at the meeting verbally if a response is subsequently received. Conclusion The organisation is required to produce a balanced financial plan for the 2012/13 financial year. The Health Board had agreed an interim financial plan in April 2012, which identified a gap between planned income and expenditure of £8M. A supplementary financial plan has been prepared and submitted to Welsh Government on 9th May identifying how the gap could be reduced through a range of actions and through a staged repayment of the early draw down of income in 2011/12. Recommendation The Board is requested to APPROVE the 2012/13 Interim Financial Plan. Report prepared by: Presented by: Rebecca Richards Rebecca Richards Director of Finance Director of Finance

FOR APPROVAL


Agenda Item 2.1

APPENDIX 1

FINANCIAL PLAN 2012/13 – SUPPLEMENTARY PAPER Purpose Powys Teaching Health Board recognises that to meet its statutory financial duty to break even it must have in place and be working to a robust plan to break even. At the end of April, the tHB’s financial plan for 2012/13 requires a further £4.2M of savings to be identified and delivered to achieve in year balance. While we assess part of this residual gap can be bridged by initiatives to contain cost pressures, the overall challenge is further exacerbated by the tHB’s commitment to repay the early drawn down of £3.9M it made in 2011/12. In combination, these two factors represent a remaining financial challenge of £8.1M in this year. Building on its initial plans and feedback on these, this paper sets out our approach to improving the plan and a proposed basis for achieving financial balance in 2012/13 and associated risks to delivery. Financial Strategy Powys tHB’s financial strategy is one of improving services and reducing cost. In progressing its plans, the Health Board will not be departing from this objective. The components of that strategy are:-

Pathway development and management to reduce volume to both English and Welsh District General Hospital providers (system change).

A programme of repatriation to bring services back in Powys and into Wales at lower cost (supplier change).

Maximising operational efficiency of preferred providers including:- o Our own local services o Primary Care provided services including GMS and prescribed drugs o Challenging the price charged by English and Welsh providers.

Developing an efficient and sustainable platform of back office functions where appropriate with NHS Wales and with Powys County Council.

Our current plans are ambitious and, whilst they have not yet provided a basis for the organisation to achieve break even in this year, they are stretching and are not without significant risk.

A savings programme of £11m – this is 4.7% of total allocation and 6.7% of non ring-fenced money.

The cost structure is such that 54% of the programme needs to be secured from external providers, through a combination of genuine service change and complex contract negotiation, which includes Welsh providers to Powys. The plan assumes national agreement on contracting arrangements and a price deflator, which mirrors the English system..

Savings in areas where we can already demonstrate that Powys is already “best in class” – the most notable example being Primary Care prescribing.

An assessment of areas of savings to ensure whole organisation coverage and that the programme is comparable with the programme of the rest of Wales.

FOR APPROVAL


Agenda Item 2.1

A savings programme that involves whole organisation coverage and this is comparable with the programme of the rest of Wales.

External Review In view of the requirement for early draw down of 2012/13 income to secure a balanced position in 2011/12, the Welsh Government commissioned an external review of the Health Board’s plans. To date only verbal feedback from this review has been received and at a high level the key messages are:-

The financial strategy is the right direction – the issue for the Health Board is therefore one of pace and depth.

The Welsh Government should support the Health Board in its approach to contracting within NHS Wales.

The organisation is in good shape to ensure success – good progress has been made in securing a permanent Executive Team; engaging with stakeholders and gaining their trust; bringing the GP community into the leadership of the Health Board.

The “Making it Happen” programme is the right approach – whilst the programme was embryonic at the time of the visit, the reviewer was able to confirm that the approach to “recovery” the Health Board was proposing would be effective.

There needs to be added rigour in the monitoring and delivery of the existing savings programme. Arrangements have been reinforced and have strengthened through an external review of financial management arrangements.

Proposed Approach for achieving break-even in 2012-13 The approach has 5 key elements:-

Delivering our current plans Securing good agreements with external providers for 2011/12 Managing our system Creating extended opportunity A 3 year plan

1. Delivering our Current Plans Securing in full our £11M savings programme will be critical to our success. Welsh Government support in the application of a deflator and other contracting arrangements within Wales is an essential pre-requisite in delivering this target. The tHB will also require the support from other NHS Wales support organisations including Organisational Development support from NLIAH and NWIS. In response to the External Review we have commenced additional processes to add rigour into the monitoring and delivery of our savings programmes, we are also using our externally commissioned support to add further improvements as we progress through the year. 2. Securing good agreements with external providers (enabling balance sheet release) Negotiations are currently on-going with our external providers to settle the year end position. We previously flagged to WG that there was some risk in reaching a favourable outcome, particularly with Shrewsbury and Telford NHS Trust and hence provision set aside in our balance sheet of £2.1M. In recent days, we have seen

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Agenda Item 2.1

some success in negotiating our year-end position and anticipate further success within the coming few weeks. The Welsh Government will further appreciate that securing our year end position for annual accounts purposes requires the inclusion of a significant proportion of estimates based on incomplete data. This applies to commissioned services, prescribing and primary care. All final positions will fully complete by end June 2012. At this point we will have certainty as to whether any further balance sheet opportunities are available. 3. Managing our system (rigorous cost containment to limit the use of reserves) Within our estimated cost pressures for the 2012/13, we have held back the following budgets – which provide for the predictable annual growth in operating costs - in reserves.

Reserves Contingency £M

Energy and Utilities Commissioning Growth above 2011/12 NICE / High Cost Drugs Orthopaedic Waiting list funding Pharmacy Services growth Displaced staff reserve General Contingency

0.681 1.682 0.500 0.336 0.214 0.270 0.800

Total 4.483 Our strategy is to limit the need to draw on these budgets held in reserve, through better management of services and systems,. Examples include:-

a. Enhancing the performance capability of localities through organisational development initiatives aimed at leadership; information; operational transformation and financial management.

b. Sustainable solutions to reduce utilisation of energy in conjunction with the Carbon Trust.

c. Use alternative local services to reduce demand on external secondary care services including increasing direct admissions to community hospitals.

d. Self financing solutions to maintain current waiting times targets i.e. rollout of orthopaedic triage

4. Creating extended opportunity The “Making it Happen” programme referred to above is a clinically led and organisational development based initiative to secure accelerated clinical change. There are a number of key components that it is envisaged will, as a minimum, extend the opportunity already included in plans. These are:-

Undertaking a “deep-dive” of the organisation to assess the opportunities and

gaps – an organisational development approach to this is being used supported by external review and statistical analysis. Two areas identified that will extend existing plans are:-

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Agenda Item 2.1

- Admission reduction for Unscheduled Care - Big ticket item repatriation of elective day cases.

Effective implementation through the use of various tools including those promoted by 1000 Lives; patient flow management etc.

Organisational development support to ensure capacity and capability.

5. Updated and robust 3 year plan Achieving an in-year break-even, requires the organisation to deliver savings of 6.5% (£15M), or 9.3% of non-ring fenced budget. When the repayment of the early draw down from 2011/12 is added to this, the size of the challenge becomes 8% (£18.9M) and this significantly diminishes the potential for the tHB to successfully deliver break-even, given the characteristics of its cost base.

Our proposal is that the repayment of the £3.9M early draw down is re-phased over 3 years, to align with a financial plan that breaks even over 3 years (to be submitted for review and approval at the end of June 2012). There are opportunities on the horizon to reduce costs further through our “Making it Happen” programme and through the planned reshape of service within the county - eg development of a day case theatre in North Powys. Our proposal is to present our three year financial plan to the Welsh Government to demonstrate our commitment to achieving this ambition by end June 2012. Work has started on this process. Summary Reflecting the above actions, the table below sets out the range of potential of the approach and sets it against the remaining challenge.

Updated Financial Plan 2012/13 £M (234.007) 252.244

15.2

(11.0) 4.2

3.9 8.1

2012/13 Revenue Resource Limit 2012/13 Anticipated Costs Requirement for savings (before the repayment of the 2011/12 draw down) Current Savings programme Residual gap to be closed by further savings and cost containment Repayment of early drawn down from 2011/12 Total Financial Challenge Further potential savings

Improving the payback of current plans Balance sheet opportunities – year end negotiations Release of reserves - better system management “Making it Happen” – new savings opportunities

-

£0-5M - £2.0M £0.5M - £2.0M £0.5M - £1.0M

Potential total £1.5m-£5.0m

The table described above shows that realizing the full potential of the approach could raise up to £5.0m against an underlying challenge of £4.2m. If this full potential is delivered, it would enable the tHB to make a contribution towards the repayment of early draw down of £3.9m at the end of this year.

FOR APPROVAL

Section 33: Agreement with Powys County council


Agenda Item 2.2


AGENDA ITEM 2.2

DEVELOPMENT OF AN AGREEMENT FOR POOLED SERVICES WITH POWYS COUNTY COUNCIL

Report of

Director of Finance


Purpose of Paper

The purpose of this report is to advise the Board of the process and structure for developing an overarching section 33 agreement with Powys County Council.


The Board is requested to:- ADOPT the overarching section 33 agreement with

Powys County Council,; and APPROVE amendment to the Board’s Scheme of

Delegation, to include delegation of powers to the Joint Programme Board.


N/A




N/A

FOR APPROVAL



Agenda Item 2.2

DEVELOPMENT OF AN AGREEMENT FOR POOLED SERVICES WITH POWYS COUNTY COUNCIL

Introduction The two statutory organisations within the boundary of Powys County have agreed to work towards closer integration with a view to bringing both front line and back office functions together in order to secure safer, sustainable and economic services to the Powys population. The means by which this closer integration will take place will be through the establishment of pooled arrangements which will provide clarity to both organisations on the role, accountability, funding contributions and performance requirements in securing and providing services together. There are several service and financial relationships already in existence between the Health Board and Council, many of which have been in existence over many years. Given the breadth of the existing financial relationship between the two organisations and the increasing likelihood of the current sharing of services extending in future, agreement has been made for the development of one overarching pooled budget arrangement, into which each service component will slot in. This report will provide an overview of how the overarching agreement has been established and seeks approval from the Board to proceed to implementation. Structure of the Overarching agreement The services of an expert consultant on the development of section 33 agreements was commissioned jointly by both the Council and the Health Board in order to ensure the interests of both parties were not compromised whilst seeking the best outcome for service delivery and value for money. In simple terms, the structure of the document is an overarching agreement which sets out the “rules” by which both parties will operate when working under a partnership arrangement. Individual functions or services will each slot into this overarching agreement by mutual consent and the two organisations will abide by the “rules” as set out, regardless of the nature, size or substance of any service under the umbrella of the agreement. The main components of the overarching agreement is summarised in bullet form below:-

• The aims and objectives of the partnership; • How financial contributions will be derived and managed; • How each organisation will operate in terms of the functions included within the

agreement; • How staff will be managed under the terms of joint working / pooled arrangements;

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Agenda Item 2.2

• The review mechanisms to monitor the implementation of arrangements; • Requirements should either party decide to terminate the agreements; and • Other legal duties required of each other such as indemnity, confidentiality

The overarching agreement is supplemented by a set of schedules which will be tailored to each individual service of function entering the agreement. These schedules set out the following:- Schedule 1 - Description of the service or function to be pooled including its aims and

objectives Schedule 2 – Functions of the Partners Schedule 3 – Scope of the service to be provided Schedule 4 – Funding contributions and use by either party Schedule 5 - HR requirements under the agreement Schedule 6 – Governance of the agreement The full agreement and supporting schedules is set out in Appendix 1. These have been contributed to by relevant employees of both organisations and drafted by the Council legal team. The draft (as appended) has been forwarded to NHS Legal and Risk services and the tHB’s employment lawyers for review and comment / amendment as necessary. The board considered an earlier iteration of the documentation at its meeting in February 2012. A number of queries were raised and the following summarises the clarifications and amendments where necessary to the documentation

– JPB Governance – This has been amended to add PCC political membership and PtHB exec member (see below).

– Duration of agreement – now confirmed 4 years with annual review – New / replacement staff – ‘at risk’ staff within the employing organisation will

be considered. – Negotiation arrangements – Unions have been consulted and have signed

off the amended agreement. – Secondment will be for 4 years.

The Board is requested to approve the overarching agreement and standard schedules, for ICT only. Joint Programme Board The governance schedule (schedule 6) establishes the Chief Executives of the two organisations, a member of the Powys County Council Cabinet and a Executive Officer of the Health board as the Joint Programme Board. Its role will be to oversee the implementation of the agreement and any individual component parts thereof. Any additional schemes will be brought to both the Powys County Council Cabinet and the Powys teaching health Board for approval.

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Agenda Item 2.2

Once consent has been received from both organisations to the agreement of a single overarching agreement, the Joint Programme Board (JPB) will be formally established. The Board is asked to approve amendment to the Board’s Scheme of Delegation, to include delegation of powers to the Joint Programme Board. Services to be slotted in from 1st July 2012 The Joint Programme Board will meet prior to 1st July 2012 to formally establish itself and agree the services and schedules to be slotted into the overarching agreement. The two organisations have been working on the basis that the first services that will enter the agreement from 1 July 2012 will be ICT – the Council will be the host organisation The schedules have been developed jointly between the respective organisations in accordance with the requirements of the agreement as set out above. Future Developments The overarching agreement has been written with the intention that it lasts for 4 years with a view to reviewing its implementation annually and using this experience to make amendments as necessary. There are a range of other services (predominately between Social Care and the Health Board) which are in the process of development. These are currently work in progress and will be brought forward for inclusion once they are mutually agreed. This work may include proposed amendments to the agreement where necessary. These include (but are not limited to)

• Substance Misuse • Reablement • Learning Disabilities • Nursing Home Commissioning

The Joint Programme Board will oversee the development of these services and determine the point at which services are ready for recommending to the board and council for approval to slot into the agreement. Financial Consequences The two organisations have commissioned the services of an external consultant to help facilitate the establishment of pooled arrangements. The sums set aside by the two organisations for this contract is £20k (costs to be shared equally). The financial consequences to implementing the pooled arrangements will be determined by each individual scheme that is slotted into the agreement and will be subject to

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Agenda Item 2.2

approval by the Joint Programme Board before onward recommendation to the board and the council. Conclusion This paper has set out the arrangements for preparing an overarching agreement between Powys County Council and Powys teaching Health Board. Recommendation The Board is requested to:-

ADOPT the overarching section 33 agreement with Powys County Council. APPROVE amendment to the Board’s Scheme of Delegation, to include delegation

of powers to the Joint Programme Board.

Report prepared by: Presented By: Rebecca Richards Rebecca Richards Director of Finance Director of Finance

Final Draft 11 as at 13th June 2012

Page 1

DATED 2012

(1) POWYS COUNTY COUNCIL

and

(2) POWYS LOCAL HEALTH BOARD

AGREEMENT

SECTION 33 OF THE NATIONAL HEALTH SERVICE (WALES) ACT 2006 OVERARCHING PARTNERSHIP AGREEMENT


Page 2

Table of contents Clause heading and number Page number

1. DEFINITIONS AND INTERPRETATION ............................................................. 5 2. TERM ................................................................................................................. 11 3. AIMS AND OBJECTIVES .................................................................................. 11 4. FINANCIAL CONTRIBUTIONS ......................................................................... 11 5. THE SERVICE ................................................................................................... 12 6. INTEGRATED PROVISION AND LEAD COMMISSIONING ............................. 13 7. STAFF AND PERSONNEL ARRANGEMENTS…………………………………..16 8. REVIEW ............................................................................................................. 22 9. FINANCIAL PLANNING AND BUDGET SETTING PROCESS ........................ 23 10. TERMINATION .................................................................................................. 23 11. EFFECTS OF TERMINATION ........................................................................... 24 12. SCRUTINY ......................................................................................................... 25 13. EXTERNAL INSPECTION AND MONITORING ................................................ 25 14. INDEMNITY AND INSURANCE ........................................................................ 25 15. VARIATION / CHANGE OF LAW ...................................................................... 27 16. CONFIDENTIALITY ........................................................................................... 27 17. DISPUTE AND RESOLUTION .......................................................................... 28 18. EXCLUSION OF PARTNERSHIP AND AGENCY ............................................. 29 19. ASSIGNMENT AND SUB AGREEMENTS ........................................................ 29 20. THE CONTRACTS (RIGHTS OF THIRD PARTIES) ACT 1999 ........................ 29 21. PREVENTION OF CORRUPTION / QUALITY CONTROL ............................... 29 22. COMPLAINTS ................................................................................................... 30 23. NOTICES .......................................................................................................... 30 24. NOTIFICATION TO THE WELSH ASSEMBLY GOVERNMENT (WAG) .......... 30 25. GENERAL PRINCIPLES ................................................................................... 31 26. FORCE MAJEURE ........................................................................................... 31 27. SEVERABILITY ................................................................................................. 32 28. WAIVER ............................................................................................................. 32 29. AMENDMENTS ................................................................................................. 32 30. GOVERNING LAW ............................................................................................ 32 Prepared in association with [email protected]


Page 3

FORM OF SCHEDULES TO BE PREPARED FOR ANY SCHEME ADMITTED TO THE PARTNERSHIP BY THE JOINT BOARD: SCHEDULE 1: NAME OF SCHEME; HOST PARTNER & AIMS AND OBJECTIVES SCHEDULE 2: THE LHB’S NHS HEALTH CARE FUNCTIONS AND THE

COUNCIL’S HEALTH RELATED CARE FUNCTIONS SCHEDULE 3: THE SERVICE: SERVICE USERS, MANNER, LOCATION AND

ACCESS, SCHEDULE 4: PERSONNEL, MANAGEMENT AND STRUCTURE SCHEDULE 5: RESOURCES SCHEDULE 6: JOINT PARTNERSHIP BOARD: JOINT MANAGEMENT GROUP

AND GOVERNANCE


Page 4

THIS AGREEMENT is made the ……….. day of 2012 BETWEEN POWYS COUNTY COUNCIL (“the Council”) of County Hall, Llandrindod Wells, Powys LD1 5LG of the one part and POWYS TEACHING LOCAL HEALTH BOARD ("the LHB") of Powys teaching Local Health Board Headquarters, Mansion House, Bronllys, Brecon, Powys LD3 0LS of the other part.

WHEREAS:

A This Agreement covers both lead commissioning arrangements and integrated provision arrangements pursuant to Section 33 of the Act and for the establishment and management of Pooled Funds and or delegated budgets as Lead Funds where either Partner from time to time will be the host partner for the purposes of the Regulations.

B Prior to the date of this Agreement the Partners have operated arrangements pursuant to Section 33 of the Act and the Regulations for the delivery of the Services, “the Previous S33 Agreements”.

C This Agreement will replace the Previous Section 33 Agreements if they are

admitted to the Partnership here. D For the purpose of the implementation of the Partnership Arrangements under

this Agreement:

1 the LHB has agreed that the Council may, in conjunction with exercising its Health Related Functions, exercise the LHB’s NHS Functions in relation to the Services and;

2 the Council has agreed that the LHB may, in conjunction with exercising

its NHS Functions, exercise the Council’s Health Related Functions in relation to the Services and

E Where the Partners commission and provide Services pursuant to Section 33

of the Act and this Partnership the Services which the Partners agree to be delivered under this Section 33 Agreement shall be set out according to the Schedules and the terms herein.

F The Partners shall carry out consultation on the proposals for any Scheme with

those persons, user groups, staff and statutory and non-statutory providers, who appear to them to be affected by the arrangement, as required by Regulation 4(2) of the Regulations.

G The Partners have agreed to enter into this Agreement to fulfil the requirements in Regulation 8(2) of the Regulations and to record their respective rights and obligations under the Partnership Arrangements and the terms on which the Partnership Arrangements will be exercised and the Service will be delivered.


Page 5

IT IS AGREED AS FOLLOWS:

1. DEFINITIONS AND INTERPRETATION

1.1 In this Agreement, except where the context otherwise requires, the following expressions shall have the meanings respectively ascribed to them:-

“Act” means the National Health Service (Wales) Act 2006;

“Agreement” means this Agreement and any variation of it from time to time agreed between the Partners;

“Authorised Officers” means the person notified by each of the Partners to the other from time to time as authorised to act on behalf of that Partner for the purposes of Clause 4 and 17 of this Agreement (which person shall until further notice be for the Council its Chief Executive and for the LHB its Chief Executive);

“Commencement Date” means 1st July 2012;

“Council” means Powys County Council (and any successor to its statutory function);

“Directions” means such statutory directions in respect of services as the Partners must follow;

“Financial Framework” means the Financial Framework set out in Clause 6;

“Financial Year” means the financial year from 1st April in any year to 31st March in the following calendar year;

“Health Related Functions” means the functions set out in regulation 6 of the Regulations;

“Host Partner” means the Partner responsible for any Services within a Scheme approved by the JPB under this Agreement and any associated Funds


Page 6

“Joint Partnership Board (JPB)” means the membership set out at Schedule 6 and which is responsible for the management of the partnership arrangements established under this Agreement, including monitoring the arrangements, receiving reports and agreeing actions in respect of the operation of the Agreement and delivery of the Service in accordance with the provisions of Schedule 6;

“Lead Commissioner” means the Partner specified for any Services according to the Scheme Schedules as being the Partner with authority to commission that service on its own behalf and that of the other Partner;

“Lead Funds“ means the fund of monies to be

available in order to purchase those parts of the Service not within the Pooled Fund and for which there shall be two (2) lead funds, with one (1) provided by the Council for the purposes of purchasing Council health related care (the “Lead Fund for Social Care”) and one (1) provided by the Trust for the purposes of the Council securing on its behalf NHS health care (the “Lead Fund for Health Care”) in accordance with the functions delegated according to the jointly agreed aims, objectives and plans set out in this Agreement;

“Lead Fund for Health Care” means the fund of monies provided by the Trust for the purposes of purchasing NHS health care;

“Lead Fund for Social Care” means the fund of monies provided by

the Council for the purposes of purchasing Council health related care;


Page 7

“Lead Provider” means the Partner undertaking the function of providing the Services on behalf of the Partners;

“LHB” means Powys Local Health Board (Known as Powys teaching Health Board) (and any successor to its statutory function);

"Month" means a calendar month;

“NHS Functions” means those functions set out in regulation 5 of the Regulations

“Operational Group” means the membership to be constituted and responsible for the day-to-day management of the Service in accordance with the provisions of Schedule 6;

“Partners” means the Council and the LHB, and the term “Partner” shall mean either one of them; the term “Partnership” shall be construed accordingly;

“Partnership Arrangements” means the arrangements as set out in this Agreement concerning the lead commissioning or integrated provision of Services and the delegation of Functions or budgets as set out in this Agreement;

“Partnership Lead” means the officer responsible within the office of the Host Partner approved by the JPB who shall be the chair of the Operational Group

“Pooled Fund Manager” means the person determined from time to time under Clause 6.6 and who has been identified in the particular Schedules for the Scheme admitted to the Partnership.

“Pooled Fund/Pooled Funds” means the joint fund or joint funds of monies maintained by the host partner from time to time being shared contributions from the Partners for the purpose of securing the Services


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pursuant to this Agreement and reference to “Pooled Fund” where the context permits shall be a reference to all The Pooled Funds for a particular Scheme taken together;

“Regulations” means the NHS Bodies and Local Authority Partnership Arrangements Regulations 2000, S.I. No. 2993 (W.193) and NHS Bodies and Local Authority Partnership Arrangements (Wales) (Amendment) Regulations 2004, S.I. No 1390 as amended or replaced from time to time;

“Revised Annual Finance Agreement” means the written confirmation of finance contributions for operation of the Agreement as set out at Schedule 4 for a Scheme;

“Revised Annual Plan” means an annual statement of agreed

intentions which shall be the subject of expenditure from the Pooled Fund and Lead Funds for a Scheme. This shall include any objectives for change to Services delivery or expenditure arrangements to be implemented by the Host Partners on behalf of the Partners in the Financial Year. The Revised Annual Plan is to be prepared by the Pooled Fund Manager and to be approved by the JPB. The Revised Annual Plan will incorporate the Revised Annual Finance Agreement and revision to the Schedules 1, 3, 4, 5 and performance framework as appended at Schedule 6 for the Scheme as required;

“Scheme” Means an arrangement governed by the terms of this Partnership which has been admitted to the Partnership after completion of the Schedules and approval of the same by PCC Cabinet and PtHb Board

“Seconded Staff” means that personnel who are

employees of the Council or of the LHB and who it has been agreed will be managed and directed in their


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duties by the Host Partner according to the terms of the Secondment Agreement;

“Secondment Agreement” means the agreement between the

Council and the LHB as set out at Clause 7 for the terms relating to the Seconded Staff;

“Services” means the commissioned or provided services as described in Schedule 3 and such other services as the Partners may agree to be included in this agreement under any particular Scheme;

“Service Users” mean the people who receive the Services to be arranged or managed by the selected host partner;

"Staff" means employees of the LHB and

employees of the Council who are responsible for assessing and or providing care to Clients as a part of the arrangements set out at the Schedules for a particular Scheme or employees responsible for the delivery of the Services. This shall be limited to those employees of the Council and the LHB who are or were immediately before the Commencement Date employed by one of the Partners and assigned to the Services or any replacement or additional employees of the Council and the Trust so assigned.

“Term” means the period from the Commencement Date and ending on 31st March 2016 subject to earlier termination in accordance with the terms of this Agreement;

“Tupe” means the Transfer of Undertakings (Protection of Employment) Regulations 2006 (as amended or re-amended);


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1.2 Save to the extent that the context or the express provisions of this Agreement otherwise require:-

1.2.1 obligations undertaken or to be undertaken by more than a single person shall be made and undertaken jointly and severally;

1.2.2 words importing any gender include any other gender and words in the singular include the plural and words in the plural include the singular;

1.2.3 References to statutory provisions shall be construed as references to those provisions as respectively amended or re-enacted (whether before or after the Commencement Date) from time to time;

1.2.4 Headings and the Index are inserted for convenience only and shall be ignored in interpreting or in the construction of this Agreement;

1.2.5 references in this Agreement to any Clause or Sub-Clause or Schedule without further designation shall be construed as a reference to the Clause or Sub-Clause of or Schedule to this Agreement so numbered;

1.2.6 any obligation on either of the Partners shall be a direct obligation or an obligation to procure as the context requires;

1.2.7 any reference to “indemnity” or “indemnify” or other similar expressions shall mean that the relevant Partner indemnifies, shall indemnify and keep indemnified and hold harmless the other Partner; and

1.2.8 any reference to a person shall be deemed to include any permitted transferee or assignee of such person and any successor to that person or any person which has taken over the functions or responsibilities of that person but without derogation from any liability of any original Partner to this Agreement.

1.2.9 This Agreement and its Schedules should be read as a whole but in the event of any inconsistency the Schedules shall have precedence

2. TERM

2.1 This Agreement shall commence on the Commencement Date and shall

continue for the Term, subject to earlier termination as provided below.

2.2 Following the expiry of the Term, the Agreement shall continue in force until it is terminated in whole or in part on one of the following grounds:


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2.2.1 on not less than 12 Months' written notice by one Partner (the "Terminating Partner") to the other, such notice to end at the end of a Financial Year;

2.2.2 in accordance with the provisions of Clause 10; or

2.2.3 by written agreement between all of the Partners.

3. AIMS AND OBJECTIVES

3.1 The aims, benefits and intended outcomes of the Partners in entering in to this Agreement are to:

3.1.1 provide high quality, efficient and cost effective Services to meet the needs of the Partners, Service Users and other authorised users according to any specific Scheme set out in the Schedules;

3.1.2 provide the best value Service to the Partners, Service Users and other authorised users;

3.1.3 develop a quality-management system for continuous service improvement in line with measures and targets for the Schemes contained in the Schedules including risk management and workforce training;

3.2 The targets for any Scheme are set out in Schedule 1 for that Scheme and which are to be updated annually for approval of the JPB along with a Revised Schedule 3 and Schedule 4 (as a revised Annual Finance Agreement) and Appendix to Schedule 6 which collectively here shall form a Revised Annual Plan

4 FINANCIAL CONTRIBUTIONS

4.1 The LHB’s contribution to the Pooled Fund for a Scheme and the Council’s contribution to the Pooled Fund for a Scheme per annum shall be set out in the Schedule 5 for that Scheme

4.2 The LHB’s contribution to the Lead Fund for a Scheme and the Council’s contribution to the Lead Fund for a Scheme per annum shall be set out in the Schedule 5 for that Scheme

4.3 The LHB and the Council shall make payments to whichever is the Host partner monthly on the 15th day of each Month.

4.4 Any increases to the amounts shown at Clauses 4.1 to 4.2 above as additional payments shall be subject to separately agreed arrangements by the JPB in respect of the relevant Scheme from time to time.


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4.5 The Partners agree that the annual contribution due under clauses 4.1 and 4.2 shall be increased or reduced according to planning assumptions and the Review process at Clause 11 and to be agreed by the JPB

4.6 The LHB may make variations to the contributions identified as LHB contributions at Clause 4.2 subject to notice in writing to the Council of one month.

4.7 The Council may make variations to the contributions identified as Council contributions at Clause 4.2 subject to notice in writing to the LHB of one month.

4.8 No provision of this Agreement shall preclude the Partners by mutual agreement making additional contributions of non-recurring monies to the Pooled Fund or Lead Funds from time to time but no such additional contributions shall be taken into account in the calculation of the Partners’ respective contributions for the purpose of Clause 4. Any such additional contributions of non-recurring monies shall be explicitly recorded in JPB minutes and recorded in the budget statement as a separate item.

4.9 All such notices issued for the purpose of Clauses 4.6 and 4.7 shall be in

writing and the notifying Partner will remain liable for any costs and expenses incurred as a result of compliance with any existing contracts and commitments previously entered into within the terms of the Agreement and use of those funds.

5 THE SERVICES

5.1 The Services shall be commissioned for or provided to the Partners in accordance with the provisions of the Schedules for a Scheme

5.2 The Partners will ensure that the Government’s Guidance on “Fair Access to Care” is fully implemented and that the Eligibility Criteria Thresholds as agreed by the Council are consistently applied.

5.3 The Eligibility Criteria Threshold for the provision of care Services may be changed and will operate according to Schedule 3 for any Scheme.

5.4 Either Partner shall from time to time be the Lead Commissioner according to the Scheme Schedules.

5.5 Either Partner shall from time to time be the Lead Provider according to the Scheme Schedules.

5.6 The Host Partner shall comply with all Statutes, Regulations, Guidance, Directions and Directives relating to the provision of the Services or any part thereof.


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6. INTEGRATED PROVISION AND LEAD COMMISSIONING

6.1 Pooled Funds or Lead Funds shall be established for the Services

6.2 For any particular Scheme The Council or the LHB shall be the Lead Commissioner and the Host Partner for a particular Scheme for the purposes of Regulations 7(4) and (6) of the Regulations.

6.3 For any particular Scheme The Council or the LHB shall be the Lead Provider and the Host Partner for a particular Scheme for the purposes of Regulations 7(4) and (6) of the Regulations.

6.4 The Joint Partnership Board will be established in accordance with Schedule 6 to carry the functions of the Joint Partnership Board as set out in Schedule 6 and shall be supported by a Operational Group according to the schedules required.

6.5 The Pooled Fund Manager shall be responsible for the management of the Pooled Fund or any Lead Funds for a Scheme.

6.6 The Pooled Fund Manager shall be approved by the Partner who is not the Host partner for a Scheme (such approval not to be unreasonably withheld) and affirmed in the role by the Joint Partnership Board at the outset of a Scheme.

6.7 The Pooled Fund Manager where the Council is the Host Partner shall be accountable directly to the Partnership Lead for an approved scheme.

6.8 The Pooled Fund Manager where the LHB is the Host Partner shall be accountable directly to the Partnership Lead for an approved Scheme.

6.9 The internal regulations of the Lead Commissioner shall apply to the management of the Pooled Funds and any Lead Funds under this Agreement

6.10 The Pooled Fund Manager shall be responsible for authorising payments and the Host Partner shall make payments from the Pooled Fund and Lead Funds in accordance with the Service description and the Aims and Objectives, as set out in the Schedules to this Agreement.

6.11 The Pooled Fund Manager shall be responsible for managing the Pooled Fund and Lead Funds and forecasting and reporting to the Partnership Board upon the targets and information in accordance with and any further targets or performance measures that may be set by the Partnership Board from time to time.

6.12 The Pooled Fund Manager shall report to both Authorised Officers in accordance with the requirements of the Regulations. The Council’s Authorised Officer shall in turn ensure reporting on the same to the officer of the Council responsible for the administration of its financial affairs.


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Financial Performance/Risk Sharing Arrangements

6.13 The Pooled Fund and Lead Funds are to be used solely to achieve the

aims and objectives set out in Schedule 1 of a Scheme

6.14 The Pooled Fund manager shall report monthly to the JPB on the information specified in Appendix 1 to Schedule 6 for a Scheme. The Partners agree to provide all necessary information to the Pooled Fund Manager in time for the reporting requirements to be met.

6.15 The Pooled Fund Manager shall ensure that action is taken to manage

any projected under or over spends from the budget relating to the Pooled Fund, reporting on the variances and the actions taken or proposed to the JPB.

6.16 If at any time during the financial year there is forecast a projected under

or overspend on the Pooled Fund, the Pooled Fund Manager will prepare an action plan to manage the under or overspend, for presentation to the JPB as quickly as possible. The JPB will consider the action plan, amend as appropriate and agree the action so be taken.

6.17 The Pooled Fund Manager will provide to the JPB monthly progress

reports or any appropriate frequency as determined by the JPB on implementation of any such action plan, until such time that the under or overspend has been dealt with to the satisfaction of the Board

6.18 The Partners through the management of this Agreement by the JPB shall be jointly responsible for any costs, claims, expenses or liabilities in excess of the Pooled Fund for a Scheme at any time.

6.19 The Partners will ensure:-

a) The Pooled Funds are used efficiently to deliver agreed outcomes.

b) The expenditure and income within the Pooled Funds remain within budget, and that any exceptions to this are reported to the Partnership Board in a timely manner.

c) A high level of probity in financial management arrangements.

d) Resources allocated to Pooled Funds are adequately protected.

e) That Pooled Fund accounts are audited in accordance with Section 28 of the Audit Commission Act 1998.


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6.20 The benefit of any surplus in the Pooled Fund at the end of any

Financial Year shall be used for such other expenditure as the JPB

may determine

6.21 Arrangements to determine liability and responsibility for Pooled

Fund deficit sharing and apportionment thereof as between the Partners

shall normally be the relative proportion of the partners contribution to

the pooled fund unless specific arrangements are set out in schedule 5

(resources) of the appropriate Scheme

6.22 A deficit in any Lead Fund will be the sole responsibility of the

organisation to which that Lead Fund supports.

6.23 The benefit of any surplus in the Lead Fund at the end of any Financial Year shall remain in the Lead Fund.

6.24 The Pooled Fund Manager will submit to the partners monthly financial performance reports detailing performance against agreed funding. The report will include a variance analysis for the period and expected forecast outturn and where required, an explanatory note setting out actions being taken to tackle areas where performance has gone awry. Annual statements of performance against the pooled fund will also be provided in line with statutory timescales required by either partner.

6.25 The Pooled Fund Manager shall maintain and provide when requested by either of the Partners at the expense of that Partner such information as shall be appropriate to the provision of the Service for so long as any part thereof is being provided to Service Users notwithstanding any notice of termination in accordance with Clause 9.

6.26 The governance arrangements shall be as set out in Schedule 6 for a Scheme.

6.27 All other reasonable administrative expenses incurred by the pooled fund or lead fund outside of the original agreement in-year will need to be sought in advance of spend and will require the agreement of the Joint Partnership Board before being accepted as an allowable charge to the pool or lead fund.

6.28 Capital Funding


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Financial contributions between the Partners towards items of capital expenditure over £0.5 million per item will normally be made under the powers contained in Sections 194 and 34 of the 2006 Act and in accordance with associated Directions such as for a proportionate repayment of contributions if an item acquired is disposed of or is no longer used for the purpose it was acquired. The NHS and Local Government Capital Asset regimes are not aligned, therefore it should be ensured that each party fulfils the requirement of its capital accounting regime for each capital purchase made. This means that Assets purchased by either party should be separately identifiable and should be contained within the fixed asset register of that party

6.29 Assets

The Partners will retain inventories of assets such as vehicles, furniture and computer equipment which are transferred between them and they will agree schedules at the time of transfer. All assets will continue to be owned by the Partner that owned them at the time of transfer. Should there be requirement for a major contribution towards a capital asset there should first be agreement of how any contribution to a capital asset will be repaid in the event of the dissolution of a pooled fund or change in the way services are provided.

6.30 Depreciation

Where the NHS has explicitly funded an asset, there will normally be a depreciation charge. This charge will be made to the pooled / lead funding. Consideration of the source of funding for this charge will be undertaken by the JPB prior to purchase.

7. STAFF AND PERSONNEL ARRANGEMENTS

7.1 The Partners have in the spirit of partnership and good employee relations agreed to the Personnel, Management Structure and Service Governance in accordance with the provisions set out at Schedule 4 pursuant to which, in addition to the provisions of this Clause 7 Staff including seconded Staff shall be managed

7.2 The Partners shall make the Staff employed in carrying out the Health Functions or Health Related Functions available for the Services pursuant to Clause 7.5. A full list of the staff in the partnership fulfilling these roles as at the Commencement Date will be provided to the LHB by the Council or by the Council to the LHB dependent upon which is the Host Partner for a particular Service.

7.3 The Partners have agreed that subject to the employing partner properly consulting with their employed Staff (and their representatives) seconded Staff will:


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7.4.1 remain in the employment of their employer after the Commencement Date on their existing terms and conditions; and,

7.4.2 be made available to the Services pursuant to this Clause 7.

7.4 The Staff who will be seconded shall be seconded on the terms set out in the Secondment Agreement for the relevant employer or such other terms as the Partners may agree from time to time. All Staff shall retain their current terms and conditions of employment as varied to give effect to the secondment. The roles of Staff will not be changed without agreement of the employer of the Staff, which agreement is not to be unreasonably withheld. The roles of Staff will not be changed without the necessary management of change policies having been followed.

7.5 The JPB may consider at any time the suitability of the Secondment Agreement to fulfilling the aims and objectives of the Agreement and in compliance with individual rights as set out in staff contracts of employment.

7.6 The Staff referred to in Clauses 7.2 and 7.3 shall continue to be employed by the Partner employing them at the date of this Agreement and subject to Clause 7.1 and 7.5 they shall retain their current terms and conditions of employment.

7.7 Both the Partners warrant that with respect to the Staff which each Partner makes available hereunder it has carried out all employment and regulatory checks reasonably required of it as an employer and, for the Council and the LHB, such as registrations, police checks or applications for a Disclosure from the Criminal Records Bureau as may be required.

7.8 Both the Partners warrant that the Staff which each Partner make available for the Services have all relevant qualifications and skills to perform the Services.

7.9 Staff made available by the Partners in accordance with this Agreement shall be on the terms set out in this Clause 7 and Schedule 4 and/or such other terms as the Partners may agree from time to time, subject to consultation. The terms and conditions of employment of any such Staff who are made available may only be varied as may be required to honour changes in their Terms and Conditions of Employment, and other national agreements such as NHS pay awards or other obligations required by Law.

7.10 The policies, code of conduct, and rules and regulations which are operative in relation to Staff shall be those in line with their terms and conditions of employment. Where joint protocols and/or procedures may be agreed separately these will be confirmed and communicated to Staff by the Partners (the “Agreed Policies”).

7.11 If after the date of the Agreement any of the Staff gives or receives notice of termination of their employment, or the employment of any Staff


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otherwise terminates, the employer of the affected Staff shall advise the other Partner forthwith.

7.12 The employer of the Staff shall be released from its obligations to make Staff available for the purposes of this Agreement whilst the Staff are absent:

7.12.1 by reason of industrial action taken in contemplation of a trade dispute; and/or,

7.12.2 by reason of an act or omission of the other Partner; and/or;

7.12.3 as a result of the suspension or exclusion of employment or secondment of any Staff by their employer where either the HOST Partner requests the suspension or exclusion or the other Partner consents to the exclusion or suspension or (such consent not to be unreasonably withheld or delayed); and/or

7.12.4 in accordance with their respective terms and conditions of employment and policies, including, but not limited to, by reason of training, holidays, sickness, injury, trade union duties, paternity leave or maternity or where absence is permitted by Law; and/or

7.12.5 if making the Staff available would breach or contravene any Law; and/or

7.12.6 as a result of the cessation of employment of any individual Staff.

7.13 During the Agreement term, both of the Council and the LHB agree to:

7.13.1 Promptly notify the other Partner upon becoming aware of any act or omission by any Staff which may constitute a material breach of the contract of employment of the Staff and/or which may prejudice either Partner, and promptly take such lawful action in connection with such action as the Employer of the Staff may require.

7.13.2 Consult with the other Partner as often as may be necessary in relation to the management, training, appraisal and monitoring of the Staff including co-operation from the non-employing partner in relation to any disciplinary or capability matters which may need to be managed by the employing partner, in line with their policies and procedures;

7.13.3 Supply to the other Partner such information and documents as may be reasonably required (and in accordance with the data protection act) to enable the Partner to fulfil its obligations under the Agreement;


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7.13.4 Manage the Staff in accordance with the provisions of the Agreement including providing such supervision and training as may reasonably be required in order to ensure the proper performance of the Services required by the Partnership Arrangements;

7.13.5 Use the Staff only for the delivery of the Services required by this Agreement;

7.13.6 Comply with its common law and statutory obligations in relation to the provision of a safe workplace for the Staff including, but not limited to, health and safety, occupier’s liabilities and any codes of practice introduced pursuant to such legislation;

7.13.7 Take no action with respect to Staff which would be contrary to the other Partner’s policies and procedures regarding anti-discrimination and equal opportunities, including those related to harassment.

7.14 In this paragraph, “duties” means those duties which the Staff are made available to the LHB or the Council to perform. During the Agreement the LHB and the Council shall take all reasonable steps to ensure the Staff shall:

7.14.1 devote the whole of their time attention and skill to their duties for the Partner to whom they are made available;

7.14.2 faithfully and diligently perform duties and exercise such powers as may from time to time be reasonably assigned to or vested in them by or under the authority of the Partner to whom the Staff are made available;

7.14.3 perform all duties assigned to them by the Partner to whom they are made available.

7.15 During the Agreement the LHB and the Council agree to the following arrangements regarding the supervision, appraisal and training of the Staff:

7.15.1 the Staff be supervised by and be directly accountable to the person who is shown as their line manager in the relevant structure chart at Schedule 3 for the Scheme approved by the JPB, regardless of whether that person is Staff of the Council or the LHB;

7.15.2 The LHB and the Council shall take all reasonable steps to ensure that Staff obey all reasonable and lawful directions given to them by or under authority of such manager and shall use their best endeavours to promote the interests of the employing Partner and the non-employing Partner. Such manager shall also direct working arrangements, rosters, agree annual leave,


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special leave etc. in a manner which is consistent with the terms and conditions of employment of the Staff;

7.15.3 The seconded employee should continue to be appraised by the employing partner on a regular basis, in accordance with their performance policies, in conjunction with the host partner. The employing partner will continue to undertake performance management, including salary reviews in conjunction with the host organisation..

7.15.4 the employer will provide the Host Partner with details of existing mandatory training obligations relating to and to be undertaken by individual Staff (including cost). The LHB and the Council will agree to a schedule of continued and future training to be provided by each of the LHB and the Council to Staff, including any transfer of costs and funding relating to such training;

7.15.5 the Host Partner will be responsible for all mandatory training relating to policies applicable to Staff, which shall include, without limitation health and safety and risk management;

7.15.6 the LHB and Council will identify future requirements for training relating to continued professional development (“CPD Training”) required by Staff. The Partners anticipate that the need for such training will be identified through the appraisal and supervision process which is to be conducted by the employing partner in conjunction with the Host partner in accordance with clause 7.15 hereof;

7.15.7 Where the Partners agree a schedule of continued and future CPD (including training undertaken and mandatory training required) and to be provided by each of the LHB and the Council, it shall include any transfer of costs and funding relating to such training.

7.16 Where it is necessary for the purposes of either Partner’s personnel procedures for a member of Staff employed or contracted by the other Partner to co-operate with the operation of any discipline or grievance procedures, the employing Partner shall use all reasonable endeavours to ensure that such co-operation is forthcoming. For avoidance of doubt such co-operation shall include any assistance which may reasonably be required by a Partner in the event of any proceeding being brought by any Staff relating to matters which are the subject matter of this Agreement.

7.17 Each Partner shall be responsible for all emoluments and outgoings in respect of the Staff employed by them (or who were so employed immediately prior to the Commencement Date) including without limitation all wages bonuses commissions holiday entitlements PAYE National Insurance contributions statutory or contractual redundancy payments and pension contributions including any early retirement


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benefits or entitlements incurred or payable prior to, during the continuation of, or following the termination of this Agreement and each Partner shall indemnify the other in respect of any claim, finding or award made in respect of the same.

7.18 The JPB may consider that it is necessary for new or replacement staff (“New Staff”) to be appointed in order to fulfil the aims and objectives of the Scheme. Where this is the case, the recruitment and appointment of New Staff will ordinarily be the responsibility of the employing organisation on the terms and conditions of the employing partner.

7.19 Where staff are funded from grant, duration of employment, liability upon termination and other terms are agreed at the commencement

of the recruitment process and may be subject to any conditions imposed as a result of the grant funding.

7.20 The Partners agree to work co-operatively towards the greater integration of service provision by means of considering the opportunities for Staff to transfer within and between the Partners PROVIDED ALWAYS that this clause shall not bind the Partners to enter into such arrangements nor shall it indicate that any such transfer has been deemed by the Partners to have taken place in accordance with the respective organisations policies and procedures.

7.21 The Partners do not believe or intend that the arrangements envisaged by or coming into effect as a result of this Agreement constitute a relevant transfer for the purposes of TUPE.

7.22 In the event that TUPE is determined to apply to either the Council Staff or the LHB Staff who are made available for the Services at any time before or after the termination or expiry of this Agreement or upon the early termination or variation of this Agreement, the LHB and the Council agree to comply with their obligations under TUPE and co-operate in a manner consistent with the principles of this Agreement and the Regulations to determine the required financial contributions and other arrangements which are thereafter required by and from each Partner in order to meet the obligations which arise under TUPE and otherwise.

7.23 The Host Partner shall indemnify and keep the other partner (and its contractors or agents) indemnified in respect of any and all:

7.23.1 Employment Liabilities incurred or payable in respect of Staff employed by the Host Partner from time to time (or Staff so employed immediately prior to the Commencement Date or nominally employed and allocated to the JPB during the continuation of the Agreement) which arise or are payable prior to, during or after the termination of this Agreement save where the Employment Liability arises as a direct result of any act or omission by the other Partner; and,


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7.23.2 liability arising from any claim made by any third party arising out of or in respect of any act or omission of any Staff after the Commencement Date, save to the extent that such liability was due to:

(a) any act or omission of the other partner(including without limitation any failure of the other partner to meet any obligations where it has to provide adequate training to Seconded Staff); or,

(b) any act or omission by any Seconded Staff which is contrary to any supervision, management, direction or instruction which has been or was provided to Seconded Staff by the Host Partner under the terms of this Agreement.

7.24 The LHB and the Council agree to review the indemnity arrangements set out in clauses 7.18 and 7.23 above from time to time in the light of in particular (but without limitation):

(a) any material changes to the staffing arrangements occurring as a

result of a material change to the provisions in respect of the contributions agreed under clause 4.

(b) either Partner considering that it is or is likely to become disproportionately responsible for employment liabilities in the provision of the Services.

7.25 Other than in the circumstances in which the terms of clause 7.22 apply, upon the termination of this Agreement for any reason, each Partner shall resume direct management control and responsibility for all Employment Liabilities arising or payable in respect of any and all Staff engaged in the provision of the Services who were so employed by them immediately prior to the termination of the Agreement or who were employed as a result of provision under Clause 7.19 insofar as the terms of Clause 11.4 shall apply unless such Employee Liabilities arise due to the action or inaction of a particular Partner in which case the Partner concerned shall have responsibility.

7.26 Any dispute arising under the terms of this Clause 7 or Schedule 4 shall, in the event that it cannot be resolved through consultation between the Partners shall be subject to the Dispute Resolution procedure set out in Clause 17.

8. REVIEW


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8.1 The Partners, through the JPB, shall review the performance of the Services for any Scheme under this Agreement after 1st July 2012 but no later than 1st October 2012 with a view to confirming the operation of the Pooled Funds and Lead Funds and their respective contributions to each Pooled Fund and Lead Fund for the Financial Year 2012/13.

8.2 The Partners, through the JPB, shall review the operation of this agreement annually thereafter by 1st July of every year.

8.3 Reviews of this agreement shall be conducted in good faith and in accordance with the governance arrangements set out in Schedule 6; shall be based upon information to be provided as set out in Schedule 6.

8.4 The Partners may review the operation of this Agreement on the coming into force (or anticipation of the coming into force) of any relevant statutory or other legislation or guidance affecting the terms of this Agreement so as to ensure that the terms of this Agreement comply with such legislation or guidance.

8.6 The formal review undertaken in accordance with Clause 8.3 and 8.4 of this Agreement shall include review of the Secondment Agreement for any Scheme.

9. FINANCIAL PLANNING AND BUDGET SETTING PROCESS 9.1 The partners will prepare planning assumptions of inflation allowances for pay

and non-pay expenditure and income together with proposed variations to the expenditure budget in respect of:

• Growth and demographic changes • Service enhancements and reductions • Required efficiency/quality improvements • Cost pressures/increases in demand; and • National initiatives

9.2 These will be considered in the context of the overall budget of Powys County

Council and Powys Local Health Board as applicable and shall be presented to the JPB no later than 31st January for the following financial year’s budget.

9.3 The budget as agreed by the JPB will take into account effects on other

budgets and other financial flows of the partners. 9.4 The Pooled Fund Manager shall ensure that any matters relating to the Pooled

Fund or Lead Funds for a Scheme that might have a material effect on expenditure or income are identified and reported to the JPB no later than 31st January for the following financial year’s budget.


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9.5 These matters together with the planning assumptions and proposed variations to the expenditure budget referred to above are to be considered by the JPB in its approval by 31st January of the budget for the following financial year.

9.6 As part of the annual budget setting process, the Partners shall ensure that

their managers provide advice as necessary.

10. TERMINATION

10.1 If the LHB or the Council fails to meet any of its respective obligations under this Agreement, the other Partner may by written notice require the Partner in default to take such reasonable action to rectify such failure within 60 days of the date of the notice. Should the Partner in default fail to rectify such failure within such time-scale, the other Partner may give a minimum of three months written notice to terminate this Agreement.

10.2 Either Partner shall be entitled to terminate this Agreement immediately by notice to the other, if the other Partner, its employees or agents either offers, gives or agrees to give to anyone any inducement or reward or confers any other benefit in respect of this or any other Agreement (even if the Partner is unaware of any such action) or otherwise commits an offence under the Prevention of Corruption Acts 1889 to 1916 or Section 117(2) of the Local Government Act 1972.

10.3 Any purported termination of this Agreement under this Clause shall be without prejudice to any continuing obligations of the Partners under Clauses 6 and 10 and the continued operation of the Partnership Board in accordance with Schedule 6.

10.4 Either Partner shall also be entitled to terminate this Agreement by written notice pursuant to clause 2.2.

10.5 Either party shall be entitled to terminate this agreement forthwith by

written notice to the other if an event of force majeure persists for more than 3 months pursuant to clause 26

11. EFFECTS OF TERMINATION

11.1 Notwithstanding any notice of termination in accordance with Clauses 2 or 9:-

11.1.1 the LHB and the Council shall continue to be liable to commission and provide the Service in accordance with this Agreement until the actual date of termination;

11.1.2 the Partners shall remain liable to operate the Pooled Fund and Lead Funds in accordance with this Agreement so far as is necessary to ensure fulfilment of the obligations in Sub-Clause 11.1.1; and


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11.1.3 the Partners shall remain liable to contribute that proportion of the cost of the Service which comprises its proportionate contribution in the Financial Year in which the termination takes effect;

such liabilities to continue for so long as the obligations to third parties under contracts remain to be fulfilled and to include any additional costs attributed to termination which shall be borne in the same proportion as the Partners respective financial contributions herein.

11.2 Subject to the foregoing commitments of the Partners, following termination of this Agreement, the Host Partner shall return to the other Partner within three (3) months any of the other Partner’s contribution to the Pooled Fund or Lead Funds which have not been spent on the provision of the Service or any part thereof.

11.3 Assets purchased from the Pooled Fund or Lead Funds will be disposed of by the Host partner for the purposes of meeting any of the costs of winding up the Service or where this is not practicable such goods will be shared proportionately between the LHB and the Council according to the level of past contributions to the Pooled Fund.

11.4 Where Staff have been appointed by the Host Partner in accordance with Clause 7.19 in order to fulfil the objectives of the Services in the event that this Agreement is terminated in whole or in part (howsoever terminated) there shall be a review undertaken by the Partners. The Partners will conduct that review jointly and shall agree to which Staff TUPE applies. Following consultation,with staff and the recognised trade unions, the Partners shall then be liable for the transfer of those Staff affected, by Host partner to the other partner as is agreed and this shall include transfer of any Employment Liabilities for those staff from the Host Partner to the other partner unless the Employment Liability arises as a result of the action or inaction of the Host Partner.

11.5 In the event that this Agreement is terminated in whole or in part (howsoever terminated) the Partners agree to co-operate to ensure an orderly wind down of their joint activities as set out in this Agreement so as to minimise disruption to all Clients, carers and Staff, and comply with individual rights as set out in their contract of employment

12 SCRUTINY

12.1 The Partners will make senior officers available to attend each other’s committees and boards with responsibility for the development of policy and the scrutiny of decisions taken in relation to the Services.

13. EXTERNAL INSPECTION AND MONITORING

13.1 The Partners:

• Will comply with any statutory inspection requirements in relation to Services and will liaise as required with the Care and Social


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Services Inspectorate Wales (CSSIW) and /or Healthcare Inspectorate Wales (HIW) and/or other relevant regulatory bodies.

• Will provide appropriate access and information to any external body empowered by statute to inspect or monitor the Partners’ discharge of the Services.

• Will work together to ensure that recommendations made to the Council pursuant to its Outcome Agreement are implemented.

• Will work together to ensure that recommendations made to the LHB in pursuant to the Welsh Government ‘Together for Health’ vision are implemented.

14. INDEMNITY AND INSURANCE

14.1 The Partners shall maintain public liability insurance in respect of the Services provided under this Agreement to a minimum level of ten million pounds (£10,000,000) per claim and aggregate cover of Ten million pounds (£10,000,000) of claims in any Financial Year and shall review the adequacy of such cover not less frequently than once in each Financial.

14.2 A Partner shall upon request from the other Partner from time to time:

14.2.1 provide evidence that the insurance arrangements required by clause 14.1 are fully paid up and in force;

14.2.2 allow the requesting Partner to inspect its insurance policies; and

14.2.3 provide the requesting Partner with copies of the full policy document.

14.3 Each Partner (the “Indemnifying Partner”) shall indemnify the other Partner, their officers, employees and agents against any damage, cost, liability, loss, claim or proceedings whatsoever arising in respect of:

14.3.1 any damage to property real or personal including (but not limited to) any infringement of third party patents copyrights and registered designs;

14.3.2 any personal injury including injury resulting in death;

14.3.3 any fraudulent or dishonest act of any of its officers, employees or contractors; or

arising out of or in connection with the Service in so far as such damage, cost, liability, loss, claim or proceedings shall be due directly or indirectly to any negligent act or omission or any breach of this Agreement by the Indemnifying Partner, its officers, or employees.


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14.4 Where the Indemnifying Partner has only contributed partially to the cause of any damage, cost, liability, loss, claim or proceedings, it shall only be liable to indemnify the other Partner for such proportion of the total costs of such damage, cost, liability, loss, claim or proceedings as its contribution to the cause bears to the total damage, cost, liability, claim or proceedings. Where the Partners are unable to agree any such apportionment, the disputes procedure in Clause 17 shall apply.

14.5 Neither the indemnity from the Council nor that from the LHB at Clause 14.3 shall apply to any such claim or proceeding:-14.5.1 unless as soon as reasonably practicable following receipt of notice of such claim or proceeding, the Partner in receipt of it shall have notified the other Partner in writing of it and shall, upon the latter’s request and at the latter’s cost, have permitted the latter to have full care and control of the claim or proceeding, using legal representation approved by the former Partner, such approval not to be unreasonably withheld; or

14.5.2 if the Partner in receipt of the claim or proceeding, its employees or agents shall have made any admission in respect of such claim or proceeding or taken any action related to such claim or proceeding prejudicial to the defence of it without the written consent of the other Partner (such consent not to be unreasonably withheld or delayed), provided that this condition shall not be treated as breached by any statement properly made by the former Partner, its employees or agents in connection with the operation of its internal complaints procedures, accident reporting procedures or disciplinary procedures or where such statement is required by law.

14.6 Each Partner shall keep the other Partner and its legal advisers fully informed of the progress of any such claim or proceeding, will consult fully with the other Partner on the nature of any defence to be advanced and will not settle any such claim or proceeding without the written approval of the other Partner (such approval not to be unreasonably withheld).

14.7 Without prejudice to the provisions of Clause 14.5.1, both Partners will use their reasonable endeavours to inform each other promptly of any circumstances reasonably thought likely to give rise to any such claim or proceedings of which they are directly aware and shall keep each other reasonably informed of developments in relation to any such claim or proceeding even where they decide not to make a claim under this indemnity.

14.8 The Partners will each give to the other such help as may reasonably be required for the efficient conduct and prompt handling of any claim or proceeding.

14.9 The Partners shall ensure that they maintain policies of insurance (or in the case of the LHB’s, equivalent arrangements through the schemes operated by the Welsh Risk Pool) to cover the matters referred to in


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Clauses 14.3 and 14.4 and Clause 12.2, including but not limited to employers liability, public liability and other liabilities to third parties.

15. VARIATION / CHANGE OF LAW

15.1 No variation to this Agreement shall be effective unless it is in writing and signed by both the Partners or has been unanimously approved by the Joint Partnership Board.

16. CONFIDENTIALITY

16.1 The Partners shall:-

16.1.1 keep confidential any information obtained in connection with this Agreement subject to the Data Protection Act 1998; and

16.1.2 take appropriate technical and organisational measures against unauthorised or unlawful processing of such personal data and against accidental loss or destruction of or damage to such personal data

16.2 The Parties shall keep and procure to be kept secret and confidential all

Business Information pursuant to the service and shall not use nor disclose the same save for the purposes of the proper performance of this Agreement or with the prior written consent of the other party. Where disclosure is made to any employee, consultant or agent, it shall be done subject to obligations equivalent to those set out in this Agreement and the parties agree to use all reasonable endeavours to procure that any such employee, consultant or agent complies with such obligations provided that the parties shall continue to be responsible to each other in respect of any disclosure or use of such Business Information by a person to whom disclosure is made. The parties confirm that should they receive any request by any third party to access the Business Information it shall declare that such information is "exempt information" under Section 41 of the Freedom of Information Act 2000.

16.3 The Council acknowledges and agrees that information relating to the

provision of services as defined in this contract may also be shared with the Welsh Government, Welsh NHS bodies’ the Audit Commission and the National Audit Office where this is necessary for them to meet their obligations as defined by statute, regulation or contractual commitment.

16.4 The obligations of confidentiality in this clause 16 shall not extend to any

matter which either party can show:

16.4.1 is in, or has become part of, the public domain other than as a result of a breach of the obligations of confidentiality under this Agreement; or

16.4.2 was in its written records prior to the start of this Agreement; or


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16.4.3. was independently disclosed to it by a third party entitled to

disclose the same; or

16.4.4 is required to be disclosed under any applicable law, or by order of a court or governmental body or authority of competent jurisdiction.

16.5 The provisions of this clause 12 shall survive the termination or expiry of

this Agreement.

17. DISPUTE AND RESOLUTION

17.1 In the event of a dispute over the application or interpretation of this Agreement, the dispute may be referred by the Partners in writing as follows:-

17.1.1 in the first instance to the Authorised Officers to resolve within 30 days; and

17.1.2 in the second instance to arbitration by an arbitrator to be appointed by the President for the time being of the Chartered Institute of Arbitrators.

17.2 Any such reference to arbitration shall be deemed to be a reference to arbitration within the provisions of the Arbitration Act 1996 or any statutory modification or re-enactment thereof for the time being in force and the allocation of the costs of any arbitration shall be borne by the Parties hereto as determined by the arbitrator.

18. EXCLUSION OF PARTNERSHIP AND AGENCY

18.1 The Partners expressly agree that nothing in this Agreement in any way creates a legal partnership between them.

18.2 Neither Partner nor any of its employees or agents will in any circumstances hold itself out to be the servant or agent of the other Partner, except where expressly permitted by this Agreement.

19. ASSIGNMENT AND SUB AGREEMENTS

19.1 The Partners shall not assign or transfer the whole or any part of this Agreement, without the prior written consent of the other Partner, except where expressly permitted by the Agreement.

19.2 Either party shall be entitled to assign novate or otherwise transfer its rights and obligations pursuant to this Agreement to a statutory successor. This Agreement shall be binding on and shall ensure to the benefit of the LHB and the Council and their respective successors and permitted transferees and assignees.


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20. THE CONTRACTS (RIGHTS OF THIRD PARTIES) ACT 1999

20.1 The Contracts (Rights of Third Parties) Act 1999 has no application whatsoever to this Agreement.

20.2 No variation to this Agreement and no supplemental or ancillary agreement to this Agreement shall create any such rights unless expressly so stated in any such agreement by the parties to this Agreement. This does not affect any right or remedy of a third party, which exists or is available apart from that Act.

21. PREVENTION OF CORRUPTION / QUALITY CONTROL

21.1 The Partners shall have mutual policies and procedures to ensure that relevant controls assurance, probity and professional standards are met

22. COMPLAINTS

22.1 Complaints regarding the Service shall in the first instance be directed to the provider and if not resolved will be managed according to the The National Health Service (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011 or the Council’s Complaints Procedure as appropriate.

22.2 The Council shall ensure that all Services commissioned and arrangements for complaints are in accordance with its policy and that of the Council for Equal Opportunities and all or any policies and procedures approved by the LHB as available through its web site under the Freedom of Information Act 2000.

23. NOTICES

23.1 All notices under this Agreement shall only be validly given if given in writing, addressed as follows:-

23.1.1 if to the LHB, addressed to its Chief Executive as above; or

23.1.2 if to the Council, addressed to its Chief Executive as above. 23.2 Any notices required to be given under this Agreement must be in writing

and may be served by personal delivery, post (special or recorded delivery or first class post) or facsimile at the address set out at the beginning of this Agreement or at such other address as each party may give to the other for the purpose of service of notices under this Agreement. Notices shall be deemed to be served at the time when the notice is handed to or left at the address of the party to be served (in the case of personal delivery) or the day (not being a Saturday, Sunday or public holiday) next following the day of posting (in the case of notices served by post) or at 10 a.m. on the next day (not being a Saturday, Sunday or public holiday) following dispatch if sent by facsimile transmission.


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23.3 To prove service of any notice, it shall be sufficient to show in the case

of a notice delivered by hand that the same was duly addressed and delivered by hand and in the case of a notice served by post that the same was duly addressed prepaid and posted special or recorded delivery or by first class post. In the case of a notice given by facsimile transmission, it shall be sufficient to show that it was dispatched in a legible and complete form to the correct telephone number without any error message on the confirmation copy of the transmission.

24. NOTIFICATION TO THE WELSH GOVERNMENT (WG)

24.1 In accordance with the relevant guidance the Partners agree that they shall notify the WG of the exercise of the flexibilities in Section 33 of the Act and the Regulations in relation to the arrangements referred to therein.

23.2 The notification referred to at Clause 23.1 shall be in summary form of

any Scheme Schedules in the manner required by the WG subject to such amendments as may be agreed in writing between the Partners.

25 GENERAL PRINCIPLES

25.1 In relation to the Service, the Partners shall:

25.1.1 treat each other with respect and an equality of esteem; 25.1.2 be open with information about the performance and

financial status of each; 25.1.3 provide early information and notice about relevant

problems; and 25.1.4 co-operate with each other to agree joint protocols and any

variance in such protocols as may be required from time to time.

26. FORCE MAJEURE

26.1 In this Agreement "force majeure" shall mean any cause preventing either party from performing any or all of its obligations which arises from or is attributable to acts events omissions or accidents beyond the reasonable control of the party so prevented including without limitation act of God war riot civil commotion malicious damage compliance with any law or governmental order rule regulation or direction accident breakdown of plant or machinery fire flood storm or default of suppliers or sub-contractors.

26.2 If either party is prevented or delayed in the performance of any of its

obligations under this Agreement by force majeure, that party shall forthwith serve notice in writing on the other party specifying the nature and extent of the circumstances giving rise to force majeure and shall,


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subject to service of such notice (and to Clause 26.4), have no liability in respect of the performance of such of its obligations as are prevented by the force majeure events during the continuation of such events.

26.3 The party affected by force majeure shall use all reasonable endeavors

to bring the force majeure event to a close or to find a solution by which the Agreement may be performed, despite the continuance of the force majeure event.

26.4 If either party is prevented from performance of its obligations for a

continuous period in excess of three months the other party may terminate this Agreement forthwith by written notice, in which case neither party shall have any liability to the other except that rights and liabilities which accrued prior to such termination shall continue to subsist.

27. SEVERABILITY

27.1 If at any time any part of this Agreement (including any one or more of the clauses of this Agreement or any sub-clause or paragraph or any part of one or more of these clauses) is held to be or becomes void or otherwise unenforceable for any reason under any applicable law, the same shall be deemed omitted from this Agreement and the validity and/or enforceability of the remaining provisions of this Agreement shall not in any way be affected or impaired as a result of that omission.

28. WAIVER

28.1 The rights and remedies of either party in respect of this Agreement shall not be diminished, waived or extinguished by the granting of any indulgence, forbearance or extension of time granted by such party to the other nor by failure of, or delay by the said party in ascertaining or exercising of any such rights or remedies. The waiver by either party of any breach of this Agreement shall not prevent the subsequent enforcement of any subsequent breach of that provision and shall not be deemed to be a waiver of any subsequent breach of that or any other provision.

29 AMENDMENTS

29.1 Any variation to this Agreement shall be in writing and signed by the

parties.

30. GOVERNING LAW

30.1 This Agreement shall be considered as a contract made in England and Wales and shall be subject to the laws of England and Wales.


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30.2 Subject to the provisions of the Dispute Resolution Procedure, both parties agree that the courts of England and Wales shall have exclusive jurisdiction to hear and settle any action, suit, proceeding or dispute in connection with this Agreement and irrevocably submit to the jurisdiction of those courts.

IN WITNESS whereof the Partners have executed this Agreement as a Deed the day and year first before written. THE COMMON SEAL of THE LHB ) was affixed to this Deed in the presence of:- ) Authorised Signatory Authorised Signatory THE COMMON SEAL of THE COUNCIL ) was affixed to this Deed in the presence of:- ) Head of Legal, Scrutiny & Democratic Services SCHEDULE 1: NAME OF SCHEME; HOST PARTNER & AIMS AND OBJECTIVES

PARTNERSHIP SCHEME

(Please complete the following sections that are marked as red)


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NAME OF PARTNERSHIP SCHEME: …………………………………………………………………………………………………

LEAD (HOST) PARTNER FOR THE SCHEME: …………………………………………………………………………………………………. TITLE OF THE SCHEME PARTNERSHIP LEAD RESPONSIBLE (this person will be the lead accountable manager within the host organisation and will chair the scheme’s Operational Group responsible to the JPB: NAME OF THE POOLED FUNDS FUND MANAGER (this person will be an officer within the host partner with accountability for the role set out in the partnership agreement to the chair of the Operational Group (The Partnership Lead)): 1. Introduction: Description and Purpose of Agreement 1.1 The overarching strategic aim of this Agreement is:-

1.2 This will enable both parties of this Agreement to:

2. Principles and Approach to Delivery 2.1 The Principles and Approach to Delivery shall address the need for:- 3. Key Aims & Objectives (You should be very clear here on what the

targets for the year ahead including any development activity affecting the longer term)

3.1 The performance targets summarised below are the key aims and objectives of

this Agreement: Service Improvement Objectives

In addition to the Objectives above, the following service improvement requirements will be met. These will be reviewed and updated as part of the annual review process


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5. Standards for Services 5.1 Standards for Services are as follows:- 6. Review

A strategic and financial annual review of these objectives will be coordinated by the ‘Pooled Funds Manager’ in accordance with Clause 9 of this Agreement and incorporated in an Annual Report to the JPB for agreement. This will include a revision of Schedules for annual agreement e.g. on targets, finance and reporting or changes/additions to service,

7. Limitation

The Partners confirm that nothing herein shall require or authorise the Council to provide or perform or procure or manage the performance of any medical procedures whatsoever such that a prudent Council being a partner being a partner would obtain appropriate insurance cover in respect thereof.

………………………………………………………………………………………………… ………………………………………………………………………………………………… SCHEDULE 2: THE LHB’S NHS HEALTH CARE FUNCTIONS AND THE COUNCIL’S HEALTH RELATED CARE FUNCTIONS

THE LHB’S NHS HEALTH CARE FUNCTIONS

The LHB’s NHS Health Care Functions of providing, or making arrangements for the provision of, Services:-


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(a) (i) under sections 2 and 3(1) of the National Health Service Act 1977,

including rehabilitation services and services intended to avoid admission to hospital but excluding surgery, radiotherapy, termination of pregnancies, endoscopy, the use of Class 4 laser treatments and other invasive treatments and emergency ambulance services; and

(ii) under section 5(1), (1A), and (1B) of, and Schedule 1 to, the National

Health Service Act 1977; and (b) the Functions under sections 25A to 25H and 117 of the Mental Health Act

1983.

THE COUNCIL’S HEALTH RELATED CARE FUNCTIONS

The Council’s Health Related Functions are:- (a) the Functions specified in Schedule 1 to the Local Authorities Social

Services Act 1970 except for the Functions under:-

(i) sections 22, 23(3), 26(2) to (4), 43, 45 and 49 of the National Assistance Act 1948; (ii) sections 6 and 7B of the Local Authorities Social Services Act 1970; (iii) sections 1 and 2 of the Adoption Act 1976; (iv) sections 114 and 115 of the Mental Health Act 1983;

(v) The Registered Homes Act 1984; and (vi) Parts VII to X and section 86 of the Children Act 1989; and

(b) the Functions under sections 5, 7, or 8 of the Disabled Persons

(Services and Consultation and Representation) Act 1986 except in so far as they assign Functions to a Local Authority in its capacity of a Local Education Authority.

EXAMPLE SCHEDULE 3

THE SERVICE: SERVICE USERS, MANNER, LOCATION AND ACCESS

1. The Services will be provided for residents of ................ who are:-


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2. The Services to be provided comprise of:

2.6 The Services will be provided from a number of community bases as listed at paragraphs 7.1 and 7.2 of Schedule 5 and on an outreach basis

3. Access to Services

3.1 Access to Services (see Appendix 1)

Appendix 1


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SCHEDULE 4

Overarching Agreement - PERSONNEL, MANAGEMENT AND STRUCTURE

1. Staff Numbers

1.1 Staff numbers to be made available will be shown on a local schedule, broken down in the following format:-

1.2 Table 1 & Table 2 show the total numbers of staff to be made available by

Powys County Council and tLHB to be managed at the direction of the JPB, as at (IMPLEMENTATION DATE).

Powys County Council

Establishment (incl vacancies)

Vacancies Headcount (excl vacancies

(Update – Relevant Section)

Powys LHB Establishment

(incl vacancies) Vacancies Headcount (excl

vacancies (Update – Relevant Section)

1.3 Table 3 and 4 show staff in post by job group, for Powys County Council

and tLHB to be managed at the direction of the JPB as at (IMPLEMENTATION DATE).

Powys County Council/ PtHB (State relevant Service Area)


Contract Hours

Contract Status

Vacancies Headcount (excl vacancies as at 12-9-11)

Management

(Job Title)

Management Total Section 1 (Update)

(Job Title)

Section 1 Total Section 2 (Update)

(Job Title)

Section 2 Total


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Overall Total

PtHB (State relevant Service Area)


Contract Hours

Contract Status


Management

(Job Title)

Management Total Section 1 (Update)

(Job Title)

Section 1 Total Section 2 (Update)

(Job Title)

Section 2 Total Overall Total

1.4 Table 5 shows the total establishment to be managed by the Host Partner

. Service Area (Update)

JPBe Establishment (incl vacancies)

Vacancies Total

PCC (PtHB) Total

2. Staff Details 2.1 All Powys County Council staff are on the Trent HR/ Payroll system.

This system lists all the staff the Host Partner will manage and direct. This system is held and updated by the HR Department of, Powys County Council, as authorised by the JPB.

2.2 A HR database (ESR – Electronic Staff Record) exists which lists all

the Powys teaching Health Board staff. This system lists all staff the JPB will manage and direct. This system is held and updated by the HR Department at Powys teaching Health Board, as authorised by the JPB.


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3. Management Structure of the Host Partner as agreed by the JPB 3.1 The Management Structures for the Service is below.

INSERT MANAGEMENT STRUCTURE 3.2 Where a member of staff employed by one Partner (the Manager) is

the manager of a member of staff employed by the other Partner (the Managed Person), the Manager is authorised by virtue of this Agreement to give reasonable management instructions to the Managed Person.

4. Secondment Agreement 4.1 Secondment agreements will be drawn up where temporary

arrangements exist. The section on TUPE will be more appropriate where permanent arrangements are being formulated.

4.2 The Council and the PtHB will have signed a Secondment Agreement as attached COPIES OF EACH PARTNERS SECONDMENT AGREEMENT IS

ATTACHED FOR USE. THESE MAY NEED REVISION TO REFLECT SPECIFIC LOCAL

CIRCUMSTANCES). ATTACH FINAL SCHEME VERSION SUBJECT TO WHICH

PARTNER IS SECONDING STAFF 4.3 Seconded staff will continue to be employed on their contractual terms

and conditions of employment. All parties (i.e. the employee, the host organisation and the seconding organisation) will enter into a written secondment agreement. 4.4 The secondment agreement will ensure that there are no terms that will have the effect of creating an employment relationship between the employee of one organisation and the host organisation. 4.5 Seconded staff will continue to be employed on their usual contractual terms and conditions of employment throughout the duration of the

secondment period.The full suite of policies are listed on the relevant organisation’s intranet sites, and main ones are listed below. Sickness Absence Policy Sickness absence should be reported in accordance with the seconding organisation’s sickness policy.


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Disciplinary and Grievance

Disciplinary and grievance processes will be carried out by the seconding organisation, in accordance with their policies, and not those of the host organisation. The host organisation will give assistance when necessary for example, by way of enabling the seconding employer to investigate.

4.6 The seconding organisation will ensure all seconded staff are kept

informed and up-to-date with policies and procedures applicable to them.

4.7 It is anticipated that the secondment arrangement will be in place for a

period of up to four+ years, with annual reviews carried out by the JPB as a part of the annual review of the specific Scheme .

5. Payment & Expenses 5.1 Seconded staff will continue to receive payment via their employer in

line with contractual arrangements. The employer will continue to pay the secondee’s wages and all connected costs (in particular income tax and national insurance contributions).

5.2 If a secondee is absent for any substantial period, for instance; maternity and/or long term sickness absence, the seconding

organisation will determine if this will be backfilled. 5.3 Any expenses incurred by employees must be claimed through the

employing organisation and paid in the normal way. Expenses will be claimed and paid in accordance with the employing organisations policies.

6. Disturbance Allowance, Movement to New Locations: Removal and Travel Expenses Policy 6.1 Any relocation or variation to base will incur additional costs based in accordance with the respective employing organisations’ disturbance allowance, Movement to New Locations: Removal and Travel Expenses policies. 6.2 Any future proposal to re-locate staff during the secondment period will

be undertaken in accordance with the respective employing organisations, Management of Change and/or Organisational Change policies.

7. Professional Development


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7.1 The seconded employee should continue to be appraised by the seconding organisation on a regular basis, in accordance with

their performance policies. The seconding organisation will continue to undertake performance management, including salary reviews with the support of the host organisation, where required.

8. Recruitment / Retention / Redeployment 8.1 Existing vacancies that arise during the defined term of any local

partnership agreement will be recruited to following the respective recruitment policies and procedures of the employing partner. If this triggers the respective partners’ redeployment process, then this policy and procedure will need to be complied with in the first instance.

8.2 Changes in the roles and skill mix of the Staff and/or increases or

decreases in staff numbers; shall be agreed by the Partners’ acting through the JPB and in consultation with the Partners’ appropriate professional leads. The respective organisations will follow their management of change policy and procedures in these circumstances.

8.3 Any new positions created under any partnership agreement will need

agreement in terms of who will be the employing organisation. 8.4 Each employing organisation will be responsible for its own workforce planning procedures in line with the Management / Organisational change, redundancy and other associated policies. 9. CRB (Criminal Bureau Disclosure) Checks 9.1 Adherence to the Powys teaching Health Board and Powys County Council CRB policies and procedures are essential. 9.2 The employing organisation will ensure compliance with their

respective CRB process during the appointment process. 9.3 Independent Safeguarding Authority Checks may be applicable for some positions, respective organisations’ policies and procedures will apply. 10. Training and Development 10.1 All staff included within the partnership will be provided with the necessary training and development commensurate with their role. Training programmes may be jointly developed and linked to

professional training requirements. Overall responsibility for training will rest with the employing organisation.

10.2 Staff performance systems within partnerships need to relate to the intended outcomes of the partnership not just to individual organisational needs.


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10.3 Internal training and development opportunities can be accessed by either partner, dependent on the competency requirements. 10.4 A training budget is to be agreed by both partners. 11. TUPE (Transfer of Undertakings Legislation) 11.1 Where there is an intention to permanently transfer a service from one

partner organisation to another, consideration of transferring the employment of the employees employed by the relevant service to the partner organisation should also be considered.

11.2 Any transfer of employment will need to be consulted upon and

managed under the Transfer of Undertakings (Protection of Employment) Regulations 2006.

11.3 Where partners have TUPE Policies and/or Procedures in place, those

Policies and/or Procedures should be followed in respect of any potential transfer.

12. Consultation and recognised Trade Unions 12.1 Consideration and agreement needs to be given to consultation processes in line with recognised trade unions and partnership agreements and arrangements. 12.2 The respective partners will be required to follow their own policies and procedures with regards to Management of Change and/or Organisational Change processes. 12.3 Powys County Council, the host partner, have an informal JCC and

formal JCNC and recognise the following Trade Unions:

- UNISON - GMB - UNITE

12.4 The Powys teaching Health Board have a partnership forum and

recognise the following trade unions:

• UNISON • The Royal College of Nursing (RCN) • The Royal College of Midwives (RCM) • Unite • GMB • The Union of Shop, Allied and Distributive Workers (USDAW)


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• The Chartered Society of Physiotherapy (CSP) • The Community and District Nursing Association (CDNA) • The Society of Radiographers (SoR) • The Federation of Clinical Scientists (FCS) • The British Association of Occupational Therapists (BAOT) • The Union of Construction Allied Trades and Technicians (UCATT) • The British Orthoptic Society (BOS) • The Society of Chiropodists and Podiatrists (SoCP) • The British Dietetic Association (BDA). 12.5 Joint communication and consultation will be agreed and undertaken by the partner organisations, for staff and recognised Trade Unions. This will be in accordance with the management of change and/or organisational change protocol, policies and procedures. 13. Confidentiality 13.1 In addition to the provisions regarding confidentiality in the Employee’s

Contract of Employment, the Employee will not disclose during or after the secondment any confidential information to which the Employee became privy during the course of the secondment, including but not limited to all trade secrets, lists or details of customers, suppliers, patients and service users, information relating to the working of any process or invention carried on or used by any subsidiary or associate, research projects, tenders, and any proprietary Powys County Council or PtHB information.

14. Data Protection / FIO 14.1 Both the seconder and the host will hold personal data (and possibly also sensitive personal data) relating to the secondee and so will be subject to obligations under the Data Protection Act 1988 (DPA). 14.2 Sharing of personal information will be in accordance with WASPI

(Welsh Accord Sharing Personal Information) guidelines to ensure compliance with the Data Protection Act 1998.

14.3 Information sharing protocol and procedures will need to be developed as part of the JPB. 14.4 A fair processing notice will need to be developed to ensure employees are aware of the purpose for processing their data in accordance with Principle 1 of the Data Protection Act 1998 (DPA) and employee consent will need to be obtained. 15. Health and Safety


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15.1 Staff working from partner organisations premises will be made aware (or trained where applicable) with regards to observing health and safety policies and procedures of their host organisation to ensure a safe method of working.

15.2 The Employee is required under Section 7 of the Health and Safety at Work Act 1974, to take reasonable care for his/her own Health and Safety and that of others who may be affected by his/her acts or omissions at work. 16. Job Evaluation 16.1 Each employing partner will be responsible for reviewing grades under

their own job evaluation schemes. These will be managed and reviewed by the employing partner with no responsibility being shared by a host partner.

17. Termination 17.1 In the event of termination of local agreements howsoever arising, the

relevant Secondment Agreements will automatically terminate, in compliance with individual rights as set out in staff contracts of employment.


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TERMS AND CONDITIONS OF THE SECONDMENT OF <NAME> FROM POWYS TEACHING LOCAL HEALTH BOARD TO

< NAME OF HOST TRUST/ORGANISATION> Parties: Powys teaching Local Health Board “the Employer “ <NAME> “the Secondee” <NAME OF TRUST/ORG> “the Host” The Host wishes to second the Secondee in order that the Secondee can fulfil certain duties for the Host to undertake the following role:- < Post> Reporting Arrangements You will report to <Name of Manger in Host Organsiation> Terms and Conditions of Employment The Secondee will remain the employee of the Employer and retain his/her current terms and conditions of employment, as specified in his/her contract of employment . Duration The secondment shall commence on <DATE> and continue until <DATE> or unless terminated earlier by either the Employer or the Host giving with one month’s notice. Following the period of secondment and whereby the Secondee’s substantive post has disappeared due to structural or managerial change in the Employer’s organisation, its Organisational Change Policy will be invoked. It will be the responsibility of the Employer to seek to secure alternative employment for the Secondee. Remuneration


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The Employer will continue to pay the Secondee’s salary and the associated employer’s NI contribution and pension costs for the duration of the secondment. The Employer will invoice the Host for these costs on a quarterly basis. The Secondee’s salary for the period of the secondment has been agreed at £XXXX per annum OR <will remain under the current contract> ( Expenses The Employer will meet the business related travel and subsistence costs during the secondment period and these will be paid together with the contractual salary. Travel and expenses incurred as a result of work associated with the Host’s business must be approved by the Host in accordance with the Secondees terms and conditions of service, before submitting to the Employer’s Payroll Department on a monthly basis for payment. The Employer shall thereafter seek reimbursement for such expenses from the Host Hours of Work The secondment will be <full time, 37½ hours per week>. Holiday/Leave The leave entitlement will not be affected. Approval of leave requests will be the responsiblity of Host . Docummentation of all approved leave whilst on secondment should be forwarded to the Employer’s Payroll Department. Incapacity for work (SICK LEAVE) Arrangements for notifying sick leave will be in accordance with the Employer’s standard procedures as varied by the Secondment Agreement or this Agreement from time to time..The Employer will be notified of any sickness absence. All documentation and Medical certificates must be forwarded to the Employers Payroll Department. Pension The Secondee will remain in the Employer’s Pension Scheme. Place of Work The secondee will be based at <DETAILS OF PLACE OF WORK> Induction and Performance Management The Host will be responsible for arranging an induction programme and for agreeing the performance management monitoring system to be used during the secondment period and for completing timely reviews.


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Disciplinary Rules and Grievance Procedures As specified in the Secondee’s contract with the Employer, but any local matters should be raised in the first instance with the Host. This secondment agreement should be read in conjunction with the current (ALL WALES ) secondment policy.


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Health and Safety The Employer will be responsible for health and safety issues whilst the Secondee is on secondment. Risk Management The Secondee will be required to comply with the Employers Health & Safety Policy and actively participate in this process. Property The Employer accepts no responsibility for damage to or loss of personal property, with the exception of small valuables handed to their officials for safe custody. It is recommended that the Secondee take out an insurance policy to cover personal property. Confidentiality In line with the Data Protection Act 1998, the Secondee will be expected to maintain confidentiality in relation to personal and patient information including but not limited to all trade secrets, lists or details of customers, suppliers, patients and service users, information relating to the working of any process or invention carried on or used by any subsidiary or associate, research projects, tenders, and any proprietary Employer or Host information. The Secondee may access information only on a need to know basis in the direct discharge of duties and divulge information only in the proper course of duties.


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Signature on behalf of (the Seconding Organisation) _______________________________ Date _________________ Print name ___________________________ (please use capitals) Position held ___________________________ Signature on behalf of (the Host Organisation) _______________________________ Date _________________ Print name ___________________________ (please use capitals) Position held ___________________________ Signature of Secondee: _______________________________ Date _________________ THIS SECONDMENT AGREEMENT is made on: (Date) BETWEEN: (1) POWYS COUNTY COUNCIL of County Hall, Llandrindod Wells, Powys

LD1 5LG (‘The Host’); and

(2) POWYS LOCAL HEALTH BOARD of Powys Local Health Board Head Quarters, Mansion House, Bronllys, Brecon LD3 0LS (the Employer); and

(3) (Update Name) (‘the Secondee’).

IT IS AGREED as follows: 1 Definitions and interpretation

15.1 In this Agreement the following words and phrases shall have the following meanings:


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1.1.1 ‘Employment Contract’ means the statement of written particulars

of employment (as amended from time to time) a copy of which is in Schedule 1 of this Agreement

1..2 ‘Partnership’ means a partnership between The Host and Employer

in pursuance of an agreement made under the overarching Section 33 Agreement in respect of which the parties hereto agreed to work in Partnership and share resources with a view to securing the most effective, efficient and economic discharge of their respective functions;

1.1.3 ‘Job Description’ means the Secondee’s job description during the Secondment Period as set out in the Schedule 2 to this Agreement;

1.1.4 ‘Loss’ includes any loss and liability directly suffered by one or both of the parties hereto together with any damage, expense, liability or costs reasonably incurred in contesting any claim to liability and in quantifying such loss and liability;

1.1.5 ‘Secondment’ is described in clause 2;

1.1.6 ‘Secondment Period’ means an initial period of 12 months commencing on (Date) , reviewed annually and renewable by agreement between the parties;

15.1 The headings in this Agreement shall not affect its construction or interpretation;

15.1 Any reference to a clause is to a clause in this Agreement;

2 Secondment

2.1 The Host shall, in pursuance of Partnership, second the secondee to the Post of (update) for the Secondment Period in accordance with the terms of this Agreement and the Job Description.

2.2 The secondee will remain the employee of and retain his/her current

terms and conditions of employment as specified in his/her contract of employment with the Employer.

2.3 The Secondment is not intended to, and nothing in this Agreement

shall have the effect of constituting, any relationship of employer and employee between (the Host) and the Secondee.


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3 Secondee’s Duties

3.1 During the Secondment Period the secondee shall devote his/her time attention and skill to his duties for the Host and (update) under this Agreement and shall faithfully and diligently perform duties and exercise such powers as may from time to time be reasonably assigned to or vested in him/her. He/She shall follow all reasonable and lawful directions given to him by the Host and/or and shall use his best endeavours to promote the interests of the Host and the Employer.

4 Remuneration During the Secondment Period:

The Employer will continue to pay the Secondee’s salary and the associated employer’s NI contribution and pension costs for the duration of the secondment. The Employer will invoice the Host for these costs on a quarterly basis.

4.1 The Employer agrees to pay the Host an amount representing (update with percentage) the Secondee’s remuneration under the employment contract together with associated on-costs such as Employer’s National Insurance and superannuation (less any portion of the Secondee’s remuneration recovered from elsewhere) such payment to be exclusive of VAT (if any).

5 Expenses

5.1 Expenses incurred by the Secondee in connection with his/her duties performed for (the Host) shall be claimed from and paid by The Employer in accordance with its prevailing rates and procedures and The Host shall thereafter seek proportional reimbursement for such expenses from The Employer

6 Place of Work

The Secondee will be based at (update) but will be capable of mobile working (delete if not appropriate) and required to work within the boundaries of Powys, or such other place as may reasonably be required under the direction of the host organisation.


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7 Annual Leave

The Secondee’s annual leave entitlement during the Secondment Period will not be affected and will be in accordance with Secondees Employment Contract.

8 Incapacity for Work

Arrangements for reporting sick leave will be in accordance with The Hosts procedures and The host will notify the Employer of any sickness absence.

9 Termination

15.1 The Host or Employer may give at least 4 weeks’ notice in writing of termination of this Agreement and upon termination the Secondee will resume his/her substantive duties as (Update) without any detrimental effect to the Employment Contract.

15.1 Notwithstanding clause 2.1, this Agreement shall automatically terminate if the Employment Contract is terminated , or if the Secondee resigns , before the expiry of the Secondment Period. In such event, The Host will be under no obligation to provide an alternative person to fill the Post.

15.1 The Host may terminate this Agreement without notice if, in its reasonable opinion, the Employee has committed any act of gross misconduct or repeats or continues any other serious misconduct. The responsibility for taking formal action against the Employee in these circumstances shall remain with The Employer but the Hostwill provide assistance and cooperation in any disciplinary proceedings.

15.1 Upon the termination of this Agreement the Secondee shall deliver to the Host all documents (including correspondence, notes, memoranda, plans, drawings, other documents or goods or products of whatsoever nature) made or compiled by, or delivered to, the Secondee during the Secondment Period and concerning the affairs and finances of The Host.

10 Indemnity

10.1 Save as provided in clauses 4.1 and 10.2, The Employer agrees to indemnify The Host against one half all Loss arising out of or in any way connected to, the Secondment and all documents signed, or actions taken by, the Secondee during the Secondment Period.


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11 Confidential information

15.1 The Secondee accepts that, during the Secondment Period, he will be in contact with confidential information belonging to The Host and accordingly agrees to treat as secret and confidential and not, during the Secondment Period, nor at any time after it, for any reason disclose or permit to be disclosed to any person or otherwise make use or permit to be made use of any confidential information belonging to the host including but not limited to all trade secrets, lists or details of customers, suppliers, patients and service users, information relating to the working of any process or invention carried on or used by any subsidiary or associate, research projects, tenders, and any proprietary Employer or Host information.

11.2 The Secondee further agrees that, upon termination of this Agreement for whatever reason, he shall, without retaining any copies, deliver up to The host all working papers or other material and copies provided to him under this Agreement or prepared by him during the Secondment Period.

12 Disciplinary Rules & Grievance Procedures

As specified in the Secondees contract with the Employer.

13. Health & Safety

The Employer will be responsible for health and safety issues whilst the Secondee is a Secondment.

14 Contracts (Rights of Third Parties)

A person who is not a party to this Agreement has no right under the Contracts (Rights of Third Parties) Act 1999 to enforce any term of this Agreement but this does not affect any right or remedy of a third party which exists or is available apart from that Act.

15 General

15.1 This Agreement constitutes the entire Agreement between the parties

in relation to the Secondment, and supersedes all prior agreements,

understandings and arrangements between them, and

representations by them, whether oral or written, which relate to the

subject matter of this Agreement.


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15.2 This Agreement shall be construed in accordance with the laws of England and Wales, and the courts of England and Wales shall have non-exclusive jurisdiction in relation to any claim dispute or difference arising from the terms of this Agreement.

15.3 This Agreement may be executed in two or more counterparts, each of

which shall constitute an original but which, when taken together,

shall constitute one instrument.

SCHEDULE 1

Written Particulars of Employment SCHEDULE 2

(Job Description & Person Specification for Seconded Post)


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IN WITNESS of which the parties have executed this Agreement as a deed on the date first before written EXECUTED as a DEED by POWYS COUNTY COUNCIL In the presence of: Name:……………………… Job Title:……………………. Signature…………………… EXECUTED as a DEED by (Update name of Organisation) In the presence of: Name:……………………… Job Title:……………………. Signature…………………… SIGNED as a DEED by (Employee Name) Name:……………………… Signature…………………… in the presence of: Name:……………………… Signature……………………

SCHEDULE 5


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RESOURCES Introduction This schedule provides details of the budgets, goods and services to be made available by the partners according to the principles of governing, budget setting and accounting for the use of resources set out in the Agreement. Financial arrangements for the operation of the agreement The JPB will agree any changes to the financial procedures and arrangements for the operation of the Agreement according to Clause 9 of the Agreement. This will include an update to this Schedule which will form a Revised Annual Finance Agreement which sets out the budget. The proposed budget will be presented to the board no later than 31st December in each financial year in accordance with Clause 9. The budget as agreed by the board will take into account effects on other budgets and other financial flows of the partners. Sources of funding Pooled Fund The funding will be:

• Powys County Council £? Which represents % of the total budget

• Powys Local Health Board £? Which represents % of the total budget

Sources of funding for Lead Funds The funding will be:

• Powys County Council £? Which represents % of the total budget

• Powys Local Health Board £? Which represents % of the total budget

Budget Breakdown The pooled fund shall be £? For the financial year 2012/13. Staff costs * Non staff costs Overheads: Accommodation


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Capital * The breakdown of staff budget is included in the Human Resource Schedule. The Lead funds shall be £? For the financial year 2012/13 as follows

Lead Fund Social Care £ Lead Fund Healthcare £

Contributions The budget amounts to be contributed by the Partners to the Pooled Fund or Lead Funds are as follows: Pooled Fund Budget Powys County Council Powys Local Health Board Total Pooled Fund Lead Funds Powys County Council Powys Local Health Board Total non-Pooled Lead Funds Resources Available Outside the Pooled Fund The Partners shall ensure access to the following resources outside the Pooled Fund as necessary for the purposes of this agreement:-

• Operations functions • IT functions • Finance functions • Property functions • Commissioning Support

The Partners shall ensure access to the following systems as necessary for

the Purposes of this agreement:-


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• …………………… • ……………………

Surplus / Deficit sharing rules <each scheme to define were there is variation from the JPB managing surplus / Deficit’s> Administrative Resources Available The Partners agree that the costs of all salaries and administrating costs of providing the Service shall be funded from the Pooled Fund. Direct Overhead costs The overhead costs to administer the Pooled Fund shall be charged to the Pooled Fund. Accommodation Arrangements for Services Premises The Partners shall continue to provide or make available the premises that they provided or made available before the Commencement Date, with the same support services and facilities management. The Council shall ensure access to the following premises:- ……………………….. …………………………. ………………………. The LHB shall ensure access to the following premises:- ………………….. …………………. ………………….


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GOVERNANCE

PLEASE COMPLETE WHERE ADVISED.

(Only complete sections currently marked in Bold Italics and complete reporting framework attached at Appendix 1- do not adjust any other

drafting here)

1. Introduction The Partners have agreed the governance arrangements set out in this schedule in furtherance of the aims and objectives as described in Clause 3 and schedule 1 of the Section 33 Agreement. It is the intention of the Partners to review the governance arrangements at least annually as a part of the Annual Review process set out below and as at Clause 8 of the Agreement. Any variation shall be effected through the mechanism of Clause 15 of the Agreement. The arrangements set out in this schedule shall apply until such time as the Partners agree otherwise. 1. Joint Partnership Board

The Joint Partnership Board “JPB” is responsible for the management of

the partnership arrangements established under this Agreement, tracking delivery of individual partnership scheme aims and objectives within defined resources and agrees any changes to scope. These responsibilities are to be carried out in conjunction with the relevant PCC portfolio member,

3. JPB Membership

The membership of the JPB will be as follows:-

• CEO PCC • CEO PtHB

or a named deputy as required by the respective CEO who will have voting rights on-behalf of the respective CEO only

• A member of the PCC Cabinet • An Executive member of the Health Board


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If agreed by the JPB, additional invitees may be requested to attend their meetings, such invitees to attend in a non-voting capacity and will usually include the following:

• The partnership lead for any established Scheme • The Pooled and Lead Funds Manager for any established partnership • HR representation • Finance representation

4. Role of JPB The JPB is authorised within the limits of delegated authority for its members (which is received through their respective organisation’s own organisation schemes of delegation):-

• To confirm and agree, pursuant to Clause 4 of this Agreement, the allocation of the budget approved by the Partners including any additional non-recurring contributions, and to agree the Revised Annual Finance Agreement;

• To confirm and agree additional non-recurring contributions where anticipated future commitments are likely to exceed the aggregate contributions of the Partners to the Pooled Fund, confirmed or agreed pursuant to Clause 4 of this Agreement; and;

• For the pooled fund; to authorise or enter into any Contract , subject to the Contract Standing Orders of the Council or LHB where these are necessary for the achievement of Scheme aims and will create a liability for both partners beyond the end of the Financial year of the contract.

• To receive the reports required under this Agreement and to agree actions or refer proposals for action back to the Partners for approval as the case may be.

• To review annually the operation of the Agreement;

• To review and agree annually a risk assessment and risk sharing protocol and to agree actions arising following the review;

• To review and agree annually each partnership scheme schedules.

• To review at least annually the operation of any secondment arrangements for staff

• To confirm any arrangements for recruitment to vacant posts (where these alter the liabilities of the partners from those at the commencement date for the Scheme) subject also to agreement of any liabilities for future employment costs

• To consider progress on the Aims and Objectives at Schedule 1.


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• To consult further and agree actions where appropriate on the plan and progress on priorities

• To provide an annual report to each Partner on outcomes against the agreed Plan

• To agree the appointment of the Partnership Lead and the Pooled and lead Fund Manager within 30 days of commencement of each financial year for each partnership scheme.

5. JPB Meetings The JPB will meet quarterly and at a time to be agreed and within 1 month of receipt of each quarterly report of the Pooled and Lead Funds Manager referred to below. A special JPB can be called at any time by CEO of PCC or CEO of PtHB where it is deemed necessary. The quorum for meetings of the JPB shall be a minimum of one (1) member from each of the Partners, not counting the Pooled Fund Manager or other non-voting members listed at 3 above. Decisions of the JPB shall be made unanimously by those present. Minutes of all decisions shall be kept and copied to the JPB within fourteen (14) days of every meeting. The JPB will be supported by an Operational Group for any agreed partnership Scheme. 7. JPB Agendas The JPB will follow a two part agenda. The first part will consider any reports from the Pool and Lead Funds Fund Manager. The second part will consider any other matters of progress from the Operational Group 8. Operational Group An Operational Group will assist the JPB in its activities through oversight of day to day management of the particular agreed Scheme. The Operational Group will meet at a least 10 times per annum. The membership of the Operational Group shall comprise: Drafting Note: Please Complete Membership and identify the Partnership Lead from the Host partner


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Drafting Note: PLEASE NOTE: Drafting Note: Each Scheme will have a Chair who is the Partnership Lead approved as a part of a completed draft Schedule membership here above , by the JPB.

• The Pool and Lead Funds Fund Manager The role of the Operational Group will be to receive such information as is necessary and as outlined in the reporting framework attached and to assist the Partnership Lead and the Pooled and Lead Funds Manager in the review, and development of the draft annual Drafting Note: Insert Name of Scheme Plan and any other actions deemed necessary or helpful to effective delivery of the Service from time to time. 9. The Pool and Lead Funds Fund Manager The Pool and Lead Funds Fund Manager may delegate the day-to-day management of funds and objectives in accordance with the Drafting Note: Insert name of Host Partner Standing Orders, Financial Regulations and such other applicable Scheme of Delegation. 10. Information Planning and Reports The Pool and Lead Funds Fund Manager shall supply to the JPB on a quarterly basis and to the Operational Group the financial and activity information as referred to at Schedule Please complete the Schedule Number on Resources and as set out at Appendix 1 to this Schedule …..Pleas complete the Schedule Number the Financial and Activity Reporting Framework as amended form time to time. The Partnership Lead and the Pool and Lead Funds Fund Manager will refine the Aims and Objectives set out in Schedule 1 into targets and performance measures to be agreed by the JPB from time to time and in any event by 30th July each year following a strategic and financial review to be led by the JPB. Any changes to the agreed partnership schedules and/or the Revised Annual Finance Agreement must be agreed by the JPB. In pursuant of clause 9 of the agreement preparation of partnership schedules for future Financial Years will be according to the following process in each Financial Year:

o October-January: The Pooled and Lead Fund Manager will prepare a draft annual Plan. This will incorporate any proposed changes will be in the form of a revised Schedule 1 of Objectives and any necessary revision of the Financial and Activity Reporting Framework content for JPB.


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o October- January: The JPB will consider the draft annual Plan and instruct upon any necessary refinements for finalisation by the Pooled and Lead Fund Manager to be assisted by the Operational Group. The Operational Group will as a result also undertake the preparation of a draft Revised Annual Finance Agreement incorporating draft annual budget contributions of the Partners to reflect the draft annual Drafting Note: Insert name of Scheme Plan.

• February: The Pool and Lead Fund Manager will submit to the JPB a draft Revised Annual Finance Agreement and a draft annual Plan for the Partnership Funds.

The draft Revised Annual Finance Agreement and annual Drafting Note: Insert name of Scheme Plan for the following financial year will be presented to the JPB no later than end of February in each financial year. The draft Revised Annual Finance Agreement and Plan for the following financial year will be taken into account in the Council and Local Health Board’s organisational budget proposals for the next financial year. The Revised Annual Finance Agreement incorporating the budgets for the Pooled and Lead Funds and the Annual Plan will be agreed by the JPB no later than 31 March in each Financial Year, taking into account agreed Council and LHB’s budget proposals for the following Financial Year. 10. Post-termination The JPB shall continue to operate in accordance with this Schedule following any termination of this Agreement under Clause 10 of this Agreement. Drafting Note: See and complete Appendix 1 overleaf


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Appendix 1 FINANCIAL AND ACTIVITY REPORTING FRAMEWORK – MONTHLY & QUARTERLY REPORTS The JPB and Operational Group shall receive Financial and Activity Reports as set out below. The reports shall include any matters referred by the Operational Group for attention by the JPB or LHB’s representatives and shall cover:- 1. Finance

Schedule Insert Number of Resources Schedule outlines the nature and detail of the financial contributions of the Partners.

2. Service Reporting

Monthly information on finance, and quarterly information on specific service and outcome performance, will be supplied for JPB and the Operational Group as set out in the table below

1. Financial Information Monthly financial reports showing budget, spend to date, commitments and variation. Monthly forecast report showing the forecast to the end of the Financial year. 2. Service Information Drafting Note: Please complete for


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Monthly, Quarterly or annual KPI’s including any proposed special reports

SCHEDULE 1

AIMS AND OBJECTIVES OF THE AGREEMENT 1. Introduction: Description and Purpose of Agreement 1.1 The overarching strategic aim of this Agreement is:-

To ensure the integrated provision of high quality, cost effective Information & communication technology (ICT) services which meet local partners needs, through the establishment of pooled and lead funds under Section 33 of the National Health Service Wales Act 2006 from 1st July 2012

1.2 This will enable both parties of this Agreement to: • Deliver efficient & effective ICT services within agreed

budgets & resources

• Support delivery & maintenance of the joint PtHB & PCC ICT strategy in line with business needs

• Maximise the efficiency of ICT services through integrated provision and the effective use of the Pooled and lead Funds within a single management structure

• Facilitate the delivery of the National public sector ICT strategy for Wales

• Manage service & project delivery performance to agreed KPI’s

2. Principles and Approach to Delivery 2.1 The Principles and Approach to Delivery shall address the need

for:-

• Providing the Services in a more co-coordinated way by enabling Staff to work within a single management structure for each Service.

• Arranging provision from a single service process where

beneficial • Standardising ICT policies & procedures where possible

• Ensuring the most efficient and effective use of resources

• Adoption of ITIL based processes

2.2 The principals and approval of a lead fund shall address the need for :-

• Replacement of end user equipment & management of end

user variable costs (such as telephone bills) will be to locally agreed processes and budgets

3. Key Aims & Objectives

3.1 The aims and objectives for year one of this Agreement are:

• Transition staff to the new working arrangements within 12 months of the start of the agreement

• Create in integrated team structure within 12 months of the

start of the agreement, in line with the ICT Resource Utilisation project

• Review ICT Governance arrangements within 12 months of

the start of the agreement

• An agreed single set of Programme and service measures will be developed in year 1 of the agreement.

• Agree a plan and commence co-location of staff, where

required, within 12 months of the start of the agreement

• Create a single point of contact and process for ICT support during the first year of the agreement

• Review present processes re ICT procurement.

• An agreed set of operational procedures will be developed in

year 1 of the agreement to provide a robust framework for working practice & service delivery

• Create a joint skills development plan within 12 months of

the start of the agreement in line with the ICT Resource Utilisation project

• Propose a PC refresh plan and process for PtHB by the end of

the first year of the agreement

• Agree aims & objectives for years 2 & 3 of the agreement by the end of the first year of the agreement

4. Standards for Services 4.1 Standards for Services are as follows:-

• All Staff will adhere to agreed ICT policies. These will be agreed and implemented across both Partner organisations where possible.

• The service standards of the host (PCC) will apply if no local

PtHB standard exists 5. Review

A strategic and financial annual review of these objectives will be coordinated by the ‘Pooled & Lead Funds Manager’ in accordance with Clause 11 of this Agreement and incorporated in an Annual Report to the JPB for agreement.

SCHEDULE 2: THE LHB’S NHS HEALTH CARE FUNCTIONS AND THE COUNCIL’S HEALTH RELATED CARE FUNCTIONS

THE LHB’S NHS HEALTH CARE FUNCTIONS

The LHB’s NHS Health Care Functions of providing, or making arrangements for the provision of, Services:-

(a) (i) under sections 2 and 3(1) of the National Health Service Act

1977, including rehabilitation services and services intended to avoid admission to hospital but excluding surgery, radiotherapy, termination of pregnancies, endoscopy, the use of Class 4 laser treatments and other invasive treatments and emergency ambulance services; and

(ii) under section 5(1), (1A), and (1B) of, and Schedule 1 to, the

National Health Service Act 1977; and (b) the Functions under sections 25A to 25H and 117 of the Mental Health

Act 1983.

THE COUNCIL’S HEALTH RELATED CARE FUNCTIONS

The Council’s Health Related Functions are:- (a) the Functions specified in Schedule 1 to the Local Authorities

Social Services Act 1970 except for the Functions under:-

(i) sections 22, 23(3), 26(2) to (4), 43, 45 and 49 of the National Assistance Act 1948; (ii) sections 6 and 7B of the Local Authorities Social Services Act 1970; (iii) sections 1 and 2 of the Adoption Act 1976; (iv) sections 114 and 115 of the Mental Health Act 1983;

(v) The Registered Homes Act 1984; and (vi) Parts VII to X and section 86 of the Children Act 1989; and

(b) the Functions under sections 5, 7, or 8 of the Disabled Persons

(Services and Consultation and Representation) Act 1986 except in so far as they assign Functions to a Local Authority in its capacity of a Local Education Authority.

Schedule 3

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Section 33 Agreement – Service Schedule

1. The Service will be provided for PtHB staff and PCC corporate users of the IT networks and systems. The Service will consist of technical support and project management using the combined teams currently providing Service Desk, Desktop, Network, Telephony and Data Centre support and Programmes & Project Management for ICT projects.

2. Current Structure and Team Roles

Current Team Roles

Powys County Council – Programmes & Governance Team

The Programmes and Governance team provide a programme and project management capability to manage and report on progress in the delivery of the joint ICT strategy. Powys County Council ‐ ICT Services Teams

Network Support This team support the network infrastructure for both data and voice. This includes support for the fixed and wireless Local Area Networks (LAN), Wide area Network (WAN), Active Directory system and file server infrastructure, email and calendaring system, spam filtering, Blackberry handsets, home‐working infrastructure and VPN infrastructure. Production Services This team support the Council's application servers and provide services for backup, database maintenance and file transfers such as the monthly BACS payroll run.

Schedule 3

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Approximately 25 physical servers are supported and another 135 virtual servers running on 7 physical VMWare virtualisation servers. 14.5Tb of data is backed up per week and application system patches are applied to core systems weekly as required by the suppliers. Desktop Support This team supports and maintains 2700 desktops including around 1000 laptops and carries out installation of new software and hardware and disposal of old equipment. They also provide cover for the Service Desk team and assit in answering the phone calls and logging and dealing with requests. Approximately 900 printers are currently supported across the County. This team also support 110 SunRay terminals and virtual desktops (VDI) for Customer Services. Service Desk All calls and emails for IT support from corporate staff, members and schools are taken by this team. This team logs all calls received and keeps users informed of progress, they also fix as many calls as possible at first contact, dealing with calls such as password resets, new users, client settings, software installation, and providing advice. Security This team manage the ICT Security policies in line with the GCSX code of connection, and the systems needed to support these policies, such as firewalls, web filtering, encryption tools, system access logging and electronic policy management. Currently 8 firewalls are providing secure connectivity to the internet, central government applications and remote access into the council network for corporate, libraries and schools. ICT Procurement & Stores Control This role liaises with technical support staff to manage quotations, ordering, progress checking and returns procedures, and manages the secure stores for ICT equipment, to ensure the accurate recording of supplier deliveries, returns and issues of high value items for all Council ICT equipment.

Powys teaching Health Board – IT Services

Network Support This team provide 2nd line support, including management of the email systems, servers, firewalls, data switches, server based system installs, upgrades. Support the first line team with expert knowledge. Look after a number of clinical systems and integration of medical devices onto the data network e.g. Endoscopy / Audiology. Look after Active Directory and act as SQL DBA. Telecoms A single administrator looks after the telephone estate, telephone switches, maintenance, supplier liaison, contracts and budget. He also orders, organises data circuit installs and Ethernet installs. IT & Telecoms Support This team provide 1st line support, including desktop support, installs and maintenance. They also look after the Video Conferencing network, supplier liaison, install desktop applications, maintenance of AD accounts e.g. new users / password resets / permission setting etc.

Schedule 3

Page 3

Projects The Project Facilitator is responsible for the support and management of local ICT Projects contained in the joint strategy, and the local project management of national NWIS ICT Projects. 3. Scope for this agreement

IT support and project management staff from both organisations will be able to work in partnership with access to each others networks, devices and projects to increase the efficiency of the ICT function, according to the pooled and lead funds. Staffing Powys County Council has 4 technical teams based at County Hall, Llandrindod Wells, providing IT support for approximately 3000 Council users, and 1 project team providing project management and support for ICT projects. The teams and number of staff included in this agreement are as follows Service Desk team ‐ 4 FTE Desktop Support ‐ 6 FTE Network Support ‐ 7 FTE Production Services ‐ 2 FTE ICT Procurement & Stores Control Clerk – 1 FTE ICT Services Manager – 1 FTE Project Manager – 3 FTE Project Support Officer – 1 FTE Powys teaching Health Board has 3 teams based at Bronllys Hospital, Bronllys, providing IT support for approximately 2500 Health Board users. The teams and number of staff included in this agreement are as follows Desktop Support ‐ 3 FTE Network Support ‐ 2 FTE Telephony Support ‐ 1 FTE IT Operations Manager – 1 FTE Project Support – 1 FTE Network Powys County Council network includes over 400 network links into corporate sites, schools, day centres and about 150 home‐workers and 17 standby workers. The network is currently based on a hub and spoke model using a variety of BT circuits and Cisco routers and is in the process of being migrated to PSBA. The PSBA network will consist of 3 VRFs – corporate, schools and public with different traffic types separated into the appropriate VRF. Powys teaching Health Board network comprises of 21 sites all on the PSBA network in one national Health VRF. The two networks are separated due to differing codes of connection and PtHB are connected via NWIS, therefore staff from PCC and PtHB will have access to both networks to provide a combined service. The service to be provided is support and maintenance of the existing network infrastructure for both partners.

Schedule 3

Page 4

Telephony The current voice platform in Powys County Council is a mixture of Siemens analogue PBX, Siemens digital PBX, Panasonic PBX and Avaya IP telephony & Avaya contact centre. Powys teaching Health Board currently has 14 NEC‐Phillips PBX running telephony for all users. The service to be provided is support and maintenance of the existing voice infrastructures for both partners. Desktop Client Estate Powys County Council has approximately 1000 Dell laptops (Latitude Series) and 1700 Dell desktops (Optiplex Series). All clients are built using a standard image using Windows XP Professional operating system. Powys County Council also has 45 SunRay thin clients connecting to a Windows Server 2008 R2 Terminal Server farm, and 110 SunRay thin clients for Customer Services connecting to a VMWare VDI cluster. Powys teaching Health Board has approximately approximately 450 Dell laptops (Latitude Series) and 650 Dell desktops (Optiplex Series). All clients are imaged and deployed using Windows Deployment Services with a standard Windows XP Professional operating system. New machines will be built with Windows 7. Windows 7 is currently under test in both organisations with approximately 20 devices using this operating system. Powys County Council is planning full Windows 7 deployment during 2011/12. The service to be provided is support and maintenance of the existing desktop infrastructure for both partners. Servers & Applications Powys County Council has a variety of servers and appliances for almost 200 applications. The main server infrastructure consists of 7 Dell servers running VMWare ESX vSphere 4.1 connected to EMC Clarion and Sun 7210 SANs which provides the platform for over 130 virtual Windows, Linux and Solaris servers. There are also approximately 25 physical servers (IBM, Dell & Sun/Oracle hardware) running applications on Solaris OS and Slackware Linux. The current standard operating systems in PCC are Windows Server 2008 R2, Ubuntu Linux and Solaris 10, and older versions of these are also still supported (Windows Server 2003, Solaris 9, Slackware Linux). The Council also support Microsoft SQL Server, Oracle and MySQL databases. Powys teaching Health Board has 16 Dell servers running VMWare ESXi v4 providing the platform for 49 virtual application servers. There are also 33 physical servers (Dell hardware). The current standard operating systems in PtHB are Windows Server 2003 and Windows Server 2008 R2. The teaching Health Board also supports Microsoft SQL Server databases and one Oracle database for Child Health. The service to be provided is support and maintenance of the existing server and application infrastructure for both partners. Service Desk Powys County Council has a Service Desk as a single point of contact for corporate ICT Services. The service provided is telephone and email call logging and support for all ICT service requests, faults and orders. Approximately 1800 telephone calls are received per month, with an average call answer time of 26 seconds.

Schedule 3

Page 5

Powys teaching Health Board has a single telephone number for staff to call for IT service requests, faults and orders. The telephone line is answered by the IT & Telecoms Support team on a rota basis. Approximately 400 telephone calls are received per month. Security Powys County Council has to comply with the GCSX Code of Connection. A team of two staff manage the policies and applications required to maintain this standard. These applications consist of hard disk encryption, endpoint encryption, electronic policy enforcement, web filtering, portal access, firewall configuration and VPN token management. Powys teaching Health Board currently has to comply with the NHS Code of Connection. The policies and applications required to maintain this standard are managed within the existing desktop and network teams. The service to be provided is advice, support and maintenance of the ICT security infrastructure for Powys County Council. Advice on ICT security will be provided to Powys teaching Health Board by Powys County Council. ICT Procurement & Stores Control Powys County Council has one person in charge of all quoting, ordering, deliveries and returns of ICT equipment for the Council. This person also manages the stores and stock control of ICT equipment. Powys teaching Health Board ICT procurement is currently managed by the IT Operations Manager. The service to be provided is a shared procurement and stores control function utilising the Powys County Council role. Projects The service to be provided is programme and project management. The service will manage the process of feasibility, commissioning, readiness, implementation and closure of the Councils ICT programme, the PtHB ICT programme and shared ICT projects. 4. Management of the Service The ICT Support and Project Management will be combined and managed under a single management structure. 5. Location of Service The service is to be provided in Powys, across all sites used by Powys County Council and Powys teaching Health Board. 6. Access The Service will be accessed by all IT users of both Powys County Council and Powys teaching Health Board via the current Service Desk phone numbers and email addresses. Powys CC – 01597 826100, [email protected] Powys tHB – 01874 712766, [email protected] or [email protected] Powys tHB – Critical cover (by‐passes Helpdesk) 01874 712754

Schedule 4 – HUMAN RESOURCES 1. Staff Numbers 1.1 Table 1 shows the total numbers of staff to be made available by

Powys County Council to be managed at the direction of the host partner, Powys County Council as at 11-04-2012.



Vacancies Headcount (excl vacancies)


30.75

1

31

1.2 Table 2 shows staff in post by job group, for Powys County Council to

be managed at the direction of the host partner, Powys County Council as at 11-04-2012.

Powys County Council Job Group


Contract Hours

Contract Status


Total Salaries

£

Management

Head of ICT 0.55 18.5 Permanent 0 1 ICT Information and Performance

0.75

28

Permanent

0

1

ICT Services Manager 0.75 28 Permanent 0 1 Management 2.05 74.5 0 3 118,365 Network Support

Principal Network Support Officer

1

37

Permanent

0

1

Senior Network Support Officer

3

111

Permanent

0

3

Network Support Officer 2 74 Permanent 0 2 Telecoms Officer 1 37 Permanent 0 1 Principal ICT Security Officer

0.7 25.9 Permanent 0 1

ICT Security Officer 1 37 Permanent 0 1 Network Support 8.7 321.9 0 9 241,142 Data Centre

Principal Technical Support Officer

1

37

Permanent

0

1

Senior Technical Support Officer

1

37

Permanent

0

1

Data Centre 2 74 0 2 58,790 Project Managers

ICT Project Manager 3 111 Permanent 0 3 ICT Project Support Officer

1 37 Permanent 0 1

ICT Project Support 2 74 Temporary 0 2

1.3 Table 3 shows the total numbers of staff of the Powys teaching Health

Board (PtHB) to be managed at the direction of the host partner, Powys County Council as at 11-04-2012.

Powys Teaching Health Board (PtHB)


Vacancies Headcount (excl vacancies

Powys Teaching Health Board

7.93

0

8

* These figures include a proposed temporary joint funded post (NWISS & PtHB)

1.1 Table 4 shows the staff in post by job group of the Powys Local Health

Board to be managed by the host partner, Powys County Council as at 11-04-2012.

Job Group Establishment

(incl vacancies) Contract Hours

Contract Status

Vacancies Headcount (excl vacancies at 11-04-12)

Total Salaries £

IT Operations Manager

1 37.5 Permanent 0 1

Telecommunications Administrator


Network Support Officer


Network Support Officer


ICT Project Facilitator

(0.93)

35 Permanent 0 1

IT and Telecommunications Support Officer


Officer Project Management 6 222 0 6 162,895 Desktop Support

Desktop Support Team Leader

1

37

Permanent

0

1

Desktop Support Officers 5 185 Permanent 0 5 Desktop Support 6 222 0 6 130,458 Call Handling Staff ICT Service Desk Team Leader

1

37

Permanent

0

1

ICT Service Desk Analysis 1 37 Permanent 0 1 ICT Service Desk Operatives

2

74

Permanent

0

2

Call Handling Staff 4 148 0 4 82,579 Procurement & Stores Control Clerk

1 37 Permanent 0 1 18,531

IT Project Manager (Funding sourced from NWIS and PtHB) - TBC

1 37 Temporary 1 0 37,500

TOTAL

30.75

1136.4

1

31

850,260


1

37.5 Permanent 0 1


1

37.5 Permanent 0 1

TOTAL 7.93 297.5 0 8 189,476 * These figures include a proposed temporary joint funded post (NWIS & PtHB)

1.4 Table 5 shows the total establishment to be managed by the host

partner, Powys County Council as at 11-04-2012. Service Area Partnership Committee

Establishment (incl vacancies) Vacancies Total

PCC IT 30.75 (TBC) 1 30.75 (PtHB) IT 7.93 (TBC) 0 7.93 Total 38.68 (TBC) 1 38.68

2 Staff Details 2.1 All Powys County Council staff are on the Trent HR/ Payroll system.

This system lists all the staff the host partner will manage and direct. This system is held and updated by the HR Department of the host partner, Powys County Council, as authorised by the partnership.

2.2 A HR database (ESR – Electronic Staff Record) exists which lists all

the Powys teaching Health Board staff. This system lists all staff the host partner will manage and direct. This system is held and updated by the HR Department at Powys teaching Health Board, as authorised by the partnership.

3. Management Structure of the Host Partner as agreed by the

Partnership 3.1 The Management Structure is as outlined within ICT Schedule 3 of the

Section 33 Agreement. 3.2 Where a member of staff employed by one Partner (the Manager) is

the manager of a member of staff employed by the other Partner (the Managed Person), the Manager is authorised by virtue of this Agreement to give instructions to the Managed Person and to take all appropriate management action in respect of the Managed Person subject to the agreed terms and conditions of their employment.

4. Grant funded staff Where staff are funded from grant. Duration of employment, liability upon termination and other terms are to agreed at the commencement of the recruitment and may be subject to any conditions imposed by the grant funding.

Schedule 5

Page 1

RESOURCES

Introduction This Schedule provides details of the budgets, goods and services to be made available by the Partners and also outlines the principles governing budget setting and accounting for the use of resources. Budget Sources of Funding The funding will be:

• Powys County Council £838,178 Which represents 67.4% of the total budget

• Powys Local Health Board £405,736 Which represents 32.6% of the total budget

Of which there will be funding from the • NHS Wales Informatics Service (NWIS) of £33,750

Which represents 2.7% of the total budget Budget Breakdown The pooled fund shall be £1,243,914 for the 9 months from 1st July 2012 to the 31st March 2013.

The detailed budget is as follows:

CONTRIBUTION REQUIRED FOR POOLED SERVICE

Cost of Combined

Service 2012/13 STAFFING COSTS £ IT Management Costs 118,365 Salaries 921,371 NON STAFFING COSTS Other Staff Costs 4,049 Premises Costs 45,015 Transport Costs 27,942 Supplies and Services 281,934 Contingencies 58,017

Schedule 5

Page 2

Service Costs Statutory Testing 519 Other Recharge 1,883 Income -215,181 Net Expenditure 1,243,914 Original Budget 2012/13 1,243,914 Budget change inc/(dec) 0 % £ Contribution to above budget Powys CC 67.4 838,178 LHB 32.6 405,736 Which includes a contribution from NWIS 33,750

Detailed breakdown of the budget is shown in the supporting documentation pooled_budget_proposal_12-03-2012.xlsx Construction of Budget and Basis of Contributions For the avoidance of doubt, any personal contributions payable by service users towards any Council services will continue to be collected by Council. Contributions The budget amounts to be contributed by the Partners to the Pooled Fund and Non Pooled funds are as follows:- Pooled Fund Budget LHB £ 405,736 Council £ 838,178 Total Pooled Fund £ 1,243,914 Which includes a contribution from NWIS £ 33,750

Schedule 5

Page 3

Lead funds The non pooled lead funds are as follows:

2 - PCC Lead Budget £ Other Staff Costs 8,625 Supplies & Services 720,690 Strategy 57,375 Income -9,938 Capital Charges 333,990 Admin 32,783

Total 1,143,525

4 - PtLHB Lead Budget £ Staffing 0 Other Staff Costs 0 Premises 0 Supplies & Services 257,789 Transport 0 Strategy 0 Income -600 Capital Charges 0 Admin 0 Statutory Testing 0 Recharge 0

Total 257,189 Detailed breakdown of the budget is shown in the supporting documentation pooled_budget_proposal_12-03-2012.xlsx Management of lead funds Lead funds are to be managed by Pooled fund staff resources.

Schedule 5

Page 4

Resources Available Outside the Contributions Above The Partners shall ensure access to the following resources outside the Contributions above as necessary for the purposes of this agreement:-

• Commissioning Support • Operations functions • Finance functions • Property functions

Accommodation Arrangements for Services

Premises

The Partners shall continue to provide or make available the premises that they provided or made available before the Commencement Date, with the same support services and facilities management. The Council shall ensure access to all Powys County Council owned or managed premises as required to undertake ICT functions The LHB shall ensure access to all Powys teaching Health Board owned or managed premises as required to undertake ICT functions Grant Funding Aims and objectives that are subject to grant funded resources are to be reviewed and amended if necessary in accordance with the award of the funding. Included within the 2012-13 budget is a contribution from NWIS of £33,750 towards the costs of a new post of IT project manager which is initially for a 12 month fixed term contract period only.

Schedule 6

Page 1

GOVERNANCE

1. Introduction The Partners have agreed the governance arrangements set out in this schedule in furtherance of the aims and objectives as described in Clause 3 and schedule 1 of the Section 33 Agreement. It is the intention of the Partners to review the governance arrangements at least annually as a part of the Annual Review process set out below and as at Clause 8 of the Agreement. Any variation shall be effected through the mechanism of Clause 15 of the Agreement. The arrangements set out in this schedule shall apply until such time as the Partners agree otherwise. 1. Joint Partnership Board

The Joint Partnership Board “JPB” is responsible for the management of

the partnership arrangements established under this Agreement, tracking delivery of individual partnership scheme aims and objectives within defined resources and agrees any changes to scope. These responsibilities are to be carried out in conjunction with the relevant PCC portfolio member,

3. JPB Membership

The membership of the JPB will be as follows:-

• CEO PCC • CEO PtHB

or a named deputy as required by the respective CEO who will have voting rights on-behalf of the respective CEO only

• A member of the PCC Cabinet • An Executive member of the Health Board

If agreed by the JPB, additional invitees may be requested to attend their meetings, such invitees to attend in a non-voting capacity and will usually include the following:

• The partnership lead for any established Scheme • The Pooled and Lead Funds Manager for any established partnership • HR representation • Finance representation

Schedule 6

Page 2

4. Role of JPB The JPB is authorised within the limits of delegated authority for its members (which is received through their respective organisation’s own organisation schemes of delegation):-

• To confirm and agree, pursuant to Clause 4 of this Agreement, the allocation of the budget approved by the Partners including any additional non-recurring contributions, and to agree the Revised Annual Finance Agreement;

• To confirm and agree additional non-recurring contributions where anticipated future commitments are likely to exceed the aggregate contributions of the Partners to the Pooled Fund, confirmed or agreed pursuant to Clause 4 of this Agreement; and;

• For the pooled fund; to authorise or enter into any Contract , subject to the Contract Standing Orders of the Council or LHB where these are necessary for the achievement of Scheme aims and will create a liability for both partners beyond the end of the Financial year of the contract.

• To receive the reports required under this Agreement and to agree actions or refer proposals for action back to the Partners for approval as the case may be.

• To review annually the operation of the Agreement;

• To review and agree annually a risk assessment and risk sharing protocol and to agree actions arising following the review;

• To review and agree annually each partnership scheme schedules.

• To review at least annually the operation of any secondment arrangements for staff

• To confirm any arrangements for recruitment to vacant posts (where these alter the liabilities of the partners from those at the commencement date for the Scheme) subject also to agreement of any liabilities for future employment costs

• To consider progress on the Aims and Objectives at Schedule 1 .

• To consult further and agree actions where appropriate on the plan and progress on priorities

• To provide an annual report to each Partner on outcomes against the agreed Plan

• To agree the appointment of the partnership lead and the Pooled and lead Fund Manager within 30 days of commencement of each financial year for each partnership scheme.

5. JPB Meetings

Schedule 6

Page 3

The JPB will meet quarterly and at a time to be agreed and within 1 month of receipt of each quarterly report of the Pooled Fund Manager referred to below. A special JPB can be called at any time by CEO of PCC or CEO of PtHB where it is deemed necessary. The quorum for meetings of the JPB shall be a minimum of one (1) member from each of the Partners, not counting the Pooled Fund Manager or other non-voting members listed at 3 above. Decisions of the JPB shall be made unanimously by those present. Minutes of all decisions shall be kept and copied to the JPB within fourteen (14) days of every meeting. The JPB will be supported by an Operational Group for any agreed partnership Scheme. 7. JPB Agendas The JPB will follow a two part agenda. The first part will consider any reports from the Pool and lead Funds Fund Manager. The second part will consider any other matters of progress from the Operational Group 8. Operational Group An Operational Group will assist the JPB in its activities through oversight of day to day management of the agreed partnership schemes. The Operational Group will meet at a least 10 times per annum. The membership of the Operational Group shall comprise: The ICT Management Team comprising:

Head of ICT and Customer Service ICT Programmes and Governance Senior Manager. ICT Service Manager ICT Operations Manager

• The Pool and lead Funds Fund Manager

The role of the Operational Group will be to receive such information as is necessary and as outlined in the reporting framework attached and to assist the Partnership lead and the Pooled and Lead Funds Manager in the review, and development of the draft annual Plan and any other actions deemed necessary or helpful to effective delivery of the Service from time to time.

Schedule 6

Page 4

9. The Pool and Lead Funds Fund Manager The Pool and lead Funds Fund Manager may delegate the day-to-day management of funds and objectives in accordance with the Powys County Council Standing Orders, Financial Regulations and such other applicable Scheme of Delegation. 10. Information Planning and Reports The Pool and Lead Funds Fund Manager shall supply to the JPB on a quarterly basis and to the Operational Group the financial and activity information as referred to at Schedule 5 on Resources and as set out at Appendix 1 to this Schedule 6 the Financial and Activity Reporting Framework as amended form time to time. The Partnership Lead and the Pool and Lead Funds Fund Manager will refine the Aims and Objectives set out in Schedule 1 into targets and performance measures to be agreed by the JPB from time to time and in any event by 30th July each year following a strategic and financial review to be led by the JPB. Any changes to the agreed partnership schedules and/or the Revised Annual Finance Agreement must be agreed by the JPB. In pursuant of clause 9 of the agreement preparation of partnership schedules for future Financial Years will be according to the following process in each Financial Year:

o October-January: The Pooled and lead Fund Manager will prepare a draft annual Plan. This will incorporate any proposed changes will be in the form of a revised Schedule 1 of Objectives and any necessary revision of the Financial and Activity Reporting Framework content for JPB.

o October- January: The JPB will consider the draft annual Plan and instruct upon any necessary refinements for finalisation by the Pooled and lead Fund Manager to be assisted by the Operational Group. The Operational Group will as a result also undertake the preparation of a draft Revised Annual Finance Agreement incorporating draft annual budget contributions of the Partners to reflect the draft annual …………….Plan.

• February: The Pool and Non Pooled Funds Fund Manager will submit to the JPB a draft Revised Annual Finance Agreement and a draft Annual Plan for the Partnership Funds.

The draft Revised Annual Finance Agreement and annual ICT Plan for the following financial year will be presented to the JPB no later than end of February in each financial year.

Schedule 6

Page 5

The draft Revised Annual Finance Agreement and Plan for the following financial year will be taken into account in the Council and Local Health Board’s organisational budget proposals for the next financial year. The Revised Annual Finance Agreement incorporating the budgets for the Pooled and Lead Funds and the Annual Plan will be agreed by the JPB no later than 31 March in each Financial Year, taking into account agreed Council and LHB’s budget proposals for the following Financial Year. 10. Post-termination The JPB shall continue to operate in accordance with this Schedule following any termination of this Agreement under Clause 10 of this Agreement.

© Lorimer

Appendix 1 FINANCIAL AND ACTIVITY REPORTING FRAMEWORK – MONTHLY & QUARTERLY REPORTS The JPB and Operational Group shall receive Financial and Activity Reports as set out below. The reports shall include any matters referred by the Operational Group for attention by the JPB or LHB’s representatives and shall cover:- 1. Finance

Schedule 5 outlines the nature and detail of the financial contributions of the Partners.

1 Service Reporting Monthly information on finance, and quarterly information on specific service and outcome performance, will be supplied for JPB and the Operational Group as set out in the table below Financial Information Monthly financial reports showing budget, spend to date, commitments and variation. Monthly forecast report showing the forecast to the end of the Financial year.

Schedule 6

Page 6

Service Information Monthly KPI’s KPI Target

PCC Achieved

PCC Comments Target

PtHB Achieved

PtHB Comments

ICT strategy delivery

- % projects completed

To be introduced in year 1of the agreement

- Of which % projects completed within time


- variance days on project completion


- Of which % projects completed within quality


- Of which % projects completed within cost (or variance?)


MTFP efficiency savings

Number of major faults (P1’s) /mth

Service desk call answer time (secs)

Service desk % calls answered

% of major faults fixed within SLA

% of minor faults fixed within SLA

%of calls fixed at first contact

Outstanding service jobs

Network downtime

Data centre downtime

e-mail downtime

Home & mobile worker infrastructure

Schedule 6

Page 7

downtime

FOR APPROVAL

BJC for Renal Dialysis in North Powys Page 1 of 3 Board Meeting27 June 2012

Agenda Item 2.3

BOARD MEETING

27 JUNE 2012 AGENDA ITEM 2.3

BUSINESS JUSTIFICATION CASE FOR A RENAL DIALYSIS UNIT IN NORTH

POWYS

Report of

Interim Director of Planning

Paper prepared by


Purpose of Paper

To approve the Business Justification Case (BJC) for the permanent Renal Unit at Welshpool.


The Board is asked to: APPROVE the revisions to the BJC as

highlighted in this paper; and NOTE progress with delivering the satellite

Renal Dialysis Unit


This paper supports Standards 1, Governance and Accountability; 7 Safe and Clinically Effective Care and 8, Care Planning and Provision


Improving Health & Well-Being Ensuring the Right Access Striving for Excellence


BJC – Business Justification Case WAG – Welsh Assembly Government WHSSC – Welsh Health Specialist Services CommitteeBCUHB – Betsi Cadwallader University Health Board

FOR APPROVAL


Agenda Item 2.3

BUSINESS JUSTIFICATION CASE FOR A RENAL DIALYSIS UNIT IN NORTH

POWYS

Background In February 2011 the Board approved the Business Justification Case (BJC) for the permanent satellite renal dialysis on the Welshpool Hospital site. The BJC was approved subject to agreement of the revenue consequences between WHSSC and BCUHB, and a revenue neutral position for Powys tHB. The Board were advised at their meeting in April 2011 that correspondence had been received advising that Welsh Health Specialised Services Committee would account for all revenue costs associated with the Business Justification Case (BJC) and the Board noted that the BJC would be submitted to Welsh Assembly Government for approval. Approved Capital Sum Welsh Government approval to proceed within a capital cost of £2.471M based on the tendered costs of the scheme.

Financial year Total /£

Works Cost 1,648,928Fees 233,317

Non-works Costs

50,000

Equipment Costs

108,800

Contingencies 57,114

VAT 372,969

Total 2,471,128

The Business Justification Case has been amended to include this allocation. The potential impairment from the initial revaluation of the asset by the District Valuer estimated at £640,000 will be supported by WG subject to the District Valuer’s final valuation on completion.

FOR APPROVAL


Agenda Item 2.3

Revenue Consequences The revenue consequences of the unit for the tHB relate to two areas: • Facilities and utility services costs will be cross-charged back to BCUHB as part

of a Governing Framework that is being negotiated between the two health boards to ensure appropriate governance of the unit.

• The Business case was approved by WG on the basis that WHSSC will support the depreciation revenue requirements calculated within the BJC as £101K per annum. The business case has been amended to reflect this position.

Welsh Government requested a copy of a finalised business case as approved by the Board that includes these figures. Current Position Following receipt of confirmation of funding from WG the tHB was able to proceed with the formal appointment of contractors to build the unit , and establish project arrangements as described in the BJC to deliver the scheme. The contractors started on site in Welshpool in November 2012 with a planned completion date of October 2012. Following initial testing of the facilities the unit should be commissioned in December 2012. This will allow the current temporary unit to be withdrawn. The project is currently forecast to be delivered on time and within budget. Conclusion The tHB has received approval and capital funding from Welsh Government for the Welshpool Satellite Renal Dialysis scheme. Work on the scheme has commenced on site. The original BJC was approved by the Board subject to some further work. This has been completed and the BJC updated accordingly. The updated BJC will be published on the tHB website and forwarded to Welsh Government Recommendation The Board is asked to:

APPROVE the revisions to the BJC as highlighted in this paper; and NOTE progress with delivering the satellite Renal Dialysis Unit

Report prepared by: Presented By: Bruce Whitear Bruce Whitear Interim Director of Planning Interim Director of Planning Background Papers BJCFinancial Consequences £2.47M of capital from WAG

Revenue as described Other Resource Implications Estates and local staff time to manage the project

on-site

FOR APPROVAL

Business Case: Mansion Decant Page 1 of 3 Board Meeting 27 June 2012

Agenda Item 2.4

BOARD MEETING


BUSINESS JUSTIFICATION CASE FOR DECANT OF THE MANSION HOUSE

TO MAIN BRONLLYS SITE

Report of


Paper prepared by

Planning Officer, Head of Estates and Property

Purpose of Paper

To present Board with the BJC for decant of the Mansion House to the main Bronllys site


The Board is asked to APPROVE the Business Justification Case prior to its submission to Welsh Government.


This paper supports Standards 6, 7, 8, 12, 18, 19 20, 22 and 24


Improving Health & Well- Being Ensuring the Right Access Striving for Excellence Involving the People of Powys Making Every Pound Count


HQ – Headquarters IT – Information Technology

FOR APPROVAL


Agenda Item 2.4

BUSINESS JUSTIFICATION CASE FOR DECANT OF THE MANSION HOUSE TO MAIN BRONLLYS SITE

Background As part of the work of the South East Powys Project, a mandate was given to map existing services and staff within the identified buildings and determine possible future plans to vacate the Mansion House and better utilise the main Bronllys site. The aim is to:

• Bring office accommodation up to standard for staff • Create a corporate headquarters • Vacate Mansion House and release it for disposal • Make more effective use of estate • Make recurrent revenue savings

This work is in parallel and supportive of the Enquiry by Design process which was undertaken in 2011 and previously reported to Board. The attached Business Case is prepared using the Five Case Model as required by Welsh Government for capital business cases and is based on the development and appraisal of options from both a non-fuinancioal and financial perspective. The identified preferred option is to decant the Mansion House through utilisation of partially vacant buildings within Bronllys Hospital. Bronllys The Bronllys site comprises some 200 HQ staff, shared services, and hosted services [NISCHR, All Wales Continuing Care] alongside clinical services. Work has been undertaken to map current Mansion House occupants to vacant blocks which could be reused for office accommodation with some investment. Plans have been developed to pre-tender stage based on detailed plans prepared by an architect and costed by quantity surveyors under contract to the tHB. The business case also includes some immediately necessary works to the main site, and supports the transfer of the IT hub to the main site. This business case therefore makes the case for capital to:

• Undertake essential work to the Monnow building on the main site (completing asbestos removal and office upgrade, to existing office accomodation) at a cost of £120K inclusive of fees and works

• Undertake urgent work to re-locate the IT hub and associated staff to an upgraded Hafren building at a cost of £160K inclusive of fees and works

• Create a new Headquarters on the main site, re-locate remaining staff in the Mansion House to the main site, and upgrade outpatients facilities at a cost of £408K inclusive of fees and works and net of an assumed £300K receipt for Mansion House that once vacated would be surplus to requirements and sold.

FOR APPROVAL


Agenda Item 2.4

It is anticiapted that the net revenue effect of these changes will be £67K saving per annum. Conclusion The options for decanting remaining staff in the Mansion House have been explored and presented in a Business Justification Case in line with Welsh Government requirements. Recommendation The Board is asked to APPROVE the Business Justification Case prior to its submission to Welsh Government. Report prepared by: Presented By: Gemma Lewis Bruce Whitear Planning Officer Interim Director of Planning Background Papers Financial Consequences As determined by the report

Other Resource Implications As determined by the report

Consultees IT Department, Works and Estates, external

consultants

THE DECANT OF THE MANSION HOUSE AND REUSE OF VACANT AND UNDER UTILISED ACCOMMODATION ON

BRONLLYS HOSPITAL SITE

BUSINESS JUSTIFICATION CASE

Version No. 6j Issue date: JUNE 2012

CONTENTS EXECUTIVE SUMMARY THE STRATEGIC CASE 3 Organisational Overview 5 Problems with the Status Quo 6

THE ECONOMIC CASE 10 Investment Objectives 10 Constraints 10 Options Appraisal 11 Non Financial Options Appraisal 15 Financial Options Appraisal 16 Risk 17 Preferred Option 18 THE COMMERCIAL CASE 19

THE FINANCIAL CASE 20 Capital Costs 20 Value Added Tax 21 Revenue Costs 22 Affordability 23

THE MANAGEMENT CASE 25 Project Management Arrangements 25 Project Team 25 Project Communication and Reporting 26 Outline Project Plan 26 Post Project Evaluation 27

APPENDICES

1. Site plan 28 2. Site control programme 29 3. Risk register 36 4. Capital costings 36 5. Revenue costs 36 6. Project plan 36

BJC - Decant of Mansion House

Page | 4

1. THE STRATEGIC CASE

1.1. OVERVIEW The Business Case Justification (BJC) seeks approval for capital investment for the provision of alternative office accommodation for Powys Teaching Health Board staff within the main Bronllys Hospital site. In this document the site is referred to in two parts as the main hospital site and Mansion House. The aim for this business case is to:

• Bring office accommodation up to standard for staff • Create a corporate headquarters • Make more effective use of estate • Make recurrent revenue savings • Secure capital for essential and urgent works to Monnow ward

and re-location of the IT hub and associated staff Powys teaching Health Board was established in October 2009 and took over responsiblity for securing and providing health services for the population of Powys. The organisation’s current headquarters is located within the Mansion House. This accomodation is not fit for purpose in the short or long term as a venue from which to manage the NHS in Powys. It poses health and safety risks to staff and visitors that can be eliminated in better designed premises and does not provide for a positive image for the NHS in Powys or Wales. The IT hub for the organisation is located in demountable buildings adjecent to the Mansion House that are past their usable life and pose a significant and on-going business continuity risk due to the poor state of the accomodation and associated security issues. In 2010 the tHB agreed its strategic outline programme (SOP) that outlined the capital requirements for the tHB over a five year period. In South Powys, where Bronllys Hospital is located, this is based on a service strategy that will maintain and extend service delivery in existing facilities and through commissioning of care through the independent care sector. In addition the tHB has worked on a master plan for the Bronllys site with the Prince’s Foundation for the Built Environment that foresees a mixed use future for the site, subject to planning approval from Powys Council, in the context of the local development plan. The Bronllys site therefore remains strategically important to the tHB particularly in respect of hosting some 200 staff in Headquarters, Corporate and other pan Powys functions. The site


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also hosts a number of NHS Wales Shared Services Partnership and other similar pan Wales staff. In the absence of a clear service strategy for the future of hospitals in South Powys previous organisations have made no investment other than basic maintenance in the Bronllys site for some years. As a consequence the overall fabric of the site and buildings is of poor quality. However continuing to do nothing is not an option, and there is an urgent need to upgrade the accomodation available to staff, create a corporate headquarters, secure IT services and reduce costs. This business case therefore makes the case for capital to:




It is anticiapted that the net revenue effect of these changes will be £67K saving per annum. Bronllys Hospital Bronllys Hospital is currently an operational centre for healthcare providing inpatient care for stroke, older people and mental health, a portfolio of outpatients services, and houses a number of corporate functions for Powys tHB including around 200 staff. The tHB has engaged the local community on the future of services and use of the site that will see a re-distribution of services currently on the site. The Bronllys Hospital site comprises approximately 29 hectares (72 acres) and contains 11,094 sq m (119,415 sq ft) of accommodation. Two of the buildings (the Chapel and the Basil Webb Hall) are Grade II listed and the entire site is included in the CADW’S Register of Parks and Gardens in Wales.


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The Bronllys site accounts for 45% of the total backlog maintenance of the Health Board. Out of the 31No blocks, only 8No have a condition B status for physical condition. The Mansion House and IT cabins are separate from the main site and are both ‘unfit for purpose’. To make both buildings fit for continued occupancy would require significant expenditure and would not deliver any revenue savings or lead to better utilisation of the existing estate. Enquiry by Design The Prince’s Foundation is an educational charity, established by the Prince of Wales, which exists to improve the quality of people’s lives by teaching and practising timeless and ecological ways of designing, planning and building. The Enquiry by Design Process (EbD) is one of the Prince’s Foundation’s key planning tools and the framework by which its values are disseminated to influence future development of the built environment. A collaborative approach to planning devised and promoted by the Foundation, EbD is used for substantial sites. The EbD was staged over five days in April 2011 involving a wide range of local stakeholders and technical advisors. The EbD resulted in a master plan for the future use of the main site that was submitted alongside an application for it to be considered as a candidate site within the Local Development Plan [of Powys County Council]. Approval of the site as candidate site would attach a wider planning status to the site enabling its future development. As it stands the site sits outside of normal development boundaries and thus would be considered the equivalent of a greenfield site in development terms. The EbD plan envisages mixed future use for the site to ensure planned development and avoid medium to long term dereliction.

1.2. ORGANISATIONAL OVERVIEW Powys Teaching Health Board (PtHB) PtHB was established on 1 October 2009. The Board is responsible for commissioning secondary health care and hospital services and co-ordinating the delivery of primary care services. It also directly delivers community care services such as district nursing, child health, midwifery, and community services in 10 local community hospitals.


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Bronllys Hospital is one of these hospitals and also provides HQ and accommodation for 200 staff with Powys wide roles. The Board employs 2,137 people in full and part time posts. In 2011/12, the Welsh Government (WG) allocated funding of £245million to the tHB. Approximately 48% of this budget was spent on purchased services and 24% on directly provided services. In 2010 the tHB moved towards a locality based system of management and it has now established Locality Teams in north, south and mid Powys largely based around the three counties of Powys, i.e. Montgomeryshire, Breconshire and Radnorshire. Women and Children and Learning Disability Services are managed on a pan-Powys basis, whist specialist Adult Mental Health Services are provided from three different NHS Health Boards, but within Powys premises. 1.3. THE PROBLEMS WITH THE STATUS QUO Bronllys Hospital, on the main site, was built in the 1920s as a Tuberculosis Hospital that served a wide geographical area. Since that time the hospital has undergone many redevelopments in order to accommodate changing requirements including transfers of services and staff from the Mid-Wales psychiatric hospital in Talgarth. The site now provides largely local services, and is the main site for the central administrative functions of the Board. The Mansion House is a Victorian house converted to offices and includes accommodation in a number of obsolete temporary buildings. It currently houses 67 staff, including the IT department. Through movement of staff to other areas onsite, it has been possible to relocate a further 29 members of staff from the Mansion House since the beginning of 2011. The Mansion House currently accommodates the following functions:

• IT department, including main server capacity • Corporate Headquarters [Directors and PAs] • Finance team • Prescribing advisor team • Quality and Safety team • Planning team • Nursing team

The Hospital site is accessed via the main drive but the Mansion House is accessed via a separate entrance which is also shared with a


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childrens residential home and neighbouring houses. Having two entrance routes causes a great deal of confusion to visitors to the site for deliveries, attending meetings and training events. A number of buildings on the main site are already vacant and due for demolition in due course. In addition further buildings are underutilised. The main examples of this are as follows:

• Hafren: the first floor of this building is occupied as offices, however the ground floor is largely empty, albeit that facilities are maintained due to the use of the first floor. The accomodation comprises an unused ward that has not been converted for alternative use.

• Llewelyn Ward: this remains in clinical use for patient care, but a number of bed areas are closed, and not in use.

• N block – outpatients: this area is currently used as an outpatient suite, but is poorly designed and under-utilised.

The organisation is significantly hampered by the logistics associated with having its HQ and administrative functions dispersed across the Mansion House and the main site. Approximately 120 staff are located on the main site and 67 in the Mansion House. 1.4.1 Quality of Environment The problems being faced in respect of the Mansion House are significant and challenging and centre on the following issues:

• Poor quality of environment The 2011 Estates Condition Survey identified that Bronllys Hospital site has a backlog maintenance value of £3,818,709 - this accounts for 45% of the total backlog maintenace for PtHB (net of fees, VAT and contingency).

The Mansion House and IT department have a backlog maintenance value of £500,663 (net of fees, VAT and contingency) indicating the scale of the refurbishment required to bring this part of the site up to standard.

The layout of the Mansion House compromises staff working conditions and general working environment. The building has been little altered from its origins as a domestic house, and a number of staff are housed in temporary buildings.


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There are concerns in respect of the loading on electrical systems that are not designed to support modern technology. The building is heated by three separate heating systems that frequently break-down and are difficult to control when in operation. The physical layout of the building includes long corridors and isolated rooms that do not lend themselves to operational requirements for staff working in the facility. The general state of the repair and decoration of the building is poor.

• Poor state of IT department/sustainability

The IT Department is located in a temporary building sited to the side of the Mansion House. The units are old and in a poor state of repair. They would require a substantial investment to bring up to an acceptable level of repair. The state of the structures causes a number of problems with the security systems that monitor the buildings, resulting in a number of false alarms being raised. The main computer room for the Health Board is contained within a former garden building attached to the IT Department.

A number of reports including Welsh Audit Office reports have identified the risks associated with the continued use of these buildings around service resilience/security including the security of person identifiable information. The Universal Power Supply system is at end of life, together with a number of air-conditioning units and the fire suppression system. The power coming into the computer room needs to be upgraded as it is at the limit of its capacity.

Service Reconfiguration is resulting in additional demands for IT and Telecommunication services from the Bronllys site. Relocating the core systems (network switches, site data servers, telephone switchboard etc) from the Mansion House will reduce single points of failure and risks to the integrity of the cabling by removing a large section of single ducting. It will also help in providing more flexibility in managing future provision of telephone extension moves and service enhancement.

• Health and Safety/Statutory Compliance

The age and layout of the Mansion House building have resulted in a number of health and safety and statutory compliance concerns. This includes:

• Unfit for the purposes of the DDA • The need to electrically re-wire the building


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• The need to upgrade emergency lighting

Disabled access is also poor in out-patients. The Mansion House is accessed via a separate road with mature woodland to either side. The house is also surrounded by gardens and further woodland that require regular maintenance for general appearance but also to minimise the risks of falling trees. Staff in the Monnow block on the main site have been temporarily re-located due to risks identified in respect of asbestos in the building. Work has been initiated to rectify this problem, but more extensive works are required than originally envisaged. Completing this work is essential to the on-going operation of the organisation.

• Headquarters and wayfinding

The main hospital site is accessed via the main drive and the Mansion House is accessed via a separate entrance which is also shared with a childrens residential home and neighbouring houses. Having both routes of access causes a great deal of confusion to patients and visitors to the site for deliveries, attending meetings and training events.

A connecting track between the main site and Mansion House is currently closed due to the additional cost of maintenance required.


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2. THE ECONOMIC CASE The Project Team has reviewed the Economic Case presented in this BJC and confirmed that the following objectives, constraints and benefits are all relevant to the scheme.

2.1. INVESTMENT OBJECTIVES The following investment objectives have been idenitified for this scheme:

• To provide an improved environment for staff currently located in the Mansion House which complies with health and safety and statutory compliance regulations

• To facilitate the efficient working of services within the entire site by achieving better utilisation of the estate, and facilitate multi-disciplinary working

• Reduce energy costs and carbon emissions through more efficient use of space

• Reduce facilities costs through more efficent use of space • Vacate those parts of the Bronllys Hospital site that no longer

have a use

2.2. CONSTRAINTS

• Health and safety and statutory compliance issues must be addressed at the earliest possible opportunity

• The project must achieve (at least) revenue neutrality • The opportunities for relocation are limited by the current

physical envelope of the site and by limited commercial opportunities on the scale required for rented office accomodation in what is a very rural area

• Moves must be carried out with the minimum possible disruption to current service delivery

• The scale of administrative staff, and their level of travel across Powys requires the availability of sufficient parking

• The capital costs of converting accomodation to office standards


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2.3. OPTION APPRAISAL A workshop was held with core team members to generate a long list of options that had the potential to achieve the planned objectives. 2.3.1 Long List of Options Options Accepted or

rejected option 1 Do nothing Accepted 2 Backlog Works to Mansion and IT Accepted 3a Decant from Mansion and IT, reconfigure

site using Glasbury option Accepted

3b Decant from Mansion and IT, reconfigure site using Monnow option

Accepted

4 Rental of Tax Office Brecon – for current Mansion occupants

Accepted

5 Purchase of Tax Office Brecon – for current Mansion occupants

Accepted

6 New build on the Bronllys site Rejected 7 New build on commercial land Rejected 8 Refurbishment of Builth Hospital Rejected

As a result of the workshop, options 6 and 7 were discounted on the grounds that the level of capital required would not be available. It was also unlikely that planning permission for Option 6 would be forthcoming given the planning status of the site. Option 8 was also discounted on the grounds that it would be too large to accommodate just the Mansion House staff, and would result in the tHB maintaining an interest in two sites and not reduce the tHBs overall estate. 2.3.2 Short listed options A more detailed narrative on the shortlisted options is given in the following section:


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Option 1: Do Nothing

Under this option, staff would remain in the Mansion House.

Advantages Disadvantages No disruption to staff Accommodation is not fit for

purpose Backlog of maintenance on

Mansion House and IT would remain outstanding

Staff remain dispersed on the site Health and safety concerns would

not be addressed Risk of catastrophic IT failure not

addressed Buildings continue to deteriorate Majority of staff continue to be

based in sub standard office accommodation

This option would not meet the current requirements for Health and Safety of employees.

Option 2: undertake backlog Works to Mansion and IT Staff would remain in the Mansion House and IT with a programme of works implemented to address the outstanding building and maintenance issues.

Advantages Disadvantages No disruption to existing hospital site

Disruption to staff whilst building works take place on existing office accommodation

Health and Safety issues would be addressed

Productivity would not improve as building layout would not be addressed

Staff remain dispersed across the site

Site utilisation not maximised High ongoing maintenance costs


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Option 3a: Decant from Mansion and IT, refurbish site including Hafren, Glasbury and N block

This option creates a new headquarters in N block, and relocates remaining staff from the Mansion House and IT into refurbished areas in Hafren, Glasbury and N block. This would require some staff currently in N block to also move to Hafren, and the relocation of outpatients to improved accommodation in Llewellyn ward.

Advantages Disadvantages Use of vacant accommodation on the hospital site maximised

Requires movement of Outpatients within the Bronllys site

Delivers fit for purpose accommodation

Parking on the main site would be more difficult

Creates HQ on the main site Disruption to Library whilst building works take place

Reduces energy costs from staff being based together in a smaller area

Improved clinical environment for Outpatients

Backlog of works to Mansion will no longer be necessary

Health and Safety issues would be addressed

Productivity and efficiency would be addressed

Creates front door for HQ

Option 3b: Decant from Mansion and IT, reconfigure site using Monnow option

This option creates a new headquarters in N block, and relocates remaining staff from the Mansion House and IT into three refurbished areas in Hafren, N block and Monnow. This would require some staff currently in N block to also move to Hafren, the relocation of outpatients to improved accommodation in Llewellyn ward, and the relocation of the manual handling training room from Monnow.

Advantages Disadvantages Use of vacant space on main hospital site maximised

Requires movement of Outpatients within site


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Advantages Disadvantages Fit for purpose accommodation

Parking needs to be identified to accommodate additional staff on the hospital site

Maintain HQ presence on the Bronllys site

Disruption to Library whilst building works take place on existing office accommodation

Reduction in energy costs from staff being based together in a smaller area

Outpatients services provided from a better clinical environment

Backlog of works to Mansion will no longer be necessary

Teams are able to be located together to forge closer working relationships and maximise efficiency

Creates front door for HQ

Option 4: Rental of Tax Office Brecon This option would allow for the transfer of a number of staff, equivalent to that currently in the Mansion House, to an empty office building in Brecon through a lease arrangement.

Advantages Disadvantages

Fit for purpose accommodation

All staff could not be accommodated in this facility so some would remain in Bronllys

Creates HQ No parking provision for staff Addresses Health and Safety issues

Additional travel expenses to be incurred due to change of base

Partially addresses productivity

Building to be returned to original state on vacation

IT infrastructure would need to be redeveloped on both Bronllys and Tax Office site

Possible staff resistance to relocation

Adds a further site to the tHB


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Advantages Disadvantages portfolio to manage

Option 5: Purchase of the Tax Office Brecon

This option would allow for the transfer of a number of staff, equivalent to that currently in the Mansion House, to an empty office building in Brecon through purchasing the building.

Advantages Disadvantages Fit for purpose accommodation

All staff could not be located in this building

Creates front door for HQ No parking provision for staff Addresses Health and Safety issues

Additional travel expenses to be incurred due to change of base

Partially addresses productivity issues

IT infrastructure would need to be redeveloped on both sites

There may be staff resistance to change in working arrangements

Adds a further site to the tHB portfolio to manage

2.3.3 Non-financial option appraisal A workshop was held with key stakeholders to undertake an option appraisal against the key benefits criteria identified by the project.

Benefits Criteria

Weighting Option 1

Option 2

Option 3a

Option 3b

Option 4

Option 5

Improved environment

for staff

5 0 50 82 85 55 55

Facilitate more

efficient and productive

working

3 0 24 42 45 18 18

Improve space

utilisation

2 0 4 26 30 14 14

Delivery of front door to HB and HQ

4 0 22 60 64 40 40


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Business continuity

and security

4 0 32 60 60 36 40

Total score per option

0 132 270 284 163 167

Ranking 6 5 2 1 4 3 2.3.4 FINANCIAL OPTION APPRAISAL An appraisal of the annual discounted cash-flow of the scheme over 15 years using a 5% annual discount factor has been undertaken based on the capital and revenue costs of each of the schemes. The DCF has assumed only the immediate quantifiable revenue savings in its calculation consistently across all options. Option Capital

requirement (incl. VAT)

Revenue consequenc

es per annum

(saving)

Annual Discounted Cash flow over 15 years

Ranking

1 Do Nothing

0 0

2 Complete back-log maintenance for Mansion House and IT

802,097 22,000 57,829

4

3a Decant Mansion House and IT with Glasbury

800,889 (54,000) 44,941

2

3b Decant Mansion House and IT with Monnow

688,680 (67,000) 21,964

1

4 Rent tax office in Brecon

387,586 91,000 99,467 5

5 Purchase tax office in Brecon

567,586 18,000 54,183 3


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The financial option appraisal demonstrates that Option 3b, whilst not the least cost capital option, is the preferred option when discounted over 15 years. Risk Listed below are the high level risks identified for the project. A full risk analysis is attached at Appendix 3. Risk Mitigation IT business continuity IT work will be completed first and

team moved to new location. Will also be advised of all moves in order to schedule accordingly.

No capital funding On-going dialogue with Welsh Government

Disruption to hospital working/ safety/fire safety arrangements Service continuity during reconfiguration

Good planning with Design Team & Contractor at an early stage. Regular site meetings with heads of dept throughout project Implementation to be carefully planned. Individual risk assessments will be undertaken regarding individual areas

Staff resistance Staff engaged in design process and improvements in working conditions identified

Planning and regulation constraints

No work is planned to listed buildings or requiring planning permission. Architect responsible for meeting building regulations

Asbestos work required in proposed areas

Refurbishment and demolition survey to be completed. Allowances for delays to be built into programme. Account taken of previous known risks within buildings

Asset value of Mansion Market valuation undertaken.


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House not realised Market property on open market.

2.4 IDENTIFICATION OF PREFERRED OPTION

Analysis of the financial and non-financial option appraisal identifies that the preferred option from the economic appraisal is Option 3b. This option is most able to realise the benefits of the project and is the most affordable revenue terms. In capital terms whilst it not the least cost option, it is the most cost effective option when the discounted cash-flow appraisal over a 15 year period is taken into account. As noted in the table above, this option incurs one of the lowest capital investments and delivers the most revenue savings consistent with qualitative costing. This option encompasses the following:

• enhance Llewellyn ward clinical rooms to enable the transfer of outpatients from N block.

• relocate Podiatry services from N block to the Day Hospital co-locating it with other therapy services

• relocate Workforce and Organisational Development team from N block to a refurbished Hafren building

• re-locate the Payroll team from Basil Webb and co-locate with the Workforce and Organisational Development in the Hafren building

• re-locate the IT Hub and team to the Hafren building • refurbish N block to create a headquarters and re-locate the

Executive team from the Mansion House • redesign the Library currently located in N block to make more

efficient use of space • re-locate the Finance team in part of refurbished M block • re-locate Medicines Management team to Basil Webb (no works

required) • re-locate other staff to other vacant space on site (no works

required)


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3. THE COMMERCIAL CASE This scheme is a priority scheme within the tHB’s Annual Plan. The Project Team identified the following objectives when considering how the scheme should be procured:

• to ensure business continuity • to address urgent health and safety and statutory compliance

issues in a timely manner • to minimise disruption to services as far as possible • to consider sustainability of services • to achieve good value for money • to complete the whole project within 1 year

This scheme will be procured within the the tHB’s capital procedures as it falls outside of the lower threshold for the Designed for Life 2 framework. The building works will be procured using the JCT form of contract without ‘quantities’. The design team will be retained by the Health Board during the construction phase.


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4. THE FINANCIAL CASE

4.1. INTRODUCTION This section describes the capital and revenue consequences of this scheme.

Main Assumptions The revenue costs are based on full year costs for 2012/13. This business case assumes that the source of capital funding will be via a Capital Resource Limit allocation from the Welsh Government. The capital costs have been prepared to pre-tender estimate costs by the scheme Quantity Surveyor (TC Consult) and include: ▪ VAT at 20% ▪ MIPS at 2Q12 ▪ Contingency at 10% on all works costs

A net capital receipt of £300K is assumed from the sale of the Mansion House to support the business case. It is assumed that this receipt would be retained by the Health Board in line with normal practice. 4.2. CAPITAL COSTS

Budget capital cost forms are attached at Appendix 4 and summarised in the table below, including fees, contingency and VAT. These costs also take into account the net capital receipt from the Mansion House where applicable:

Option Description £000

1 Do nothing 0

2 Undertake backlog works to Mansion and IT

802

3a Decant from Mansion using Glasbury option

801

3b Decant from Mansion using Monnow option

689

5 Rental Tax office 388 6 Purchase Tax office 568

All options include an equivalent level of essential works in the capital costs to repair L ward roof and decant Mansion House and the IT hub.


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4.3. CAPITAL COSTS OF PREFERRED OPTION

The capital costs of the preferred option are assumed to be funded by WG and are summarised in the table below.

Element Cost (excluding

VAT) £'000 Cost (Including

VAT) £'000

Works Essential Works to M ward and Llewellyn roof 86 103

Essential works to relocate IT

119 143

Other works costs to vacate Mansion House

576 691

Works Total 781 937 Fees 45 45 Non-works costs 5 6 Equipment 0 0 Contingency1 Incl. Incl. VAT Reclaim 0 0 Capital receipts (300) (300) Total 531 689

In summary the capital costs of this scheme total £689K that includes:




VAT Treatment

1 10% contingency is included within the building cost estimates


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VAT is calculated at 20% and the Powys tHB VAT advisor will be asked to assess the position on recoverable VAT. For the purpose of the BJC we are assuming at this stage no (zero) VAT will be recoverable, with the exception of fees which are assumed to be fully recoverable. However experience of similar refurbishment schemes would suggest that up to 20% of VAT could be recoverable which would reduce the capital costs by approximately £30,000. Capital Charges (Depreciation)

In accordance with the Capital Investment Manual (2.4.2), VAT that is paid and not recovered is included in the calculation of the capital charge. Capital Charges now only consist of Depreciation. The District Valuer will be asked to provide a valuation of the completed unit; the estimated final valuation is expected to be 25% lower than the construction cost, the effect of the valuation discount being a reduction of future capital charges. The building asset will be recorded on the balance sheet of Powys tHB at the initial valuation given by the District Valuer and written down over its useful economic life. The downward revaluation would be classified as an AME under the current accounting guidance and therefore Powys tHB will be seeking resource funding from the Welsh Government and this will not have an adverse impact on the Operating Cost Statement.

• It is assumed that building will have a reassessed 30 year lifespan.

• It is assumed that the equipment has a 7 year life.

4.3 Revenue costs The table below provides a summary of the revenue saving estimates for each option, full details of which are provided in Appendix 4

Option Revenue consequences per annum (saving)

1 Do Nothing 0 2 Complete back-log maintenance for Mansion House

22,000


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and IT 3a Decant Mansion House and IT with Glasbury

(54,000)

3b Decant Mansion House and IT with Monnow

(67,000)

4 Rent tax office in Brecon

91,000

5 Purchase tax office in Brecon

18,000

Revenue costs that have been included in the analyis are:

• facilities and maintenance costs • capital charges • staff costs (cleaning/maintenance/portering/post-room) • site efficiencies (transport, stationery, equipment) • staff productivity

It is assumed that all other staff costs remain equal in all options.

4.4.2 Affordability

With the approval of this business case it is expected that the capital costs will be funded through the all Wales capital programme. Additional capital charges together with all additional revenue costs from the implementation of this project and associated service developments will be fully offset by savings. The net savings to the Health Board of £67K is predominantly achieved through the greater utilisation of the site. It is assumed that the saving that will result from this development will be retained by the Health Board to offset its structural deficit. Assumptions that Underpin Affordability

The working assumptions in calculating the above costs are as follows;

• Costs are based on standard rates at 2012/13 prices and are indicative.


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• One off costs associated with disruption as a result of the development have not been factored in. It is assumed these will be fully mitigated by the Health Board.

• WG will fund the capital costs.


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5. THE MANAGEMENT CASE The project will be managed in accordance with the principles laid down within the Capital Investment Manual and the Treasury Green Book 5.1 PROJECT MANAGEMENT ARRANGEMENTS The Project Sponsor will be Powys teaching Health Board. The Interim Director of Planning and Public Health (Powys tHB) has been appointed as Project Owner and is the Senior Responsible Officer (SRO). It is the responsibility of the SRO to ensure that project management arrangements to deliver the project on time, to budget and to the desired quality have been put in place. The project also reports to the South East Powys Project Board as a workstream within that project. The following Project Management arrangements have been put into place:

• Locality General Manager South Project Director • Head of Estates and Property Project Manager

A Project Team is already in existence and in the next phase will be supported by the following external advisors

• Design George and Tomos • M & E Corporate Consult Services • Quantity Surveyor TC Consult • CDM Co-ordinator TC Consult

5.2. PROJECT TEAM

The Project Team will be chaired by the Project Director who will:

• establish an appropriate project organisational structure and communication process;

• ensure that the project brief, clearly, reflects the project objectives

• ensure the project achieves the expected benefits and is completed within the approved costs and timescales

• approve any additional expenditure


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• ensure that the project remains a viable business proposition • approve the quality criteria and the control mechanisms for the

delivery of the projects • establish a progress and reporting procedure ensuring that any

changes affecting the project are fully evaluated • report the progress of the project to the tHB’s Board of Directors

through the Project Owner The tHB’s design champion will be consulted as part of the process. The team will be advised on risk management issues by the tHBs’ Risk Management Officer.

5.3 PROJECT COMMUNICATIONS AND REPORTING ARRANGEMENTS Project records will be maintained based upon good audit practice and will be determined by the responsibility of the Project Team. Minutes will be taken at all meetings. In order to ensure the task-focus of the project, prior to the closure of each meeting an agreed action list will be circulated for all team members. The Project Director will be responsible for providing regular progress reports to the Senior Responsible Owner. (Powys tHB) The Project Director will be responsible for providing the key link with major stakeholders not represented on the Project Board to report progress All members of the Project Team will have responsibility for cascading information within their respective work areas and departments. The Project will report to the South East Powys Project Board andPowys Teaching Health Board Executive Management Team. Regular reports will also be submitted to the Powys Partnership Forum.

5.4 OUTLINE PROJECT PLAN

June 2012 submission of draft BJC to Board of Directors/tHB Board

July 2012 receipt of tendered costs


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July 2012 formal submission of BJC to Welsh Government

July 2012 approval of BJC

August 2012 begin works onsite

March 2013 Executives move into new HQ

April 2013 Mansion House placed for sale on the open market

5.5 POST PROJECT EVALUATION Powys tHB is fully committed to ensuring that a thorough and robust post-project evaluation is undertaken to ensure that positive lessons can be learnt from the project. The lessons learnt will be of benefit to: ▪ Powys tHB – in using this knowledge for future projects including

capital schemes ▪ Other key local stakeholders – to inform their approaches to

future major projects ▪ The NHS more widely – to test whether the policies and

procedures which have been used in this procurement effective The review will establish whether the anticipated benefits have been delivered. It is anticipated that this review will commence one year after the completion of the project, and will be completed by the Project Director and Project Manager for submission to the tHB’s Capital Planning and Estates Strategy Group.


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APPENDIX 1 – SITE PLAN

DP01d Site Development Plan_14


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APPENDIX 2 – SITE CONTROL

MANSION HOUSE AND BRONLLYS HOSPITAL

SITE CONTROL PROGRAMME

Bruce Whitear: Interim Director of Planning Andrew Barron: Head of Estates and Property


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Area proposed for disposal

Mansion House This houses approximately 90 office based staff including the executive team. It also houses the boardroom and post room. It has a high level of backlog maintenance and is no longer fit for purpose.

IT & Information This department is located in a group of cabins at the back of Mansion House. It was intended to be temporary accommodation some years ago when this function was less important to the organisation. It is not fit for purpose.

Main site proposed for retention

Please refer to the Development Control Plan in Appendix A.

Medical Accommodation (“The Orchards”) A group of 4 bungalows constructed in 2002 specifically as residential accommodation for Doctors in training. The units consist of 2 bungalows each with 3 bedrooms; 1 bungalow with 2 bedrooms and an “On Call” bungalow with 1 bedroom. All 4 units are in excellent condition.

P Block This is currently empty and is in poor condition.

N Block This currently houses the Outpatients department, Workforce Development and Medical Library. In general the building is in reasonable condition.

Day Hospital and L Ward Llewellyn Ward was refurbished in the 1990’s is generally in an acceptable condition and accommodates up to 24 General Practitioner and Consultant lead general medical patients including stroke.

Ambulance Station Small detached building to the west of the site.

Hafren Ward The ground floor of this building is unused and available for immediate access for refurbishment.

The first floor is occupied by Occupational Health and Psychology.

Admin Block This currently houses administration teams and medical secretaries.

Current use


Page | 32

AMI This was opened in 1999 to accommodate 29 Acute Mentally Ill patients with facilities for Occupational Therapy support. Currently able to accommodate 24 patients with OT area now largely converted to LDU unit for 2 patients.

Defynnog Ward is part of AMI and was refurbished in 2006/2007 to accommodate the Learning Disabilities Unit which moved from Llanidloes. This accommodation has recently become occupied by the Mental Health Planning team.

Pain Management Pain management centre building provides office and residential accommodation. At present, this is working on a two month on - two month off schedule for residential programmes with outpatient programmes being run in between. 10 people are staying at the centre when running residential programmes. The pain management centre also houses offices and administration for the pain and fatigue service.

Chapel The Chapel was built and dedicated in 1920 and is a Grade 2 listed building. The Chaplains have agreed there are insufficient patient numbers or staff to justify its continued allocation as a place of worship. The building is not in use.

O Block Approximately 1/3rd of the building is sublet as an independently run crèche on a non repairing lease inclusive of heating lighting and water. The remainder of the building is used for document storage and amongst the poorest of the building stock.

Monnow Ward A former ward constructed in the 1920’s; it is currently used as office accommodation and as a training base for manual handling training. It is approximately 70% occupied with poor use being made of available space. Asbestos removal is currently being undertaken.

Vera Vallins, Dining and Kitchen Much of this block has been the subject of refurbishment in recent years. It is generally in a good state of repair. A large proportion of the building is used as offices.

Stores This building is currently used as a short term store and waste handling facility.

Shop This area is divided into 2 rooms and is currently used for document storage.

Glasbury Ward This is currently empty.

E Ward This is currently empty.


Page | 33

Basil Webb This is a Grade 2 listed building. It currently accommodates operational HR and Payroll functions along with a meeting room.

Bungalows 1 and 2 Located towards the middle of the site next to Basil Webb these are currently used as locum residential accommodation. The buildings have high occupancy rates and are in reasonable overall condition. They are adequate for the current purpose in the short to medium term.

Hillview This is currently occupied as office and outpatient accommodation by the Child and Mental Health Services (CAMHS). It is in better condition than the other 2 bungalows having been refurbished prior to its current occupancy.

Concert Hall The concert hall is currently used by patients attending the pain management courses.

Courtyard Adapted and added to over the years. Parts are currently used for office accommodation and as stores and offices space for the Estates and Works department.


Page | 34

Area proposed for disposal

It is proposed that the accommodation and services currently provided from the Mansion House and IT cabins are re-provided on the main site to enable the disposal of the top part of the site.

The Health Board also has plans to reduce the overall need for office accommodation on site over the next 10 years through:

• Introducing flexible working • Relocation of staff to locality teams • Reductions in HQ staff • More efficient use of accommodation

The impact of this is difficult to quantify in terms of the specific buildings and their use, but will enable flexibility as to which buildings can be released for non-NHS use and/or demolition for development.

In addition the clinical service model for services on site is in the process of being changed that will require reductions in the clinical space requirements on site.

Main site for Retention

Medical Accommodation (“The Orchards”) These are to be retained under Enquiry by Design (EBD).

PtHB is likely to have no need to use these buildings from the autumn of 2012 following changes to the model of medical care currently being developed and implemented.

P Block Demolish.

N Block It is proposed that this block will house the Executive Team and the Medical Library.

PtHB will need to retain this building in the long-term (5 years+) unless alternative accommodation is provided.

Day Hospital and L Ward The tHB is planning to consult on the transfer of 8 beds and associated services to Brecon Hospital from June 2012. This will enable the transfer of outpatients from N block into vacant accommodation.

12 GP beds will remain that will require accommodation in the long term. The tHB’s intention would be to commission these from a care home provider as the opportunity arises. PtHB will need to retain this building in the long-term (5 years+)

Ambulance Station The ambulance service has indicated that their strategy for the deployment of ambulance services is unlikely to require future use of this building.

Future use


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Hafren Ward This building is planned for retention under EBD. It is planned to utilize it for office staff as part of the mansion house decant.

Admin Block This building will have a use as office accommodation, but could be released for demolition.

AMI The current model of mental health services is not sustainable and there are plans to move to a community based crisis model that would likely no-longer have a requirement for hospital beds.

Alternative forms of accommodation for people with mental health problems in crisis may be required in and around South Powys. Further work is underway to define these requirements.

Pain Management This service is currently planned to be retained on site, though there are some risks to the sustainability of the service due to numbers of patients referred. If the service has a long term future, improvements in the residential accommodation are required: an option would be to achieve this through changed use of the medical accommodation on site.

Chapel This needs to be retained as listed.

PtHB has no need to use this building.

O Block Alternative accommodation would need to be found for the crèche and records storage to enable this block to be released for demolition.

Monnow Ward This block will be fully utilized for office accommodation following decant of mansion house.

Vera Vallins, Dining and Kitchen This block is earmarked in part for retention under EBD. It could be released in future as the requirement for catering on-site reduces and office staff are accommodated elsewhere.

Stores This has no long term use.

Shop This building is retained under EBD but has no long term use to the tHB.


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Glasbury Ward This is currently empty and it is proposed to demolish.

E Ward Demolish.

Basil Webb Under the EBD plans this was to be vacated and offered to the local community for community use.

Bungalows 1 and 2 No long term use by the NHS

Hillview No long term use by the tHB. New accommodation required, co-located with other children’s services.

Concert Hall This building has no long term use by the tHB.

Courtyard This building has no long term use by the tHB.


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APPENDIX 3 – RISK REGISTER

Risk register June review v4.xlsx

APPENDIX 4 – CAPITAL COSTINGS

Capital costings for Mansion decant June APPENDIX 5 – REVENUE COSTS

Mansion revenue (Discounted cash flow

Mansion revenue (13 June 12).xlsx

APPENDIX 6 – PROJECT PLAN

Mansion Decant v15 (for BJC.pdf

FOR APPROVAL

Strategic Equality Plan Page 1 of 3 Board Meeting 27 June 2012

Agenda Item 2.5


AGENDA ITEM 2.5

STRATEGIC EQUALITY PLAN

Report of Director of Workforce and OD

Paper prepared by Equalities Manager

Purpose of Paper To present the Strategic Equality Plan

Action/Decision required The Board is asked to APPROVE the Strategic Equality Plan and the Strategic Equality Objectives to enable the objectives to be operationalised and implemented.


1. Governance and accountability framework 2. Equality, diversity and human rights 3. Health Promotion, Protection and Improvement 5. Citizen Engagement and Feedback 6. Participating in Quality Improvement Activities 7. Safe and Clinically Effective Care 8. Care Planning and Provision 9. Patient Information and Consent 10. Dignity and respect 11. Safeguarding Children and Safeguarding 18. Communicating Effectively 19. Information Management and Communications Technology 24. Workforce Planning 25. Workforce Recruitment and Employment Practices 26. Workforce Training and Organisational Development




SEP – Strategic Equality Plan

FOR APPROVAL


Agenda Item 2.5

STRATEGIC EQUALITY PLAN

Background Producing a Strategic Equality Plan and Strategic Equality Objectives is a specific duty imposed on public bodies in Wales to help demonstrate that they are paying due regard to the Equality Act 2010. A relevant process of engagement and consideration of evidence informed the development of this plan which was published on 2/4/2012 in accordance with Welsh Government directive. The plan was published in draft at that time to offer a six week opportunity for secondary engagement which included Health Board staff as well as the general public. Only one additional comment was received during the period, which suggested that the section profiling the Powys population needed more in respect of children. The SEPlan The updated Plan is attached. The first section of the Strategic Equality Plan (SEP) introduces the Equality Act 2010 and the specific duties for Wales. The next section provides a profile of Powys together with information regarding the Health of the population. This section is followed by a description of the work of the Health Board and the particular challenges of delivering services in a largely rural area with an aging population. The final section of the plan contains the Strategic Equality Objectives. These reflect both what people told us was important to them and analysis of the evidence available to us. Interestingly, the objectives are similar to those recently published by the Welsh Government and other Health Boards which serves to validate Powys Health Board’s “direction of travel”. The Health Board worked closely with Powys County Council whilst formulating the objectives and continues to do so. One innovation resulting from this collaboration is that the Health Board and Powys County Council share an objective to engage effectively with members of the public on equality matters. The objectives as they are set out in the SEP are listed below. Objective 1 – Better more accessible information on services; Objective 2 – Engagement – Joint Objective with Powys County Council; Objective 3 – Attitude; Objective 4 – Access to services; Objective 5 - Working for us; Objective 6 – Collating and analysing evidence; Objective 7 – Healthy and sustainable communities; Objective 8 – Communication; Objective 9 – Employment and gender pay monitoring

FOR APPROVAL


Agenda Item 2.5

The objectives incorporate reporting arrangements against each objective which will be monitored by the Equality Steering Group.

Conclusion The Strategic Equality Plan acknowledges and will compliment other key Health Board business and service frameworks such as the One Plan, the Annual Plan and the Standards for Health Services through objectives, the HB will support delivery of these strategies to strengthen relationships between the Health Board its staff and the population of Powys by ensuring the organisation is paying due regard to the Equality Duties. Recommendation The Board is asked to APPROVE the Strategic Equality Plan and the Strategic Equality Objectives to enable the objectives to be operationalized and implemented. Report prepared by: Presented By: Susan Stavrides Joanna Davies Equalities Manager Director of Workforce and OD Background Papers Strategic Equality Plan

Financial Consequences Aligns with core activities.

Other Resource Implications As above

Strategic Equality Plan

2012 – 2016

June 2012

of 43 Strategic Equality Plan Final version 11 June 2012

Foreword

Powys Teaching Health Board (tHB) covers a large rural area from Machynlleth in the north to Ystradgynlais in the south. Serving a population of approximately 130,000, the tHB leads the delivery of primary care services through GP surgeries, dental practices, ophthalmic practices and pharmacies; provides a range of community based services through a network of community hospitals and community based teams and is responsible for arranging more specialist health care for the people of Powys. The tHB has a dedicated public health function and also plays an important role in supporting other organisations such as the County Council, the voluntary sector and carers, who contribute to the Health and Well Being of the people of Powys.

As a Health Board we recognise that all of us have a role to play in achieving our shared aspirations for Powys; everyone has an important contribution to make and we must ensure that everybody has an equal opportunity to contribute. In delivering services to a diverse population we also realise that everyone has different needs. This Powys tHB Strategic Equalities Plan sets out what we will do to meet these needs to help improve the quality of life for all the people of Powys. As a public services provider we have to do this in a more challenging economic climate. The necessity of delivering better value for money will require an improved understanding of the needs of the people of Powys and how they interact with services. This understanding will enable us to target our resources towards those who need them most. Essentially it’s about understanding the diversity of our communities as a whole and responding to need on that basis. Working with partner organisations is key to enabling us to do this effectively. This Powys tHB Strategic Equality Plan will allow us to work in partnership with our staff, with other organisations and with the people of Powys. It will ensure we are a good employer and a good place to work, as well as a provider of excellent health services. The Plan also sets out to help those people in Powys who may not find it easy to enjoy the same life opportunities as others because their needs are different.

We are delighted and excited by this opportunity to work with our staff, partner organisations and the people of Powys as we embed the new equality legislation into our daily activities, exploring with local communities ways in which we can all work together to enhance the health and well being of the people of Powys.

Andrew Cottom Mel Evans


Contents

Introduction 3

What do we mean by equality? 3

Equality ‘Act 2010 3

General Duty 3

Public Sector Duties (Wales) 4

About Powys 4

Healthy Powys? – some facts 4

About the Health Board 6

How Powys Teaching Health Board created its strategic equality objectives 6

What we are already doing 7

Leadership 8

Equality Information 8

Monitoring, reporting and publication 9

Employment Information 9

Procurement 10

Your views 10

How to contact us 10

What you told us 11

The Strategic Equality Objectives 15


Introduction

Welcome to Powys Teaching Health Board’s first Strategic Equality Plan. Described as a “road map”, the Plan sets out how Powys tHB will pay due regard (proper reasonable attention) to its duties under the Equality Act 2010.

Equality is everyone’s business. The Health Board knows that individuals have different needs and that they should be given the opportunity to ensure the services we provide and arrange meet those needs.

What do we mean by equality?

Equality means “An equal society protects and promotes equal, real freedom and opportunity to live in the way people value and would choose, so that everyone can flourish. An equal society recognises people’s different needs, situation and goals and removes the barriers that limit what people can do and be”

Equality Act 2010

The Equality Act 2010 came into force 1st October 2010. The Act brought together many pieces of equality legislation into one place to provide a single legal framework. This makes it easier to define what all public bodies should do to more effectively tackle disadvantage and discrimination. This obligation is called the “General Duty”.

General Duty

Public bodies must pay due regard to:

• Advancing equality of opportunity between persons who share a relevant protected characteristic and persons who do not share it;

• Eliminating discrimination, harassment, victimisation and any other conduct that is prohibited under the Act

• Fostering good relations between persons who share a relevant protected characteristic and persons who do not share it.

What are the protected characteristics?

• Gender • Age • Disability • Race • Gender re-assignment • Religion or belief • Sexual orientation • Pregnancy and maternity • Marriage and civil partnership


Public Sector Equality Duties (Wales)

In Wales, public bodies have been given specific duties to undertake in order to help demonstrate that they are paying due regard to the public sector duty. These duties are different from the rest of the United Kingdom.

The specific duties are:

• Setting equality objectives and publishing a Strategic Equality Plan by April 2012; • Engaging with people in relation to the protected characteristics; and • Collecting and publishing information relevant to compliance with the General Duty.

The Welsh Government set out these requirements in its Equality Act 2010 Statutory Duties Wales (Regulations) 2011 and offered the following principles to guide this work:

Use of evidence; Consultation and involvement; Transparency; Leadership.

About Powys

Powys is an extensive, largely upland and extremely rural county covering 2000 square miles, representing approximately a quarter of the area of Wales. With only 1 person in every 10 acres (4 hectares) it is one of the most sparsely populated local authority areas in England and Wales.

The county has tremendous landscape assets ranging from the dramatic mountains of the Brecon Beacons National Park and the rolling hills of Radnor Forest to the Berwyn Mountains in the north, with some of Britain's most spectacular river valleys including the Severn, Wye and Usk, sweeping through its glorious scenery.

The economy is based on agriculture and tourism, with high self-employment and small businesses predominating, and an important contribution to employment opportunities from the public sector.

Healthy Powys? - some facts. (Welsh Health Survey as at September 2011)

Adults who reported meeting physical activity guidelines in the past week - 38% (Wales 30%)

Adults who were obese - 17% (Wales 22%)

Adults who reported being a current smoker - 23% (Wales 24%)

Adults who reported binge drinking on at least one day in the past week - 25% (Wales 27%)

Adults who reported currently being treated for a mental illness - 7% (Wales 10%)

Adults who reported currently being treated for high blood pressure - 17% (Wales 20%)


Adults who reported currently being treated for a respiratory illness - 14% (Wales 14%)

Adults who reported currently being treated for arthritis - 11% (Wales 13%)

Adults who reported currently being treated for a heart condition other than high blood pressure - 7% (Wales 9%)

Adults who reported currently being treated for diabetes - 6% (Wales 6%)

As reported by the Director of Public Health for Powys, we know that overall the people of Powys enjoy better health and wellbeing than Wales as a whole. However, when we look deeper, it is apparent that there are hidden inequalities between different communities in Powys.

Additionally, the statistics above do not fully reflect the inequalities arising from living in a rural area. Of particular concern is the aging population. The number of residents aged 80 or over in Powys is projected to rise and many more people are living much longer. This makes it all the more important that individuals are able to enjoy the extra years available to them. It also makes it especially important that appropriate support and services are available to enable this to happen.

Hard to reach groups

Hard to reach groups such as households under stress, vulnerable people and ethnic minorities are all less likely to engage in consultations, democratic processes and community activity. Residents belonging to minority groups are individually more likely to become victims of hate crime in rural areas than in urban areas, because there are relatively fewer of them, despite a lower actual incidence rate of hate crime.. Carers

Informal carers, usually family members or friends, contribute substantially to maintaining individuals with complex needs due to long term physical or mental ill health, disability or old age in the community or at home. Many carers themselves have specific needs, as their own health and well being can be affected by their caring responsibilities. Their caring responsibilities can also compromise their ability to access the services they need. Overall, 42.7% of respondents in the Rural Wales Survey 2007 said that they had provided care for neighbours or friends in the last twelve months Single adult households Poverty is a major cause of inequality affecting life opportunity and the quality of life of all ages The estimated percentage of Powys households with children that had only one adult rose from 11% in 1991 to 21% in 2007 (Wales 14% in 1991 27% in 2007). The first Census of Children in Need in Wales, (CIN census 2010), identified that for every 10,000 children aged 0 to 17 in Powys there were 60 children in need due to their family being in acute distress compared with a Wales ratio of 24 per 10,000 children.


The Children and Young People’s plan highlights the particular issues for children living in a rural and sparsely populated county. These issues: isolation, transport, access to services etc are similar to other population groups. About the Teaching Health Board Powys tHB’s core purpose is to improve the quality and range of services available to local people and to ensure timely access to safe and appropriate health services when needed. Working with a range of other organisations, including our partnership with Powys County Council, Community Health Councils and voluntary sector organisations, the tHB is responsible for providing local services to reflect the needs of the people of Powys. Powys tHB operates in a very challenging environment and is required to meet targets for access to services and high standards for the delivery of care within the finite budget provided by the Welsh Government. Powys tHB has particular challenges in terms of delivery of care in a large rural area with difficult transport links, and an aging population which is living longer and therefore likely to place greater demands on the services we provide. How Powys Teaching Health Board has created its strategic equality objectives

With the Welsh Government guiding principles in mind we analysed what our own organisation was doing and looked at what other information and evidence was available.

Together with Powys County Council we arranged a number of events, surveys and focus groups under the banner of “How Fair is Powys”. We asked our communities what they wanted us to include in the strategic equality objectives and whether they agreed with what our research was telling us.

Strategic Equality Objectives

Based on what you told us and the evidence available we have arranged our Strategic Equality Objectives under the following headings:

• Objective 1 – Better more accessible information on services; • Objective 2 – Engagement – Joint Objective with Powys County Council; • Objective 3 – Attitude; • Objective 4 – Access to services; • Objective 5 - Working for us; • Objective 6 – Collating and analysing evidence; • Objective 7 – Healthy and sustainable communities; • Objective 8 – Communication; • Objective 9 – Employment and gender pay monitoring;


What we are doing already

Powys One plan

As a key organisation responsible for delivering public services in Powys, the tHB has joined forces with other Powys public bodies in a new way of working called One Powys. The aim of this approach is to improve the Well Being of the people in Powys by working together to deliver services.

To achieve this public bodies in Powys have formed a Local Service Board. (LSB). The LSB has agreed to focus efforts on delivering 10 key outcomes:

• People in Powys live in supportive, sharing and self-reliant communities; • People in Powys benefit from a thriving, diverse economy; • People in Powys have the skills to pursue their ambitions; • Powys families are safe and supportive places in which to live; • People in Powys are healthy and independent; • People in Powys live in good quality affordable homes; • People in Powys enjoy a clean, safe and green environment; • People in Powys feel and are safe and confident; • People in Powys are supported to get out of poverty; • People in Powys can easily access the services they need;

In developing these outcomes, the LSB used a similar approach to the one the tLHB has used to identify its strategic equality objectives, i.e it looked at available evidence and asked individuals for their views.

Powys Teaching Health Board’s Annual plan

Each year the tHB is required to prepare a plan that sets out what it wants to achieve for its residents, how it will do it and when. This Annual Plan has indentified the following strategic aims.

• Improving the health of all communities • Delivering access to integrated services that are fit for the 21st century • Aiming/Driving/Striving for excellence in everything we do. • Involving/engaging the people of Powys • Making every Powys pound count.

Impact assessment.

The Health Board routinely considers how its policy making and activities might affect individuals and groups including those protected under the Equality Act 2010. If an assessment of the impact of a policy or activity reveals the likelihood of a substantial impact with regards equality, the assessment as well as the action taken to mitigate this impact will be published.

Putting The Citizen First – Standards for Health Services in Wales


“Putting the citizen at the heart of everything and focussing on their needs and experiences, making the organisation’s purpose the delivery of a high quality service,” is at the heart of the Welsh Government’s Citizen Centred Governance principle.

The Standards for Health Services in Wales set out the

“common framework of standards to support the NHS and partner organisations in providing effective, timely and quality services across all healthcare settings”.

The Standards for Health Services in Wales include a specific standard for equality.- Standard 2. The actions planned to make sure that the organisation meets the standards are part of the Annual Plan.

There are clear links between the One Powys Plan, the Annual Plan and the Strategic Equality Objectives.

Leadership

The Director of Workforce and OD is the Executive portfolio holder for Equalities and Welsh Language. Professor Paul Dummer is the Board Equality and Welsh language champion. A strategic Equalities and Welsh Language Steering Group with Board level membership provides assurance to the Board that the organisation is paying due regard to its equality duties. The Chief Executive regards Equality as the golden thread running through the organisation. This is emphasised in the annual plan and directorate plans. All papers submitted to the Board or to meetings of the Directors are required to have been equality impact assessed beforehand.

Equality information

As well as the information already held by the Health Board in fulfilling its Annual Plan, other evidence scrutinised has included:

• The evidence from the How Fair is Powys engagement events with Powys County Council. “How Fair is Powys” is how the Health Board and Powys County Council described their joint engagement activities;

• The How Fair is Wales investigative report undertaken by the Commission for Equality and Human Rights;

• The “How Fair is Powys” public questionnaire undertaken with Powys County Council; • Statistical analysis for Powys with Powys County Council; • Needs assessment generated from the Powys One Plan; • Staff diversity questionnaire; • Case study on access to gender re-assignment; • Case study on domestic abuse provision in Powys; • Focus group on transport; • Welsh Language Framework; • The Older People’s Commissioner’s report on dignified care; • The Health Board’s Annual Quality Framework; • Welsh Government statistical analysis.


Monitoring, reporting and publication

Monitoring

The strategic equality objectives will form the basis of an equality monitoring action plan. The first version of the action plan, a companion document to this Strategic Equality Plan, will be published by the end of June 2012. The action plan will be monitored by the Strategic Equality Steering Group. The action plan is where we will set out what we want to achieve, by when, how we will achieve it, and how we will know change has occurred.

Reporting

We will report at least once a year on progress in meeting the strategic equality objectives. During 2016 we will report to the Welsh Government on how well we have performed in relation to the specific public sector equality duties for Wales. We will contribute as required to Welsh Government when the Government reports on how public bodies in Wales are paying due regard to the General Duty. The first of these reports will be during 2014.

All of these reports will be made available publically together with relevant equality impact assessments arising from our policy and decision making.

We will also update and keep people informed during the How Fair is Powys events and the other activities and networking opportunities planned to fulfil our engagement objective.

Publication

Our reports will be published on our public website and circulated to key mailing lists. Reports will be available in different formats and some written reports displayed in public areas.

Employment information

In addition, to producing a Strategic Equality Plan and Strategic Equality Objectives, the Health Board is required to report at least once a year on how we are paying due regard to the General Duty with regard to our employment practices. To do this, we will need to carefully and confidentially consider the following.

Gender (equal pay)

Men and women employed arranged by job, grade, pay, contract type and working pattern

By protected characteristic

The people we employ on 31st March each year.

• People who applied for and were appointed to jobs over the last year • Employees who have applied to change position within the Health Board, how many were

successful and how many were not. • Employees who have applied for training, how many succeeded in their application and

how many completed the training. • Employees involved in grievance procedures either as a complainant or as a person

against whom a complaint was made.


• Employees involved in disciplinary procedures. • Employees who have left the Health Board’s employment.

Procurement

Procurement is a Specific Duty for Wales. Powys Teaching Health Board enters into agreements and contractual arrangements with external organisations to provide works, goods and services. We will ensure that due regard is given to the General Equality Duty throughout every stage of the procurement process and when monitoring these agreements and contracts.

Training

Training has been highlighted as a Specific Duty for Wales. Training is strongly featured within our strategic equality objectives.

Your Views

We welcome you views and comments on any aspect of this plan to help us inform and further develop our work.

How to contact us

To comment on this plan or to find out more about how Powys Teaching Health Board is embracing the Equality Act 2010, to share your views or experiences with us or to request a copy of this document in an alternative format please

Contact

Susan Stavrides, Equality Team Powys Teaching Health Board Mansion House Bronllys Brecon LD3 0LS

Email: [email protected]

Tel: 01874712637


What you told us

A significant amount of information has been collected from our engagement process and as part of the analysis of information. The engagement process included public events, focus groups, one to one interviews, public and staff questionnaires, and workplace meetings and activities. As well as tHB staff, managers and the Board members, contributors to the process included individuals and representatives from voluntary organisations and County Councillors. All of the protected characteristics were represented but we know that further work is needed to engage with the harder to reach groups of people. This will be one of the actions arising from implementation of the shared engagement objective with Powys County Council.

The engagement process also gave us the opportunity to raise public and staff awareness of the equality duties and the associated Strategic Equality Objectives. During the How Fair is Powys public events, people were asked whether or not they agreed with the key findings within the How Fair is Wales report produced by the Equality and Human Rights Commission. They were asked what if anything was missing or different for Powys and what they considered the key issues to be. They were also asked to identify a key priority.

The questionnaires also asked some general questions regarding equality and diversity.

Interestingly, the staff questionnaire and the engagement events held by the tHB for its staff and managers identified similar issues and priorities to those identified during the public activities. The Strategic Equality Objectives incorporate these.

The information provided below provides some examples of the key themes which have emerged and which have informed our equality objectives. These can be summarised into the following areas:

• Communication and information about services provided and how to access these;

• The attitudes of service providers towards people using services

• Transport issues and access to services

• Rural isolation and poverty

1 COMMUNICATIONS/CUSTOMER CARE/ UNDERSTANDING AND AWARENESS

“Shortcoming and failures in accessing services are never put right. This must change even if some individuals’ problems seem unsolvable. "

The strongest views expressed around life and health were around attitude, particularly of health workers, engagement generally and information. Delegates acknowledged that on the whole, the services that were needed were already available but that members of the public and other organisations either did not know about them or were put off by difficulties in accessing them.

For instance


“Could we use the internet to provide a confidential service for health – a doctor online for advice and information – thus improve access to health services in rural areas”

The fact that in health we believe that this facility already exists serves to emphasise the mismatch between the service and users. Clearly, the way we currently provide information and access to services needs to be reviewed and where appropriate improved.

Alongside this, there was a clear message on the need to raise awareness of the populace of several issues impacting on health and well being. Or put another way – targeted campaigns. For instance you said:

“Promote the image of different backgrounds to gain acceptance and tolerance"

“Develop health promotion campaign series specifically for men”

“Farmers Health – Help make them aware of what is available”

With regards specifically to farmer’s health, a group of delegates suggested a manned information stand at markets. Some thought that this idea could easily transfer to provision of a multi-agency stand at local produce markets as well.

There were also a number of comments around the theme of the need to raise basic awareness of the difficulties facing some of our communities and individuals for example;

“Disability links/leads to mental health due to a lack of understanding and support from social services/housing.”

“Acknowledge that people need to access services in different ways – deaf and hard of hearing – education; basic skills levels – mental health/abuse – reluctance for invasive examinations.”

“Understanding the pressures people face on a day to day basis not only from time to time”

2 TRANSPORT AND ACCESS

“There need to be more accessible services in County, i.e. specific services, counselling, hospital appointments”

“Transport to carry on being funded”

“Poverty restricts access to health care, social and economic activity. More joint planning and delivery of services particularly transport needed”

Transport and concern about the continuation of existing funding for community transport initiatives was a recurring theme. Some users of community and patient transport also felt that the current model of provision does not meet their needs. For instance:

“ I have a bus pass due to my disability. Will community transport accept my bus pass in lieu of payment of the unaffordable (to me) charges”


The correlation between lack of mobility in a rural area and life opportunities was also a concern for many. Young people expressed their fears of not being able to find suitable future employment due to transport difficulties.

During discussion an advocate suggested that there might be funding streams available to bid for driving lessons for young people.

“Older people, disabled people, people on low incomes either cannot access or cannot afford to get to health/social/educational appointments. Quality of life/self esteem affected”

Systems and processes/changing the way we work

“services are often geographically spread. Understand how that impacts”

“For some vulnerable people, receiving their healthcare in their first language Welsh is a necessity. We should recognise and address this.”

“With no ICD10 code GPs are not empowered with diagnostic or treatment protocols for conditions such as electro magnetic hypersensitivity.”

“Interpreter funding – cross border issues”

“Booking appointments in surgeries. Could we incorporate self-booking technology over the internet”

“Why is it only 10p a mile for HC2 holders in Powys when for the rest of Wales it is 15p a mile?”

3 EMPLOYMENT OPPORTUNITIES AND PAY

Delegates also queried the fairness and transparency of employment policies. References to the gap between the highest and lowest paid public body staff were frequently made. As was the view that the highest paid public body staff should take a salary cut before resorting to laying off lower paid staff.

Employment was raised during all group discussions and also highlighted by some as a priority issue with regards health. The correlation between income, life opportunity and self esteem and resulting health was continually emphasised. A delegate suggested the community enterprise model as a way of alleviating poverty.

4 VOLUNTEERING AND ISOLATION

“Rural isolation and the importance of individuals is my top priority”

“Support networks for older LGBT people should be accessible or developed to reduce isolation and the impact on potential mental health issues”

A delegate spoke about recent incidences of suicide amongst the LGBT community in Powys exacerbated by lack of awareness within the primary care services. The need for emotional support and education to be provided to LGBT people to prevent them turning to drugs and alcohol and further mental health issues was also stressed.


Another recurring theme was that of the opportunity to foster intergenerational links.

“People to visit old people in their homes – re: loneliness, rural isolation and age”

The suggestion of facilitating communities to work together to address the problems of rural life was also explored with regards to the potential benefits to young people as well as older people. For instance, during discussion about apprenticeships for young people, older people teaching young people to drive was mooted.

“Mentors in schools and colleges”

Although ostensibly mentoring in schools aligns more with education and employment, some thought there would be benefits by offering mentoring support in relation to hate crime and health prevention, particularly with regards self-health screening in boys, sexual health and sexual identity. Disability Wales suggested sports idols as powerful influencers of boys and creating ways to harness this.

5 LANGUAGE AWARENESS

The importance of understanding the language needs of services users was another theme, both in terms of Welsh and other language needs.

“For some vulnerable people receiving their health care in their first language Welsh is a necessity. We should recognise and address this”

“Dignity and respect to language and culture - Language awareness.

There were many other views expressed during the engagement sessions, ranging from the particular issues around domestic abuse and those facing the gypsy/traveller communities, to the problems and insecurities of deaf, mentally ill people and others such as Welsh speakers wanting to access health services but feeling unable to and disenfranchised.


The Strategic Equality Objectives

Objective 1 Better, more accessible information on services

Why do we want to do this?

You told us: We know: Who will benefit You told us that it was not always easy to know what public services are available to people living in and visiting Powys. You also told us that even when you do know what is available it is not always easy to find out how and when to use a particular service. For instance, there are many advocacy schemes available in Powys but the need for advocacy was raised during all of our engagement activities.

We know from our research and from the findings of others that this is not a new problem or a problem unique to Powys. We also know that Powys is well served by organisations providing services that enhance the experiences and knowledge of health service users but that these have sometimes been developed in a separate rather than planned coordinated way. We also understand the importance of language choice and need.

Everyone will benefit, including service users, health service professionals and members of all the protected characteristic groups. The more people know about and use existing services, the more efficient and effective and relevant those services will be.


What are we doing already?

One Plan (Powys Community Strategy) Annual Plan (Powys Health Board’s business and service framework)

People in Powys can easily access the services they need People in Powys are healthy and independent People in Powys live in supportive, sharing and self-reliant communities

Delivering access to integrated services that are fit for the 21st Century Aiming/striving for excellence in everything we do.

Protected Characteristics covered Gender, pregnancy and maternity, age, religion and belief, race, disability, sexual orientation, gender re-assignment and also Welsh language.

What else can we do?

How will we do it When will we do it We will look at and analyse what information the Health Board currently provides and how we make it available. We will update and enhance existing information if needed and add any information on services that might be missing. We will also find out what information other organisations provide on their services and activities and where relevant add details of these services to our own information. The Health Board’s website will be one of our main ways of publicising services but we will also use our Annual Report and the Powys communications hub. Information will be made available in other formats and be displayed in public areas. The Health Board’s recent appointment of a communication officer will help greatly to strengthen this area.

We expect to have completed our initial look at what is available by March 2013 but we will make some early improvements to our website and other sources of information in the meantime. During 2012/13 we will also work with other organisations to find ways of making it easier for people to find out what they need to know about public services. By year two, 2013/14 we anticipate being told by you that things have improved.


We will work with others including the local authority and voluntary organisations to find ways of making it easier for people to find out what they want or need to know regardless of where they might make contact or look.

How will we know how well we are doing? How will you know how well we are doing? The initial fact finding exercise will in itself prompt areas for improvement. This will provide actions that can be easily measured. Each completed action will indicate that this objective is being achieved. We will also ask you if you are finding it easier to find information on and use health related services.

We will update you on progress at least once a year at one of our engagement events. We will also publish a written report, which will also be available in other formats, once a year.


Objective 2 Engagement - Joint Objective with Powys County Council


You told us: We know: Who will benefit You told us that you wanted more opportunity to let us know how we are doing and how we could do better especially when providing services for those with particular needs or characteristics. You also told us that it is important that we feedback to you. This objective as well as the communication objective will help us to do that.

We know how important it is to ask people who need and use health services how well those services are meeting their needs when planning and reviewing our work. This is especially true of our equality work. We also know that all public bodies in Wales have been asked to devise strategic equality objectives and that it makes sense for public bodies to work together when asking the same questions. We know we need to find better ways of finding out what people with certain particular protected characteristics think of and want from their health providers. We know this from the engagement activities we arranged to inform the equality objectives.

Everyone will benefit, including service users, health service professionals and members of all the protected characteristic groups. Those harder to reach groups of people will especially benefit as this objective will require us to work harder to find out what people who share a particular protected characteristic think of their health services.


What are we already doing?


People in Powys are healthy and independent. Involving/Engaging the people of Powys Protected Characteristics covered

Gender, pregnancy and maternity, age, religion and belief, race, disability, sexual orientation, gender re-assignment and also Welsh language.


How will we do it When will we do it We will have a joint Strategic Equality Objective with Powys County Council specifically for engagement. This objective will continue the work of “How Fair is Powys” that was used to inform our strategic equality objectives. How Fair is Powys is how the Teaching Health Board and the local authority are describing the events and activities they have undertaken together to inform this plan and the strategic equality objectives.

The work will begin April 2012 and will be monitored and reported on at least annually. During 2012/13 we will continue with the How Fair is Powys events and other engagement activities.. By year two, 2013/14 we anticipate being told by you that things have improved

How will we know how well we are doing? How will you know how well we are doing? You told us that you want more opportunity to let us know how we are doing and you also told us that you want us let you know how we have acted upon what you have told us. We will know how well we are doing this by asking you and by

We will update you on progress at least once a year at one of our engagement events. We will also publish a written report, which will also be available in other formats, once a year.


expanding the range of views put forward to us to include those more difficult to reach groups of people who are not already engaging with us.


Objective 3 Attitude.


You told us: We know: Who will benefit You told us that you sometimes find it difficult or don’t want to use our services because our staff do not always understand or are aware of your particular difficulties. You also told us that you have seen instances of hate crime within your community. One or two of you told us that the attitude of some staff towards other members of staff could be better.

We know from our research and from the findings of others that this is not a new problem or a problem unique to Powys. We also know that the attitudes, beliefs and values of individuals and those they interact with can have a profound effect on those around them and their health and well-being. From hate crime to treating vulnerable people with dignity and respect; from dignity in the workplace to embracing the Welsh language “fostering good relations” is a fundamental equality duty.

Everyone will benefit, including service users, health service professionals and members of all the protected characteristic groups.




People in Powys live in supportive, sharing and self-reliant communities. People in Powys feel and are safe and confident.

Improving the health of all communities. The tHB creates an organisational culture in which it treats all its service users, staff and partners with dignity and respect at all times

Gender, pregnancy and maternity, age, religion and belief, race, disability, sexual orientation, gender re-assignment and also Welsh language.


How will we do it When will we do it We will use our influence as an employer to make sure that people who work for us understand and value difference and the importance of treating everyone with dignity and respect. We will do this in a number of ways including providing appropriate training, standard setting, seeking feedback from service users and routine monitoring mechanisms such as reviewing complaints and letters of thanks. Recognising that success in this area will be more easily achieved through strong leadership, Executive Directors and Independent Board members will be taking a keen and active interest in progress and will personally demonstrate how important a healthy and respectful attitude is in the workplace.

The work will begin April 2012 and will be monitored and reported on at least annually. During 2012/13 we will review the training needs of the organisation to address attitude not only in terms of relationships between staff and members of the public but also as leaders and peers within the organisation. We will also participate in the national NHS staff survey. During 2012/13 we will also work with other organisations to tackle hate crime and negative behaviours. By 2013/14 we anticipate being told by you that things have improved.


Working with others including the local authority we will run specific campaigns and initiatives.These will aim to make members of the public more aware of the impact of negative attitudes and hate crime on health and wellbeing and how they can help minimise this. Others things we will do include, a staff survey, continuing to using quality improvement tools such as the fundamentals of care to monitor patient care, and continuing through workplace initiatives to ensure and improve the health and well being of our staff. .

By 2014 we plan to have been awarded the Platinum Corporate Health Standard.

How will we know how well we are doing? How will you know how well we are doing? We will ask you. We will ask other organisations including Dyfed Powys police. We will monitor staff training and our business and service improvement plans.

We will update you on progress at least once a year at one of our engagement events. We will also publish an annual written report which will also be available in other formats.


Objective 4 Access to services


You told us: We know: Who will benefit You told us of the difficulties of using services, especially health services in a rural and sparsely populated area such as Powys. Transportation, distance travelled and opening times featured largely here. You also told us about the difficulties the way we do things can cause people with different needs. An example you gave us was the difficulties experienced by a deaf person being asked to telephone to confirm a hospital appointment Other things you told us included the fact that sometimes people providing health services do not always understand or respond the special needs of some people wanting to use the services. Also, that you don’t always know what services are available and how to use them.

We know that transport is a major issue in many parts of Wales and especially so in Powys. We know that there are many reasons why people do not use health services and attend their appointments. We know that low income families and people with caring responsibilities find it especially difficult to access services. Again the reasons are many but examples might be not being able to afford to travel to the service, or to take time off work or away from caring duties. We know that you want services to be available to you as locally and conveniently as possible.

Everyone will benefit, including service users, health service professionals and members of all the protected characteristic groups. The more people use existing services and attend their appointments the more efficient effective and relevant those services will be. The health benefits of making health (and other public) services more accessible to people are many. Taking action to make it easier for certain groups of people to use their public services could improve their emotional well-being, reduce isolation, and improve life opportunities from an early age. By making services more accessible, the number of hospital and other health service appointments which people fail to attend will be reduced which in turn will improve efficiency, help to reduce waiting times and save public money.




People in Powys can easily access the services they need. Delivering access to integrated services that are fit for the 21st century

Protected Characteristics covered Gender, pregnancy and maternity, age, religion and belief, race, disability, sexual orientation, gender re-assignment and also Welsh Language


How will we do it When will we do it We will explore with the Local Authority and others the transportation difficulties with distance to and from health services being a particular focus for us. We will review our systems and processes to make sure they are sensitive and responsive to the different needs of people. We will begin with those issues you have already drawn our attention to during the “How Fair is Powys” campaign. We will make sure that our staff are given relevant and appropriate training.

The work will begin April 2012 and will be monitored and reported on at least annually. We expect to have completed the initial review of our systems and process on what is available by the end of 2013. During 2012/2013 we will also work with other organisations to find solutions to the transport issues. By 2015/16 we anticipate being told by you that things have improved.


How will we know how well we are doing? How will you know how well we are doing? The initial fact finding exercise will in itself prompt areas for improvement. This will provide actions that can be easily measured. Each completed action will indicate that this objective is being achieved. We will also ask you when we meet you if you are finding it easier to use health related services.



Objective 5 Working for us.


You told us: We know: Who will benefit You told us about the difficulties finding and sustaining work and especially well paid and permanent work in and around Powys. You told us that it is even more difficult for people who experience mental health problems and other disabilities to secure and maintain a job. Age was also of major concern; not only the problems associated with being perceived as an older worker but also the fears and experiences of young people in these financially challenging times. The impact on families, especially children, where the household income is restricted as a result of caring responsibilities or other earnings limiting factors was another area of concern. You also told us that the Health Board, as a major employer in Powys has an important role to play in ensuring fairness and opportunity for all of its existing employees. A general concern raised during “How Fair is Powys” was the gap between the

We know from our research that this is not a new problem or one unique to Powys. We know that equality of opportunity, especially with regards employment is of major concern to the Welsh Government and the Commission for Equality and Human Rights. This is why there is a specific requirement for public bodies to report on employment information by protected characteristic. We also know that child poverty and life opportunity is another major concern of the Welsh Government. Access to good, well paid employment for Powys people is fundamental to alleviating this.

This objective will benefit staff who already work for us by helping to ensure that the Health Board is a fair and good employer and by helping them to reach their full potential. Older and younger people will benefit from the innovative work experience, training and employment schemes being put in place. These schemes will also encourage good relations between generations. Sensitive employment practices and initiatives that assist people with particular difficulties into work will help to reduce economic disadvantage and improve the social mental health problems associated with unemployment and low income.


lowest paid and highest paid public body employees and the difficulty for certain groups of people to progress within their organisation. Suggestions you made included, apprenticeships, innovative work experience initiatives, older and younger people working together or otherwise benefiting from spending time together.




People in Powys live in supportive, sharing and self-reliant communities People in Powys benefit from a thriving diverse economy People in Powys have the skills to pursue their ambitions Powys families are safe and supportive places in which to live People in Powys are healthy and independent People in Powys live in good quality affordable homes People in Powys feel and are safe and confident People in Powys are supported to get out of poverty

Making every Powys pound count. Improving the Health of our communities The latest plan includes plans for apprenticeships, cadet schemes and other workforce innovations designed towiden access to employment and Healthy Workplace initiatives including the platinum corporate health standard. The Annual Plan contains a section addressing Workforce and Organisational Development and good employment practices




How will we do it When will we do it We will explore further what might be preventing people from obtaining and or retaining employment with the Health Board. We will also explore the perception that it is difficult for some individuals or groups to progress further with their career development within the Health Board, the NHS or public sector. When we understand what issues there may be, we will take appropriate action to eliminate any practices that might be hindering job opportunities with and within the Health Board. We will also consider ways of providing young people with work experience and opportunities to learn from our more experienced staff. .

The work will begin April 2012 and will be monitored and reported on at least annually. The working group already tasked with looking at pay information will be asked to extend their remit to consider the wider implications of pay inequality. A further small working group will be established at the same time to consider innovative ways of helping people to obtain the experience and skills they need to obtain employment. It will also consider how sensitive policies and procedures are to the needs of specific groups, in particular the protected characteristic groups. We will expect you to tell us that things are improving by, 2014/2015

How will we know how well we are doing? How will you know how well we are doing? We will monitor recruitment and staff movement. We will also ask you how well we are doing. We will participate in the NHS Wales staff survey



Objective 6 – Collating and analysing evidence.


You told us: We know: Who will benefit That you want your public services to be sensitive to your needs. You also told us of your fears for those in the community with fewer advantages or opportunities than others. Additionally you told us that you want to be more involved in the planning and design of services and to be listened to.

We know that successful business cases and clinical interventions are those which collect and base service design and delivery on evidence and best practice. We also know that in order to be able to build an accurate picture of how fair society is and how relevant the services provided are to the needs of the community, we need to be able to examine as wide a range of information as possible.

Those with the greatest need but perhaps not the loudest voices will benefit the most from an improved information base and analysis. Ultimately, everyone will benefit. Good information will make it easier to demonstrate those areas of work that have improved. It will also identify those areas of work requiring development and improvement. Better information will also help us to operate more efficiently by providing services that people want to use and will benefit from using.



One Plan (Powys Community Strategy) objectives: Annual Plan (Powys Health Board’s business and service framework) headings

People in Powys are healthy and independent. Aiming/Driving/Striving for excellence in everything we do. Making the Powys pound count. Improving the health of the community.




How will we do it When will we do it The tHB has already identified the need to increase the availability, analysis and utilisation of high quality information as a key priority. We will secure additional expertise to work with Health Board managers and others to find out what additional information gaps we have and how we can address these.

The work will begin during April 2012. We will complete the initial work by September 2012 and will agree and put effective systems in place by the end of 2012. We will continue to assess information gaps and needs on an ongoing basis thereafter.

How will we know how well we are doing? How will you know how well we are doing? The quality and quantity of our information will increase as will our ability to interpret the information.

We will report at least once a year on this objective. We will also ask you if you notice an improvement in the quality of our services and their relevance to you and the community.


Objective 7 Healthy and sustainable communities.


You told us: We know: Who will benefit You told us that you recognised that it was not possible for the difficulties of living in a rural and sparsely populated area such as Powys to be solved by the Health Board either working alone or with others. You said that with help and guidance from public bodies, individuals and communities could do much to alleviate many of the problems experienced by people especially vulnerable people and people from ethnic and minority groups. You suggested that interaction between older people and younger people might help to reduce isolation and loneliness and to foster good relations. You suggested that the Social Enterprise model might be one way of boosting a community. You suggested people helping one another with their transportation and employment difficulties and with imparting their knowledge and expertise to others, particularly to young people.

We know from our research and from the findings of others that this is not a new problem or one unique to Powys. We know that life opportunity beginning with educational attainment is lower for children living in poorer and more isolated households. We know that there is a higher suicide rate among men in Wales. We know that people over 55 are more likely to be registered as disabled in Wales. We know that younger people often have to move away for work and other opportunities. We know that the population of Powys is an ageing one.

Everyone will benefit, especially older and younger people and people suffering mental health problems attributable to loneliness and isolation. The Health Board will benefit if people use health services more effectively and appropriately and perhaps less often as a result of the support of their peers and communities.


You suggested the use of role models such as sports people in increasing the knowledge of young people to specific health issues or in tackling hate crime.


One Plan (Powys Community Strategy) objectives Annual Plan (Powys Health Board’s business and service framework) headings

People in Powys live in supportive, sharing and self-reliant communities

Improving the health of all communities Involving/engaging the people of Powys Delivering access to integrated services that are fit for the 21st century. Working towards the platinum Corporate Health Standard.




How will we do it When will we do it We will consider what role we have to play as part of our core business and what might be considered to be our additional corporate social responsibility and how we might be able to influence this. We will explore joint initiatives with the Local Authority and others. One idea is to encourage and facilitate greater uptake of exercise for poorer families and isolated individuals. This simple initiative would help to alleviate many inequalities especially mental health and foster well-being and good relations within families. Another joint initiative to be explored with the Local Authority will involve looking at domestic abuse and the roles we as public bodies play in preventing it.

The work will begin April 2012 and will be monitored and reported on at least annually. We expect to have completed our initial look at what is available by the December 2012 but this will not stop us participating with the Local Authority in any obvious and easily achieved initiatives in the meantime.. By year three, 2014/15 we anticipate being told by you that things are improving.

How will we know how well we are doing? How will you know how well we are doing? The initial fact finding exercise will in itself prompt areas for improvement. This will identify actions that can be easily measured. We will also ask you when we meet you if you are finding it easier to find out about and to use health related services and will seek your views on how we are doing as part of our ‘How fair is Powys’ work.



Objective 8 Communications .


You told us: We know: Who will benefit You told us that it was not always easy to deal with the Health Board. Being able to communicate effectively with staff delivering services was your main concern regarding communications. Another area you said you would like us to strengthen was raising public knowledge of how to stay healthy and well You also said that communications between other agencies and organisations and staff who work with patients was sometimes poor and disconnected.

We know from our research and from the findings of others that this is not a new problem or one unique to Powys. We also know that Powys is well served by organisations providing services that enhance the experiences and knowledge of health service users but that these have sometimes been developed in a separate rather than co-ordinated way.

Everyone will benefit, including service users, health service professionals and members of all the protected characteristic groups. The more people are better able to communicate with us about what we do the more efficient and effective and relevant our services will be.




People in Powys feel and are safe and confident People in Powys can easily access the services they need People in Powys are healthy and independent

Involving/engaging the people of Powys Aiming/Striving/driving for excellence in everything we do.

Protected Characteristics This objective covers all of the protected characteristics and the Welsh Language.


How will we do it When will we do it We will look at our communication and engagement systems and processes for sensitivity and relevance to the differing needs of people we want to use them. Under the banner “How fair is Powys” we will, at times working with others, run specific campaigns on “how to stay healthy” or “understanding difference” We will work with others including the local authority and voluntary organisations to find ways of making it easier for people to deal with public services, in particular with regards their health and social care needs. This will include specific focus on how we work with partner organisations and how we communicate with our service users.

The work will begin April and will be monitored and reported on at least annually. By the end of 2012 we hope to have been told by you during the next round of “How fair is Powys” events that the situation is already improving. During 2012 we will have undertaken with the Local Authority at least one awareness raising campaign. During 2012 we will continue to implement the Welsh Language Scheme which commits public bodies in Wales to providing Welsh language services.


We will make it easier for people using our services to do so using Welsh if they choose to. We will also further develop our patient experience work to seek the views of individuals using our services on all aspects of our communications with them before, during and after they have accessed our services.

How will we know how well we are doing? How will you know how well we are doing? The initial fact finding exercise will in itself prompt areas for improvement. This will provide actions that can be easily measured. Each completed action will indicate that this objective is being achieved. We will also ask you when we meet you if you are finding it easier to communicate with the Health Board and other related services.

We will update you on progress at least once a year at one of our engagement events. We will also publish an annual written report which will also be available in other formats


Objective 9 Gender Pay and Employment monitoring.


You told us: We know: Who will benefit You told us that it was difficult for women to obtain well paid employment in Powys. You also told us that you believed that there was too much of a gap between the highest and lowest paid workers.

We know from national evidence that men are paid more than women. All staff who are directly paid by NHS organisation except for medical and very senior managers are paid under a pay system called Agenda for Change which is based on a job evaluation system. Within Powys Health Board, an initial analysis of workforce information shows a mixed position amongst the lower and middle bands. It does appear that in the highest bands men are paid more than women. We need to do more work to understand why this is and what if anything we need to do about it.

By looking closely at pay from an equalities perspective the Health Board will be assured that its policies and procedures are indeed fair. Should it become apparent that any of the protected groups are disadvantaged in any way, a specific equality objective and action plan will be drawn up. Those most likely to benefit from any corrective action would be women, lower paid and part-time workers and people with a debilitating illness or caring responsibilities.



One Plan (Powys Community Strategy) objectives: Annual Plan (Powys Health Board’s business and service framework) headings

People in Powys are supported to get out of poverty People in Powys have the skills to pursue their ambitions People in Powys are healthy and independent People in Powys feel safe and confident

This objective fits with the Aiming/driving/striving for excellence heading of the Health Board’s annual plan.




How will we do it When will we do it A working group with representation from workforce information and equalities experts and trades unions will undertake an audit and analysis of available data, identify any gaps and consider how best to report on findings whilst paying due regard to the Data Protection Act. As well as looking at gender pay differences, this group will also look at the pay profile of the Health Board with regards all of the other protected characteristics. As with gender pay due regard will be paid to information governance. This includes obtaining consent from individual members of staff to collect equality data and robust controls as to who can access this information.

The work will begin April 2012 and will be monitored and reported on at least annually. The first few months of this objective, will be crucial to our understanding the current position and whether or not we will need a specific strategic equality objective to address equal pay. Therefore, we will undertake to publish our preliminary findings by no later than 31st December 2012. We will also commit to publishing what we can of the pay profile information by end of September 2012.

How will we know how well we are doing? How will you know how well we are doing? The initial fact finding exercise will in itself prompt areas for improvement. This will provide actions that can be easily measured We will know by monitoring staff progression and movement, pay bill analysis and other monitoring data. Finally, we participate in the NHS Staff Survey.

We will update you on progress at least once a year at one of our engagement events. We will also publish a written report once a year which will also be available in other formats,. You will also over time be able to compare the employment information we will be publishing each year.

FOR APPROVAL

Workforce Plan 2012/2013 Page 1 of 5 Board Meeting 27 June 2012

Agenda Item 2.6

BOARD MEETING


INTEGRATED WORKFORCE PLAN SUBMISSION 2012

Report of

Director of Workforce and OD

Paper prepared by

Workforce Development Manager

Purpose of Paper

To provide the Board with the integrated workforce plan and education commissioning requirements submitted to NLIAH on 31st May 2012.


The Board is asked to:-

APPROVE the submission of the workforce plan in its current form, noting that it will be subject to further development and refinement over the year as service plans are further developed; and

APPROVE the education commissioning proposals for 2012


The workforce plan incorporates the actions required to make progress across the Standards for Health Boards




N/A

FOR APPROVAL


Agenda Item 2.6

INTEGRATED WORKFORCE PLAN SUBMISSION 2012 BACKGROUND It is a Welsh Government requirement for organisations to submit a workforce plan to NLIAH by the 31st May 2012. This paper summarises the key points within the Powys Teaching Health Board workforce plan submission. The first draft of the workforce plan is attached to this report and is subject to amendments following a review by the Board and also the wider service. The workforce plan reflects the requirements of the entire workforce within Powys Teaching Health Board and there has been widespread engagement and involvement in developing this plan. The workforce plan serves 2 purposes:

- From an organisational perspective to develop the future workforce - From a Welsh Government perspective to inform the education commissions

FUTURE SERVICE DIRECTION FOR POWYS Stage 1 of the workforce plan summarises the strategic direction for Powys Teaching Health Board. It integrates the way forward from a series of policy documents as well as One Powys, New Directions for Powys, the Service Workforce and Financial Framework, the Annual Plan for 2012 – 13 and the Making It Happen Programme. This section also reinforces the future direction of Powys Teaching Health Board as being towards achieving ‘Truly integrated care, centred on the individual’ by

• Improving health and well-being (health) • Ensuring the right access (services) • Striving for excellence (delivery) • Involving the people of Powys (people) • Making every pound count (money)

CURRENT WORKFORCE CONFIGURATION

Within Stage 2 of the workforce plan, a detailed analysis of the current workforce is given which covers:

- Staff Group - Part Time and Full Time by Gender - Equality Profile - Annual Turnover Rate - Age Profiles by Staff Group - Retirement Scenarios by all Staff Groups at age 55 and 60 - Nursing and Midwifery Retirement Scenarios at age 55 and 60 to inform

Education Commissions - Allied Health Professionals/ Additional Professional and Technical and

Healthcare Scientists Retirement Scenarios at age 55 and 60 to inform Education Commissions

- Skill Mix Analysis - Additional hours analysis

Worked FTE in addition to the contracted FTE Agency /Overtime and Bank Usage

FOR APPROVAL


Agenda Item 2.6

FUTURE WORKFORCE CONFIGURATION TO DELIVER THE VISION Stage 3 of the provides an outline in terms of the future workforce configuration. Due to the development of the service model being in progress and the implementation of “Making it Happen” being in its early stages of development, the workforce configuration can only be developed based on what is known about service developments and is within the public domain. As such, at this stage, the plan is unable to fully integrate on both a workforce and financial basis. Utilising the Workforce Configuration Tool, the plan sets out the predicted change in staffing numbers over the next 5 years. This sees a total reduction of 33.32 FTE by 2017. The Tool does not include those staff that will transfer to Shared Services this year. ACTION PLANNING FOR DELIVERY Stage 4 of the plan identifies the key actions, enablers and range of workforce solutions required to meet the future workforce configuration. These include: Recruitment and Retention Deployment and Redeployment Exiting strategies including VERS Workforce re-profiling Changes to work processes and use of technologies EDUCATION COMMISSIONS FOR SUBMISSION IN 2012 Stage 4 of the plan summarises the education commissions required for submission in 2012. There is a nil return for Medical and Dental beyond 2017, as these students are already in the system. There will be a requirement to recruit to Consultant posts in CAMHS and Elderly Care Medicine in the short term as well as some Dentists. The Non-Medical education commissions are detailed in the table below. This table shows:

- Previous requests for education commissions from 2008 to 2011. - The blue shaded column is the column for approval entitled “2012

Submission”. Information has been drawn from the Workforce Configuration Tool, a separate analysis based on future turnover, projected retirements and management intelligence.

- The final 3 columns relate to a piece of work that calculates the projected turnover for a given year and assume a retirement at 55 for Nursing and Midwifery and Allied Health Professionals.

- This can be used to compare the 2012 submission request with the likely total number of leavers for that year broken down into normal turnover and age related retirement projections.

- The retirements assume that all people reaching 55 that year will leave and does not take into account other people already aged 55 or over leaving in the same year, or people leaving earlier than aged 55. Hence, it is likely that this still gives the “higher” end of the demand and is for guidance purposes and to inform decision making.

FOR APPROVAL


Agenda Item 2.6

Proposed commissions for 2013/2014

Course TitleCourse

duration Year Band 2008 2009 2010 20112012

CommissionsTurnover Retirements TOTAL

Ambulance Paramedics 2 years 2015 Band 5 0 0 0 0 0 0.00 0.00 0.00DENTALDiploma in Dental Hygiene 2 years 2015 0 0 0 0 0 0.00 0.00 0.00Diploma in Dental Therapy 27 months 2016 Band 6 0 0 0 0 0 0.04 0.00 0.04NURSING & MIDWIFERYBachelor of Nursing (B.N.) Adult 2016 Band 5 20 20 21 13 18 13.14 15.80 28.94Bachelor of Nursing (B.N.) Child 2016 Band 5 0 0 1 1 0 0.00 0.22 0.22Bachelor of Nursing (B.N.) Mental Health 2016 Band 5 10 10 0 0 0 0.00 0.37 0.37Bachelor of Nursing (B.N.) Learning Disability 2016 Band 5 4 4 1 0 1 0.48 1.00 1.48Return To Practice 6 months 2014 0 0 0 0 0 0.00 0.00 0.00B.Sc. Midwifery 3 years 2016 Band 5 0 5 2 0 2 1.48 0.82 2.30B.Sc. Midwifery 18 months 2015 Band 5 0 0 2 0 2 1.48 1.40 2.88COMMUNITY HEALTH STUDIESDistrict Nursing (Part-time) 2 year 2015 Band 6 3 3 3 0 6 1.00 2.52 3.52District Nursing Modules (in modules) 1 year 2014 0 0 3 11 11* 0.00 0.00 0.00Health Visiting (Full-time) 1 year 2014 Band 6 0 4 2 2 3 1.50 1.20 2.70Health Nursing (Part-time) 2 year 2015 Band 6 0 0 0 0 0 0.00 0.00 0.00School Nursing (Full-time) 1 year 2014 Band 6 1 2 4 7 3 0.62 0.00 0.62School Nursing (Part-time) 2 year 2015 Band 6 0 0 0 0 0 0.00 0.00 0.00School Nursing Modules (in modules) 1 year 2014 0 0 0 0 0 0.00 0.00 0.00Practice Nursing (Part-time) 2 year 2015 0 0 0 0 1* 0.00 0.00 0.00Practice Nursing Modules (in modules) 1 year 2014 4 4 0 0 1* 0.00 0.00 0.00Community Paediatric Nursing (Part-time) 2 year 2015 Band 6 0 0 0 0 2 0.09 0.00 0.09Community Paediatric Nursing Modules (in module 1 year 2014 0 0 1 1 0 0.00 0.00 0.00CPN (Part-time) 2 year 2015 Band 6 0 0 0 0 0 0.00 0.00 0.00CPN Modules (in modules) 1 year 2014 11 11 0 0 0 0.00 0.00 0.00CLDN (Part-time) 2 year 2015 Band 6 0 0 0 0 0 0.30 0.00 0.30CLDN Modules (in modules) 1 year 2014 0 0 0 0 2 0.00 0.00 0.00Modules to enable individuals who completed previous module(s) to undertake additional module(s) 1 year 2014 0 0 0 0 8 to 15* 0.00 0.00 0.00

PHARMACYRegistered pharmacists 5 years 2018 0 0 0 0 0 0.00 0.00 0.00Pre Reg Pharmacy 1 year 2015 0 0 0 0 1 0.18 0.00 0.18Pharmacy Diploma 2 years 2016 3 3 0 0 0 0.00 0.00 0.00Pharmacy Technician 2 years 2015 Band 4 3 3 0 0 1 0.10 0.00 0.10SCIENTIFIC PTPB.Sc. Clinical Physiology cardiology 3 years 2016 Band 5 0 0 0 0 0 0.00 0.00 0.00B.Sc. Clinical Physiology audiology 3 years 2016 Band 5 1 1 1 0 0 0.08 0.00 0.08B.Sc. Clinical Physiology respiratory 3 years 2016 Band 5 1 1 0 0 0 0.00 0.00 0.00B.Sc. Clinical Physiology Technician (Medical Phys 3 years 2016 0 0 0 0 0 0.00 0.00 0.00B.Sc. Biomedical Sciences 3 years 2016 Band 5 0 0 0 0 0 0.00 0.00 0.00B.Sc. Neuro Physiology 3 years 2016 0 0 0 0 0 0.00 0.00 0.00B.Sc. Clinical Engineering in Rehab 3 years 2016 0 0 0 0 0 0.00 0.00 0.00RADIOGRAPHYB.Sc. Diagnostic Radiography 3 years 2016 Band 5 4 4 3 2 0 0.38 0.30 0.68B.Sc Therapy Radiography 3 years 2016 Band 5 0 0 0 0 0 0.00 0.00 0.00Assistant Practitioners Radiography - Diagnostic 1 year 2014 Band 4 0 0 0 0 0 0.00 0.00 0.00Assistant Practitioners Radiography - Therapy 1 year 2014 Band 4 0 0 0 0 0 0.00 0.00 0.00ALLIED HEALTH PROFESSIONALSB.Sc. Human Nutrition - Dietician 2 & 4 years 2017 Band 5 2 2 2 1 0 0.26 0.00 0.26PG Dip. Medical Illustration 2 years 2015 0 0 0 0 0 0.00 0.00 0.00B.Sc. Occupational Therapy , 3 & 4 year 2016 Band 5 11 11 5 6 1 1.29 0.79 2.08Diploma in ODP 2 years 2015 Band 5 0 0 1 0 0 0.05 0.00 0.05B.Sc. Physiotherapy 3 years 2016 Band 5 11 11 4 6 2 1.81 1.84 3.65B.Sc. Podiatry 3 years 2016 Band 5 5 5 0 2 2 0.37 1.00 1.37Orthoptist 3 years 2016 Band 6 0 0 0 0 0 0.00 0.00 0.00Clinical Psychology Doctorate 3 years 2016 Band 8a 0 0 0 0 1 0.15 1.42 1.57B.Sc. Speech & Language Therapy 4 years 2017 Band 5 5 5 0 1 0 0.57 1.00 1.57B.Sc. Speech & Language Therapy - Welsh Langu 4 years 2017 0 0 0 0 0 0.00 0.00 0.00Surgical Care Practitioners 2 years 2015 0 0 0 0 0.00 0.00 0.00PRESCRIBINGV300 Full Independent Prescribing 1 year 2014 0 0 0 0 12** 0.00 0.00 0.00Supplementary Prescribing 1 year 2014 0 0 0 0 2 0.00 0.00 0.00V150 Limited Independent Prescribing 1 year 2014 0 0 0 5** 0.00 0.00 0.00

Total 99 109 56 53 83 - 90 25.37 29.68 55.05

Separate Analysis to inform commissions

Community Modules Numbers which have a * are subject to further validation and also clarification of route for Practice Nursing

The requirements to undertake the Fundamentals of Care as part of the prescribing modules have NOT been taken into consideration

FOR APPROVAL


Agenda Item 2.6

CONCLUSION This workforce plan informs the future direction for the workforce for 2012 – 2017, it is based on the current knowledge about the future service configuration and information that is within the public domain. As such this plan does not fully integrate across service, workforce and finance. However, it can be further developed once service models are agreed and as part of the Making It Happen Programme. This meets the first purpose of the plan as an enabler for the organisation to realise workforce change. To fulfil the second purpose of the plan in order to inform the education commissions for NHS Wales, the plan has integrated information from the sub-organisational plans and the workforce configuration tools, a discrete analysis of projected turnover and retirements and management intelligence to outline the requirements for Powys Teaching Health Board. RECOMMENDATION The Board is asked to:-

APPROVE the submission of the workforce plan in its current form, noting that it will be subject to further development and refinement over the year as service plans are further developed; and

APPROVE the education commissioning proposals for 2012 Report prepared by: Presented By: Lynn Turner Joanna Davies Workforce Development Manager Director of Workforce and

Organisational Development

1

INTEGRATED WORKFORCE PLAN 2012-2017

Name of NHS Organisation Powys Teaching Health Board

I confirm that this Integrated Workforce Plan reflects the organisation’s service delivery plan for the entire workforce, and is a realistic and affordable projection of the workforce implications of those plans, based on our understanding of current workforce intelligence and knowledge of future developments and financial projections. I confirm that we have worked in partnership with trade unions, social care, education, independent, Primary Care and voluntary sectors in the local health economy. I confirm that approval and validation of the information has occurred together with alignment to service and financial plans for all participants. I confirm that all planning occurred in multi professional teams and not by professional groups. Signed (Chief Executive) Name in full: Andrew Cottom Date: 31st May 2012 The organisation’s aggregated plan must be submitted to Workforce Development, NLIAH by 31st May 2012.

2

INDEX

CONTEXT OF THE WORKFORCE PLAN 3

STAGE 1: DEFINE THE FUTURE SERVICE PROVISION AND PLANS 9

STAGE 2: ANALYSIS OF CURRENT SERVICE AND WORKFORCE CONFIGURATION 19

STAGE 3: FORECASTED WORKFORCE REQUIREMENTS AND CONFIGURATION TO MEET FUTURE SERVICE NEED 31

STAGE 4: PLANNING FOR DELIVERY 39

STAGE 5: PERFORMANCE MANAGEMENT 50

STAGE 6: WORKING IN PARTNERSHIP 51

APPENDIX ONE - ANALYSIS OF THE CURRENT WORKFORCE PROFILE 52

1. Staff Group 52

2. Equality profile 52

3. Part Time/Full Time & Gender 53

4. Annual Turnover Rate 53

5. Age Profiles 54

6. Retirement Scenarios for All Staff Groups 56

7. Retirement Scenario: Nursing & Midwifery Registered 57

8. Retirement Scenario: Allied Health Professionals/Additional Professional & Technical and Healthcare Scientists 58

9. Skill Mix 59

10. Workforce Costs (Source: Finance Department) 61

11. Use of Temporary Workforce (Source: Finance Department) 61

12. Sickness Absence 64

3

CONTEXT OF THE WORKFORCE PLAN

C1. Attach the executive summary of the Workforce Plan. The Service Powys teaching Health Board (tHB) was established in October 2009 to set a new direction for the delivery of health care services to the people living in Powys. This means not only thinking about how we currently deliver services, but also looking forward to how we ensure that we improve the quality of what we do for our rural communities over the next 20 years and beyond. We face a number of challenges that are unique in Wales that include:

- the rural nature of Powys; - a small population living in a large geographical area; - the increasing average age of local people; - delivery of advances in medicine in small communities; - a difficult financial and economic climate.

If the tHB does not take action to change the way in which it provides services it is likely that more and more people would need to travel out of the county for treatment, and local services could be lost. Since being established we have been listening carefully to what communities have being saying to us about their services; people of Powys tell us they want the services in the county to be retained and made stronger. They want public services to work closer together and provide a single service. We believe we can make that commitment to the people of Powys but it will also require some difficult decisions both for local people and the tHB. We believe it is best if we tackle these difficult decisions together. Our focus will be to provide services that meet the genuine need that Powys people have for care. Healthcare in the 21st century continues to change rapidly. Complex and effective treatments for common conditions such as cancer, stroke and heart disease need to be provided in increasingly specialist units. For Powys residents this means travelling out of the county for their treatment. Although travelling can be difficult and time consuming, access to the high quality services available in major hospitals does save lives. Advances in medicine mean that providing such care in Powys would no longer be safe. This is not to say that there is no need for local services for the people of Powys. Living in a rural area should not mean that people feel remote from access to healthcare. The tHB is committed to ensuring that, where safe to do so, services are provided locally. These service changes provide an exciting opportunity for Powys staff to develop their skills, making it more attractive for people to work in Powys in a new range of diverse and rewarding roles. With an ageing population and a desire to provide services locally there will always be a need for people to work with patients. This includes both professionally qualified clinical staff and people in support roles that that work directly with patients, often in their own homes. For example we can see the need in the future for:

- nurses with extended skills, including prescribing and in managing chronic conditions, who are able to work across all care settings;

- senior therapists with extended skills able to manage the overall care of individuals; - developing the role of the care manager for nurses, therapists and social workers; - new integrated carer roles working with people at home in support of nurses, therapists and social work teams.

We recognise that change is challenging. We will need to work with each individual in the organisation to ensure that they have a clear development plan that will support them to fulfil their important role in the future of the organisation, and meet the needs of the patients we serve. The Teaching Health Board and Powys County Council are committed to working closely together. Both organisations have a common purpose to provide high quality public services to the people of Powys. We also share common challenges in providing services to a sparse, rural population with limited resources. One of our first priorities in bringing the work of the two organisations together was to share some of our administrative functions. This work is already moving forward and helps us to protect front line services by saving money on support functions. We aim to bring together health and social care services as a single integrated service. Working with the voluntary and community organisations to design and deliver local services is also important to us. We will be able to provide a far greater range of more flexible services for the population, with a choice of care options. Taking a new direction will mean that Powys tHB will be an organisation that:-

- promotes health and wellbeing;

4

- continuously improves safety, effectiveness and patient experience; - captures the benefits of integration across the public sector; - empowers its staff; and - lives within its means.

The Money The total revenue budget for Powys Teaching Health Board is approximately £237 million. Due to the unique position of Powys Teaching Health Board within NHS Wales, two thirds of this budget is utilized for the commissioning of acute and primary care services. The remaining third is attributable to the provider services. The total paybill is approximately £47.5million which is 19% of the total overall revenue budget and 71% of the provider costs. Powys Teaching Health Board is no different than other Health Boards in Wales, in that we are aiming to take costs out of the acute sector. The difference is that we buy this service in rather than directly deliver. This means that whilst we must ensure efficient running of our local hospitals and community services, we will be reliant upon them to deliver services locally in order to avoid onward acute care costs. Our plan is therefore based on the assumption that we will not be significantly diminishing local services but to ensure that they are used efficiently and effectively and that financial balance will be realised by:

- Effective and efficient commissioning of acute and primary care services - Repatriation of services into Powys - Ensuring provider services are efficient and effective

The Workforce Once the scale of the service change is realised both within Powys and also the wider NHS in Wales, workforce redesign will begin to gain pace. This workforce plan articulates the workforce changes that have taken place during the last year but there is much more to be achieved as service change occurs. As such, the workforce configuration in this plan does not show significant change as it only reflects what is currently known and within the public domain. It is recognised that this limited approach will not realise the education commissioning numbers that will be required to meet future service need or indeed to replace our ageing workforce. As a result, we have undertaken a separate piece of work based on detailed analysis and engagement with professional leads to produce the education commissioning numbers. From the workforce analysis we have identified the following key implications:

Workforce Flexibility Currently, Powys has a predominantly part time workforce which gives increased flexibility in service

provision. This may not be a continuous feature of the workforce in Powys as working patterns change in relation to their family commitments.

It is apparent that as the workforce ages, they are likely to increase their hours over time as their family commitments reduce. When they subsequently retire the replacement workforce are likely to be younger and may not want to work full time.

Age Profile The changes from a default retirement age make workforce planning more complex, potentially over the

next five years the Health Board could lose nearly 30% (331.95 FTE) of its workforce based on the current age profile. This poses a risk to the Health Board, particularly in the light of further changes to the NHS Pension Scheme which may accelerate people’s decision to leave. Whilst 2 scenarios have been presented for retirement at 55 and 60, it is likely that neither scenario will be fully realised and management intelligence will be key to ensuring effective workforce planning.

The age profile of the Estates and Works workforce poses a significant risk to the Health Board in terms of service sustainability.

Some of the Allied Health Professionals/ Additional Professional and Technical and Healthcare Scientists groups have small numbers aged over 55, but because of the proportionate size of this workforce, even these small numbers can have a significant impact if they were to retire at the same time.

A lack of a succession plan for an ageing clinical and estates workforce could seriously impact on the Health Board’s ability to deliver critical services.

Temporary Workforce and Sickness The analysis relating to the temporary workforce raised many more questions that require more in-depth

analysis and the engagement of service managers, finance and staff representatives.

5

These implications have been further explored and triangulated throughout the plan resulting in a very comprehensive action plan to develop the workforce which focuses on the following areas:

- Recruitment and retention - Deployment and redeployment - Workforce Reprofiling - Changes to work processes and use of technologies

The Conclusion The production of this workforce plan signifies the start of the journey to deliver the strategic direction of Powys Teaching Health Board. It is recognised that it does not give the full picture of workforce change as the service models are not fully defined. However, what this plan does outline is a comprehensive series of actions that are aligned to the strategic direction of Powys Teaching Health Board that will contribute to delivering a workforce that is fit for the 21st century. We recognise that setting clear objectives however is only one part, albeit an important one, of delivering the expectations of the Board. The focus on translating aims and objectives into practice is of absolute importance, therefore it is not good enough to have ambition and to say what we want to achieve without the ability and discipline to make it happen. Turning ideas and will into delivery will be the success criteria on which this plan is measured.

6

C2. Outline the services covered by this workforce plan. The following charts show the services covered by the plan.

The services highlighted in blue are services provided in Powys but hosted by another agency currently or in the process of being transferred.

- Mental Health services are now a commissioned service provided by Betsi Cadwaladr University, Abertawe

Bro Morgannwg and Aneurin Bevan Health Boards.

- Sexual Health Services and Paediatric Audiology are also a commissioned service.

- Information Services will be transferred from the 1st July 2012 to Powys County Council utilising a Section 33 Agreement. As the transfer of staff is imminent, no workforce developments have being identified in this plan.

- Personnel Operations as part of Workforce and OD will be transferring to Velindre NHS Trust as part of the Wales Shared Service Partnership and therefore no workforce developments have being identified in this plan.

- Procurement to Payment (P2P) and Contractor Payments as part of Finance will be transferring to Velindre

NHS Trust as part of the Wales Shared Service Partnership and therefore no workforce developments have being identified in this plan.

The grey shaded boxes denote the provider services and the unshaded boxes denote the corporate functions.

Locality/Directorate Service / Area Of Work Corporate

Directors Corporate Administration Pain Management

Finance Financial Planning Business Intelligence Management Accountancy Financial Accountancy Financial Services Procurement to Payment (P2P) Contractor Payments.

Performance Information, Communication and Technology Services Performance Management Planning & Commissioning

Planning

Transport Service Planning Emergency Planning Communications

Workforce and OD Human Resources Workforce & OD Modernisation Personnel Operations Occupational Health

Nursing Services

Nursing Management Patient Quality & Safety Clinical Governance Clinical Strategy Complex Care Women and Children’s Services – see detail below. Learning Disabilities Mental Health Quality & Safety Continuing Care Bank Staff Co-ordination Chaplaincy

7

Locality/Directorate Service / Area Of Work Medical Services

Consultant workforce (directly employed) Primary Care Dental Services National Institute for Social Care and Health Research

(NISCHR) Medicines Management/Pharmacy Research & Development

Estates and Works Estates Works

Localities - Community Hospital and Community Services (North, Mid and South)

Hospital Nursing Community Nursing Diabetes – Hosted Domestic Services Elderly Care Medicine Physiotherapy Speech and Language Therapy Locality Management Medicine Occupational Therapy Palliative Care Service Parkinson’s Disease Service Dietetics Lymphoedema service Continence Service Audiology Cardiology Services Radiography Respiratory Services Theatre

Localities - Support Services and Facilities (included in Locality Plans)

Hospital Facilities Portering Services Patient Services Catering Domestic Services Contact Centre

Women & Children Children and Adolescent Mental Health Services Community Paediatric Nurses Community Paediatric Medicine Health Visiting School Nursing Midwifery Paediatric Physiotherapy Paediatric Occupational Therapy Paediatric Speech and Language Therapy Paediatric Audiology Sexual Health Services

8

C3. Insert organisation chart. Board Structure and Accountability

C4. Describe the methodology adopted by your Organisation to develop this plan.

The following is a summary of the methodology adopted to develop this plan.

- Each of the services were allocated according to the chart in C3 above.

- The service providers (shaded grey) in the chart above completed or updated Appendix E from the previous year.

- A workshop was held on the 3rd April which was attended by representatives from all of the service providers, corporate functions and the Executive Team. Each of the service providers presented a summary of their plans at this workshop which allowed for questions, challenge and clarity on the plans. Support required for implementation of the plan was also identified from the corporate functions present.

- Each of the Corporate services gave an overview of their service direction, identify the implications for the workforce and identify any critical issues and future service or workforce requirements.

- The information from the Appendix E plans, presentations, meetings and other forms of communication were summarised into the organisational Powys plan.

- The organisational plan was then circulated out to all the service to ensure that it adequately reflected the individual services.

Main Lead Contact Details: Name: Lynn Turner Telephone: 07976 409 714 Email: [email protected]

Chief Executive

Director for

Public Health

Medical Director

Director Of

Therapies & Health Sciences


Director of

Finance

Associate Director of Performance

Director of Nursing

Director of Planning

Mid Powys Locality

North Powys Locality

South Powys Locality

Women & Children Directorate

Mental Health & Learning Disabilities

9

STAGE 1: DEFINE THE FUTURE SERVICE PROVISION AND PLANS This stage will assist organisations to develop an understanding of the future service activity and associated issues that could affect the profile of the workforce. This stage should be developed alongside the organisation’s Service Strategies.

1.1 Embed a copy of the organisation’s future service plan The ability of the organisation to meet its challenges has been strengthened by action taken during 2011/12 in relation to a number of key factors:

- Appointment of a new Chair, a substantive Chief Executive and substantive Executive Directors following a 4 year period where most directors were interim and there were significant changes in senior personnel.

- Tangible progress in relationships with GPs particularly those who are keen to take a lead in developing health services for the population alongside the teaching Health Board. There is however only a window of opportunity for change, and inaction on the part of the tHB is likely to see an ebbing away of support from General Practitioners.

- Good progress in relationships with local communities, although demonstrable action to deliver on commitments is essential to maintain this still fragile support.

- Restructuring of the teaching Health Board’s senior leaders and managers posts. This foundation will contribute to the delivery of the vision outlined in “New Directions for Powys”.

11 02 06 New Directions for Powys F This is supported by the Annual Plan which describes the aims for the organisation for 2012/13 and probably beyond. It provides clarity on the deliverables and sets out the priorities that all staff in the tHB will be working toward across the following 5 themes:

1. Improving health and well-being (health) 2. Ensuring the right access (services) 3. Striving for excellence (delivery) 4. Involving the people of Powys (people) 5. Making every pound count (money)

These 5 themes will all contribute towards the overall vision and ambition for Powys which is to enable “truly integrated care, centred on the individual”. Setting clear objectives however is only one part, albeit an important one, of delivering the expectations of the Board. The focus on translating aims and objectives into practice is of absolute importance, therefore it is not good enough to have ambition and to say what we want to achieve without the ability and discipline to make it happen. Turning ideas and will into delivery has been a challenge and thus the organisation has at times fallen short of what it wanted to achieve. The recently developed (April 2012) “Making it Happen” programme which will be the key vehicle to enable the delivery of the Annual Plan and achieve a step change in service and financial delivery and performance. The programme will be clinically led and will outline a :

- Compelling vision and common aim based on what is good for patients, the public, staff and the organisation - true understanding of the baseline in relation to performance gaps and opportunities - True understanding of the baseline in relation to organisational capacity and readiness - Robust and relentless programme of improvement which the whole system is aligned to deliver

The Making It Happen programme will provide a systematic and targeted focus, through an organisational development approach, to improve services and reduce costs. It has identified 4 key priorities initially. An analysis of the remainder of the services will determine future priorities. The initial priorities for Making It Happen are:

- Emergency care (non-elective) South East Powys - Elective Care - Maternity Day care - Builth Wells and District Clinical Service Change

10

The diagram below shows the interaction of service, workforce and financial planning on the Health Board. This highlights the strategic direction from both Welsh Government and Powys County Council and the Local Service Board.

New Directions for Powys

SWAFF

Annual Plan

Making it Happen

Setting the

Direction

Rural Health Plan

Joint ICT Strategy

Integrated Health‐ Social Care Services in PowysStrategic Outline Programme

Welsh Government•Programme for Government•Together for Health

Powys County Council • One Powys Plan 2011 – 2014

Powys Integrated Workforce Plan 2012‐

2017


Powys Public Health Strategic

Framework

Working Differently, Working Together A Workforce & Organisational

Development Framework

Mental Health & Learning Disabilities

Women & Children

South Locality

Mid Locality

North Locality

NHS Wales Health Boards

£Financial Plan

2012/13 and beyond

In addition, the table below identifies the key strategies both across and individually for each of the provider services:

Localities Women and Children Mental Health and Learning Disability

Across all services Powys Strategic Direction for Learning Disability Services A Therapy Strategy for Wales Mental Health Measure (Wales) (2010) Children and Families Measure (Wales) 2010 Carers Strategies (Wales) Measure 2010 Sexual Health Services Review for Powys

Individual impact A Vision for Health Care Services in SE Powys

Community Nursing Strategy

N SF for Older People in Wales

Continuing NHS Healthcare Framework

National Stroke Strategy

National Dementia Plan for Wales

The management for Chronic Conditions

Designed to Smile

Powys Single Plan for Children and Young People

NSF for Children, Young People and Maternity Services

A Framework for School Nursing In Wales

A Strategic Vision for Maternity Services in Wales

Integrated Family Support Services

Children’s Continuing Care Guidance (2011) Draft

Delivery Plan for Mental Health Services

Powys Strategic Direction for Learning Disability Services

Mental Health (Wales) Measure 2010

Dementia Vision for Wales Together for Mental Health

2012

The following table shows the interface of all the key strategies in relation to some of the key deliverables in the Annual Plan. The shaded areas denote the strategies which are:

- National - Specific to Powys - Service specific

12

NATIONAL STRATEGIES WHICH

IMPACT ON POWYS POWYS - SPECIFIC

SERVICE SPECIFIC

OBJECTIVES FROM THE ANNUAL PLAN

Programm

e for Governm

ent

Together for Health

NH

S Wales D

elivery Framew

ork

Setting the Direction

Rural H

ealth Plan & W

orkforce Strategy

NSF for O

lder People in Wales

The National Stroke Strategy

Continuing N

HS H

ealth Care

Managem

ent of Chronic C

onditions in Wales

Designed to Tackle C

ancer in Wales

A Therapy Strategy for W

ales

Public Health Strategic Fram

ework

Joint ICT Strategy

One Pow

ys

Powys SW

AFF

New

Directions for Pow

ys

A Vision for H

ealth Care Services in South East Pow

ys

A C

omm

unity Nursing Strategy for W

ales

NSF for C

hildren, Young People and Maternity Services

A Strategic Vision for M

aternity Services in Wales

Powys Single Plan for C

hildren and Young People

Framew

ork for School Nursing

Integrated Family Support Services

Powys Strategic D

irection for Learning Disability

Designed to Sm

ile

STRIVING FOR EXCELLENCE 1 Continuously improve safety, quality and experience of care in all

settings

2 Improve citizen experience of care through listening and learning 3 Create an organisational culture in which the tHB treats all its service

users, staff and partners with dignity and respect at all times

4 Ensure all medicines are prescribed, administered and monitored appropriately

5 Develop and promote a culture of continuous quality improvement 6 Improve strategic risk management and compliance with key legislation

IMPROVING HEALTH AND WELL BEING 1 Improve the opportunities and life chances for Children 2 Reduce the impact of alcohol on individuals, families and communities

3 Decrease the risk of death and disability due to vascular and respiratory disease

4 Increase self-responsibility and self - care

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ENSURING THE RIGHT ACCESS 1 Ensure older frail people are enabled to live safely in the most

appropriate setting through access to local services

2 Ensure that people with a chronic condition are able to access the services they need to manage their condition

3 Ensure early treatment and prompt rehabilitation for people experiencing Stroke

4 Ensure people receive a timely, co-ordinated clinically appropriate response to their need through access to appropriate evidence based unscheduled care pathway

5 Ensure people receive a timely, co-ordinated clinically appropriate response to their need through access to appropriate evidence based scheduled care pathways

6 Ensure people with cancer have access to clearly defined and co-ordinated pathways of care

7 People with learning disabilities live fulfilled healthy lives supported by the appropriate tier of care

8 Improve emotional wellbeing and mental health of the population, supporting people with appropriate tier of care

9 Maximise the proportion of cared for children provided within Powys where safe to do so

10 Maximise the uptake of the Powys midwife led service where clinically appropriate and to support highly effective obstetric led care

11 Develop effective multi-disciplinary working to provide integrated care internally and across organisational and sector boundaries

14

1.2 Define the assumptions on which your plan is based using all the following subheadings • Service • Workforce • Finance, including the total amount of cash releasing efficiency savings to be made.

Service The detail of the service model for the whole of Powys Teaching Health Board is not yet fully developed. Decisions made as part of the Case for Change, the South Wales Reconfiguration Programme will significantly impact on Powys from a commissioning perspective and the ease of access to specialist inpatient care for our residents. However, it is recognised that the following direction of travel will be followed and the plan is based on the following assumptions:

- Increased services delivered closer to home for Powys Residents - Development of out of hospital care services - Repatriation of services into Powys - Develop service models within Learning Disability which help to prevent or delay the need for more intensive

Continuing Healthcare placements and hospital admissions or facilitate a return to lower level support (for example, through prevention, reablement or rehabilitation)

- Working in partnership with other agencies to deliver an increased range of services locally. This means that the workforce solutions identified may not be solely delivered by directly employed staff and subsequently will not be reflected in the Workforce Configuration Tool

- Optimisation of the buildings and premises in Powys - Delivery of the the core Tier 1 and Tier 2 delivery targets set out in the NHS Wales Delivery Framework - The need to develop and strengthen a sustainable approach that improves health, enhances patient

experience and controls costs At this stage, it is difficult to make assumptions about the impact of the future commissioning model of care on the provider services. Depending on how future services are commissioned, an increase in the workforce to support the delivery of care closer to home cannot be ruled out. The lack of clarity on the future of the service model within NHS Wales and its impact on Powys means that this plan is unable to fully integrate on a service, workforce and financial basis. The plan is primarily based on the local changes that are known and within the public domain. Finance The total revenue budget for Powys Teaching Health Board is approximately £237 million. Due to the unique position of Powys Teaching Health Board within NHS Wales, two thirds of this budget is utilized for the commissioning of acute and primary care services. The remaining third is attributable to the provider services. The total paybill is approximately £47.5million which is 19% of the total overall revenue budget and 71% of the provider costs. Powys Teaching Health Board is no different than other Health Boards in Wales, in that we are aiming to take costs out of the acute sector. The difference is that we buy this service in rather than directly deliver. This means that whilst we must ensure efficient running of our local hospitals and community services, we will be reliant upon them to deliver services locally in order to avoid onward acute care costs. Our plan is therefore based on the assumption that we will not be significantly diminishing local services but to ensure that they are used efficiently and effectively. Due to the complexity of the budget for the Health Board, the financial position will be realised by:

- Effective and efficient commissioning of acute and primary care services - Repatriation of services into Powys - Ensuring provider services are efficient and effective

Workforce The workforce plan assumes a turnover of 4.68% across all staff groups. Significant service changes within NHS Wales as a result of the Case for Change are currently being considered. These changes will impact on the commissioning of both acute and primary care services and subsequently upon the workforce. This plan assumes that where plans are known and within the public domain then the workforce change will be evident. This is more likely to be only at a local level and it is assumed that these changes will not be significant. Consequently, this may not produce the required levels of education commissioning numbers in order to provide a sustainable service. For this reason, a more detailed piece of analysis has been undertaken to clarify the future requirements based on the age profile of the staff groups and the known future service direction.

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1.3 Define the implications of any changes e.g. technological changes and advances, structural changes or reconfiguration of services, research etc. The PESTLE analysis below outlines the definite and probable changes that are anticipated. There was no clear distinction definite and probable so they have been collated together. The implications of these changes are summarised at the end as they cross cut across a range of the changes identified. Political - Case for Change reconfiguration of services - Care delivered closer to home where it is safe to do so - Meeting the rising expectations from our service users and politicians of what public services should be delivering and how we should improve - Fostering links and partnerships with employers and other private, public and voluntary sector organisations so as to increase participation in learning - Supporting children, adults and older people to access the health and social care services at the right time and in the right place Economic - Achieving financial balance - Repatriating services back into Powys - Integrating services in the County to work more effectively together. - Provision of targeted support to third sector organisations who wish to develop and run services on behalf of their communities. - Development of innovative, small scale, business and community led development initiatives and development of new social enterprises - Equipping individuals with the skills and qualifications that enable them to contribute effectively to social, economic and cultural activity - Equipping individuals with skills and qualifications that enable them to fulfil personal aspirations and find sustained employment - Maximising value for money from the Shared Service approach Social - Citizens and community groups are able to engage with the planning, delivery and commissioning of our services - A small population living in a large geographical area - The increasing average age of the community - The need for Powys residents to travel further for some specialist services that cannot be provided safely in Powys e.g. Cancer, stroke and heart disease - Access to services from remote areas - Provide services to support older people to remain living in the community for longer, in particular, supporting people with dementia, complex and end of life care - Tackle the causes of ill health, reduce inequalities and promote health and well being (One Powys) - Support the third sector to enhance its contribution to health and social care through the provision of training, information and funding advice provide a safe and effective

emergency response for the community (One Powys) - Develop the quality and range of early intervention and prevention services in order to provide timely responsive and integrated family support - Strengthen local health teams for adults around GP practices, community resource teams and provide a single point of access for residents increase in older people with

mental health problems projected over the next 15 years. Local Integrated Teams for Children and Young People will be based around Community Focused Schools. - Longer life expectancy for people with learning disabilities

Technological - Delivery of advances in medicine in small communities - Expanding the use of telemedicine, telecare & telehealth - Make use of technology for learning - Joint strategy for ICT - Development of single electronic patient record - Integrated information system for children - Development of digital dictation and voice recognition software

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Legal - Mental Health Measure (Wales) 2010 - Children and Families Measure (Wales) 2010 - Carers Measure (Wales) 2010 - Mental Health Act (1983) - Children Act 1989 and 2004 - Welsh Government “Statutory Guidance” e.g. Toward a Stable Life and a Brighter Future. - Estates compliance for water (legionella/pseudomonas), electrical, fire, general health and safety (asbestos, confined spaces, working at height), medical gases, gas

boilers and ventilation - Unified assessment and trusted assessment protocols and direct referral - Compliance with information governance requirements. - Compliance with Mental Health Act, Deprivation of Liberty Safeguards and Mental Capacity Act Environmental - Rural implications - Climate change compliant with ISO 14001 carbon reduction programme for government - Protect communities by improving our ability to deal with the consequences of major incidents and extreme disruption - Ensure the provision of good quality community run transport services which meet identified local needs

1.3 (Continued) Define the implications of any changes e.g. technological changes and advances, structural changes or reconfiguration of services, research etc. . These are the long term changes that are likely to affect Powys

Development of diagnostic and treatment centre for Powys Development of potential integrated health and social care facility in East Radnorshire Longer working days for GPs Seven day working for therapy services LGH development Llanidloes service development Llandrindod Hospital Redesign Powys Schools Modernisation Programme Integrated Children with Disability Service Reduction of DGH beds/acute services Rural based remote lab facilities

Implications of Definite, Probable and Long Term Changes Given the financial constraints that the service will continue to operate in, the implications of these definite, probable and long term developments will see a continuation of :

- A whole system approach to service provision and ways of working - Robust commissioning arrangements - Integrated working across professional and organisational boundaries - Increased utilisation of community hospital based services - Increased use of technology

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1.4 From your response to 1.2 and 1.3, identify the impacts on the organisation with regard to:

• Service • Workforce • Finance

The need to significantly improve the fitness and ability of the organisation to exceed the challenges and to grasp the opportunities will require a step change in the approach to organisational development and improvement. The conditions appear favourable for such a step change in that:

- The current approach to improving services and reducing cost has been helpful but is not deep enough or quick enough to result in significant change

- A salami-slicing approach to cost reduction is not universally supported by those who commit the majority of the resource, i.e. clinicians, and this approach can de-motivate rather than empower people to lead and implement change

- Any approach to improvement will need to last in the medium to long term and will need to be sustainable and self-perpetuating

- Whole organisation/whole system change with pace is evidenced to be a more effective change management strategy, through the development of a ‘movement’ aimed at delivering a common goal.

- The Programme of Government is clear. Delivery that leads to demonstrable improvement is required and is expected to be delivered within the next 18 months. There is likely to be increasing scrutiny/holding to account in relation to the Programme of Government and a reducing window of opportunity for change following this period. Rapid delivery therefore is the only option.

The broad impacts on Powys from a service, workforce and financial perspective are:

1. Improving quality and improving cost savings simultaneously 2. Using the platform of cost pressures to deliver results in quality improvement and cost reduction 3. Aligning the efforts of staff, partners and the public to the challenge and opportunity 4. Building capacity, capability and discipline in service improvement and cost reduction will deliver results 5. Achieving greater whole system change rather than incremental approaches in parts of the system.

The specific elements are: Service

- Shift to repatriate a range of services into Powys and to deliver care services closer to home. - Recognition that the repatriation of services may not solely be provided by staff employed by Powys

Teaching Health Board but also by other Private, Independent, Social Care or Voluntary Agencies. - As Powys is dependent on both Welsh and English organisations for secondary care services, any

remodelling undertaken by these organisations may have a negative impact on Powys residents by moving secondary care services further away.

- Need to develop a robust contractual framework with non – NHS providers. - Increased use of Local Enhanced Services to develop care closer to home e.g. Hospital and Home

services. Workforce

- Need to develop broad generic skills within both the Medical and Dental Workforce and non-medical workforce to ensure the effective delivery of services and interventions within a rural environment

- Need to work in partnership with Higher Education Institutes to ensure increased utilisation of placements for students and an attraction strategy for hard to fill posts.

- Need to widen access for employment of young people in Powys. The area’s age and sex profile is different to that of Wales as the proportion of young working age people (20 – 39 years) is substantially lower than that of Wales and the proportion aged 50 and over is larger (The Public Health Observatory for Wales (2010) Powys Teaching Health Board: Demography Profile)

- Need to ensure robust governance arrangements are in place when delivering services closer to home, by a shared partnership clinical accountability framework with secondary care services.

- Not solely reliant on new nursing graduates from NHS Wales as Powys has a requirement for more experienced nurses and attracts new graduates from England, particularly in the North Locality.

- Ensure capacity and capability to deliver financial balance Finance

- Achievement of financial balance - Developing a medium term service strategy which ensures the Health Board lives within its means. - Opportunities are maximised to secure value for money.

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1.5 Identify how this workforce plan impacts on other organisations and outline how you are Planning to address this. Powys Teaching Health Board is in a unique position within NHS Wales as not only will its own plan impact on other organisations and services but also other organisation’s plans in both Wales and the bordering English Counties will impact on Powys. The impacts are identified below.

From Impact Action South Wales Reorganisation of Services and Reconfiguration of Shrewsbury and Telford Hospital Services

Powys residents may have further to travel for Secondary Care services.

Involvement in the South Wales Reorganisation.

Medical Director and Chief Executive to raise concern at the outset and part of ongoing service planning.

Higher Education Medical and Dental Schools and Post Graduate Deanery

The workforce plan highlights a difficulty in attracting Doctors and Dentists once qualified. A lack of exposure to rural healthcare during undergraduate and postgraduate training exacerbates this situation which is recognised by the Medical Schools, the Deanery and the Rural Health Plan.

To work with medical schools and others to increase placements of medical and dental students.

To work with the Deanery to increase the uptake of available training places.

Repatriation of Services into Powys

The repatriated services will be delivered by one of 5 models using: - Own staff e.g. Theatres - Private providers but delivered locally in Powys (e.g.

Gynaecological procedures) - Social Services. Independent and Voluntary services - Consultants from Secondary Care to deliver

increased outpatients appointments - GPs through utilisation of Local Enhanced Services.

Need to ensure robust contractual arrangements are in place and to strengthen the commissioning function of the Health Board.

Need to identify the options for service and workforce models for repatriation of services

Repatriation of Services into Powys

Reduced numbers of outpatient appointments in hospitals external to Powys and increased travelling time for Consultants. Difficulty in attracting visiting Consultants in certain specialities.

Robust contractual arrangements Increased use of Local Enhanced Services.

Need to ensure high levels of attendance at locally provided outpatient appointments.

Maximisation of telehealth, telecare and telemedicine

Need to assess the impact of repatriation and to determine whether to increase the use of visiting clinicians or to recruit our own.

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STAGE 2: ANALYSIS OF CURRENT SERVICE AND WORKFORCE CONFIGURATION This stage defines the current service activity and workforce profile, and identifies key issues within your current staffing configuration.

2.1 Define the configuration of your current workforce using the Workforce Configuration Tool and the Primary Care Workforce using the General Medical Workforce Spreadsheet.

The table below outlines the current directly employed FTE, Headcount and Participation Rate figures for Powys tHB as of January 2012 and yearly salary (Source ESR). The salary value includes on costs, but excludes enhancements and staff seconded in. However they do include 10 (9.37FTE) Admin and Clerical staff who will be transferring to Shared Services this year. From January 2011 the organization has seen an increase of 16.15 FTE; this is mainly due to secondments being made substantive and the appointment of Community Health Care staff. Powys tHB employs 3.15% of the projected working age population (16 – 64) currently in employment for 2012. In addition, it employs 2.62% of the 71,817 people directly employed by NHS Wales.

In addition, to the above FTE and Head Count, Powys tHB has 8 secondees into Powys and also 2 Joint Appointments with Powys County Council. The BSC and CHC Staff have been omitted from all data due to our service plans being based on provider services.

Current Christmas Tree Configuration & FTE Selected Staff by Pay Band (Excludes BSC &

CHC)

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This table gives a percentage breakdown of the staff groups as a proportion of the Health Board. Administrative and Clerical and Estates and Ancillary appear to occupy a relatively high proportion of the overall Board.

The following table gives a further breakdown of the participation rate for Staff Groups: Allied Health Professionals, Estates & Ancillary and Nursing and Midwifery Registered.

GENERAL MEDICAL SERVICES: The General Medical Service’s spreadsheet is attached. It highlights approximately 9 G.P.s will be retiring during the period of this plan and also 3 Practice Nurses. From the annual appraisal visits that have been conducted with the Practices, the intention of the Practices is to replace these G.P.’s with Partners and not with Salaried G.P.s or to redesign and increase their Practice Nurses.

GMS WORKFORCE spreadsheet v2.xlsm

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2.2 Identify the key workforce pressure areas and define the impact on services associated with these pressure areas. The key workforce pressures and the associated impact are detailed below in service areas. In summary the following themes are emerging:

Workforce Pressure Impact Localities Fragility of teams: - Brecon and Llandrindod audiology team fragile - Dietetics

High sickness rates in certain areas. Added pressure on staff attending work Local labour market for providing personal care is an increasing challenge

Inability to deliver an appropriate service and ineffective deployment.

Community Nursing/ Therapy Capacity Delivering safe services with difficulty in attracting carers to work within this sector

Ageing workforce, loss of a standardised retirement age and imminent changes to pension arrangements.

Difficulties in forecasting future turnover patterns and unpredictability for succession planning.

Professional barriers - internal and external Transfer of staff from hospital based service to community, competency mapping and attrition of workforce through transition process. Unable to develop and modernise the services.

Women and Children's Services

Birth Rates: Overall, Powys Service, Obstetric services, free birth

Birth rates in Powys have fallen during 2011. The establishment and skill mix in maternity needs to be able to meet fluctuations in demand and provide a safe and effective service

Above target DNA rates Ineffective deployment of staff AOF Primary Mental Health Worker Targets AOF Sexual Health Targets Currently breaching access targets AOF Vaccination and Immunisations Targets Public Health, Health Promotion and preventative medicine

provision suffer as resources are focused on acute pressures

AOF Waiting Time Targets For CAMHS Waiting times of up to twenty weeks (community paediatrics in exempt from NHS waiting time target reporting) preventing children being assessed, treated and reviewed in a timely way

Child Death Review and PRUDiC Can place unexpected demands on the workforce Child protection work

Demand for Health Assessments for: Looked after Children, Education Statements, and Adoption

Not meeting some statutory targets in relation to Statements of special Educational need, Powys child deaths and Fostering & adoption

High Referral Rates Increased demands on the workforce Integrated Family support Service (Children and Families Measure)

New roles in Health Visiting and Community Mental Health Nursing, Agenda for Change Bands being determined by Welsh Government.

Mental Health Measure (Wales) 2010 requirements (specialist CAMHS)

Change of function for Primary Mental Health Workers, New systems for assessment, care planning and case management.

Multi-agency case work and discussion Peri-natal Death Review Secondary care consultation and advice to Primary care, schools, public health and universal services

Estates and Works

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Ageing works department workforce Potential risk of being able to implement new computer based technology to improve efficiency. Specialist skills and site knowledge lost.

Workforce Pressure Impact Primary Care A recent review of enhanced service audits has identified that further monitoring of the practices involvement in the specifications is required.

Lack of staff resources limits effective monitoring

Dental Lack of specialist in special care and other specialists

Patients have to travel long distances for routine treatment

Not enough Oral Health Education sessions Difficult to offer training in prevention to all care homes etc. Resulting in reduced oral care knowledge in care homes

Patient Demand is too high for the number of dental officers

Long intervals between visits, reduced school and home screening, patients with high needs have reduced access to a dentist, difficult to accommodate domiciliary patients

Medicines Management Maintenance of current and growing activity will require skills training, and some additional admin support, along with the department deputy post being filled.

Delays in the introduction or repatriation of services, etc, with consequential delays in the savings to be derived from them.

Support required from the central team for engaging GP practices in prescribing change for cost saving, as well as quality, improvements, and the support for meeting the needs of other healthcare professionals.

Supporting safe services in care homes, and domiciliary care, and supporting localities, for services required to meet Setting The Direction aims, and for serving patients in Powys rather than outside DGH services.

2.3 Analyse the current workforce profile for all staff groups. From the analysis summarise the key issues affecting the workforce.

A detailed analysis of the workforce for all staff groups can be found in Appendix One. Further analysis can be found in the Workforce Intelligence Report 2012 (Appendix Two). Appendix One analysis covers: 1. Staff Group 2. Equality Profile 3. Part Time and Full Time by Gender 4. Annual Turnover Rate 5. Age Profiles by Staff Group 6. Retirement Scenarios by all Staff Groups at age 55 and 60 7. Nursing and Midwifery Retirement Scenarios at age 55 and 60 to inform Education Commissions 8. Allied Health Professionals/ Additional Professional and Technical and Healthcare Scientists Retirement

Scenarios at age 55 and 60 to inform Education Commissions 9. Skill Mix Analysis 10. Workforce Costs 11. Temporary workforce analysis

Worked FTE in addition to the contracted FTE Agency/Locum, Overtime and Bank Usage

12. Sickness Absence

A summary of the key issues for the Powys workforce are detailed below: FTE, Head Count and Participation Rate

1594 staff (1228.50 FTE) are employed in Powys across all staff groups. Nursing and Midwifery Registered

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are the largest staff group within Powys tHB accounting for 34% of the whole workforce. Administrative and Clerical and Estates and Ancillary appear to occupy a relatively high proportion of the overall Board. (Appendix 1 : 1.1 Graph)

The overall participation rate of Powys is 0.77, which is attributable to 85% (1358 HC) of Powys tHB workforce being female and of these 65% (883 HC) work part time. (Workforce Plan, Stage: 2.1 Table)

30% (73 HC) of the male workforce work part-time. However, this is not significant as 29 (HC) of this figure is attributable to the sessional employment within Medical and Dental and Additional Professional, Scientific and Technical. Of the remaining male workforce, the majority of them are from the Ancillary Staff Group (27 HC). (Appendix 1: 3.1 Table)

The participation rates of the professional groups vary considerably, low participation rates are more apparent in School Nursing and Health Visiting and amongst Radiographers and Speech and Language Therapists which range from 0.58 (Radiography) – 0.73 (School Nursing). Midwifery is higher than expected at 0.85. (Workforce Plan Stage 2.1 Table)

Equality Profile

80% (1270 headcount) of the workforce within Powys tHB have no record of their disability status. Only 1% (15 headcount) are recorded as having a disability. (Appendix 1: Point 2)

Almost 73% (1161) of the workforce are British, 13% (205) Welsh and 12% (190) have no record of Ethnic Origin. (Appendix 1: Point 2)

55% (875) have no record of Religious Belief, with 6% (90) not wishing to disclose. 32% (508) are Christians. (Appendix 1: Point 2)

55% (883) have no record of sexual orientation, 3% (51) did not wish to disclose and 41% (650) heterosexual. (Appendix 1: Point 2)

Age Profile

21% (249.74FTE) of the current workforce are already over the age of 55; 8% (82.21FTE) are over 60. (Appendix 1: 5.1 Graph)

By 2022, if the current workforce were to remain in post, this would rise to 59% (728.16FTE) for over 55 and

40% (491.13) over 60. (Appendix 1: 5.1 Graph) The largest hot spot for an ageing workforce is within Estates, Works and Ancillary. For the ancillary

workforce, there are 48.21FTE aged 56 and over currently. For Estates and Works, this equates to 35.48% (11 FTE) mainly from the trade professions. Estates are covering a vacant electrician role with an agency worker. (Appendix 1: 5.2 Table)

For CAMHS, Health Visiting, Learning Disabilities, Midwifery, Paediatric Nursing, School Nursing and Sick

Children there are small numbers reaching 55 steadily over the next 10 years until 2022 (Range 1 – 4 per year). The areas of concern are from District Nursing and Acute, Elderly and General (Appendix 1: 7.2 Table)

For District Nursing the range of staff reaching 55 per year is 3 – 14, averaging out at almost 9 per year. This

excludes the 18 staff who are currently aged over 55. (Appendix 1: 7.2 Table) The numbers from Acute, Elderly and General staff reaching 55 are significantly higher averaging at nearly

14HC per year (Range 3 = 18). This excludes the 54 staff who are currently aged over 55. (Appendix 1: 7.2 Table)

The situation is slightly improved if the Nursing and Midwifery Registered workforce retire at age 60, however

a similar pattern emerges. (Appendix 1: 7.3 Table) Within the Allied Health Professionals/ Additional Professional and Technical and Healthcare Scientists

workforce, whilst the numbers of staff aged over 55 currently are small (Range of 1 – 9), the proportionate percentage of the ageing workforce in relation to their professional group is very high (Range from 25% to 93%). This is because the professional groups are much smaller. (Appendix 1: 8.2 Table)

The numbers of staff reaching 55 occur most consistently between now and 2017 which could have an

impact on the Health Board. For 2018 onwards, the age profile reaching 55 is more spread out.

This situation may be exacerbated when you consider the existing staff numbers (24) currently aged over 55, with the majority of these being from Physiotherapy (9), Podiatry (4), Radiography (5) and Occupational

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Therapy (3). (Appendix 1: 8.2 Table). The retirement at 60 profile gives a more even spread during the 10 year period.

Skill Mix

Overall for Powys, there has not been a reduction in Bands 5 – 9 in line with the AOF target. For Bands 1 – 4 there has been an increase in 15.64 FTE. However, the baseline data and target may have been affected by restructuring. (Appendix 1: 9.1 Table)

The issue for Powys in relation to this target is that the arbitrary percentage changes may not be appropriate Powys Health Board as it assumes that the whole care pathway for most conditions will be delivered within Health Board provided services.

For rural services delivering care outside of a hospital environment, there is a greater requirement for Registered Practitioners with a broad range of assessment and intervention skills.

Workforce Costs

For the period 2011 – 2012, the total workforce bill for Powys was £40,920,160 this included basic pay and enhancements but excluded the cost of the temporary workforce which is detailed below. (Appendix 1:Table 10.1)

Temporary Workforce

Utilisation of a temporary workforce can be from a number of different sources: - Excess hours and overtime hours can be worked from existing staff employed. - Bank hours can be worked by staff employed by the Health Board. - Agency and Locums are arranged through private firms. Excess, overtime and bank hours can be analysed through E.S.R. Agency and Locum hours are recorded through the financial system. Currently, these 2 elements are reported separately to the Board which does not give a full picture of the situation.

Excess hours and bank hours are a cost effective way of managing fluctuating workforce demands, whilst overtime and agency/locum costs are more costly. Due to the low participation rates within the service, excess hours and bank hours are an accessible way of covering workforce gaps.

Due to the nature of how the 2 systems record the different element, it is difficult to get a complete picture of the total FTE and associated costs. The ESR system currently reports in FTE and the agency costs are recorded in costs. Comparisons across the 2 systems show some discrepancies. The workforce analysis has attempted to integrate all of this information together to give a cost for the temporary workforce, although it is recognised that further work is required in this area to fully understand the reporting systems.

It is not clear from the analysis how additional hours, overtime and agency and locum are deployed throughout the service delivery period, e.g. utilisation across standard hours or enhanced hours.

The cost of temporary workforce costs across Powys is significant at just over £1.7million which is broken down into (Appendix 1: Table 11.4)

Temporary Workforce Use £ Overtime £120,177 Agency £241,855 Excess £687,282 Bank £660,168Grand Total £1,709,483

Excess Hours and Bank Hours

The financial analysis provided on monthly average FTE contracted against monthly average paid shows that on average 133.24 FTE additional hours are utilised per month, with the majority occurring in Additional Clinical Services, Estates and Ancillary, Nursing and Midwifery Registered. This equates to an additional 11% of the whole workforce being employed per month. (Appendix 1: 10.1 Table). The annual cost of this is nearly £1.35 million with £687,282 attributable to Excess Hours and £660,168 attributable to Bank Hours. (Appendix 1: Table 11.4)

Agency and Locum Usage

The total annual cost for agency and locum is £241,855 with the majority of this spend occurring in the South Locality. The majority of this locum cost is associated with annual leave cover for employed doctors and also

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a vacant Consultant in Psychiatry. An electrician is also employed on a full time basis through the Agency. North Locality incurred some agency/locum expenditure during 5 months of the year. (Appendix 1: Table 11.4 and 11.5) Overtime

The cost of overtime for 2011 – 2012 was £120,177. (Appendix 1: Table 11.4) Sickness Absence

The target sickness for Powys tHB is 4.42%. Up until January 2012, this was being achieved on a monthly basis but has crept above the target for February and March 2012. However, overall for the year the target has been exceeded as the annual sickness rate is 3.99%. (Appendix 1: Table 12.1)

The range of sickness in percentage terms is 3.25% to 4.67%. The equivalent FTE days lost range from 1,510 to 2,235 days lost per month. (Appendix 1: Table 12.2)

Of the largest staff groups, the range is from 2,668 (Estates and Ancillary) to 8,436 (Nursing and Midwifery Registered) FTE days lost. (Appendix 1: Table 12.3)

Whilst, the sickness target has been achieved across the Health Board, there are exceptions to staff groups where the annual sickness rate is higher than the target figure, notably Healthcare Scientists, Additional Clinical Services and Nursing and Midwifery Registered.

Implications

The implications of this analysis from a workforce planning and development perspective are: Recording of Information

There is a need to improve the recording of disability status, religious belief and sexual orientation. However, this is subject to the outcome of an issue being raised from the Data Protection Council.

Workforce Flexibility Currently, Powys has a predominantly part time workforce which gives increased flexibility in service

provision. This may not be a continuous feature of the workforce in Powys as working patterns change in relation to their family commitments.

It is apparent that as the workforce ages, they are likely to increase their hours over time as their family commitments reduce. When they subsequently retire the replacement workforce are likely to be younger and may not want to work full time.

This may necessitate education commissions in some professional groups by Head Count rather than on FTE requirements, e.g. Health Visiting, Midwifery and School Nursing.

Age Profile The changes from a default retirement age make workforce planning more complex, potentially over the next

five years the Health Board could lose nearly 30% (331.95 FTE) of its workforce based on the current age profile. This poses a risk to the Health Board, particularly in the light of further changes to the NHS Pension Scheme which may accelerate people’s decision to leave. Whilst 2 scenarios have been presented for retirement at 55 and 60, it is likely that neither scenario will be fully realised and management intelligence will be key to ensuring effective workforce planning.

The age profile of the Estates and Works workforce poses a significant risk to the Health Board in terms of service sustainability.

Whilst some of the Allied Health Professionals/ Additional Professional and Technical and Healthcare Scientists groups have small numbers aged over 55, because of the proportionate size of this workforce, even these small numbers can have a significant impact if they were to retire at the same time.

A lack of a succession plan for clinical and estates workforce with an ageing workforce could seriously impact on the Health Board’s ability to deliver critical services.

Competence Requirements Further analysis is required to understand the competency requirements and the associated skill mix for

clinical service delivery. Temporary Workforce and Sickness Additional hours, bank, overtime and agency/locum costs require further analysis in order to understand the

complete picture in terms of FTE and associated costs. More detailed interrogation of information systems and engagement with service managers about how these hours are deployed.

Further work needs to be undertaken to understand the utilisation of the temporary workforce within the context of sickness levels, headroom calculations, patterns of deployment, baseline establishments and

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other measures of productivity. Further work needs to be undertaken to understand sickness patterns more clearly and to increase the

granularity of the sickness data. 2.4 Identify any current roles where recruitment is difficult. The table below outlines current recruitment difficulties. The numbers in FTE equivalent appear small; however, in a rural area like Powys, this can have a significant impact on the service delivery. In addition, to the recruitment challenges detailed in the table, the following issues have also being identified: - Recruitment of GPs has been traditionally difficult - Recruitment of specialist MDT roles can be difficult - Recruitment/ funding of Dental Practitioners GDP/ CDS has been difficult In addition, difficulties have being accounted in recruiting staff with specific skills: - Nursing- nurses with sub speciality skills such as Emergency Nurse Practitioners, Theatre Nurses or specialist Nurses such as respiratory & oxygen Therapy and cardiac and heart failure - Difficulty in recruiting some specialist OT and physiotherapy posts as no DGH to support development - Medicine, visiting specialist consultants (although this does not impact on planning in Wales, but involves contractual arrangements.)

Professional Group Role or Speciality Band/Grade FTE Location Medical and Dental Psychiatry for Learning

Disabilities service Consultant 1.00 Powys wide

Additional Clinical services

Reablement Support Workers

Band 2 Mid Locality

Additional Professional, Scientific and Technical

Experienced pharmacists Band 8A 0.15 Medicines Management

Allied Health Professionals

Occupational Therapists Band 5 and 6 1.37 Mid Locality

Paediatric Physiotherapist Band 6 1.00 Women and Children's services Physiotherapists Band 6 0.60 North Locality Occupational Therapists Band 6 0.60 North Locality

Nursing and Midwifery

Health Visitors Band 6 0.4 Women and Children's services School Health Nurse Band 6 1.31 Women and Children's services

2.5 During the last 12 months outline the changes you have made to your workforce Workforce change has occurred across all staff groups. The workforce changes which primarily support service development and policy requirements have included:

- Development of new roles following restructuring of the Health Board and to fill gaps in service delivery. - Extended roles to increase capacity and capability of the teams and the development of specialist skills - Changed roles to increase flexibility in service delivery

The benefits of introducing these new, extended and changed roles have:

- improved access to the service - increased activity and patient flow - improved recruitment to the service - increased both service and workforce flexibility - broadened the skills that the teams can deliver to meet patient needs - optimised the roles at all levels through the appropriate use of delegation - enabled the service to meet compliance and governance requirements

Full details of the workforce changes are detailed below:

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Professional Group

New, Extended

or changed role

Role Band Identified Benefits Location

Additional Clinical Services

Changed Oral Health Education Team

Band 5 Help to deliver the DS2 programme/other oral health promotion activity including one to one with patients.

Dental

Extended Dental Nurses Band 5 Provide Fluoride Varnish Application DentalAdditional Clinical Services

Changed Reablement Service Mid Locality

New Autistic Spectrum Disorder co‐ordinator

Band 7 Supports assessments and care Women and Children's

Sexual Health outreach Worker

N/A Uses big lottery funding and employed by the Terence Higgins Trust

Women and Children's

Administrative and Clerical

Extended Administrative Workforce

Band 3/4

Helped to delay the need for increasing establishment amongst pharmacists and technicians.

Medicines Management

Care Development Officer

Band 4/5

Expanded roles now allow a broader range duties/ responsibilities to be undertaken

Primary Care

Primary Care Administrator & Primary

Band 2 to 3

Expanded roles now allow a broader range duties/ responsibilities to be undertaken

Primary Care

New CCM care co‐ordinator Mid Locality


New Advanced Orthopaedic Physiotherapy Practitioner

Band 7 Invest to save in the orthopaedic pathway

North Locality

Specialist Physiotherapist

Band 6 To support Community Physiotherapist, including Reablement and COPD

North Locality

Estates and Ancillary

Changed Hotel services role to include porter/domestic and hotel services assistants

Mid Locality

Medical and Dental

Changed DF2 post into DF1 Help with recruitment and access DentalExtended All staff Inhalation Sedation Techniques to

improve access. Avoid GA in secondary care

Dental

Dental Officers Performer numbers to provide GDS/PDS capacity if required

Dental

GDS/PDS service Provide routine dental treatment to high needs/ access difficulties

Dental

Nursing and Midwifery

Extended Cardiac specialist Nurse into Cardiac and Heart Failure Specialist Nurses

Band 6/7

Nurses trained in Caledonian heart failure programme

South Locality

District Nurse Team Leader into Team leader Complex case Manager role

Band 7 Significant reductions in DToC's South Locality

Respiratory and Oxygen Therapy Specialist nurses

Band 6/7

South & Mid Locality

New Bowels Screening Nurse Specialist

Band 6/7

Supported by Bowel screening Wales South Locality

28

Infant Feeding co‐ordinator

Band 6 Implementation of Baby Friendly Project/meeting Wales standards for breast feeding rates

Women and Children's services

2.6 Identify services currently provided in Welsh.

All client facing services appear to have some access to Welsh speaking staff. The table below gives a summary of the availability of Welsh Language.

Location Who How well How many Training/ Service Women and Children's Services

Midwives, School nurses, Health visitors

Fluently Small number Internet based counselling service 'Kooth' available in Welsh language s Midwives, School nurses,

Health visitors Limited degree Small number

Midwives, School nurses, Health visitors

No understanding

Half workforce

CAMHS Fluently Limited None

1 Small number Majority

Mid Locality Across the Mid when needed

Fluently Small number Language Line and bi-lingual patient information

South Locality

Each hospital has at least one identified speaker

Fluently 1 No specific services are provided although a Welsh language scheme is in place to improve access to Welsh language speakers

YCH – Physio & OT Fluently/little Many Services provided by English providers

No understanding

All Costly to translate

North Locality

Administration Staff – Contact Centre

Fluent 3 Patient Services/Transport

North Locality Llanidloes Hospital

Administration Fluent 3 Patient Services Physiotherapy Assistant Some

understanding 1

OT Team Leader Fluent 1 North Locality Machynlleth Hospital

Ward Clerk/Patient Services/ Secretary

Fluent 3

Physiotherapist Fluent 1 OT Team Fluent All

North Locality Welshpool Hospital

OT Team Leader & Reablement

Fluent 1

North Locality Newtown Hospital

Physio Assistant and Reablement Physio Assistant

Fluent 2

OT Team Leader Fluent 1 Quality and Safety

Advisors Fluently 2

Planning and Facilities

N/A N/A None as no patient contact

Estates and Works

None N/A None as no patient contact

Dental Have staff if required Fluently Primary Care

Service translation provided if needed


Head of Department PA Currently learning

1 Leaflets in Welsh. Don't provide any face to face translation

30

2.7Total cost of your current workforce.

This section should be completed by the Director of Finance.

Basic Salary including on costs

£42,185,561

Variable Pay

£ 2,262,500

Locum or agency costs

£ 269,000

Total

£44,717,061

Source of Information: Financial Ledger May 2012

2.8 Is the total cost of your current workforce within your budget? This section should be completed by the Director of Finance. The cost of the current workforce is within the 2012-13 budget 2.9 If the cost of your workforce is higher than your funded establishment, how do you plan to reconcile this difference? Not applicable. 2.10 Detail the financial pressures affecting your current workforce budget. Powys Teaching Health Board has a cost pressure associated with termination of funding at a national level for the implementation of the School Nurse Framework. This equates to approximately £230,000 which may rise in future years because of increments. The Women and Children’s plan has identified steps to meet this cost pressure.

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STAGE 3: FORECASTED WORKFORCE REQUIREMENTS AND CONFIGURATION TO MEET FUTURE SERVICE NEED

This stage quantifies the future configuration of the workforce, incrementally over the next 1 to 5 years, taking into account the future service plan articulated in Stage 1 and the current workforce configuration identified in Stage 2. This information will inform your recruitment and retention and also inform centrally funded education commissioning requirements for the future. 3.1 Identify key areas of anticipated increased or decreased demand on services which may affect the workforce. The shift to repatriate services back into Powys and to deliver care closer to home is placing changing demands on the service. In addition, policy implementation, particularly within the Women and Children’s Directorate also impacts on the way that services are delivered. This demand isn’t arising from existing demand but is a consequence of delivering a different type of service. The key areas of “increased” demand are:

- Outpatient (5% per annum, linked to Referral to Treatment Targets) - Day case surgery and theatre utilisation - Reablement services - 15% increase in older people with Mental Health problems over the next 15 years - Extended District Nursing Services - Hospital@Home services - Non Emergency Patient Transport - Sexual Health Services to meet the AOF Target - Low risks births (see point below*) - Managing out of county placements (Women and Children’s Directorate) - Number of Local Authority children placed in Powys from other authorities - Referrals to CAMHS - Primary Mental Health Assessments (Mental Health Measure) - Safeguarding requirements - Child Death Monitoring and Reporting - Continuation of the School Nursing Framework - Weights and measurement requirements for school aged children - Developing training capacity internally - Estates compliance in for water (legionella/pseudomonas), electrical, fire, general health and safety

(asbestos, confined spaces, working at height), medical gases, gas boilers and ventilation - Delivering a community based Medicine Management service within Powys rather than through the DGH - For residential and nursing home bed - The impact of repatriation on clinical coding to meet a Welsh Government target of 95% of clinical coding

achieved within 12 weeks. The decreases in services are outlined as:

- A shift of care from Community Hospital provision to Community Service provision with a focus on predictive services. This is demonstrated in 3.2 where there is a correlating shift in the workforce from hospital based nursing to community nursing.

- *A decrease in demand for DGH obstetric services for low risk mothers. As the DGH services are provided by another Health Board, the resources cannot be readily shifted from secondary to primary care, placing a further pressure on Powys Teaching Health Board.

- School Action Plus giving a reduction in children with a Statement of Special Educational Needs - Reliance on external trainers

The table below gives more detail on the issues.

32

Increased/ Decreased

Location Service Reason

Decrease North Locality Commissioning Providing services locally, more community hospitals/ community nurses/ therapy care

Community Hospitals Increase in Community and predictive services

Quality and Safety External trainers In the long term more in‐house expertise

Women and Children

Demand on DGH obstetric services for low risk mothers

Care closer to home

School Action Plus Reduction in numbers of children with a statement of special educational needs

Increase All Localities Community Services Moving care closer to home and aging population Estates and Works

“catch‐up” on compliance items Health and safety, Asbestos, water, electricity. Once completed there will be a need to continuingly improve.


Community Pharmacy Services Serving patients in Powys rather than outside DGH services.

Mid Locality Reablement Team Due to above

Out‐Patient/Day Case Service Improved patient pathways

North Locality 15% in older people with MH problems over next 15 years

Demographic changes

5% per annum growth in OPD New out Patients referral

Assessments facilities closer to home Larger demand

OPD facility Maintain RTT targets. Capacity at moment is at maximum

Residential and nursing home beds Increase in ageing population

South Locality Brecon Community Hospital 15 single occupancy rooms

Community Resource Teams, Reablement and Therapy teams

Provide services to GP bed and hospital outpatient service. Development of and 4 therapy assistants to help the demand

Extended District Nursing services and care Transfer Coordinators

As reduction in the flow of patients from DGH setting into a community hospital setting and progressively into a community care setting. Also increase for inpatient facilities to accommodate transfers from DGH

Hospital @ home‐ community skills Shift from GP community hospital beds to GP Hospital @ Home service. Therefore transfer of skills from community hospitals to community teams

Non Emergency Patient Transport waiting list increasing year on year due to increase in ageing population

Staff levels in Patient services Increase to repatriate patients referred out of Powys Theatre and Out Patient Services Improved patient pathways

Women and Children

Child death monitoring and reporting Policy implementation

Demand on managing out of county placements

Need to access specialist tertiary services

Low risks births in Powys Moving care closer to home

Referrals to CAMHS Demand for all under 18s from April 1st 2012

Safeguarding requirements Policy implementation

School nursing workforce Implement the framework of the school Nursing services for Wales

Screening for Sexual Transmitted Infections within 2 working days. Increase of IUD Contraception (long acting)

Sexual Health quality requirements

Common Assessment framework and Multi‐agency work

Policy implementation

Innovative programmes to prevent out of county placements

Repatriation

Number of looked after children and children placed from other Authorities

Policy implementation

33

3.2 Define the future configuration of your workforce using the Workforce Configuration Tool. The table below from the Workforce Configuration Tool sets out the change in staffing numbers over the next 5 years. This sees a total reduction of 33.32 FTE by 2017. The changes are shown below by Pay Band. The Tool does not include those staff that will transfer to Shared Services this year.

The increase in FTE from 2011 to 2012 is due to vacancies which have been filled. The Workforce Configuration Tool only shows staff in post. The workforce projection is in line with future financial assumptions at this stage. The main changes In the Workforce Configuration Tool are summarised below (please note minor changes have not been included):

34

Band Change FTE

Increase Decrease

Medical and Dental

+1.80 0.10 CAMHS 1.00 Learning Disabilities. 0.70 Dental Officer.

9 + 3.00 3.00 Directors

8d -0.81 0.81 Senior Manager in Womens and Childrens directorate

8c +0.98 0.79 Clinical Psychologists 0.19 Learning Disability Psychologists

8b -1.00 1.00 Senior Manager (1.00).

8a -0.80 0.40 Pharmacists 0.80 LD Clinical Psychologist

2.00 Senior Nursing role

7 +4.66 0.50 CAMHS Clinical Psychologist 2.00 in CAMHS Community Nursing (IFSS) 2.00 Health Visitors 0.56 Paediatric Physiotherapist 0.80 Child Protection Team 1.31FTE in Mid Community Nursing 0.80 LD Speech & Language Therapist 1.00 Practice Development Nurse employed in Pharmacy

3.66 Midwives 1.00 Planning Directorate Admin

6 +21.04 1.49 CAMHS Community Nursing 0.40 Paediatric Nursing 2.40 Health Visitors 4.53 Midwives. 1.20 School Nursing 1.00 in South Community Nursing 3.29 increase in South Hospital Nursing 1.00 Audiologist 0.80 Radiographer.

5 -20.40 1.86 Primary Care Admin 10.12 Community Nursing in the Mid Locality 2.00 in Theatre 0.70 Paediatric SaLT

15.17 Hospital Nursing (offset by increase in community nursing)

2.00 Planning Directorate 14.47 Hospital Nursing in the South due to the closure of ward in Bronllys hospital

1.40 Midwifery 2.00 School Nurses.

4 -0.82 0.40 in Pharmacy Admin 0.80 in Dental Nursing 1.00 OT support in Mid 2.00 Health Visitor Support

2.00 Estates and Facilities 0.60 CAMHS Admin 0.80 School Nurse Support 0.79 Paediatric S&LT Support.

3 -4.35 1.00 Theatre Nursing support. 1.10 Community Nursing support in the Mid Locality,

2.45 in Hospital Nursing 1.80 Admin support 2.64 Domestic and Catering 1.40 Nursing support in the South.

2 -36.35 1.00 Domestic in Brecon. 2.00 Admin staff for Women & Children Health Visiting team.

12.94 in Facilities staff in Mid. 16.63 HCA in the Mid 2.24 of Admin support Mid. 8.36 Nursing support in the South

1 -0.27 0.27 Domestic

35

A further breakdown of the same information is shown below by Staff Group.

This table shows the changes in staff groups. It gives a summary of the key changes to show the direction of travel for the workforce and therefore the FTE in the rationale does not fully reflect the FTE in the 2nd column.

Staff Group FTE % Change Rationale Additional Clinical Services -23.23 -11% These reductions related to service

modernisation and the move away from a traditional bed based model of care provision by the tHB to care within the health and social care centers and care close to patients homes.

Estates and Ancillary -17.57 -10% Nursing and Midwifery -5.18 -1%

Additional Professional and Technical

+1.87 17% 0.40 FTE Pharmacist FTE LD Clinical Psychologist 0.50 FTE CAMHS Clinical Psychology

Administrative and Clerical +2.86 1% There is an increase of 2.86 FTE which relates to the appointment of 3.00 FTE directors

Allied Health Professionals +5.13 5% 0.80 FTE S&LT Learning Disabilities 0.90 FTE in Paediatric S&LT 1.39 FTE in Radiography Mid locality 0.20 FTE increase in Physio 0.56 FTE in Paediatric Physio 0.20 FTE in Physio in the South Locality. Appointment of 1.00 FTE Multi Therapist in the South Locality.

Healthcare Scientists +1.00 +58% Appointment of a further audiologist in 2016. Medical and Dental +1.80 +9% This is due to the increase of 0.70 FTE Dental

Officer and consultants in CAMHS 0.10 FTE and learning disabilities 1.00 FTE

Total -33.32 -2.8% from 2011

3.3 Give a summary of the future workforce changes including timescales Workforce change has been identified across all staff groups in order to fulfil the vision and ambition within “Making It Happen”. The changes identified to date are based on what is currently known and within the public domain. It is recognised that these changes will not be enough in themselves to achieve the future service vision and financial balance; however, they will contribute to the future service direction. Timescales will be identified in line with the “Making It Happen” programme. The key features of the future workforce changes are:

- Development of Reablement Services, particularly at a Support Worker level and working across professions

- Integration of Health Board Occupational Therapy Services with the County Council - Alignment of Health Care Support Workers with Domiciliary Carers - Pharmacist Support for Care Homes and development of technician roles

36

- Skill mix review in Paediatric Therapies - Integration of Hospital Services and Patient Administration Roles. - Diagnostic Imaging Referral for Podiatry - Physiotherapy Orthopaedic Triage - Supplementary Prescribing for Podiatry - Development of Advanced Practitioner roles in Physiotherapy - Development of Reporting Radiographers - Development of Specialist Therapist Roles for Children’s Services - Shift from hospital based nursing service to community nursing service - Expanded Public Health Role for School Nursing - Independent Nurse Prescribing - Development of Emergency Nurse Practitioner for rural based walk in centre and provide Hospital at

Home cover to 3 main sites in Powys. - Specialist Nurses to provide local community based service, case managing complex patients. - Development of Nurse Practitioners with a Specialist Interest to work with GPwSI – in Dermatology,

Rheumatology, Nurse Endoscopy - Developing Specialist Nurses in Community Paediatrics. - Integrated multi-agency working will present an opportunity to develop new roles working across Health,

Education and Social Care in areas such as Therapy Assistant and Support Worker for children with a disability.

The benefits of introducing these new, extended and changed roles and new ways of working will:

- deliver the future vision and ambition of - increase productivity - give improved access to the service - increase activity and patient flow - improve recruitment to the service - increase both service and workforce flexibility - broaden the skills that the teams can deliver to meet patient needs - optimise the roles at all levels through the appropriate use of delegation - enable the service to meet compliance and governance requirements

There are some Changed Roles identified which do not fully meet the definition, but they are identified as they demonstrate a shift in the environment in which care is delivered. There is also evidence of Administration and Clerical roles being introduced to support clinical roles to support productivity and more effective deployment following implementation of the Delegation Guidelines. Full details of the workforce changes are detailed below:

37

New,

Extended or Changed

Role

Professional Group

Role Band Identified Benefits Location

Changed Additional Clinical Services

Integration of Health Board and County Council OT services

All Workforce efficiency and integrating working

Mid Locality

Occupational Therapy teams integrating with Reablement

All Workforce efficiency South Locality

Technician Support for Care Homes

Band 4 Realising cost savings from quality improvements in medicines use and reductions in volume of prescribing


Nursing & Midwifery

School Health Nursing Band 6 Expanded Public Health role that will include service to excluded children and children 'educated otherwise'

Women and Children

Extended Additional Clinical Services

Quality and Safety Advisors All Increased scope and productivity of Trainers

Quality and Safety

Administrative and Clerical

Primary Care Development Officer

Band 5 Podiatrists referring for Diagnostic Imaging

Primary Care


Physiotherapy Practitioners Band 7 Chronic Conditions Management Mid Locality

Podiatric therapist Band 7 Podiatrist undertaking referral Diagnostic Imaging and supplementary Prescribing

South & Mid Locality

Reporting Radiographers Band 7 Increase productivity of Consultants North Locality

Specialist Occupational Therapist

Band 6/7

Within in the Autistic spectrum disorder

Women and Children

Specialist Paediatric Dietician Band 6/7

Meet specialist standards and enhanced community provision

Women and Children

Nursing & Midwifery

District Nurse Case Manager Team Leader

Band 7 Independent prescribing, physical assessment skills and case management skills

South Locality

Emergency Nurse Practitioner Band 6/7

Rural based walk in centre service and provide 'Hospital at night' cover to 3 main sites in Powys (Including Brecon)

South Locality

Specialist Nurses Band 7 To provide local community based expertise and advice, case managing the most complex and frail citizens

South Locality

New Additional Clinical Services

Development Reablement Support Workers

Band 4 More patients able to remain in the own home

All Localities

Health and Social Care Support Worker

Band 2 Integrated working between health and Social Care

South Locality

Therapy Assistant Practitioner Band 3/4

Development post in the community supporting Reablement services

North Locality


Health Therapist Mid Locality

Sonographers tied in with consultant services

Increase productivity of Consultants. New to Powys.

North Locality

Estates and Ancillary

Compliance Officer Band 7 Overview of all compliance related items

Estates and Works

Nursing & Midwifery

Nurse Endoscopists Band 6/7

Increase productivity of Consultants and care closer to Home

North Locality

Specialist Nurse‐ Dermatology Band 6/8


North Locality

Specialist Nurse‐ Rheumatology Band 6/9


North Locality

Specialist Nurses in Community Paediatrics

Band 6/7

Quality assure Children's NHS Continuing ~Care funding and repatriate clinical activity from District General Hospitals into Powys's community services

Women and Children

38

3.4 Identify the forecasted total cost of the future workforce

Basic Salary including on costs

£40,661,144

Variable Pay

£ 2,262,500

Locum or agency costs

£ 269,000

Total

£43,192,644

Source of Information: Financial Ledger May 2012

3.5 Is the total cost of your future workforce within your planned/anticipated budget taking into account the cash-releasing efficiency savings?

This section should be completed by the Director of Finance. The cost of the forecast workforce in 2017, based on the current pay and on-cost rates, is within the 2012-13 budget level. However, it is not possible to predict budget levels in 2017 as this will be dependent upon the level of the Welsh Government funding settlements. 3.6 If the cost of your workforce is higher than your funded establishment, how do you plan to reconcile this difference? Whilst the cost of the workforce is not higher than the funded establishment, there is still a need to ensure that the budget is spent effectively. The “Making Every Penny Count” theme of the Annual Plan outlines the following key actions in order to deliver a balanced financial position.

1. Develop a medium term service strategy which ensures the tHB lives within its means

2. Implement a whole system cost approach to the development of improved pathways of care resulting in overall reduced spend

3. Develop the technical tools to expose unnecessary variation in spend across pathways and delivery modes

4. Develop the technical tools to expose where resources utilised are not matched by health need

5. Opportunities are maximised for securing value for money from corporate functions

6. Opportunities are maximised for securing value for money from the shared service approach

7. Ensure capacity and capability to deliver financial balance

8. The Finance Function provides support to the organisation in accordance with best practice

9. Agree a clear clinical procurement strategy for securing quality and economic services to its population

10. Agree a defined prioritisation strategy which is based upon the triple aim of quality, patient satisfaction and value

for money

39

STAGE 4: PLANNING FOR DELIVERY In Stage 3 you have identified the future workforce configuration to meet the service needs over the next 1-5 years and the key changes that will need to take place to achieve this. Stage 4 begins the process of planning for these changes in more detail.

4.1 Summarise the key actions for achieving the future workforce configuration. This is summarised in 2 parts. Firstly there is a summary of the key workforce development actions from the Making It Happen Programme and secondly, there are a series of workforce development actions which are required to meet the future workforce configuration outlined in Stage 3 of this plan. These actions will be prioritised and lead people and timescales will be allocated. In addition, they will be reviewed against the objectives within the newly launched workforce and organisational development framework, “Working Differently, Working Together” MAKING IT HAPPEN Developing the workforce to meet the key aims in the Workforce and Annual Plan is a key feature of the newly launched Making It Happen Programme which will be clinically led and organisational development based. It consists of:

A compelling vision and common aim based on what is good for patients, the public, staff and the organisation A true understanding of the baseline in relation to performance gaps and opportunities A true understanding of the baseline in relation to organisational capacity and readiness A robust and relentless programme of improvement which the whole system is aligned to deliver (timescale June

2012) The key workforce development actions drawn from the 5 key themes from Making It Happen are:

1. Improving Health And Well-Being Powys tHB is aiming to:

Enhance the public health skills of the workforce Optimise the health and wellbeing of the workforce Contribute to widening access to employment and training for the population of Powys Pursuing the Platinum Corporate Health Standard

2. Ensuring The Right Access

Powys tHB is working to: Develop effective multi-disciplinary and wider team working skills to provide integrated care internally

and across organisational and sector boundaries Ensure that the tHB has the capacity and competence to effectively commission healthcare for the

population of Powys from all providers Improve capacity and capability of the organisation, and its partners, to undertake integrated workforce

planning to ensure that the right staff deliver the right care at the right place and time Improve partnership working to secure involvement of staff and their representatives in the design and

delivery of service change

3. Striving for Excellence Staff need to be developed to be given the autonomy to tackle poor practice and waste. The opportunities for the tHB to lead and contribute to research and development will be further supported, giving definition and direction to the ‘teaching’ status of the Health Board. Powys tHB is aiming to:

Create an organisational culture in which the tHB treats all its service users, staff and partners with

dignity and respect at all times Develop and promote a culture of continuous quality improvement Ensure that the tHB has the capacity and capability to delivery its vision and objectives Ensure all staff are appropriately skilled to undertake their roles and able to develop to full potential Ensure the organisation has developed effective integrated information management and ICT systems

to support service planning, commissioning and performance management processes Continue to implement the Workforce Information System (WfIS) Develop effective and efficient work structures and deployment of staff resources

40

Continually improve professional standards, conduct and competence across professional disciplines 4. Involving the People of Powys

Powys tHB staff are key local advocates for the tHB and are central to helping deliver the message of positive change. Powys tHB is working to: Ensure active two-way communication with key stakeholders with an interest in Powys tHB services Systematic, open, honest and active engagement with Powys residents in service planning and decision

making

5. Making Every Pound Count Powys tHB is aiming to: Develop the technical tools to expose unnecessary variation in spend across pathways and delivery

modes Develop the technical tools to expose where resources utilised are not matched by health need Ensure capacity and capability to deliver financial balance The Finance Function provides support to the organisation in accordance with best practice

Other key areas with a workforce implication for development and management within the Programme:

Accountabilities and performance management Recruitment of Locality General Managers and other key positions The availability and use of information to determine areas for change

and outcomes from action Technical skill such as commissioning and contracting across all

sectors including primary care and secondary care A whole system approach to improvement and cost reduction

WORKFORCE DEVELOPMENT ACTIONS TO MEET FUTURE WORKFORCE CONFIGURATION Recruitment and Retention

The recruitment plan will be based on a rural model promoting the opportunities that working in the environment offers e.g. Development of broad-based advanced practice skills with the opportunity to work across professional and organisational boundaries for both the medical and non-medical workforce.

Clinical placements for doctors and dentists need to be extended and promoted to attract the future workforce.

Clinical placements will continue to be offered for students on pre registration programmes and it is planned to further develop the provision.

To develop an attraction strategy for the Medical and Dental workforce in light of forthcoming Consultant vacancies in CAMHS, Geriatric Medicine and Psychiatry and an ageing G.P. workforce.

To complete a project on the Teaching Health Board role and function and to exploit the opportunities that this status brings to attract the future workforce across all professional groups.

Provision of work experience for year 11 students and NHS open days, particularly targeted towards the future workforce model and the opportunities available in Powys.

Continue to build on the links with Higher Education Providers. Development of Apprenticeships/cadetships to support a career pathway within the Health Board, with a

particular focus on Estates and Works roles. Partnership working with Powys County Council to ensure that recruitment within the Health Board does not

negatively impact on the Council’s ability to sustain their services. Joint working with Third Sector/Independent Sector partners in the development of integrated services. Develop a talent management and succession planning strategy. Further work is required to understand the impact of migration patterns for new graduates in nursing and

other healthcare professions. Use of portable technologies to support productivity and effective deployment, e.g. hand held devices for the

Estates and Works team. Deployment and Redeployment

Develop a competence based framework to outline the skills and competences required within a rural setting. Utilise existing programmes and develop new programmes to increase the capability and capacity of the

workforce. Additional hours, bank, overtime and agency/locum costs require further analysis in order to understand the

complete picture in terms of FTE and associated costs. More detailed interrogation of information systems and engagement with service managers about how these hours are deployed.

Further work needs to be undertaken to understand the additional hours worked within the context of sickness levels, headroom calculations, patterns of deployment, baseline establishments and other measures of productivity.

41

Identify opportunities for integrating working and joint service delivery with Powys County Council, Private and Independent Contractors and the Third Sector.

Introduction of the Safer Nursing Care Tool in Community Hospitals Assess the impact of repatriation on both the clinical and corporate workforce e.g. increased demands on the

clinical coding team. To undertake more work in relation to travel expenses.

Exiting strategies including VERS

Consider opportunities for workforce change through the management of turnover, retirements and vacancies.

Workforce re-profiling

Management of change programme including review of vacancies and displacement of staff. Employ competence based workforce design methodology to identify competence based teams and roles to

meet service need e.g. Builth project. Maximise support worker potential 1 and optimise skill mix, employing the principles of safe and effective

delegation 2 and to identify any requirements for Assistant Practitioner development. Use a competence based approach to support opportunities for working across professional and

organisational boundaries Understand the impact for the Health Board on the utilisation of some of the workforce enablers developed

nationally e.g. Delegation Guidelines, Advanced Practice Framework and Induction Standards for Health Care Support Workers.

To undertake a more detailed piece of work across all professional groups on the shift from a hospital to community based service and to assess its impact on the current and future uptake of community modules.

Changes to work processes and use of technologies

Process Mapping of the services, such as midwifery and the pregnancy pathway to identify service and workforce change.

To ensure the maximisation of prescribing skills. Explore the use of digital dictation and voice recording software. To maximise the opportunities of using video conferencing and webex technology. Continue to explore and implement appropriate telecare, telehealth and telemedicine systems and instil

confidence and upskill staff in their effectiveness to support service and workforce change. Use of portable technologies to support productivity Use of e-learning methodology and blended learning approaches to support workforce development. To ensure staff have the basic level of IT skill required to utilise e-learning packages. I.T. equipment across the Health Board does not meet the e-learning specification and for people living in

some rural areas, broadband access is not possible. To link in with the national e-learning strategy group to explore solutions to maximising e-learning opportunities where appropriate.

E.S.R. Self Service will be fully introduced by the end of the year. E-expenses to be introduced in September 2012.

Key Enablers to achieve workforce change

An organistional development approach to service and workforce change through the “Making it Happen” programme.

Review of variable pay costs to also include travelling expenses Introduction of Aston University Team Based Working. Consistent KSF Performance and Development Reviews taking place regularly and consistently across all

teams and staff groups – this is a priority for the restructured Workforce and Organisational Development directorate.

Develop a systematic and continuous process for identifying and sharing good practice Identify opportunities to work in partnership with Powys County Council across the Workforce and

Organisational Development function. Maximise the opportunities of the Section 33 Framework that has been developed between the Health

Board and Powys County Council. Increase opportunities for multi-agency training Staff preparation, training and education - building on the competence based approach. Staff engagement through the use of existing staff forums for engagement and consultation Early identification of the benefits for change Continue to improve communication through the Health Board and with Stakeholders and other

Organisations Change Management & Leadership, integrating workforce redesign, service change and improvement skills

with communication skills and team working. Leadership and development at all levels, and notably Band 7 posts

42

Partnership, integrated and team working Staff Motivation and empowerment.

1 The support workforce: developing your patient-facing staff for the future, Briefing 75, November 2010. NHS employers. 2 All Wales Guidelines for Delegation(2010), NLIAH.

43

KEY COMPETENCE AREAS NEEDED TO MEET THE FUTURE VISION AND AMBITION It is very apparent that 21st century Healthcare workers require a new set of core skills. The future skills and the strategy drivers are identified below: There is a need to map these skills against current provision and identify opportunities for integrated programmes of learning for the future, working closely with the programme providers and linking it to the Making It Happen Programme of interventions.

KEY SKILLS FOR THE 21st CENTURY HEALTHCARE WORKFORCE

NATIONAL - IMPACT ON ALL SERVICES IN POWYS

POWYS - SPECIFIC SERVICE SPECIFIC

Working D

ifferently, Working Together

Programm

e for Governm

ent

Together for Health

NH

S Wales D

elivery Framew

ork

Setting the Direction

Rural H

ealth Plan & A

ssociated W

orkforce Strategy

NSF

forOlderPeople

inW

ales

The National Stroke Strategy

Continuing

NH

SH

ealthC

are

Managem

ent of Chronic C

onditions in W

ales

Designed to tackle C

ancer in Wales

ATherapy

StrategyforW

ales

Public Health Strategic Fram

ework

Joint ICT Strategy

One

Powys

Powys

SWA

FFN

ew D

irections for Powys

A Vision for H

ealth Care Services in

SouthEastPow

ys

A C

omm

unity Nursing Strategy for

NSF for C

hildren, Young People and A

Strategic Vision for Maternity Services

Powys Single Plan for C

hildren and Fram

ework for School N

ursing Integrated Fam

ily Support Services

Powys Strategic D

irection for Learning D

isability

Designed

toSm

ile

Health Promotion Skills Enablement Skills Team and Integrated Working Skills Community Working Competences Quality Improvement Communication Skills; Listening, Empathy, Emotional Intelligence, Mindfulness

Coaching Functional ITC Skills

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4.2 What local (organisational and regional) education and training provision will support the development of your future workforce? Delivery Existing workforce development programmes will be utilised and further programmes developed to meet the skills needs as identified. Opportunities to utilise existing national education and training programmes, e.g., Learning @NHS Wales and other programmes provided by NLIAH and PSMW or commissioned by NLIAH, need to be maximised. Links and partnerships with other health boards, Powys County Council and education providers, both within and outside Wales will continue to be explored to improve the standard and efficiency of education and development for the Powys tHB workforce. A competence based, blended learning model best meets the needs of the Powys tHB workforce, with work-based learning featuring strongly, supported by E-learning, distance learning, face to face tutorials, mentoring, shadowing, self directed learning etc. The current use of the expertise of staff within the organisation will be further developed, with a network of ‘work-based trainers’ each linked in to a trainers forum and subject area standards subgroups. The subgroups will ensure that the competences being developed are anchored in NOS, NICE guidelines, NSFs, local policy and procedures, and are recognised good practice. This will support equitable standards and best practice of care across all areas of Powys tHB. An accredited ‘Train the Health trainer’ programme is being developed, working with Coleg Powys, to ensure all staff involved in training the workforce develop key skills in the delivery of training. Alongside this programme, the trainers’ forum will be the vehicle for equipping trainers with the knowledge and skills to embed, in the training they deliver, key themes such as: Enablement, which includes dignity and respect, equality and diversity, informed patient choice Utilising a coaching style Essential literacy, numeracy and ITC skills Customer service

Learning is accredited whenever possible and we will continue to develop our productive relationships with Agored Cymru, the Institute of Leadership and Management, Coleg Powys, the University of Glamorgan, Swansea University and the Open University. Our infrastructure of mentors, assessors and internal verifiers needs to be developed and expanded to increase our capacity to accredit learning for all staff groups. By accrediting learning we are ensuring the standards of knowledge, skills and practice in the workforce, and supporting individual career development. Work needs to be undertaken to explore the opportunities of apprenticeships provision with in Powys tHB, not only in the traditional areas of estates and works but also in clinical areas. The support from NLIAH will be utilised and partnerships with local schools and colleges will be explored to set up apprenticeships with in Powys tHB. Through the work outlined above, we are aiming to widen participation and access to learning and development for Powys tHB staff. We believe that learning is everyone’s business and that it is the key to the organisation achieving its vision and ambition. Statutory and Mandatory Training

The Welsh NHS Values3 state the importance of putting quality and safety above all else, eliminating harm and investing in our staff through training and development.

Statutory and Mandatory Training is overseen by the newly restructured Quality and Safety Unit, within the Nursing Directorate.

A new system is being put in place to ensure that all staff under take timely essential training. This workforce plan takes account of the needs of the staff within the Quality and Safety Unit in order to fulfill

the ongoing requirement to provide statutory and mandatory training alongside other essential training. 3 NHS Wales Annual Quality Framework 2011/2012, Welsh Assembly Government The following tables summarise the education and training requirements to develop the future workforce.

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LOCAL EDUCATION AND TRAINING REQUIREMENTS

STAFF GROUP Bands 1- 4 COMPETENCE /TRAINING All staff Communication and Customer service

Functional IT Skills

Powys tHB Workforce systems

Quality improvement Getting the most from your Performance and Development Review

All Clinically Focused HCSWs Enablement (incorporates dignity , respect, equality and diversity, informed choice), Dementia care, Health promotion

Nursing HCSWs Clinical Nursing Skills

Rehabilitation, Physio and OT support workers

Rehabilitation skills

Hospital based staff moving into a community care setting

Community Skills Development Programme – to be developed alongside a similar programme for registered staff.

Porters and domestics Simple repair and maintenance competences

Estates New technologies, i.e. personal digital assistant (PDA)/palm top computers and computer package which assists with compliance monitoring

Estates, ancillary and Q&S staff Asbestos safety

All staff with a supervisory function

Management skills - Core Skills for Policy Application, facilitating team work, coaching, conducting performance and development reviews

STAFF GROUP Bands 5+ COMPETENCE /TRAINING All staff Functional IT Skills

Powys tHB Workforce systems Getting the most from your Performance and Development Review

All Clinical Healthcare Professionals

Enablement Dementia care

Band 7 District Nurse Case Manager /Team Leader roles Case management skills Nurses Clinical Nursing skills relevant to role Radiographers Pattern recognition Estates officers Approved Person training Q&S unit staff Train the trainer - Manual Handling

Train the trainer - Personal Safety Train the trainer - Adult protection Train the trainer - Infection control IOSH (Institute of Occupational Safety and Health) Managing Safely Course – refresher every 3 years

All staff who deliver training Train the trainer - core skills Train the trainer - embedding key themes in training: enablement, quality improvement, customer service, dignity and respect Train the trainer - embedding functional numeracy and literacy in training

All staff with a management function

Management skills - Delivering Collaborative leadership interventions: Core Skills for Policy Application, Influencing though understanding, facilitating team work, coaching, conducting performance and development reviews.

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STAFF GROUP Bands 1- 4 COMPETENCE /TRAINING National provider/partner

All Staff Customer service Learning@NHSWales HCSWs: Nursing and AHPs Routes for HCSWs to undertake pre registration programmes HEIs

STAFF GROUP Bands 5+

COMPETENCE /TRAINING National provider/partner

All Staff Customer service Learning@NHSWales

Quality improvement 1000 lives /NLIAH All Clinical Healthcare Professionals

Rural Health Practitioner specific competences, e.g. Recognition of own and others roles, signposting, recognition of own and others competences, team working, communication skills, integrated working with other agencies, promoting and fostering community and family support and networks, broader base competency development, secondary care skills delivered in the community, adaptability and resourcefulness, risk management, Telecare and Telehealth systems.

TBD with NLIAH and HEIs/IRH

To consider modular provision for Pre-registration Therapy Education Commissions

NLIAH

Health promotion HEIs

Supporting self-management TBD NLIAH/HEIs Band 7 Clinical posts

Leadership

NLIAH/PSMW/HEIs/ Partnership with Health Boards

Palliative Care Diploma/Degree modules with HEIs Complex Wound Management

COPD Respiratory Care Coronary Heart Disease care Diabetes management

Community based staff, e.g. Specialist Nurses and Therapists

There is a requirement for expanding the access to some of the modules that have been developed for Community Nursing. These modules are aimed at Community and District Nurses but have some value for other practitioners working in a community setting.

Working with NLIAH and the HEIs

Nurses, relevant to role Advance Life Support Adult and Paediatric HEIs/Partnership with other Health Boards Emergency Nurse Practitioner

Theatre Nurse New School Health Nurses Specialist Community Nursing post registration qualification HEIs Hospital staff moving into a community care setting

Community Skills First Programme TBD with HEIs

Nursing and AHP Independent Prescribing HEIs Estates, ancillary and Q&S staff

Asbestos safety Level 2

All staff with a management role

Management skills - Quality Improvement, coaching Workforce planning skills, Service Change through Workforce Redesign

1000 lives+/ NLIAH / PSMW HEIs/ Partnership with Health Boards

4.3 Identify what national (NHS Wales wide) education and training provision is required to support the development of your future workforce.

This information should also be recorded in the relevant section of the Workforce Configuration Tool. Some of the workforce pressures identified in this plan have arisen because of specific national guidance on the provision of roles with associated Agenda for Change bandings. There is no objection from the Health Board in delivering national strategy; however, it would be welcomed if the outcomes of what needs to be achieved could be articulated rather than the specifics to take into account of local service requirements. This would be of great assistance in achieving service, workforce and financial integration. Below is a summary of the national education and training provision is required to support the development of the workforce.

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This is a summary of the education commissions required from Powys Teaching Health Board taken from the Workforce Configuration Tool. There is a nil return for Medical and Dental beyond 2017, as these students are already in the system. There will be a requirement to recruit to Consultant posts in CAMHS and Elderly Care Medicine in the short term as well as some Dentists.

Medical Grade 2012 2013 2014 2015 2016 2017 2018 Total

Consultant 0 0 1.5 0 0.8 0 0 2.3

Consultant Locum 0 0 0 0 0 0 0 0

Consultant Locum Max 0 0 0 0 0 0 0 0

Specialist Registrar 0 0 0 0 0 0 0 0

Specialty Registrar 0 0 0 0 0 0 0 0

Senior House Officer 0 0 0 0 0 0 0 0

House Officer 0 0 0 0 0 0 0 0

PRHO 0 0 0 0 0 0 0 0

Foundation House Officer 2 0 0 0 0 0 0 0 0

Foundation House Officer 1 0 0 0 0 0 0 0 0

Associate Specialist 0 0 0 0 0 0 0 0

Specialty Doctor 0 0 0 0 0 0 0 0

Senior Clinical Medical Officer 0 0 0 0 0 0 0 0

Staff Grade Practitioner 0 0 0 0 0 0 0 0

Salaried GP 0 0 0 0 0 0 0 0

Salaried Primary Dentist 0 0 0 0 1 0 0 1

Med/Gen Dental Practitioner 0 0 0 0 0 0 0 0

TOTAL 0 0 1.5 0 0.8 0 0 2.3 The Non-Medical education commissions are detailed in the table below. This table shows:

- Previous requests for education commissions from 2008 to 2011. - The blue shaded column is the column for approval entitled “2012 Submission for Approval”. Information

has been drawn from the Workforce Configuration Tool, a separate analysis based on future turnover and projected retirements and management intelligence.

- The final 3 columns relate to a piece of work that calculates the projected turnover for a given year and assume a retirement at 55 for Nursing and Midwifery and Allied Health Professionals.

- This can be used to compare the 2012 submission request with the likely total number of leavers for that year broken down into normal turnover and age related retirement projections.

- The retirements assume that all people reaching 55 that year will leave and does not take into account other people aged 55 or over leaving in the same year, or people leaving earlier than aged 55. Hence, it is likely that this still gives the “higher” end of the demand and is for guidance purposes and to inform decision making.

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Proposed commissions for 2013/2014

Course TitleCourse

duration Year Band 2008 2009 2010 20112012

CommissionsTurnover Retirements TOTAL

Ambulance Paramedics 2 years 2015 Band 5 0 0 0 0 0 0.00 0.00 0.00DENTALDiploma in Dental Hygiene 2 years 2015 0 0 0 0 0 0.00 0.00 0.00Diploma in Dental Therapy 27 months 2016 Band 6 0 0 0 0 0 0.04 0.00 0.04NURSING & MIDWIFERYBachelor of Nursing (B.N.) Adult 2016 Band 5 20 20 21 13 18 13.14 15.80 28.94Bachelor of Nursing (B.N.) Child 2016 Band 5 0 0 1 1 0 0.00 0.22 0.22Bachelor of Nursing (B.N.) Mental Health 2016 Band 5 10 10 0 0 0 0.00 0.37 0.37Bachelor of Nursing (B.N.) Learning Disability 2016 Band 5 4 4 1 0 1 0.48 1.00 1.48Return To Practice 6 months 2014 0 0 0 0 0 0.00 0.00 0.00B.Sc. Midwifery 3 years 2016 Band 5 0 5 2 0 2 1.48 0.82 2.30B.Sc. Midwifery 18 months 2015 Band 5 0 0 2 0 2 1.48 1.40 2.88COMMUNITY HEALTH STUDIESDistrict Nursing (Part-time) 2 year 2015 Band 6 3 3 3 0 6 1.00 2.52 3.52District Nursing Modules (in modules) 1 year 2014 0 0 3 11 11* 0.00 0.00 0.00Health Visiting (Full-time) 1 year 2014 Band 6 0 4 2 2 3 1.50 1.20 2.70Health Nursing (Part-time) 2 year 2015 Band 6 0 0 0 0 0 0.00 0.00 0.00School Nursing (Full-time) 1 year 2014 Band 6 1 2 4 7 3 0.62 0.00 0.62School Nursing (Part-time) 2 year 2015 Band 6 0 0 0 0 0 0.00 0.00 0.00School Nursing Modules (in modules) 1 year 2014 0 0 0 0 0 0.00 0.00 0.00Practice Nursing (Part-time) 2 year 2015 0 0 0 0 1* 0.00 0.00 0.00Practice Nursing Modules (in modules) 1 year 2014 4 4 0 0 1* 0.00 0.00 0.00Community Paediatric Nursing (Part-time) 2 year 2015 Band 6 0 0 0 0 2 0.09 0.00 0.09Community Paediatric Nursing Modules (in module 1 year 2014 0 0 1 1 0 0.00 0.00 0.00CPN (Part-time) 2 year 2015 Band 6 0 0 0 0 0 0.00 0.00 0.00CPN Modules (in modules) 1 year 2014 11 11 0 0 0 0.00 0.00 0.00CLDN (Part-time) 2 year 2015 Band 6 0 0 0 0 0 0.30 0.00 0.30CLDN Modules (in modules) 1 year 2014 0 0 0 0 2 0.00 0.00 0.00Modules to enable individuals who completed previous module(s) to undertake additional module(s) 1 year 2014 0 0 0 0 8 to 15* 0.00 0.00 0.00

PHARMACYRegistered pharmacists 5 years 2018 0 0 0 0 0 0.00 0.00 0.00Pre Reg Pharmacy 1 year 2015 0 0 0 0 1 0.18 0.00 0.18Pharmacy Diploma 2 years 2016 3 3 0 0 0 0.00 0.00 0.00Pharmacy Technician 2 years 2015 Band 4 3 3 0 0 1 0.10 0.00 0.10SCIENTIFIC PTPB.Sc. Clinical Physiology cardiology 3 years 2016 Band 5 0 0 0 0 0 0.00 0.00 0.00B.Sc. Clinical Physiology audiology 3 years 2016 Band 5 1 1 1 0 0 0.08 0.00 0.08B.Sc. Clinical Physiology respiratory 3 years 2016 Band 5 1 1 0 0 0 0.00 0.00 0.00B.Sc. Clinical Physiology Technician (Medical Phys 3 years 2016 0 0 0 0 0 0.00 0.00 0.00B.Sc. Biomedical Sciences 3 years 2016 Band 5 0 0 0 0 0 0.00 0.00 0.00B.Sc. Neuro Physiology 3 years 2016 0 0 0 0 0 0.00 0.00 0.00B.Sc. Clinical Engineering in Rehab 3 years 2016 0 0 0 0 0 0.00 0.00 0.00RADIOGRAPHYB.Sc. Diagnostic Radiography 3 years 2016 Band 5 4 4 3 2 0 0.38 0.30 0.68B.Sc Therapy Radiography 3 years 2016 Band 5 0 0 0 0 0 0.00 0.00 0.00Assistant Practitioners Radiography - Diagnostic 1 year 2014 Band 4 0 0 0 0 0 0.00 0.00 0.00Assistant Practitioners Radiography - Therapy 1 year 2014 Band 4 0 0 0 0 0 0.00 0.00 0.00ALLIED HEALTH PROFESSIONALSB.Sc. Human Nutrition - Dietician 2 & 4 years 2017 Band 5 2 2 2 1 0 0.26 0.00 0.26PG Dip. Medical Illustration 2 years 2015 0 0 0 0 0 0.00 0.00 0.00B.Sc. Occupational Therapy , 3 & 4 year 2016 Band 5 11 11 5 6 1 1.29 0.79 2.08Diploma in ODP 2 years 2015 Band 5 0 0 1 0 0 0.05 0.00 0.05B.Sc. Physiotherapy 3 years 2016 Band 5 11 11 4 6 2 1.81 1.84 3.65B.Sc. Podiatry 3 years 2016 Band 5 5 5 0 2 2 0.37 1.00 1.37Orthoptist 3 years 2016 Band 6 0 0 0 0 0 0.00 0.00 0.00Clinical Psychology Doctorate 3 years 2016 Band 8a 0 0 0 0 1 0.15 1.42 1.57B.Sc. Speech & Language Therapy 4 years 2017 Band 5 5 5 0 1 0 0.57 1.00 1.57B.Sc. Speech & Language Therapy - Welsh Langu 4 years 2017 0 0 0 0 0 0.00 0.00 0.00Surgical Care Practitioners 2 years 2015 0 0 0 0 0.00 0.00 0.00PRESCRIBINGV300 Full Independent Prescribing 1 year 2014 0 0 0 0 12** 0.00 0.00 0.00Supplementary Prescribing 1 year 2014 0 0 0 0 2 0.00 0.00 0.00V150 Limited Independent Prescribing 1 year 2014 0 0 0 5** 0.00 0.00 0.00

Total 99 109 56 53 83 - 90 25.37 29.68 55.05

Separate Analysis to inform commissions

Community Modules Numbers which have a * are subject to further validation and also clarification of route for Practice Nursing

The requirements to undertake the Fundamentals of Care as part of the prescribing modules have NOT been taken into consideration

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Amber or Red

Risk Mitigating Actions Location

Red Inability to obtain apprentices to meet future workforce gaps as a consequence of an ageing workforce in the Trade Professions.

Make contact, in conjunction with Workforce and OD, with local colleges.

Estates and Works

Red Lack of required skills within the local labour market and low numbers of young people in Powys

Development of career pathways for young people. Work with Powys County Council to attract younger people into employment. Promotion of the wider employment opportunities e.g. within corporate functions.

Localities

Red Low turnover rates impact on the speed of workforce change

Assess impact through the Making it Happen Programme

Localities

Red New retirement influence staff turnover Management knowledge to inform decision making and effective workforce and succession planning.

Localities

Red Failure to recruit Medical and Dental staff and G.P.s to Powys

Attraction strategy and increased clinical placements and development of a Rural pathway.

Health Board

Amber Mismatch between staff deployment and workload patterns

Detailed understanding of service demands and workforce deployment patterns to inform future action.

Localities

Amber Lack of funding to purchase new technology Production of business cases to show how new technology can create savings

Estates and Works

Amber Lack of redesign expertise within the Health Board to facilitate service and workforce change

Workforce and OD team to build capacity and capability within the service.

Health Board

Amber A very small number of women assessed at 'high risk' but choosing to birth at home or in a Powys Birth Centre, compromise the maternity service.

Engagement with individuals

Women and Children

Amber Local dental nurse training schemes are not locally available in rural areas which may prove to be a barrier.

Raise awareness through national Dental Committee

Medical and Dental

4.4 Identify the key Amber or Red risks associated with achieving your future workforce using the Welsh Risk Pool chart to calculate the seriousness of the risk

Likelihood of occurrence

Rare Unlikely Possible Probable Expected

Impa

ct o

n se

rvic

e if

this

si

tuat

ion

occu

rred

Negligible Green Green Green Green Yellow Minor Green Green Yellow Yellow Amber Moderate Green Yellow Amber Amber Red Major Green Yellow Amber Red Red Critical Yellow Amber Red Red Red

There are currently no risks on the Corporate Risk Register relating to the workforce. General risks associated with culture are:

- not creating a sense of urgency to change the service - Risk adverse culture

This is a summary of the key risks identifed from the services across Powys:

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STAGE 5: PERFORMANCE MANAGEMENT This stage sets out the process for Performance Management 5.1 Identify who will take lead accountability for the Performance Management of the workforce plan. Joanna Davies, Director of Workforce and OD will have lead accountability. 5.2 Identify who, within the organisation, will be responsible for the implementation of the workforce plan. Each of the workforce areas have a lead as identified in C2. Each lead will have clear responsibility for delivering on this plan. Some of the actions identified in Stage 4 will be implemented on a Powys wide scale where appropriate. Actions will be identified as Stage 4 of the plan will be converted into an action plan. This will be co-ordinated by the Workforce and Organisational Development Team, although lead responsibilities will be allocated across the Health Board. There is Executive commitment that this plan will be developed as service models emerge and the actions identified within this plan will be integrated into the Making It Happen Programme. 5.3 Identify how the delivery of your workforce plan will be monitored and reported by the organisation.

(You may wish to include your meeting structure.) The Making it Happen programme will be the organisational development vehicle to achieve service and workforce redesign. This is still in the early stages of development as outlined in Stage One. There will be a need for the workforce development actions identified in Stage 4 of this plan to integrate with the Making it Happen programme. The Workforce and OD function within Powys is under new leadership and as the direction for this function emerges, an infrastructure to support the implementation of this plan will become clearer. This will integrate with existing structures to save duplication. In the interim, reporting arrangements will be to the Informal Executive Group, Partnership Forum and then to the Executive Board.

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STAGE 6: WORKING IN PARTNERSHIP In this last stage, you are required to identify areas where you have and propose to develop services, in partnership with other agencies and stakeholders. You should identify where these changes have/will result in development of the workforce. 6.1 Detail any cross boundary / partnership work that you need to undertake to achieve stage 4 actions.

- With Powys County Council for partnership work across commonalities in the workforce and organisational development agenda.

- Identify opportunities for utilising the Section 33 Framework that has been developed between Powys County Council and the Health Board.

- Once the impact of repatriation is realised, work in partnership with Powys County Council, other Health Boards within NHS Wales and adjacent health organisations in England as well as the third sector.

- To work with NLIAH/HEI’s and other Health Boards on the potential sourcing and development of the educational pathways to support workforce development and aid succession planning.

6.2 What support from national organisations is required to achieve this plan? The actions for delivery that require national support are clearly identified in Stage 4. There is a need to work closely with NLIAH and PSMW as well as Higher Education Institutions to realise this plan.

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APPENDIX ONE - ANALYSIS OF THE CURRENT WORKFORCE PROFILE

Information sources: Unless otherwise stated, information is taken from the Electronic Staff Record (E.S.R.) and Finance Department.

1. Staff Group As you can see from the pie chart below Nursing and Midwifery Registered are the largest staff group within Powys tHB accounting for 34% of the whole workforce. 1.1: Staff Group by %

2. Equality profile Disability 80% (1270 headcount) of the workforce within Powys tHB have no record of their disability status. Only 1% (15 headcount) are recorded as having a disability. There is a need for a data capture exercise to address not only disability issues, but also religious belief and sexual orientation. Ethnic Origin Almost 73% (1161) of the workforce are British, 13% (205) Welsh and 12% (190) have no record of Ethnic Origin.

Religious Belief 55% (875) have no record of Religious Belief, with 6% (90) not wishing to disclose. 32% (508) are Christians. Sexual Orientation 55% (883) have no record of sexual orientation, 3% (51) did not wish to disclose and 41% (650) heterosexual.

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3. Part Time/Full Time & Gender 85% of Powys tHB workforce is female. Only in the Medical and Dental Staff Group do male employees exceed female employees. Table 3.1: Gender by Full Time/Part Time

4. Annual Turnover Rate The annual turnover for 2011 turnover was 8.10% which includes age retirements. 4.1: Annual Turnover by Month

Medical and Dental turnover rates is high due to the small number employed under this staff group.

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5. Age Profiles The chart below provides the current age profile for Powys tHB.

5.1: Current Age Profile

21% (249.74 FTE) of the current workforce are already over the age of 55, 8% (82.21 FTE) are over 60, rising to 59% (728.16 FTE) and 40% (491.13 FTE) over 60 by 2022. The following table provides the % of staff already over 55 by Designation. Particular hotspots have been highlighted. 5.2: Staff Already Over 55

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6. Retirement Scenarios for All Staff Groups The following two graphs give age retirement scenarios at age 55 & 60 over the next 10 years for all Staff Groups 6.1: Retirement Scenario at Age 55

21% (249.74 FTE) of the current workforce are already over the age of 55, rising to 59% (728.16 FTE) 6.2: Retirement Scenario at Age 60

Currently 8% (82.21 FTE) of the workforce are over 60; this will rise to 40% (491.13 FTE) by 2022.

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A further analysis of Nursing & Midwifery Registered and Allied Health Professionals/Add Professional and Technical/Healthcare Scientists follows:

7. Retirement Scenario: Nursing & Midwifery Registered

7.1: FTE and Headcount of Nursing & Midwifery Registered Staff as of January 2012.

Currently 15% (59.10 FTE) of the qualified nurses in Powys are over the age of 55. Over 8% (31.85 FTE) of these are within the Acute Elderly and General. By 2017 37% (155.27) will be over 55 and by 2022 this will rise to 59% (248.45).

7.2: Retirement Scenario: Age 55

The hot spots are highlighted in the charts in red and blue respectively.


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8. Retirement Scenario: Allied Health Professionals/Additional Professional & Technical and Healthcare Scientists

FTE and Headcount figures as of January 2012 for Qualified Therapy staff, including Psychologist and Pharmacists, by Designation and Locality, along with the current Age Profile and Retirement Scenarios at age 55 & 60. The chart below provides an overview of all Therapies Staff by Headcount and FTE by Age Group. 13% of these staff are already over the age of 55, the majority of which lie within Physiotherapy and Radiography. 8.1: FTE & Headcount of Allied Health Professionals/Additional Professional/Healthcare Scientists


Hot spots are highlighted in the tables in red and blue respectively. 8.3: Retirement Scenario: Age 60

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9. Skill Mix

The AOF national target to reduce the FTE of Bands 5 to 9 by 3% per annum with a corresponding increase in FTE of Bands 1 to 4 between 2010 and 2013. Baseline data and target are subject to change as a result of ongoing work to align budgets and the ESR hierarchy due to restructuring. 9.1: AOF National Target

9.2 Pay Bands by Staff Group

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With exception of Doctors, Dentists and Executive Level posts, all staff are directly employed are paid on the Agenda for Change Pay Bands.

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10. Workforce Costs (Source: Finance Department)

Table 10.1: Basic Pay and Enhancements

Total Basic Pay (£38,679,371) and Enhancements (£2,241,239) for 2011/2012 comes to a total of £40,920,160.

11. Use of Temporary Workforce (Source: Finance Department)

11.1: Variance between FTE Contracted and Worked by Month 2011-12 (includes Bank & Enhancements)

Additional Clinical Services, Estates & Ancillary and Nursing & Midwifery Registered regularly work over contract. In June, August, November and February the FTE is significantly raised. (CHC and BSC figures are included)

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11.2: Variance between FTE Contracted and Paid by Month 2011-12

11.3: Monthly average The following table provides a monthly average FTE contracted, worked and paid for the year 2011/2012.

)

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11.4: Temporary Workforce

Temporary Workforce Use Annual Total Overtime £120,177 Agency £241,855 Excess £687,282 Bank £660,168Grand Total £1,709,483

11.5 Agency Usage

The table above shows the monthly cost of Agency Staff. The total cost for the year 2011/2012 £236,485 with the majority of expenditure in the South Locality and Planning Directorate. Planning costs are for an electrician that is employed on a full time basis on Agency.

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12. Sickness Absence The target sickness for Powys tHB is 4.42%. Up until January 2012, this was being achieved on a monthly basis but has crept above the target for February and March 2012. Table 12.1 Percent Sickness by Month

Table 12.2 Total FTE Days Lost by Month

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Table 12.3 Total FTE Days Lost by Staff Group against FTE available

This gives an annual sickness rate of 3.99%; however, some staff groups notably Healthcare Scientists, Additional Clinical Services and Nursing and Midwifery Registered remain higher than the Powys sickness target of 4.42%. Table 12.4 Total FTE Days Lost by Staff Group by Month

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Table 12.4 Total FTE Days Lost by Staff Group in 2011 – 2012

Kay Williams Workforce information and Data analysis Workforce & OD Directorate May 2012

Page 1 of 46

POWYS THB

2012


WORKFORCE PLANNING REPORT 2012 WORKFORCE INTELLIGENCE (WI)

Workforce & OD Directorate

P OW Y S T E A C H I N G H E A L T H B O A R D


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INDEX

Page

1. Current Workforce 4

2. Skill Mix 6

3. Gender & Full Time/Part-Time 7

4. Equality Profile 9

5. Turnover 9

6. Age Profile 10

7. Retirement Scenarios – Age 55 & 60 13

8. Leavers 20

9. Recruitment 22

10. Residency of Current Staff 24

11. Sickness Absence 25

12. Workforce Costs 27

13. Training & Education Activity 30

14. Labour Market Intelligence 41


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Workforce Planning LMI Report

This report has been compiled by the Workforce and OD Directorate using information held in the Electronic Staff Record (ESR) it excludes all BSC, CHC unless otherwise stated. The ESR system is in the process of being reconfigured to match the ongoing restructuring of Localities and Directorates. Until this work is finalised differences will exist within the data when comparing with other performance reports and previous months. The roles included in the Staff Groups reported are; Staff Group Roles Add Prof Scientific and Technical Chaplain, Clinical Psychologists, Pharmacist Additional Clinical Services Counsellor, Dental Assistants/Nurses, Healthcare

Assistant, AHP Helper/Assistant/Technicians Administrative and Clerical Admin Staff Allied Health Professionals Chiropodist/Podiatrist, Dietician, Occupational

Therapist, Physiotherapist, Radiographer, Speech and Language Therapist

Estates and Ancillary Catering Staff, Domestics, Transport, Works Staff Healthcare Scientists Audiologist Medical and Dental Dental Officer, Medical Staff Nursing and Midwifery Registered All Qualified Nursing Staff In 2012 Powys has a projected working age population (16‐64) of 79,166 of which 59,800 are in employment, 2.38% by Powys tHB. Powys currently employs 2.62% of the 71,817 people directly employed by NHS Wales.


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1. Current Workforce As of January 2012 the total headcount of staff paid via Powys ESR Payroll (including BSC, CHC) is 1934 (1886 Primary Assignments). This is only inclusive of staff paid via ESR and will not include staff seconded in to Powys who are paid via other NHS organizations. N.B. (3.77 wte Displaced Staff are included in Directorate of W&OD) The table below outlines the current directly employed FTE and Headcount figures for Powys teaching Health Board as of January 2012, including the Participation Rate by Staff Group and Yearly Salary Value (Source ESR). The salary value includes on‐costs, but excludes enhancements and secondments into Powys. Table: 1.1

The following table gives a further breakdown of the participation rate for Staff Groups: Allied Health Professionals, Estates & Ancillary and Nursing and Midwifery Registered Table: 1.2


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Graph 1.3 outlines the distribution of staff by Staff Group within Directorates and Localities. Graph: 1.3

Graph 1.4 gives the cumulative increase/loss in FTE by Locality for Jan‐11 to Jan‐12. There is a growth of 16.15 FTE. From analysis the reason for this increase is mainly due to the appointment of Community Health Care Staff and secondment posts being made substantive. Graph: 1.4


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2. Skill Mix

Nearly 44% of Powys workforce are within Bands 1‐4, with 56% in Bands 5‐9 and other. Bands 1‐4 account for just over 28% of staff expenditure. Graph 2.1 provides the FTE on Agenda for Change Pay Bands from 1 to 8D. The largest groups by Pay Band are Band 2 at nearly 24% and Band 5 at 21%. Graph: 2.1

The AOF national target to reduce the FTE of Bands 5 to 9 by 3% per annum with a corresponding increase in FTE of Bands 1 to 4 between 2010 and 2013. Baseline data and target are subject to change as a result of ongoing work to align budges and the ESR hierarchy due to restructuring. The table below provides the information by Locality/Directorate. Table: 2.2


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3. Gender & Full‐Time/Part‐Time Over 85% (1358) of the current workforce are Female, and as you will see from the table below 55% (883) of them work part‐time. Add Prof Scientific & Technical have a high number of part‐time staff due to Chaplains being including in this Staff Group. Table: 3.1

(Part‐time is defined as hours less than 37.5 per week) As you will see from the Graph 3.2 below, the highest percentage of part‐time workers fall within: 1. Mid Locality: mainly Healthcare Assistants, Qualified Nursing and Domestic/Catering

Staff. 2. Women & Children: majority of which are Midwives and Health Visitors 3. North Locality: as with the Mid, part‐time staff are mainly within Healthcare Assistants,

Qualified Nursing and Domestic/Catering Staff


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Graph: 3.2

Table 3.3 below provides hotspot area’s for professional staff where the workforce is currently mainly part‐time staff, which could have an effect on Commissioning Education numbers. Table: 3.3 STAFF GROUP % Part Time

Staff Allied Health Professionals Dietician 37.50%Occupational Therapist 48.48%Physiotherapist 45.83%Podiatrist 54.55%Radiographer 85.71%Speech & Lang Therapist 64.71%

Nursing and Midwifery Registered Community Nurse 66.67%Comm Nursing ‐ LD 28.57%Health Visitor 73.33%Hospital Nursing 58.72%Midwife 69.23%Nursing ‐ CAMHS 50.00%Nursing ‐ Paeds 50.00%Nursing Theatre 80.00%School Nurse 50.00%


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The majority of part‐time staff are contracted between 21 and 30 hours per week (range is 5 – 37 hours) within the Nursing and Midwifery staff group. 4. Equality Profile

• Disability Status ‐ 80% (1270 headcount) of the workforce within Powys tHB have no

record of their disability status. Only 1% (15 headcount) are recorded as having a disability. (Appendix 1: Point 2)

• Ethnic Origin ‐ Almost 73% (1161) of the workforce are British, 13% (205) Welsh and 12%

(190) have no record of Ethnic Origin. (Appendix 1: Point 2) • Religious Belief ‐ 55% (875) have no record of Religious Belief, with 6% (90) not wishing

to disclose. 32% (508) are Christians. (Appendix 1: Point 2) • Sexual Orientation ‐ 55% (883) have no record of sexual orientation, 3% (51) did not

wish to disclose and 41% (650) heterosexual. (Appendix 1: Point 2)

5. Turnover (Starters & Leavers) Yearly Turnover for 2011 = 8.10% based on: Leavers in period Average number of staff in period This is above the assumption figure of 4.68% used in our Workforce Configuration Tool, which excluded Age Retirements and TUPE transfers. Graph 5.1 gives a yearly turnover percentage by Staff Group and Graph 5.2 provides a mothly turnover by Locality. Graph: 5.1


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Graph: 5.2

6. Age Profile

The following graphs provide a breakdown of the Age Profile of Staff by Staff Group and Locality/Directorate.

Graph: 6.1


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Graph: 6.2.

21% (249.74 FTE) of the current workforce are already over the age of 55, 8% (82.21 FTE) are over 60, rising to 59% (728.16 FTE) and 40% (491.13 FTE) over 60 by 2022. Table 6.3 provides the % of staff already over 55 by Designation. Particular hotspots have been highlighted. Table: 6.3


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The following graphs show a comparison of the Age Band of Staff currently and in the next 5 & 10 years. Graph 6.4

Graph: 6.5


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Graph 6.6 presents headcount of staff over the age of 55 by Locality/Directorate. The Mid Locality has the highest percentage of staff over the age of 55 with 28% (77 HC) of the Locality, these mainly Healthcare Assistants, Ancillary and Qualified Nursing staff based in the Hospitals.


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Table: 6.6

7. Retirement Scenarios for All Staff Groups Graphs 7.1 &7.2 give age retirement scenarios at age 55 & 60 over the next 10 years for all Staff Groups Graph: 7.1


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21% (249.74 FTE) of the current workforce are already over the age of 55, rising to 59% (728.16 FTE) Graph: 7.2

Currently 8% (82.21 FTE) of the workforce are over 60; this will rise to 40% (491.13 FTE) by 2022. Further analysis on Staff Groups Nursing & Midwifery Registered and Allied Health Professionals/Additional Professional/Healthcare Scientists follows: Nursing & Midwifery Registered Graph 7.3 provides the FTE and Headcount of Nursing & Midwifery Registered Staff as of January 2012 and 7.4 the breakdown of FTE by Locality/Directorate. Currently 15% (59.10 FTE) of the qualified nurses in Powys are over the age of 55. Over 8% (31.85 FTE) of these are within the Acute Elderly and General. By 2022 this will rise to 59% (248.45 FTE).


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Graph: 7.3.

Graph: 7.4

Contained within the above figures are the following Management Positions by Age Band.


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Table: 7.5

The following tables explore the possible retirements over the next 10 years with an assumed retirement age at both 55 & 60 for Nursing & Midwifery Registered Staff: Table:7.6.‐ Retirement Scenario at Age 55

The hot spot areas are highlighted in red and blue respectively. Table: 7.7 ‐ Retirement Scenario at Age 55


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Allied Health Professionals/Additional Professionazl/Healthcare Scientists

FTE & Headcount of Allied Health Professionals/Additional Professional/Healthcare Scientists FTE and Headcount figures as of January 2012 for Qualified Therapy staff, including Psychologist and Pharmacists, by Designation and Locality, along with the current Age Profile and Retirement Scenarios at age 55 & 60. The chart below provides an overview of all Therapies Staff by Headcount and FTE by Age Group. 13% of these staff are already over the age of 55, the majority of which lie within Physiotherapy and Radiography.

Graph: 7.8

The following information outlines the directly employed FTE as of January 2012 by Designation and Locality, along with the current Age Profile and Retirement Scenarios at age 55 & 60.


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Graph: 7.9

Table: 7.10


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Table: 7.11.‐ Retirement Scenario at Age 55

Hot spots are highlighted in the tables in red and blue respectively. Table: 7.12.‐ Retirement Scenario at Age 60

Contained within the above figures are the following Management positions by Age Band. Table: 7.13


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8. Leavers There were 124 Leavers in 2011, 41% of which had less than 6 years service in Powys 33% of which were in the Nursing & Midwifery Staff Group and the majority leaving voluntary with no known reason. Additional Clinical Services and Estates and Ancilliary had equal percentage of nearly 19%, mainly Healthcare Assistants and Facilites staff. Graph : 8.1

Graph: 8.2


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46% of the Leavers in 2011 were retirements, with the majority in Nursing & Midwifery and Estates & Ancilliary, mainly in the North & South Locality Graph: 8.3

Graph: 8.4


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9. Recruitment There were 98 new staff enrolled within 2011, nearly 38% of which were over the age of 46 and 40% of the total were recruited to the Nursing & Midwifery Staff Group. Graph: 9.1

Graph: 9.2


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Graph: 9.3

On analysis of professional staff recruited in 2011 it is noted that approximatly half of these staff were recrutied from an NHS Wales Organisation. Recruitment Sources : The following graph gives the recuritment source of staff over the past 5 years. Nearly 45% (239) of these staff were recurited from an NHS Organisation nearly 80% are professionally qualified staff. For those recurited from NHS England the type of staff recruited were varied which included Consultant/Medical Staff, the areas are varied but the majority were from Shropshire and Wye Valley. Graph: 9.4

10. Residency of Current Staff


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Graph 10. 1 below shows the current staff home location by headcount. Just over 75% of the workforce live within Powys, 3% live in England, which leaves the remaining 22% living in other parts of Wales. Graph: 10.1


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11. Sickness Absence

Graph 11.1 gives the monthly Sickness percentage and Graph 11.2 the FTE days lost for Powys 2011‐2012. (These figures include BSC & CHC)

Graph: 11.1

Graph: 11.2


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Table: 11.3

Above are the total FTE Days Available and the Total FTE Days Lost, This gives an annual sickness rate of 3.99%; however, some staff groups notably Healthcare Scientists, Additional Clinical Services and Nursing and Midwifery Registered remain higher than the Powys sickness target of 4.42%. Graph 11.4 below gives a breakdown of FTE Days Lost by Staff Group and month. Table: 11.4


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12. Workforce Costs

Basic Pay Costs ‐ Graph 12.1 gives the Basic Pay & Enhancements for the period Apr‐11 to Mar‐12. Total Basic Pay (£38,679,371) and Enhancements (£2,241,239) comes to a total of £40,920,160. (Source: Finance Department)

Graph: 12.1

Graph 12.2 provides further costs of the temporary workforce: Bank, Excess, Agency and Locum : (Source: Finance Department) Graph: 12.2


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Total Overtime (£120,177), Agency (£241,855), Excess (£687,282) and Bank Usage (£660,168) gives a Total of £1,709,483. Table 12.3 gives the variance between Contracted and Worked FTE by Month for 2011‐12 (this information includes Bank & Enhancements) Source: Finance Department Table: 12.3 ‐ Variance between Contracted and Worked FTE by Month for 2011‐12 (this information includes Bank & Enhancements) Source: Finance Department

Table: 12.4 ‐ Variance between Contracted and Paid FTE by Month for 2011‐12


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Table: 12.5 – Monthly Average The following table provides a monthly average FTE contracted, worked and paid for the year 2011/2012.

Table 12.6 below shows the monthly cost of Agency Staff. The total cost for the year 2011/2012 £236,485 with the majority of expenditure in the South Locality and Planning Directorate. Planning costs are for an electrician that is employed on a full time basis on Agency. Table: 12.6


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13. Training & Education Activity

Nursing and Midwifery A recent audit identified that at Bands 5‐8 a significant number of our workforce do not possess a Degree, Post registration qualification or Management and Leadership training. This illustrates that many Nursing staff have not completed further academic learning since they became a registered Nurse. Allied health professions staff are more active in undertaking training and development this is true across the range of development available. The most significant profession are Physiotherapists. This service has a proactive lead manager who ensures that development needs for each employee are detailed on an Annual basis. The training and development budget is largely consumed by Statutory and Mandatory training requirements. Steps are being taken to facilitate long term pro active planning. The aim is for training and development programmes to be coordinated, planned and delivered as efficiently and effectively as possible . Our capacity to understand the skills we have within the workforce and the skills we require is improving. The use of improved electronic systems and a commitment to ensuring Performance and Development Reviews (PADR) are undertaken annually is supporting our incremental steps to improve in this area. Training and Education Activity April 9 – March 11 North Locality Management Table: 13.1 Category Community

Health Studies Programmes

Educational Panel Leadership Programmes

Study Leave

Add professional, Scientific & Technical


7

Admin & Clerical AHP 6 36 Estates & Ancillary 1 1 Healthcare Scientists Medical & Denal Nursing & Midwifery 4 9 36


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South Locality Management Category Community



Study Leave


1 1 2


18

Admin & Clerical 1 AHP 4 42 Estates & Ancillary Healthcare Scientists Medical & Dental Nursing & Midwifery 5 7 43

Mid Locality Management Category Community



Study Leave



21

Admin & Clerical 3 15 AHP 2 25 Estates & Ancillary Healthcare Scientists Medical & Dental Nursing & Midwifery 6 12

Women & Children’s Directorate Category Community



Study Leave


1


17

A&C AHP 2 49 Estates & Ancillary Healthcare Scientists Medical & Dental Nursing & Midwifery 5 1 7 21


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Headquarters Category Community



Study Leave


2 4


8

Admin & Clerical 3 7 14 AHP 2 2 Estates & Ancillary Healthcare Scientists Medical & Dental Nursing & Midwifery 1 8 15

Training and Education Activity April 09 – January 11 North Locality Management Graph: 13.2

South Locality Management Graph: 13.3


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Mid Locality Management Graph: 13.4

Women & Children’s Directorate Graph: 13.5


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Headquarters Graph: 13.6


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Courses attended by Powys THB staff, all time Table: 13.7

Staff Group Clinical Conference Continuing Professional

Development Elective Essential to

role Mandatory Optional Relevant Statutory Grand Total

Add Prof Scientific and Technic 6 7 6 6 42 18 13 98

Additional Clinical Services 12 6 45 33 166 48 44 354

Administrative and Clerical 62 36 5 120 117 587 212 249 11 1399

Allied Health Professionals 2 8 2 4 16

Estates and Ancillary 4 15 56 2 1 78

Medical and Dental 1 1

Nursing and Midwifery Registered 17 6 1 20 150 202 41 104 541

Headquarters Total 97 55 6 195 323 1062 323 415 11 2487


Administrative and Clerical 23 5 9 69 182 76 67 431

Allied Health Professionals 33 2 1 64 181 23 76 380

Estates and Ancillary 32 5 26 116 344 137 95 755

Medical and Dental 8 36 16 2 62


Mid Locality Management Total 232 19 7 250 883 2186 562 654 4793


Administrative and Clerical 5 1 52 193 49 65 365



Medical and Dental 1 1 4 2 1 9 Nursing and Midwifery Registered 199 2 8 120 731 1090 187 568 2905 North Locality Management 375 10 18 271 1196 2733 384 1210 6197


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Staff Group Clinical Conference Continuing Professional Development Elective Essential to role Mandatory Optional Relevant Statutory Grand Total

Additional Clinical Services 44 1 14 153 141 939 83 223 1598

Administrative and Clerical 8 13 63 314 122 85 605



Healthcare Scientists 2 8 6 2 18

Medical and Dental 13 20 1 11 45


South Locality Management 223 10 32 280 1207 3592 535 1140 7019

Add Prof Scientific and Technic 9 9 7 25


Administrative and Clerical 2 1 6 14 93 21 12 149

Allied Health Professionals 6 9 68 244 44 79 450

Medical and Dental 1 8 10 3 7 29


Women & Children Directorate 107 4 6 43 687 1052 325 415 2639

Grand Total 1034 98 69 1039 4296 10625 2129 3834 11 23135


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Placements and NHS Careers (Janet Morgan, Programme Manager, Powys tHB) Supporting Student and Work Experience (Annual Report 2010/11)

The following information has been taken from the above report and highlights the organisations commitment to education and training by supporting those who are pursuing or considering a career within the health service by offering a wide range of placements within clinical and non clinical areas. We are now also raising awareness in schools and colleges of the numerous job roles within the NHS. The continued support and co‐operation of managers and mentors is very much appreciated. Pre and Post Registration Student Nurses/Midwives This year we have had students on placement from the following universities:

• Swansea • Bangor • Glamorgan • Glyndwr • Stafford • Bristol • Brighton

• Student Nurses on placement throughout the year = 58 • Student Midwives on placement throughout the year = 19 •

Graph: 13.8

Specialist Community Nursing/Specialist Community Public Health Nurse Placements

• Total number of staff undertaking training Sept 09 – Sept 10 = 7

Specialties: District Nursing = 2 Mental Health Nursing= 1 School Health Nursing = 1 (part time 2nd year)

Health Visiting = 3 (1 external candidate, 1 part 1st year)


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• Total number of staff undertaking training Sept 10 to Sept 11 = 10

Specialities: District Nursing = 5 (1 part time 1st year) School Health Nursing = 1 Health Visiting = 3 (1 part time 2nd year) Community Children’s Nursing = 1 (part time 1st year)

These are our own staff undertaking post registration specialist community nursing or specialist community public health nurse training; if capacity allows we also accommodate external students for their clinical placements. Health Care Support Worker Initiative

• Total number currently on secondment = 1 (University of Glamorgan)

This initiative allowed Health Care Support Workers to undertake their nurse training – this funding is no longer available. However, NLIAH have introduced a new initiative under the title “HCSW Development Scheme”. Return to Practice Placements Nursing

• Total number on placement = 1 Occupational Therapy

• Total number on placement = 1 This scheme supports individuals who wish to return to nursing but have let their NMC registration lapse. We offer clinical placements to those attending a HEI return to practice course; whilst undertaking the course these individuals will qualify for a bursary and financial support for child care. Clinical Educational Audits


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These have been on‐going throughout the year and are undertaken by HEI’s to ensure that we provide an appropriate learning environment for students and are reviewed every three years. Mentorship Update Training Update training has been delivered by Higher Education Institutes here in Powys. To comply with NMC regulations and for staff to remain on our register of mentors for pre registration nursing students they are required to attend an annual mentorship update. Work Experience placements for School and College Students Graph: 13.9

• Total number of work experience placements throughout the year in clinical and non‐clinical areas = 125

Student activity in others areas:

• Occupational Therapy = 13 • Physiotherapy = 24 • SLT = 6 • Podiatry = 8 • Psychology = 3 counselling placements • Dietetics = 9 • Medical = 19 • CAMHS = 2 Play Therapists • Dental = 1 Dental Nurse

NHS Careers We have again this year a range of Career Events organised by Careers Wales and Powys Schools with the aim of raising awareness of the wide range of career opportunities available within the NHS.


Page 43 of 46

Details of events supported: Date Venue – School Event No of

contacts/ event attendees

20.4.10 Brecon High Careers Convention 328 7.5.10 Builth Wells High Industry Day – Yr 9 65 28.5.10 Brecon High Industry Day – Yr 9 93 7.7.10 Maesydderwen Industry Day – Yr 9 70 In partnership with Careers Wales – careers advice/guidance sessions were held at each of the community hospital. The staff interest in these sessions was very poor. Please note: The responsibility for co‐ordinating Work Experience and NHS Careers advice service for schools and colleges has been transferred to the Workforce Operational HR Team.

**************** If you have any queries or require further information regarding this report please contact: Janet Morgan


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14. Labour Market intelligence Sources (2008‐Based Principal Population Projections (Stats Wales) & Powys.gov.uk) Population: The population of Powys is set to increase up to 2017 by over 3,500 and over 6,900 by 2022. The increase is projected to be through migration into Powys with this coming from the age group of 65+. Age group 16‐24 is projected to decrease by nearly 14% by the year 2022. The number of pupils aged 15 in 2012 is projected to be 1,716 with a drop to 1,577 in 2022 which is an 8% decrease. The decrease is in both genders but mainly boys giving a 54/46% ratio. Unemployment: The claimant unemployment rate in Powys for January 2012 was 2.7% an increase of 0.4% in the last year. This was based on the resident population of 16‐64 year old. The highest Community within the County was estimated to be Llandrindod Wells with 5.0%, Ystradgynlais 3.9% and Knighton 3.8% Births and Deaths: Number of Deaths outweigh Births Migration by age 2009‐2010 : 16‐24 losing more than gaining 25‐44 losing more than gaining 45‐64 gaining more than losing 65+ gaining more than losing Employment ‐ Year end June 2011 There were 59,800 (compared with 58,600 in 2009 ) people in employment in Powys, with skilled trades the largest occupational group, followed by Managers and Senior officials. Organisations covering Public admin, Health and Education are the largest employer group in the County. Followed by Transport and communication Unemployment: Powys is above the Welsh average of persons unemployed although the number had decreased from last year—as of Mar 2011= 1,908 Average earnings: Gross weekly earnings in 2011 Powys and Monmouthshire had below the Welsh average Women paid less than Men

• Men £518.40 gross per week = £ 27,030 p.a. • Women £412.40 gross per week = £ 21,504 p.a.

Number of Jobs available: 2009 figure of 44,100 of which 36,000 are in Service industries Households: As of Dec 2009


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8,000 workless households 2,900 of these have children 40,000 households Average 3 people per household Enterprise: Majority of Businesses in Powys employ less than 10 people. Businesses have a 50% survival rate after 5 years Training and Education: In 2009/10 the number of people in Powys leaving education without a qualification is below the Welsh average (although there has been a slight increase in the past 2 years) Volunteer Sector in Powys: PAVO ‐ Powys Association of Voluntary Organisations) has 26,346 volunteers registered and employs 3,344 paid staff 903 on a full time basis. 20% of Powys population volunteer 25% involved in voluntary work either via paid or unpaid employment. PAVO has 2,056 groups registered 1,000 based outside Powys but have some activity in County. Social Care Sector in Powys ‐ Powys County Council employs a total of 915 people in the Social Care sector. This is split between 196 in Childrens services with 49 identified posts and 719 in Adult services with 66 identified posts.

FOR APPROVAL

Powys Public Health Strategic Framework

Page 1 of 56 Board meeting27 June 2012

Agenda Item 2.7


AGENDA ITEM 2.7

POWYS PUBLIC HEALTH STRATEGIC FRAMEWORK 2011-14. ANNUAL REFRESH (2012-13)

Report of

Consultant in Public Health / Acting Director of Public Health

Paper prepared by


Purpose of Paper To present the Board with a draft Annual Refresh of the Powys Public Health Strategic Framework 2011-14.


The Board is asked to NOTE and APPROVE the contents of the draft Annual Refresh of the Powys Public Health Strategic Framework 2011-14. .


This paper supports Standards 1, 2, 3, 5, 6, 7, 8, 11, 12, 13, 14, 18, 21


Improving Health of All Communities Delivering Access to integrated services that are fit

for the 21st Century


Powys Public Health Strategic Framework (PPHSF) Our Healthy Future (OHF) Community Safety Partnerships (CSP) Community Action Partnership (CAP) Sexually transmitted infections (STIs) Results Based Accountability (RBA)

FOR APPROVAL



Agenda Item 2.7

POWYS PUBLIC HEALTH STRATEGIC FRAMEWORK 2011-14 ANNUAL REFRESH (2012-13)

Aim of paper The aim of this paper is to present the Board with a draft Powys Public Health Strategic Framework 2011-14 Annual Refresh (2012-13). Background A Powys Public Health Strategic Framework 2011-14 (PPHSF) was initially drawn up in 2011, with the original document finalised in July 2011. The aim of the PPHSF is to assist the Board, through the Director of Public Health to “set out the services and activity required to meet identified local population needs, priority activities, outcomes and milestones agreed within local partnerships”. The PPHSF sits under the One Plan and provides an organisational structure to lead on the public health priorities as identified by Our Healthy Future. The PPHSF was developed in partnership, and its implementation, prioritisation, evaluation and updating has been and will continue to be carried out in partnership. The Strategic Health Improvement Group (SHIG), on behalf of the LSB and partnerships has taken on the responsibility of turning the PPHSF into real activities that positively impact health and wellbeing. Welsh Government requested a refreshed and signed off (Local) Public Health Strategic Frameworks by 11th May 2012 (Appendix A). Welsh Government agreed that a draft document that had been reviewed by the Board of Directors could be submitted for 11th May 2012, with the final report being submitted after approval by the Board in June 2012. Summary of 2012-13 Refresh A “light touch” approach has been taken to the PPHSF Annual Refresh in view of the LSB / Thematic Partnership review that is underway. The full draft report can be found in Appendix 2. Changes that have been made to the original report are:

• Links to recent reports and guidance e.g. Together for Health, Programme for Government, Fairer Health Outcomes for All, Chief Medical Officer for Wales Annual Report.

• Ensuring that the document reflects the current situation in Powys. • Updating actions that have been undertaken in 2011-12. • Highlighting our priorities for action in 2012-13.

The report has been shared with partners e.g. within the Children and Young People’s Partnership, Health and Social Care Wellbeing Partnership, Community Safety Partnership, members of the SHIG and feedback has been incorporated into the report.

FOR APPROVAL



Agenda Item 2.7

Recommendation The Board is asked to NOTE and APPROVE the contents of the draft Annual Refresh of the Powys Public Health Strategic Framework 2011-14. . Report prepared by: Presented By: Consultant in Public Health / Acting Director of Public Health

Dr Sumina Azam


Background Papers Powys Public Health Strategic Framework 2011-14

– Annual Refresh Financial Consequences As determined by the report


Consultees LSB co-ordinators

Health and Social Care Wellbeing Partnership Children and Young People’s Partnership Strategic Health Improvement Group Community Safety Partnership

FOR APPROVAL



Agenda Item 2.7

APPENDIX A

Issued to Directors of Public Health in January 2012 Copied to Chief Executives of Local Health Boards and NHS Trusts Guidance for the Annual Refresh (2012-13) of the Local Public Health Strategic Frameworks for Local Health Boards and NHS Trusts This update is issued to provide guidance in support of the annual refresh of (Local) Public Health Strategic Frameworks ((L)PHSFs) for 2012-13. This guidance should be considered in conjunction with the “Guidance for the development of Public Health Strategic Frameworks for Local Health Board and NHS Trusts” issued in Jan 2011 (attached at Annex A). Together for Health, endorsed by the cabinet, says - The time has come to make a decisive shift from just managing sickness to creating a healthy Wales…….Sometimes it is suggested improvement will take a generation. Some things will, but we must also focus on real, substantial changes within five years.

Action: Every Local Health Board will set clear targets for action and deliver against them, explaining each year how health is improving and health inequalities are narrowing.

The Minister will every six months present a report on progress on Together for Health to plenary, and that will be an opportunity for any AM from any part of Wales to question her on any element of the document. It is important that every LHB clearly addresses the above requirement and that the Minister is able to report exactly what each LHB is doing and the progress it is making. (L)PHSFs are a key mechanism for the Boards of both LHBs and NHS Trusts to clearly set out their priority outcomes and intended actions in support of Together for Health. It is expected that in refreshing (L)PHSFs Boards will also wish to give clear consideration to; -

• Programme for Government • Fairer Health Outcomes for All • Professional reports such as the Chief Medical Officer for Wales Annual

Report, Directors of Public Health Annual Reports and Primary Care Annual Reports

FOR APPROVAL



Agenda Item 2.7

For Boards it is expected that the public health focus will be to protect and improve health and wellbeing for all, with the pace of improvement increasing in proportion to the level of disadvantage. By :-

• continuing to sharpen activity on public health priorities and the drive for health improvement

• taking forward actions to deliver agreed outcomes • identifying and tackling health inequalities • supporting and encouraging partnership working on shared agendas • identifying and sharing best practice and lessons learned with others

Specific consideration should be given to how action will support the achievement of the Fairer Health Outcomes for All target to improve healthy life expectancy and to close the gaps in Wales. It is expected that each Board will take forward a targeted campaign on the most deprived communities within the populations they serve. (L)PHSFs are key public documents which will need to be used in conjunction with Director of Public Health Reports in setting out locally agreed and shared outcomes and setting out priorities for action. It is expected therefore that LHB and NHS Trust Boards will wish to publish final documents on their websites to support the planning and delivery activity of local and national partners. When considering scale and content of the refresh of (L)PHSFs it is expected that Boards will wish to consider any changes in population needs / evidence base, revisions to locally agreed priorities, and actions required from key guidance and documents issued since April 2011. It is anticipated that in some instances Boards may consider that a “light touch” approach is only required for the annual refresh for 2012-13 and plan to give the 2013-14 refresh greater prominence to support any changes in planning processes shared outcomes and priorities in their locality. The Chief Medical Officer would be pleased to receive your refreshed and signed off (Local) Public Health Strategic Frameworks by 11th May 2012. Progress reports at end October 2012 and April 2013 will be welcomed. In accordance with the guidance at Annex A, I look forward to receiving your end of 2011-12 progress reports against outcomes identified in your 2011-12 (L)PHSFs. Chief Medical Officer for Wales January 2012

FOR APPROVAL



Agenda Item 2.7

(Annex A) Guidance for the development of Public Health Strategic Frameworks for Local Health Boards and NHS Trusts This guidance has been provided to assist Local Health Boards in the development of Local Public Health Strategic Frameworks (LPHSFs). While the guidance is not presented with a formal template, it will facilitate the development of locally appropriate frameworks and mechanisms. This guidance provides information on the nature and purpose of LPHSFs which should be developed with reference to the national priorities and aims of Our Healthy Future and those specific priorities identified in the Annual Quality Framework 2011-12. It will assist the Board, through the leadership of the Directors of Public Health, to set out the services and activity required to meet identified local population needs, priority activities, outcomes and milestones agreed within local partnerships. The plan should also describe those activities that are delivered by collaborative working arrangements between health boards and Public Health Wales. For NHS Trusts, it is anticipated that their Boards will consider the priorities and actions identified within the Annual Quality Framework in conjunction with this guidance. To fulfil their Public Health Strategic Framework (PHSF) planning requirements, Trusts will wish to set out their contribution and how they will work in partnership with each other and with Health Boards on this agenda. In its PHSF, Public Health Wales will wish to set out what it will deliver on its own and may also wish to include a “schedule of services” or similar, showing the totality of services it will deliver to Local Authorities, Local Health Boards and Trusts. With this in mind, Public Health Wales will wish to take account of the Health Boards’ LPHSFs and other Trusts’ PHSFs before finalising its own. Background Our Healthy Future (OHF) published in October 2009 set out the priorities and challenges for public health to 2020. One of the key actions arising from OHF was the development of Local Public Health Strategic Frameworks to support Local Health Boards, NHS and broader partners to make significant and demonstrable improvements in population health outcomes and wellbeing. The requirement for the development of Local Public Health Strategic Frameworks was reiterated in the Annual Operating Framework for 2010-11 and reflected in the draft Health Social Care and Wellbeing Strategy Guidance and draft interim Children and Young Peoples Plan guidance.

FOR APPROVAL



Agenda Item 2.7

The development of (local) public health strategic frameworks will be a critical tool for Boards in seeking to achieve the 5 year vision for NHS Wales. “to do more to protect and improve health for all, using an integrated services approach to deliver and sustain excellent services to meet the needs of the resident population.” Purpose of (Local) Public Health Strategic Frameworks (L)PHSF

To provide a locally appropriate planning, resource, and performance management tool for the Board to support it in discharging its statutory duty to protect and improve the health of the resident population.

To provide assurance to the Board that there is an effective contribution being made to achieve national priorities as set out in Our Healthy Future and the Annual Quality Framework and: • that it is continuing to deliver, sustain and improve services in accordance

with, and building on, the achievements and requirements as set out in the Upstream Prevention and Promotion chapter of the Annual Operating Framework 2010/11

• that activity is directed to meet local need and locally agreed priorities based on evidence which supports the selection of these priorities

• that milestones delivered in accordance with, and through, effective local partnership arrangements where appropriate

• that it has fulfilled its obligations to identify inequities in health outcome, identify actions to close the gap and to deliver and report on those actions. There is a political imperative to reduce unfair and avoidable variation in health outcomes

Local Public Health Strategic Frameworks (LPHSFs) also provide an opportunity for the Boards of LHBs to reflect local needs, priorities and service adjustments in light of information provided through their Director of Public Health’s annual report. Whilst information may already be available and reviewed from other work streams, this framework provides an opportunity for the Board to consider the overall approach to the management and development of public health services and activity and to ensure that work is prioritised and coordinated appropriately. In reflecting locally agreed priorities and activities as set out in Health Social Care and Wellbeing Strategies, Children and Young Peoples Plans and other key partnership planning documents (L)PHSFs should provide a summary, with reference to more detailed information, where appropriate. Local Health Boards will also wish to consider how they might more effectively realise the potential of primary and secondary care services to support the improvement of public health and wellbeing for the local population. It would be

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appropriate to highlight relevant links to the Primary Care Annual Report and to Setting the Direction: Primary & Community Services Strategic Delivery Programme. It is expected that Boards will wish Directors of Public Health to demonstrate how the use of evidence and information, prioritisation according to need, and the rigorous evaluation of services, are all being used to ensure improvement. Consideration should also be given to an analysis of any barriers to health improvement, particularly where these might be addressed nationally and/or through policy development. Governance Our Healthy Future sets out priority activity to 2020. A 5 year Service, Workforce and Financial Framework is in place for the NHS and local partnerships have multi-year plans. Improving public health is not a short term option; it is investment for the future. As such it is expected that Boards will wish to develop locally agreed long and short-term milestones for improving health and wellbeing outcomes, prioritised in accordance with local need. To support this it is expected that (L)PHSFs will be multi-year plans, with an annual refresh. The Chief Executive of the Board as the designated accounting officer is responsible for the agreement and delivery of their (L)PHSFs. Draft (L)PHSFs will be required to be provided to the Welsh Assembly Government each year following the annual refresh for scrutiny and comment by the date set - for 2011-12 this will be the 21st March 2011. A final agreed (L)PHSF, signed by the Chief Executive, co-signed by the Director of Public Health where applicable (or in the case of NHS Trusts by a Board member with designated responsibility for public health) and lodged with the Welsh Assembly Government by the date required. For 2011-12 this will be the 30th April 2011. For the purposes of the AQF performance management process, formal comprehensive written reports on achievements, activity and key associated risks and issues against (L)PHSFs should be returned to WAG at

• the end of September to cover the first six months of the year • the end of April to cover the year end position

The Directors of Public Health reports will be utilised to help inform the planning and performance management process. Final Board agreed copies of the Directors of Public Health reports should be provided to WAG by the date agreed, for 2011 this is the 1st of June. Performance management of (L)PHSFs will be carried out through formal review at six month and end year.

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APPENDIX 2

Powys Public Health Strategic Framework 2011-2014

Powys: the healthy green heart of Wales

ANNUAL REFRESH (2012-13)

DRAFT

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Annual Refresh (2012-13) Version History Version Date

Issued Brief Summary of Change Owner’s Name

0a 18th April 2012

Revision made to PPHSF 2011-14 by Dr Sumina Azam

SA

0b 24th April 2012

Additional comments Gerry Davidson

0c 30th April 2012

Inclusion of CYPP lead’s comments

Dominique Jones

0c 30th April 2012

Comments added about Trading Standards work

Ken Yorston

0d 2 May 2012

Inclusion of comments from Board of Directors, Powys tHB

SA

0d 9 May 2012

Inclusion of comments from CSP lead

Louisa Kerr

Pending June 2012

Powys tHB Board comments and approval pending

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Contents 1 INTRODUCTION ......................................................................................... 12

1.1 Statutory Context ....................................................................................... 13

1.2 The link to Our Local Plans and Priorities ................................................. 14 2 THE SOCIAL DETERMINANTS OF HEALTH ............................................. 18 3 REDUCING HEALTH INEQUITIES ............................................................. 19 4 OUR HEALTHY FUTURE HEALTH IMPROVEMENT PRIORITIES ............ 29

4.1 SMOKING ............................................................................................. 30

4.2 PHYSICAL ACTIVITY AND HEALTHY EATING .................................. 33

4.3 ALCOHOL AND SUBSTANCE MISUSE .............................................. 36

4.4 SEXUAL HEALTH AND TEENAGE PREGNANCIES ........................... 38

4.5 REDUCING ACCIDENTS AND INJURY RATES ................................. 42

4.6 IMPROVING MENTAL WELLBEING .................................................... 45

4.7 IMPROVING HEALTH AT WORK ........................................................ 47

4.8 INCREASING VACCINATION RATES TO RECOMMENDED LEVELS50 5 DEVELOPMENT OF ACTION PLANS ........................................................ 52 6 MONITORING IMPLEMENTATION ............................................................. 55

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1 INTRODUCTION The Powys Public Health Strategic Framework 2011-14 (final report published in July 2011) set out the Powys response to the ten challenges identified in Welsh Government’s public health strategy Our Healthy Future (OHF): • stopping growth in health inequities • reducing smoking rates • increasing physical activity rates • reducing unhealthy eating • stopping growth in harm from alcohol and drugs • reducing teenage pregnancy rates • reducing accident and injury rates • improving mental well being • improving health at work • increasing vaccination rates to recommended levels The Powys Public Health Strategic Framework 2011-14 (PPHSF) specified our collective approach to these ten challenges within the context of the population outcomes we wanted to achieve in Powys as set out in the One Powys Plan. This document is our annual (2012-13) refresh of our Public Health Strategic Framework. Here, we highlight our progress for our priority areas, explaining how we are working to improve health and narrow health inequalities in Powys. In conjunction with the Director of Public Health Report, this document sets out our locally agreed priorities and actions. This document links to the Health Challenge Powys website (www.healthchallengepowys.org.uk) where information is available for the general public in Powys to enable them to make positive changes to their own health and well-being. Our refresh report is made in light of recent guidelines and reports: Together for Health Like Wales, Powys is also facing challenges such as “rising elderly population, enduring inequalities in health, increasing number of patients with chronic conditions, rising obesity rates and a challenging financial climate”. We share the vision set out in Together for Health, that in 2016 “health will be better for everyone”, with

• More children having a good start in life • The health of the least and most deprived will be more similar • Obesity, smoking, drug and alcohol abuse will level off or fall • People will be enjoying more years of high quality life

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In order to move to a “world class” service, the report highlights the need for the NHS to move from just treating sickness to improving health and creating a healthy Wales. Partnership working is central to tackling the roots of poor health. Programme for Government 2011 Preventing poor health and reducing health inequalities is a key strand of the Programme for Government 2011. Priorities that are directly linked with and will be taken forward through the Powys Public Health Strategic Framework are:

• Implement the actions in Our Healthy Future • Increase immunisation among children to eradicate the health problems

caused by measles, mumps and rubella • Implement Fairer Health Outcomes for All to reduce the health inequalities

that exist between communities in Wales • (Support) annual public health campaigns to tackle obesity, smoking,

teenage pregnancies and drug and alcohol misuse • Introduce local targeted action on inequities • Forge stronger links between the NHS and Ministry of Defence (Veterans

Health) Chief Medical Officer for Wales: Annual Report 2010 Findings and recommendations from the report are used to help shape and determine our local priorities and actions. Nationals Prevention and Promotion Programme Our work takes into account the National Prevention and Promotion Programme1, which is a five year national programme that has identified five areas for action that are evidence based and would produce a return in investment in five years. These priority areas are:

• Reducing the burden of tobacco use • Reducing the burden of alcohol misuse • Vascular risk – assessment and management of high risk patients • Preventing falls in older people • Health at work

1.1 Statutory Context Section 40 of the National Health Service Wales Act 2006 places a statutory duty on each local authority and each local health board to prepare a health, social care and wellbeing strategy for that local authority’s area.

1 National Prevention and Promotion Programme – Final Report and Recommendations. Public Health Wales NHS trust. 2011

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Sections 25-28 of the Children Act 2004 require local authorities and key partners to co-operate across the range of functions to improve well-being of children and young people. It also places local authorities under a statutory duty to prepare and publish Children and Young People’s Plans.

1.2 The link to our local Plans and Priorities One Powys Plan In Powys, the Local Service Board are working together to take forward a joint approach to planning and delivering public services called – One Powys. This approach is about making sure that we achieve the best possible outcomes for the people of Powys. To achieve the best possible outcomes, this approach focuses on early intervention and prevention and making sure we safeguard the most vulnerable children, young people, adults and elderly people within Powys. In doing so, we address gaps and remove duplication to ensure people receive the best possible services and value for the Powys pound. The plan brings together and replaces a range of existing strategies, plans and agendas, to provide a single focus for the individual organisation’s plans in Powys. Figure 1: One Powys Plan

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As part of this new approach, members of the Local Service Board are focusing their activity and resources towards achieving ten outcomes for the people of Powys. 1. People in Powys live in supportive, sharing and self-reliant

communities. 2. People in Powys benefit from a thriving, diverse economy. 3. People in Powys have the skills to pursue their ambitions. 4. Powys families are safe and supportive places in which to live. 5. People in Powys are healthy and independent. 6. People in Powys live in good quality affordable homes. 7. People in Powys enjoy a clean, safe and green environment. 8. People in Powys feel and are safe and confident. 9. People in Powys are supported to get out of poverty. 10. People in Powys can easily access the services they need. The Powys Public Health Strategic Framework 2011-2014 sits under the One Powys Plan and provides an organisational structure to lead on the public health priorities as identified by Our Healthy Future. At the heart of the structure is the Strategic Health Improvement Group (SHIG), which is currently chaired by the Director of Public Health. SHIG was established in early 2009 as a shared sub-group between the Health, Social Care and Well Being Partnership and the Children and Young People’s Partnership. The group also links to the Community Safety Partnership on the themes of substance misuse and injuries. The Powys Public Health Strategic Framework 2011-2014 (PPHSF) sets out how the 10 outcomes of One Powys would be addressed in respect of public health oriented activities. The PPHSF was developed in partnership, and its implementation, prioritisation, evaluation and updating has been and will continue to be carried out in partnership. SHIG, on behalf of the LSB and partnerships has taken on the responsibility of turning the PPHSF into real activities that positively impact health and wellbeing. This refresh document needs to be read in the context of a review of partnerships that is currently underway in Powys. The review includes the Children and Young People’s Partnership, the Health and Social Care Wellbeing Partnership and the SHIG, as well as existing Multi Agency Reference Groups. One of the approaches being considered as a mechanism for delivering One Powys, and therefore the PPHSF is Neighbourhood Management. Neighbourhood Management is a nationally recognised model of good practice of joined up working at a local level in order to improve the delivery of services. Service providers link together through mutual agreement, as well as linking in with the community, with the aim of co-ordinating the delivery of services in a efficient and cost effective way. There are nine key principles of neighbourhood management:

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1. Strong strategic leadership 2. Clearly defined and agreed national neighbourhoods 3. Shared and publicly agreed priorities 4. Shared information, feedback and communication processes 5. Co-location (if possible) 6. Multi-agency problem solving 7. Evidence based allocation of resources 8. Joint engagement 9. Nominated neighbourhood lead

Powys teaching Health Board Annual Plan The identified priorities and actions are aligned with the Powys teaching Health Board annual plan and contribute to the following Aims and Improvement Actions: Figure 2: Links of the Powys Public Health Strategic Framework with the Powys teaching Health Board Annual Plan Aim Improvement Action

Improve the opportunities and life chances for children

• Implement early years strategy including roll out of Flying Start; considering the outcome of the national review of Health Visiting (1)

• Achieve immunisation targets for children (2)

• Develop the healthy pre-schools scheme and maintain the healthy schools schemes across Powys (7)

• Implement the suicide prevention action plan (10)

Reduce the impact of alcohol on individuals, families and communities

• Support the development and delivery of the Powys Substance Misuse Commissioning Strategy (13)

• Implement brief intervention alcohol training programme (14)

Decrease the risk of death and disability due to vascular and respiratory disease

• Develop and initiate implementation of the Powys Tobacco Action Plan (15)

• Develop and implement a local obesity strategy (16)

• Implement key actions in Our Healthy Future to increase physical activity levels (17)

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Optimise the health and wellbeing of the workforce

• Further development of health and wellbeing activity with programme of work to secure Platinum CHS (25)

Frail and Older People: Ensure older frail people are enabled to live safely in the most appropriate setting through access to local services

• Increase flu immunisation uptake (35)

Ensure people receive a timely, co-ordinated clinically appropriate response to their need through access to appropriate evidence based scheduled care pathways

• ......Including the implementation of the Sexual Health Strategy (52)

Improve emotional wellbeing and mental health of the population...

• Implement the all age mental health measure (64)

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2 THE SOCIAL DETERMINANTS OF HEALTH It has been recognised within public health for at least a century that health is a consequence of many factors unrelated to the type and standard of health care services they receive. Health practitioners largely respond to people’s needs when disease, illness or frailty has already started to take their toll. The causes of those conditions are partly genetic and age related, but at a population level they are caused or exacerbated by wider factors within society. This has been illustrated in Figure 3. A person may not want to smoke, but if brought up within a family of smokers, or mixing with friends who smoke it will be difficult to resist peer pressure and social norms. Poor educational attainments will reduce employment opportunities, reduce income and perhaps reduce the chance to eat healthily or cause debt related depression. If people feel unsafe due to high crime or perception of high crime or are worried about the recession, this will undermine their sense of wellbeing. Figure 3: Social determinants of health model (after Dahlgren & Whitehead, 1991).

EnvironmentPublic economic

strategies

Tobacco

Eating habits

Age, sex,heredity

Sleephabits

Physical activity

Education

Sex &life together

Housing

Illicit drugs

Contactchildren and adults

Agri-culture& food

Traffic

Work environment

Alcohol

Leisure &culture

Socialnetwork

Health-&medical care

Socialsupport

Socialassistance

§Social-insurance

Employ-ment

?

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This understanding has several consequences:

• Action to improve one’s health may be possible at the individual level (vaccination, don’t abuse tobacco, alcohol or drugs, exercise more, eat more healthily) but society in general and public organisations in particular must also play a major part in addressing socio-economic conditions, such as providing better housing and education, changing values around smoking, tolerance of inequity.

• Improved health at the population level is only marginally affected by how well health services are provided. Health is everyone’s business, and improved health levels will need concerted activity from all sectors not just the NHS.

• Society’s agents, whether statutory or voluntary organisations, must work together in partnership to maximise the impact of their respective inputs and to reduce waste and duplication wherever possible.

3 REDUCING HEALTH INEQUITIES “Together for Health” tasks Local Health Boards to take action and demonstrate how health inequalities are narrowing, so that “The health of the least and most deprived will be more similar”. In order to reduce inequities in health, it is imperative that action is targeted toward the most vulnerable and those most in need. One way this can be achieved is to ensure that groups or organisations who represent the interests of specific population groups play an enhanced role. In Powys our planning structure is under review in the context of the Local Service Board and One Powys Plan approach. However, our existing Multi Agency Reference Groups can potentially play an enhanced role. In addition to targeting our actions in connection with priorities in Chapter 4, we can identify additional issues that should receive our attention by paying heed to Maslow’s Hierarchy of Needs.

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Figure 4: Maslow’s Hierarchy of Needs Maslow’s theory portrayed in the pyramid figure shows how each of us is motivated by needs, our most basic being the need to quench our thirst, to satisfy our hunger and the need for shelter and warmth. These are our most basic biological and physiological needs we must satisfy to ensure our short term survival. Only once these needs are met can we strive to move up a level toward higher order needs of influence and personal development. At the top of our game, only once all needs below have been met do we reach and fulfil our personal fulfilment and reach ‘self-actualisation’. Those who reach this level are in a minority and at any level along the way, if our most basic of needs are swept away from the bottom, we can no longer be concerned with the higher needs. But our hierarchical needs are not strictly mutually exclusive but interdependent and failure to have opportunities for belongingness, love and self-esteem can lead to isolation. Isolation in turn can lead to depression and the spiral of neglecting our basic needs such as not eating healthily, the abuse of substances with the consequence of ill health. The majority of people are fortunate in that their basic needs as described in the two lowest levels of the tier are continuously met. This allows them to move towards the higher tiers of the pyramid. Whilst not all may reach the very top to realise our very best potential, it is the journey along the way that brings meaning and satisfaction to life. It is those struggling at the lowest levels that we must turn our attentions to in order to reduce inequities. It is those who do not have the means to satisfy their hunger, those who struggle against the cold and those who have inadequate or no shelter who need the most assistance. Our priorities must be to tackle social isolation, homelessness, poverty and address housing issues including poor conditions such as dampness, safety, fuel poverty and disabled adaptations.

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What we do within the NHS or statutory social services to address sickness has a limited impact on overall health and wellbeing of populations. Increased attention to the determinants of health and greater effort on sickness prevention and health promotion are cheaper and result in a better quality of life for more people. The health effects of aging can be postponed, people can enjoy not just longer lives but longer more healthy, more active, more fulfilling lives. To use a phrase popular within the NHS in Wales about 20 years ago, we can ‘add years to life and life to years.’ It is also important to acknowledge the extent to which people can take greater responsibility for their own health. The European Commission’s health strategy 2020 highlights that we can add an average of two year’s relatively quickly to most people’s lives by encouraging changed behaviours supported by healthier policies. In relation to this, a debt is owed by society to unpaid carers and the voluntary sector without who’s often unseen commitment and sacrifice many more people would have to be taken care of in institutional settings, and at far greater cost. Carers themselves need support, information, advice and sometimes respite. Goals for the future should include making greater use of the experience and knowledge of patients and carers themselves, developing better support for carers, mobilising and supporting self-help groups and better co-ordination of what resources already exist from the voluntary sector. What is the current situation? Powys covers a quarter of the area of Wales, with a North-South axis similar to the distance between Bristol and London. Many of the natural catchment areas and travel routes flow east-west and it is the most sparsely populated county in England and Wales, with 26 people per square kilometre. It is an essentially rural population, which could be described as “diffuse rurality” i.e. the population is spread thinly across the area with a few market towns and relatively bigger conurbations. Consequently, where facilities require a critical mass of people to be economically or socially sustainable, they will of necessity be spread out, making factors of accessibility and transport critically important. In Powys, there is less of a gap between the most and least deprived fifths of the population compared with Wales overall. Figure 5 below shows that two thirds of the Lower Super Output areas within Powys are in the least or next least deprived section of the national deprivation scale.

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Figure 5:

Source: Public Health Wales Observatory The following illustration (figure 6) shows deprivation levels within Powys, with all Lower Super Output Areas (LSOAs) being ranked into fifths, based on the Welsh Index of Multiple Deprivation (2008). These are Powys local fifths and depend on the deprivation distribution within Powys. Figure 6: Fifths of deprivation within Powys

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A recent report on health inequalities by Public Health Wales Observatory2 showed that across Wales, people are not only living longer but also living longer in good health. However, the inequality gap (the gap between those in the most and least deprived communities) in life expectancy, healthy life expectancy and disability free life expectancy has widened for both males and females between 2001-05 and 2005-09. Analysis of trends in Powys3 between 2001-05 and 2005-09 shows life expectancy has increased from 77.5 years to 79.1 years for males and from 81.2 to 82.7 years for females. Over this same time period, the gap in life expectancy between the most and the least deprived fifth of the population decreased from 6 years to 5.5 years for males and for females, the gap decreased from 5.7 years to 4.9 years. An increase in healthy life expectancy and disability free life expectancy for both males and females has also been seen, with the inequality gap (difference between most and least deprived communities) in Powys narrowing for these indicators. Figure 7: Life Expectancies in Powys

63.3

62.8

67.5

66.7

82.7

81.2

62.5

61.6

67.7

66.7

79.1

77.5 6.0

5.5

6.4

5.9

7.16.3

5.74.9

13.713.6

9.69.3

2001-05 2005-09

Life expectancy

Healthy lifeexpectancy

Disability-free lifeexpectancy

Life expectancy

Healthy lifeexpectancy

Disability-free lifeexpectancy

Males

Females

Life expectancy with 95% confidence interval

Inequality gap (SII in years)

Source: Public Health Wales Observatory, using ADDE/MYE (ONS), WIMD/WHS (WG)

2 Measuring inequalities. Trends in mortality and life expectancy in Wales. Public Health Wales Observatory. November 2011. 3 Measuring Inequalities: trends in mortality and life expectancy in Powys. Public Health Wales NHS Trust. November 2011.

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Higher levels of deprivation are associated with higher rates of premature death from all causes, coronary heart disease and smoking related disease. Deprivation is also associated with higher all age deaths for some cancers, some respiratory disease and circulatory diseases. In Powys, between 2001-03 and 2007-09, there was a fall in mortality rates for All Ages All Cause Mortality, All cause Mortality under 75, mortality from circulatory disease, mortality from respiratory disease and smoking attributable mortality in those aged 35 and over. There was also a reduction in mortality from cancer for females, although the rate for males remained static. For these causes of death, the difference between the most deprived and least deprived communities either remained static or reduced. However, despite this overall positive picture, there remain concerns about the poorer health outcomes faced by some of our communities. For example, the mortality rate in males under 75 years for all causes is 1.6 times higher in the most deprived fifth of the population, compared with the least deprived fifth of the population. Figure 8 below highlights that some areas of Powys have nearly double the rate of all person all cause mortality than other areas and are significantly worse than the Welsh average. Figure 8: All cause mortality, all persons

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MS

OA

EASR per 100,000

MSOA EASR with 95% confidence interval

748

007

003

Local Authority

Wales (EASR = 635)

Health Board (EASR = 550)

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Statistics available at a lower geographical level demonstrate that there are serious inequalities and inequities facing communities within the county. These were highlighted in the Powys Director of Public Health’s Interim Annual Report 2009 -10. In the Powys Public Health Strategic Framework 2011-14 (final report published July 2011) we noted that: 24 of the 75 Electoral Divisions in Powys were among the worst 20% of areas for housing quality in the Welsh Index of Multiple Deprivation (WIMD) 2000. The 2004 survey commissioned by Powys County Council concluded that only 1 in a thousand private sector dwellings would meet the Welsh Housing Quality Standard if it were applicable to private housing stock. Only 9% of private sector dwellings met the WHQS SAP4 ratings in Powys in 2004. Insulation of private sector dwellings was found to be poor overall in the Powys 2004 survey, with 53% meeting the WHQS standard for hot water tank insulation, 26% for loft insulation and 21% for water pipe insulation. In Powys, quarterly additions of households to the homeless register (as measured by the number of households that have applied for assistance and been deemed eligible, unintentionally homeless and in priority need) have fluctuated in the last decade from 37 households in Q1-2000, to 48 in Q1 20010, reaching a peak of 155 in Q4-2003. Homelessness, as measured by the number of homeless households in Powys being provided with temporary accommodation, has increased from 28 households at the end of Q1-2000, peaking at 368 at the end of Q4 2004, and since then fluctuating to reach 126 at the end of Q1 2010. Poverty remains the most important wider determinant of health and wellbeing. Just 1% of the Powys population in 2009 lived in an area defined in the Welsh Index of Multiple Deprivation (WIMD) 2008 as among the 10% most Income Deprived areas in Wales and 3% in the 20% most Income Deprived (Wales 10%, 19% respectively). The percentage of pupils eligible for free school meals in Powys fluctuated between 11.1% in 1998/99 and 10.1% in 2009/10 (Wales 20.7% in 1998/99, 17.3% in 2009/10). The estimated percentage of Powys households claiming Council Tax Benefit and Housing Benefit rose from 10.9% in August 2009 to 11.4% in August 2010 (Wales 15.7% August 2009, 16.5% August 2010). The percentage of Powys children living in workless households fluctuated between 13.0% in 2004 and 12.5% in 2009 (Wales 18.8% in 2004, 19.9% in 2009). The percentage of Powys households with no-one working declined from 19.1% in 2004 to 17.1% in 2007, then rose to 20.2% in 2009 (Wales 21.6% in 2004, 22.9% in 2009).

4 SAP rating: – Standard Assessment Procedure using information on appliances and insulation to profile energy efficiency, giving a score between 1 and 100

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The percentage of people aged 60 plus in receipt of Pension Credit in Powys rose from in 13% in November 2004 to a peak of 16.5% in November 2005, since when it has fallen very slightly to 15.9% in July 2010 (Wales 18.1% in November 2004, 21.9% in July 2010). Rising levels of individual debt can lead to a range of negative impacts on people’s well-being such as losing their home, being made bankrupt, or being forced to find alternative and possibly illegal sources of credit, as well as on their health due to stress and worry. The incidence of County Court Judgments passed on Powys residents rose from 105 per 10,000 adults aged 16+ in 2003 to 151 per 10,000 in 2005 (Wales 122 per 10,000 in 2003 , 168 per 10,000 in 2005). The incidence rates of personal insolvencies rose in Powys from 7.0 per 10,000 adults in 2000 to 26.3 per 10,000 in 2009 (Wales 6.7 per 10,000 in 2000, 31.8 per 10,000 in 2009). Mortgage possession claim rates per 1000 households in Powys dropped from 2.37 in 2009 to 2.03 in 2010 (Wales 5.10 in 2009 to 3.92 in 2010). Unemployment is a major contributor to poverty, deprivation and ill-health, and negatively impacts on housing affordability. Lack of good employment opportunity in the county can also be one of the causes of the net outward migration of young adults. The yearly average percentage of adults aged 16 to 64 claiming unemployment benefits in Powys had peaked at 2.6% in 2009, and fell to 2.2% in 2010 (Wales 4.1% in 2009, 3.9% in 2010). The % of young people aged 18 to 24 claiming Job seekers allowance had risen steeply to 7.9% in Powys in December 2009 but fell to 6.5% by December 2010 (Wales 9.0% and 7.9% respectively). More recent data shows that unemployment claimant benefit figures for Powys have risen from 2.4% in 2011 to 2.6% (March 2012). This data is available at ward level and shows that:

• Llandrindod Wells East / West and Newtown East are in the top 100 worst areas in Wales for unemployment benefit claimant rates (there are 881 electoral divisions in total).

• Llandrindod has a high proportion of long term unemployed compared with Powys average (Llandrindod 50%, Powys 35%).

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What are our priorities? Working in partnership under the One Plan, we will: • Tackle geographical inequity:

o Improve identification of isolated, hard to reach vulnerable people and improve local access to accurate service information and advice

o Jointly develop local “community champions” backed by area Information Workers and a Powys Information web site portal. • Tackle homelessness:

o Provide additional housing options for households who might otherwise be faced with the prospect of homelessness

o Increase the capacity in the supported housing services to older people through the introduction of “Systems Thinking” and explore the potential for extending this across supported housing • Tackle poor housing conditions:

o Work to improve the condition of private sector housing stock o Put in place a range of measures to ensure vulnerable people such

as the elderly receive practical support to maintain their independence at home o Deliver a supported accommodation service integrated with adult

social care o Through financial assistance and advice enable people to remain in

their homes through the provision of housing improvements including adaptations o Aim to Reduce emissions of the greenhouse gas carbon dioxide

from the domestic housing stock • Tackle poverty:

o Develop a strategy and action plan to tackle fuel poverty o Develop a strategy to encourage Powys residents to commit to a

Pension Plan at an early working age o Develop a strategy to increase opportunities for people over 50 to

become or remain economically active until they are personally financially able to retire

o Support the development of Credit Unions o Implement the CYPP’s Families First Plan including the Joint

Assessment Family Framework (Common Assessment Framework, Local Resource Solution Panels and Team Around the Family). • Tackle vulnerability:

o Develop specific plans to apply the Our Healthy Future themes to vulnerable groups within Powys, including veterans, young people in care, Travellers, people with learning difficulties, people with physical disabilities, those with sensory impairment, older frail people, unpaid carers and minority and ethnic communities.

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Case Study 1: Improving Veterans Health in Powys The Health of Ex-Service Personnel (Veterans) has been identified as an area of priority in a number of national and local documents including The Welsh Health Circular (2008) 051: Priority Treatment and Healthcare for Veterans and The Annual Operating Framework 2010-2011. In March 2010 a Wales-wide Health and Military Liaison Workshop was held for senior leaders from NHS bodies in Wales with the aim of improving the healthcare of veterans by strengthening partnerships between Welsh Government, NHS, Ministry of Defence and third sector. One of the key outcomes was the establishment of a Welsh Mental Health and Well Being Service for Veterans Steering Group. Following the national developments Powys teaching Health Board took steps in 2010 to develop an action plan for Powys, running a series of events that were facilitated by Powys Public Health team. The last event was held in November 2011 to finalise an action plan. A final report has been produced that summarises the actions identified and agreed in the workshops (see figure 9 for the workshop titles). The next step will be to pull together a multi-disciplinary group to oversee the implementation of the action plan and monitor its progress. Figure 9: Workshop themes

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Case Study 2: Protecting vulnerable residents from rogue traders and scams

Work has been carried out by Trading Standards to protect our isolated, elderly or vulnerable populations from rogue traders or scams.

The Trading Standards team have run awareness campaigns to raise awareness of the issue, including being involved in “Scamnesty”, which includes encouraging residents to hand in any scam mail they receive to designated libraries in Powys. “Ringmaster”, a community alert messaging system, is being used to disseminate information on current scams. The system is free and residents are alerted either by text, e-mail or automated phone messages. Currently, there are a couple of thousand users signed up to this scheme.

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Agenda Item 2.7

4 OUR HEALTHY FUTURE HEALTH IMPROVEMENT PRIORITIES

4.1 SMOKING Why does it matter? Despite a fall in smoking prevalence rates in Wales in recent years smoking remains the largest single cause of avoidable morbidity and mortality across the country and a significant cause of health inequality between the most and least deprived areas. Almost a quarter of the Welsh population are smokers. Smoking is associated with a number of cancers, heart disease and respiratory disease. Smokers’ risk of dying before the age of 65 years is double that of non smokers. There is also evidence to show that non smokers are affected by secondary smoke. In adults, secondary smoke has been associated with lung cancer and heart disease. In children secondary smoking has been associated with respiratory disease, including asthma and sudden infant cot death syndrome. Recent research from Swansea University reported that treating smoking related diseases in Wales cost the NHS 7% of the total healthcare expenditure in 2007/8, equivalent to £129 per head of population. What is the current situation? In Powys the trend in smoking prevalence has fluctuated around the 22% mark since 2003/4. These rates are lower compared to average rates for Wales as a whole (Figure 9). Figure 9: Proportion of adults who smoke Year Powys Wales2003/04 to 2004/05 24%2004/05 to 2005/06 25% 24%2005/06 to 2007 22%2007 to 2008 18%2008 to 2009 22% 24%2009 to 2010 23% 23%

In February 2011 the Welsh Government produced a document for consultation called ‘Draft Tobacco Control Action Plan for Wales’. This plan builds on and

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Agenda Item 2.7

takes further current activity in Wales around Tobacco Control. The ultimate vision is to create a smoke free society in Wales. The plan includes the aim of reducing smoking prevalence rates to 16% by 2020. To this end the plan includes the intention to ban vending sales of tobacco products across Wales and the intention to lobby the UK Government on non-devolved issues such as price increases through taxation and reducing tobacco imagery to young people. It also tasks each local authority area with developing a Tobacco Control Forum and Tobacco Control Action Plan. This Action Plan became ‘live’ in February 2012, identifying four strategic action areas:

• Promoting better leadership and partnerships • Prevention (reducing the uptake of smoking, especially amongst children

and young people) • Cessation (helping smokers become quitters) • Reducing exposure to second-hand smoke, particularly to protect children

and to reduce inequalities in health

What are our 2011-14 priorities? We will:

• Develop an action plan which should include action to promote smoking cessation services and to reduce smoking prevalence amongst target groups including:

o Younger women, particularly teenage girls o Pregnant women o Young carers o Pre-operative patients o Older People with a chronic health conditions

• Continue to enforce the ban on smoking in public places. • Undertake enforcement activity regarding the sale of tobacco to underage

children • Continue to work in partnership with Stop Smoking Wales to deliver brief

intervention training to primary care staff to support their patients wishing to quit.

• Continue to work in partnership with Stop Smoking Wales to provide an equitable support service for those trying to quit, across the county.

• Continue to lead by example and support our own staff to quit smoking • Educate children and young people about the harm of smoking and

encourage those who smoke to quit through links with the Stop Smoking Wales Service.

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Update of 2011-14 priorities

• We are working to address our priorities through establishing a Powys Tobacco Control Forum and developing a Powys Tobacco Control Action Plan. This will enable a co-ordinated, systematic partnership approach to tackling smoking in Powys.

• We work closely with Stop Smoking Wales to enable Brief Intervention Training, which is currently being piloted as e-learning. In addition, this close working enables us to facilitate the equitable provision of the service across Powys.

• Stop Smoking Wales is actively promoted throughout Powys teaching Health Board e.g. through posters, intranet, Occupational Health. Powys teaching Health Board has achieved Gold Corporate Standards and as part of this has a peer support buddy system to help those who are trying to stop smoking.

• The Healthy Schools Team continues to support schools through the Substance Use and Misuse theme of the National Quality Award.

• The ASSIST programme has been provided to 3 secondary schools in Powys by Public Health Wales, but is now only provided in Newtown, as this is one of the most deprived areas of Powys, as well as having the highest proportion of the population aged under 18 years.

• The Healthy Schools Scheme is working to recruit Key Stage 2 pupils to Smokebugs e.g. through recruitment events.

• The Healthy Schools team link in and work closely with the Police Core Liaison Programme, who provide education in school settings about smoking, safety and substance misuse.

• In 2010 the LHB successfully bid for £10k from the WG Rural Health fund to develop and implement a community pharmacy stop smoking service. The pilot began in 2011 in 7 community pharmacies in 4 locations across Powys. The pharmacies offered a 12 week programme of one to one support. Evaluations have been extremely positive.

In 2012-13, we will focus on:

• Establishing a Powys Tobacco Control Forum, consisting of key partners and reporting to the Strategic Health Improvement Group. (15)

• Developing a Powys Tobacco Control Action Plan using the all Wales model to address the four key strategic areas highlighted in the Tobacco

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Control Action Plan for Wales and address local issues identified in the Powys Tobacco Control Workshop in March 2012. (15)

• Supporting No Smoking Day in Powys. (15)

• Supporting school teachers in their development of a Professional Learning Community, where resources, examples of best practice, key partners etc will be shared. The group will look at Substance use and misuse, including smoking. (7)

(Numbers in brackets refer to actions in the Powys teaching Health Board Annual Plan 2012-13)

4.2 PHYSICAL ACTIVITY AND HEALTHY EATING Why does it matter? Adequate levels of physical activity coupled with a balanced and healthy diet are key factors in maintaining the good health of a population across all ages. Physical activity contributes to well being and is essential for good health. It can delay the effects of ageing and enable people to live fulfilling and independent lives for longer. People who have a physically active lifestyle have approximately 50% less risk of developing coronary heart disease, stroke and type 2 diabetes compared to those who have a sedentary lifestyle. The effects of lack of physical activity and a sedentary lifestyle tend to be cumulative with the greatest impacts experienced later in life. Low levels of physical activity in Wales along with unhealthy eating patterns are leading to increases in the prevalence of obesity. As the media reports regularly, obesity is a real threat to our health. A greater dependence on fast foods and soft drinks (most of which are rich in unhealthy fat and salt levels and high calorie sugars), coupled with bigger portions and a non-active life style fuel the growth in weight. The lack of activity that characterises most modern lives also has a bad impact on our fitness and health. This in turn leads to high levels of cardio-vascular disease that result in premature heart attacks, strokes and the less obvious but debilitating heart and respiratory diseases which limit many people’s lives. It also causes type 2 diabetes, and again, the average age of onset is falling. Within Western countries the number of people developing diabetes is growing rapidly, and it can lead to a wide range of problems including eyesight problems and amputations. For the vast majority of people cutting down on fats, sugars and alcohol, reducing portion sizes, less snacking, and eating more fresh fruit and vegetables (“5 a Day”) would help to reduce obesity, reduce cholesterol levels and reduce some cancers.

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Our sedentary lives contribute to obesity and associated conditions. Walking several times a week for half an hour or so, building more activity into our regular routines, such as parking further away from the office or schools, or using the stairs rather than a lift, all contribute to burning calories and improving fitness. Creating an Active Wales Strategic Action Plan (Welsh Government) was launched in January 2011 and focused on increasing physical activity in work, leisure and play, towards the target of at least 30 minutes moderate intensity physical activity on 5 or more days of the week for adults and moderate to vigorous intensity of 60 minutes on 5 or more days for children (Physical Activity Guidelines, 2011). What is the current situation? The most recent data from the Welsh Health Survey (2009 and 2010) shows that 56% of adults in Powys were overweight or obese (compared with 57% for Wales) and 17% were obese (compared with 22% for Wales). A higher proportion of adults met physical activity guidelines in Powys (38%) compared with Wales (30%). In addition, a greater proportion of adults met fruit and vegetable consumption guidelines (37% in Powys, compared with 35% in Wales). Despite this, there is room for improvement in Powys. In 2006 the Health Behaviour in School-aged Children study found that Wales had among the highest levels of overweight and obesity among the participating European and North American countries at 21% and 18% for 15 year old boys and girls respectively. The Welsh Health Survey (2010) showed that in Wales 52% of children reported that they were active for at least 1 hour each day on 5 or more days in the last week. The foundations of healthy nutrition are laid by breast feeding, which has many widespread benefits for the baby and its development. The latest figures show that Powys currently has the highest breastfeeding (at birth) rates (78%) compared with 55% in Wales as a whole. What are our 2011-14 priorities? Promoting healthy levels of physical activity across all ages: We will:

• Improve access and sustainability through new models of delivery of physical activity

• Make better use of the Powys outdoor environment for increasing physical activity

• Improve the co-ordination of information, evidence and resources to support the development of physical activity

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• Step up the level of ‘active health promotion’ and ensure targeted support where needed, to encourage active lifestyle choices

• Continue to promote the wide ranging benefits of being active within our Healthy Schools Scheme.

• Promote physical activity in work, leisure and play. Promoting healthy eating: We will: Improve access to food for vulnerable people through:

• transport and support to people to shop for themselves • supporting existing ‘Food Co-ops’ under the Rural Regeneration Unit • supporting people to home cook nutritious meals • improved access to frozen meals and a universal meals service at cost • identifying and promoting local opportunities to eat communally at

accessible and concessionary food outlets (Cafes, Restaurants, Hotels and Pubs and lunch club venues).

• monitoring and evaluating the nutritional and hydration condition of older people assessed in hospital and on discharge

• promoting the ‘5 a day’ message, • continuing to raise awareness of healthy eating amongst children and

young people via the Healthy Schools Scheme • supporting our secondary schools to all have active School Nutrition

Action Groups under the Healthy School Scheme • continuing our partnership work with the Powys Catering Department and

the Community Dietitians to promote healthy eating within the school environment via the Healthy Schools Scheme.

• continuing to promote and support breast feeding.


• The Healthy Schools Team continues to support schools through the Food and Fitness theme of the National Quality Award.

• The Healthy Schools Team are also working in partnership with the School Sports Development Team and 5x60 Officers in High Schools to increase the volume of physical activity and the opportunity for pupils to participate in a variety of sports within schools. The team are advising schools on how to work towards achieving Appetite for Life standards.

• Flying Start and Early Year providers, together with the Healthy Schools Team are introducing a Healthy Setting Standard for pre-school settings.

• Powys teaching Health Board has attained stage 1 accreditation to

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UNICEF UK Baby Friendly Initiative and is currently working towards stage 2 accreditation.

• MEND, (Mind Exercise Nutrition Do it), a secondary prevention and primary treatment programme targeting 7 – 13 year olds and their families, was introduced in one locality in Powys (Ystradgynlais) in 2009 as part of the WG’s 5 year Food and Fitness Plan 2005-2010. Since then the programme has been extended into 3 more locations (Brecon, Newtown and Welshpool) and a junior fitness class has been established in each MEND location to add sustainability to the programme.

• Powys Trading Standards, together with Social Services have undertaken nutritional examinations of meals offered in Care Homes to identify whether residents are receiving nutritious meals. Where problems have been found, Care Home staff have been offered training. Community dietitians are also delivering a training programme on nutrition to all staff working with the elderly.


• Holding a joint conference organised by the Healthy Schools Team and Powys County Council to support schools in developing School Nutrition Action Groups. (7)

• Work in partnership with Powys County Council to implement the Health and Leisure Strategy 2011-14. (17)

• Developing a Healthy Weights initiative in partnership with key organisations. (16)

• Delivering and extending MEND throughout Powys. (16)

• Extending the delivery of Flying Start is areas of disadvantage to ensure that families with young children gain the support they need. (1)


4.3 ALCOHOL AND SUBSTANCE MISUSE Why does it matter? “People who misuse drugs, alcohol or other substances cause considerable harm to themselves and to society. This includes harm to their physical and mental health and well being, and possibly to their ability to support

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themselves. They may harm their families’ lives by damaging the health and well being of their children and place a burden of care on other relatives (including their children). There is also harm to the communities in which they live through the crime, disorder and anti-social behaviour associated with substance misuse. The total economic and social cost of Class A drug use in Wales has been estimated to be around £780 million, and drug related crime accounts for 90 per cent of this.”(Welsh Government 2008) It is widely recognised that alcohol misuse causes the greatest problems to individuals and society and yet it is culturally more readily accepted than other substances. There are mixed messages around the use of alcohol and this can be confusing to the public, especially with recent evidence highlighting the benefits of sensible drinking on lowering the risk of heart disease and stroke in older people. Alcohol is responsible for:

• 1000 Welsh deaths per year • Wales having the highest percentage of 13 year olds having reported they

had ‘been drunk in the last year’ out of 40 countries surveyed (Welsh Health Survey)

• 18,000 violent crimes in Wales in 2007/8 • An increase in hospital admissions due to alcohol • Half of respondents in the British Crime Survey perceive alcohol as a

major cause of crime What is the current situation? Working together to reduce harm 2008 is the Welsh Government’s 10 year substance misuse strategy for tackling the harms associated with the misuse of alcohol and drugs. Nationally, an all Wales educational programme has been established and at a local level Community Safety Partnerships (CSP) have been given extra funding to commission services and tackle local problems. These Boards are intended to bring agencies together to better plan and deliver substance misuse services, with a greater emphasis on health and social care needs rather than focussing on criminal justice aspects. The CSP commissioned an on line survey called ‘Viewpoint’ in 2011 for all High Schools in Powys, with a view to feeding results to the local commissioning strategy. The survey will be repeated as part of ongoing monitoring of current prevention programmes and results fed back into the commissioning strategy. Current research informs us that 41% of Powys adults reported drinking above recommended levels on at least one day in the past week, compared with 44% across Wales. In addition, 25% of adults reported binge drinking on at least one day in the previous week, compared with 27% across Wales5. 5 Welsh Health Survey 2009 & 2010

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The incidence rate of Powys people presenting to treatment services for alcohol misuse rose from 279 per 100,000 population in 2008/9 to 331 per 100,000 in 2009/10, (Wales 386 per 100,000 in 2008/09, 371 per 100,000 in 2009/10). Powys has the lowest rate of hospital admissions within Wales for males due to drugs at 98 per 100,000 population. For females, Powys has the third lowest rate amongst the health board areas at 88 per 100,000 population. What are our 2011-14 priorities? We will:

• Undertake enforcement activity regarding the sale of alcohol and solvents to underage children

• Develop a substance misuse prevention action plan • Review the VALIDATE proof of age scheme • Identify the extent of the problem of alcohol and other drug misuse by

people aged over 50 in Powys • Continue to raise awareness of alcohol and substance misuse in the

school setting through the healthy schools scheme • Raise awareness to ensure that the potential for harm through the misuse

of prescribed medication is minimised. • Continue the practice of ensuring that issues relating to dual diagnosis are

recognised and managed by all service providers. • Continue to prevent the abuse of children, young people and adults

through Safeguarding Boards and all organisations in Powys will respond promptly when abuse is suspected.

• Promote responsible sales of alcohol through the liquor licensing regime


• There is ongoing work by Trading Standards to undertake test purchasing of alcohol for underage sales.

• A substance misuse prevention action plan is being developed through the Substance Misuse Area Planning Board Commissioning Strategy.

• VALIDATE (voluntary proof of age scheme) is provided free within Powys, although this is under review.

• The Healthy Schools Team continues to support schools through the Substance Use and Misuse theme of the National Quality Award.

• The Healthy Schools team link in and work closely with the Police Core

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Liaison Programme, who provide education in school settings about smoking, safety and substance misuse.

• A sub group of the Powys CSP is currently about to launch a pilot Community Action Partnership (CAP), the first in Wales, in the Brecon area. This is a partnership approach to tackling underage drinking through a number of approaches.


• Supporting and monitoring the Brecon Community Action Partnership pilot in the Brecon area. (13)

• Supporting the development of the Powys Substance Misuse Commissioning Strategy. (13)

• Supporting school teachers in their development of a Professional Learning Community, where resources, examples of best practice, key partners etc will be shared. The group will look at Substance use and misuse. (7)

• Supporting the All Wales Brief Intervention Training being developed by Public Health Wales. (14)

• Using the findings from the Viewpoint survey to monitor prevention programmes and help with developing the Commissioning Strategy. (13)


4.4 SEXUAL HEALTH AND TEENAGE PREGNANCIES Why is it important? Sexual health is an important part of physical and mental health and well-being. The consequences of poor sexual health can be serious including unplanned pregnancy, avoidable illness and mortality from sexually transmitted infections and HIV/AIDS. There has been a marked increase in sexually transmitted infections in Wales over the past decade. In the document “Sexual Health and Wellbeing Action Plan for Wales, 2010-2015”, Welsh Government specified its commitment “to improve the sexual health and wellbeing of the population, to narrow sexual health inequalities and to develop a society that supports open discussion about relationships, sex, and sexuality. To support these aims, the action plan’s objectives are to:

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• Increase sexual health and relationships literacy; • Improve access to good quality sexual health services; • Reduce the number of unintended pregnancies, particularly among

teenage girls; • Reduce the rates of new Sexually Transmitted Infections (STI) and HIV; • Improve the health and social care for people living with HIV; • Reduce the number of new diagnoses of sexually transmitted Hepatitis B

and the number of people at risk; • Strengthen the monitoring, surveillance and research of the population’s

sexual health and well-being.” What is the current situation? In 2009 there was a reduction of episodes of uncomplicated Chlamydia infection nationally (4394 cases compared to 4440 in 2008). However the rate of new Chlamydia infections has been steadily rising in recent years with 147 per 100,000 recorded during 2009. The rates are highest amongst the 20-24 year old male population and the 16-19 female population. Sexually transmitted infections (STIs) within Powys are relatively uncommon, although there is likely to be under reporting, due to a proportion of our population being diagnosed at Genito Urinary Medical services out of county. Teenage conception rates are lower in Powys than any other Health Board in Wales, at 5.8 per 1000 under 16 year old females. What are our priorities?

• Develop a sexual health action plan to improve access to information advice and support especially for :

o Adults with learning disabilities o Looked After Children o School aged children o Young people (up to 25 years)

• Develop a clear strategy to reduce the level of teenage pregnancies in Powys.

• Continue the delivery of the APAUSE programme as a partnership between Health and Education and develop the programme across other settings that support young people.

• Implement a C-card scheme to enable younger people to access condoms.

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• A Sexual Health Action Plan has been developed through a Sexual Health Forum, which has membership from a wide range of stakeholders.

• Through the sexual health forum, there is a co-ordinated approach to reducing teenage pregnancies in Powys.

• The Healthy Schools Team continues to support schools through the Personal Development and Relationships theme of the National Quality Award.

• APAUSE continues to be supported by High Schools in Powys, although funding is required to continue the scheme after 2013.

• A C-Card scheme has been developed through the Sexual Health Forum


• Supporting Powys teaching Health Board to develop integrated and accessible sexual health services. (52)

• Continuing to work through the sexual health forum to have a co-ordinated approach to reducing teenage pregnancies in Powys. (52)

• Understanding the gaps in sexual health information and support in Powys.

• Support the Public Health Wales Empower to Choose Project to reduce Teenage conceptions.

• Support the Sexual Health Forum to ensure that the C Card scheme is sustainable within Powys.


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4.5 REDUCING ACCIDENTS AND INJURY RATES Why is it important? The main strategic drivers for the reduction of accidents are the Department of Health Report of the Chief Medical Officer “Preventing Accidental Injury – Priorities for Action” (2006) and the Welsh Government funded document written by Children in Wales called “Working towards a Child Safety Strategy for Wales”. Accidents are a leading cause of death in children and young people. Between 2007-09, accidents were the principal cause of death for males aged 1 – 39 years and for females aged 15 – 24 years6. Injuries to children in the UK account for approximately 2 million visits to Accident & Emergency departments each year, with an associated cost of over £146 million7. Road traffic accidents harm drivers, passengers other road users and pedestrians. The cost to public services for each fatality on the roads has been estimated at £1.6m. Half of all fatal accidents in young people are due to road traffic accidents. Many other injuries which may end up in Minor Injury Units or Accident & Emergency Departments are also preventable. Farms and other workplaces can be dangerous, and there are a surprising number of injuries in the home caused by ill fitting slippers, hazards and alcohol. The maintenance of independence of older people can be compromised by accidents, in particular falls. These can be caused by a variety of preventable factors which includes the effects of medication. The reduction in the “unscheduled care” caused by such accidents would reduce the resources currently used to treat them, and allow service providers to give a more efficient service to everyone else. What is the current situation? Powys has a higher than Wales average risk of road traffic fatalities, with relatively more car accidents occurring to younger drivers. Contributing to the high death rates associated with road traffic accidents is the diffuse rurality of Powys, with longer time taken for emergency services to reach accident sites. The number of killed or serious road accident casualties per 100,000 population in Powys fell from127 in 2004 to 98 in 2009 (Wales 63 in 2004, 49 in 2009). 6 Chief Medical Office for Wales. Annual Report 2010. 7 Audit Commission and Healthcare Commission, 2007.

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Powys receives numerous visitors from outside the county, particularly motorcyclists who are more vulnerable as they are not familiar with the roads. There are peaks of visitors during all holiday times, not just during high summer. However, these are often in groups in which less experienced riders fail to cope with the demands of Powys’ roads. Euro RAP findings show that Powys has higher than average high to medium risk roads. The number of deaths due to accidents (excluding road accidents) per 10,000 population in Powys fell from 3.3 in 2003 to 2.1 in 2007 (Wales 2.5 in 2003, 2.8 in 2007). The proportion of fire incidents that were accidental went up in Powys from 77% in 2002 to 82% in 2006 (Wales 42% in 2002, 49% in 2006) Only 21% of Powys private sector dwellings met the WHQS standard for smoke detection equipment in a Powys County Council commissioned house condition survey 2004. The rate of casualties in fire incidents per 100,000 population in Powys fell from 38.5 in 2002 to 13.8 in 2006 (Wales 31.2 in 2002, 23.1 in 2006). For the elderly population, falls is a serious risk. General practice data indicates that there are around approximately 475,000 falls in those aged over 60 years in the UK each year. The potential consequences of a fall include fractured hip and even death. In 2008, more than 3,400 people were estimated to have died from a fall in England and Wales8. The aging population in Powys means that falls are likely to place an increasing burden on health services in future. What Are Our 2011-14 Priorities? We will:

• Target high risk businesses in Powys to assess compliance with Health and Safety requirements

• Undertake enforcement activity regarding the sale of alcohol and solvents to underage children.

• Seek to encourage a joint and coordinated approach to Home Safety, Maintenance and Repair to include all agencies that currently contribute aspects of the need and are regularly visiting homes.

• Revise the Powys Community Safety Partnership Road Safety Action Plan, structured around PEEP (Prevention, Education, Enforcement and

8 ONS. 2009

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Provision) targeting older drivers, young drivers, young passengers, motorcyclists and drivers of commercial vehicles.

• Continue to deliver an effective approach to policing our roads, tackling the criminals who use them, and reducing the number of collisions that occur

• Encourage small businesses to access Workboost Wales to improve health and safety.

• Extend the existing falls prevention programmes already operating in parts of Powys.

• Support the programme of fire prevention through Home Fire Safety Checks, Electric Blanket testing and the education of youngsters who are most likely the ones to start deliberate fires.


• The priorities that have been identified will continue to be progressed through the Community Safety Partnership, with closer links being developed with the Strategic Health Improvement Group.

• The Falls Prevention Programme is continuing in Powys, with Public Health linking in through a Healthy Ageing workstream within Powys teaching Health Board.

• Programmes related to fire prevention are promoted widely throughout Powys as part of the Keep Well This Winter campaign.

• The Healthy Schools Team continues to support schools through the Safety theme of the National Quality Award.

• The Healthy Schools team link in and work closely with the Police Core Liaison Programme, who provide education in school settings about smoking, safety and substance misuse.

• The Road Safety Partnership has prepared a 2012 action plan. The priority within this plan is to reduce Road Traffic Collisions in our most vulnerable groups in Powys, particularly young passengers and older drivers. Commercial drivers have also been identified as a priority group.

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• Supporting the Community Alcohol Project Pilot in Brecon, its evaluation and potential roll out. (13)


4.6 IMPROVING MENTAL WELLBEING Why is it important? One of the biggest causes of people taking time off work, and one of the biggest costs for medication is depression. It is also a significant predetermining factor of admission to residential care for older people and a notable undiagnosed cause of older peoples’ struggle to remain independent. “Loneliness” is identified in all recent surveys of older people to be a common experience. There are no easy answers to this situation, and trying to reduce the prevalence of depression, especially during an economic recession, will require many agencies working together to improve the environments we live in, reduce debt, improve work and training opportunities and improve support systems. There is also evidence that people can reduce their susceptibility to depression by ensuring they set themselves new goals such as learning new skills and by socialising more. Taking up a new past time or hobby which takes us out of the house and promotes fresh achievements can be effective. In Together for Health, there is a pledge to have a new comprehensive approach to mental health care, including promoting mental health through reducing stigma. In addition, key actions in Welsh Government’s Programme for Government 2011 include reviewing access to talking treatments for those with mental health problems and implementing the Mental Health Measure. What is the current situation? The individual’s perception of their personal physical and mental health is a vital component of their overall well being, and an indicator of their likely need for support or health care. The Welsh Health Surveys 2009-10 asked respondents about their own perception of their physical and mental health and how it affects their day to day living. In Powys, the average score for adults using the self assessment questions was found to be 51.1, which is marginally higher than the Wales average of 50 (on a scale of 0 worst to 100 best). In addition, 7% of adults in

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Powys reported being treated for any mental illness, compared with 10% of adults across Wales. Overall, self harm and suicide rates are generally low within Powys compared with Wales as a whole, although any suicides are a cause for concern. What are our 2011-14 priorities? The Welsh Government are in consultation to produce an All Wales Mental Health Strategy and Powys will be taking this forward through the Mental Health Strategy:

o Continue Support for DIY Futures Partnership Project (ends 2013) through its final phase in preparation for the funding ending in March 2013.

o Promoting Mindful Employer and developing commitment within Powys teaching Health Board to the principles of being a Mindful Employer.

o Promoting Mental Health Week Conference and events • Implementing new guidance on Care Programme Approach and Mental

Health Measure for Care and Treatment Plans which will provide information to people about how they can get the support they need (e.g. crisis planning)

• To continue to implement the Families First programme to include; o An Integrated Disability Service for Children and Young People o A Family and Behaviour Support Service for parents and carers o A Mental Health and Wellbeing Service for Children and Young

People o An infrastructure that enables children, young people, families and

services to work together at a local level – this will include the Team Local Resource Solution Panels, a Common Assessment Framework and the Team Around the Family approach.

• To support the effective implementation of the rural befriending scheme (AdvantAge) for older people and those with poor mental health

• Continue to promote attendance at Mental Health First Aid courses across the private, statutory and third sectors

• Promote the use of circle time and other effective tools to support positive mental health within our schools through the Healthy Schools Scheme


• The Healthy Schools Team continues to support schools through the Mental and Emotional Health and Well Being theme of the National

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Quality Award.

• To continue to support Powys teaching Health Board to achieve the “Mindful Employer” award.

• To continue to support key agencies across Powys to be aware of the mental health issues that may face ex-service personnel.

• Continue to promote attendance at the Mental Health First Aid courses, including Youth First Aid, across the private, statutory and third sectors.


• Working in partnership to produce the Mental Health Strategy for Powys. (10, 64)

• Supporting the implementation of the Mental Health Care Standards across Powys. (64)

• Working in partnership to reduce suicide and self harm through implementing the actions set out in Talk to Me. (10)

• Promoting the All Wales Veterans Health and Wellbeing service across Powys.

• Supporting the roll out of the mental health awareness course across the private, statutory and third sectors. (10)

• As part of delivering the Families First Plan we will establish a fully integrated Emotional Health and Wellbeing Service for children and young people. (2)


4.7 IMPROVING HEALTH AT WORK Why is it important? Evidence suggests that good work is important for physical and mental health and well-being. The workplace is viewed as a setting in which large populations can be reached, and where people spend a significant amount of time. The workplace provides an environment which can reinforce positive health messages through social networks, supporting behaviour change and providing an opportunity to monitor and evaluate activities. There is also the potential to

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actively disseminate messages learnt by employees to their families and social networks outside the workplace resulting in indirect positive effect on the health of the community. The business case for workplace health improvement continues to strengthen as it leads to the improved engagement and motivation of employees and increased effectiveness, productivity and competitiveness. In the document ‘Healthy Working Wales, Health, Work and Well-being Action Plan for Wales 2011-2012’ Welsh Government has identified the business costs which equate to absenteeism:

• Mental health problems are costing the Welsh economy £1.2 billion per year

• The cost of smoking borne by employers in Wales is around £80 million • The cost of recruitment to fill a vacancy is between £3,000 and £8,000,

depending on the position of the employee The longer someone is off work there is a lower likelihood of them returning to work:

• If you're off sick for six months, you have an 80% chance of being off for five years.

• 90% of people making a claim for incapacity benefits expect to return to work, but if you claim for two years or more, you are more likely to retire or die than return to work.

The workplace is an ideal setting for many health improvement priorities. However, the size of businesses in Powys has its own challenges as the figures from Stats Wales below show: Micro business 0-9 employees 94.5% Small 10 - 49 3.3% Medium 50 – 249 0.5% Large 250+ 1.2% What is the current situation? There are several national programmes in place through ‘Health Working Wales’ to support workplaces to improve health and well-being. There are two awards, the Corporate Health Standard aimed at workplaces employing more than 50 people and the Small Workplace Health Award aimed at those employing less than 50. Workboost Wales provides free, confidential, practical advice on workplace health and safety, management of sickness absence and return to work issues. The service is provided for workplaces which employ between 5 and 250 employees.

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Powys teaching Health Board and Powys County Council, the two biggest employers in Powys are leading the way and setting an example as exemplary employers. These organisations have achieved the Corporate Health Standard Award and it is anticipated that they will achieve platinum level by 2013. These organisations are now working together to share best practice and joint working where possible to improve the health of their staff. What are our 2011-14 priorities? We will:

• Improve health and well-being at work, reduce the impact of ill health and reduce accidents and injuries through promoting the Healthy Working Wales programmes

• Reduce accidents and injuries in the workplace • Promote the Healthy Working Wales programmes to our partners and

suppliers • Continue to lead by example and support our own organisations to

improve their health and well-being at work such as: o Encourage appropriate staff to have a seasonal flu vaccination o Promote smoking cessation services o Promote the ‘5 a day’ message o Achieve either the Corporate Health Standard or Small Workplace

Health award.


• Healthy Working Wales programmes are promoted through existing award holders and partnership networks.

• Workboost Wales (part of Public Health Wales) has provided advice and support on Health and Safety across Powys.

• Powys teaching Health Board, Powys County Council, as well as a few small workplaces have achieved the Gold Corporate Health Standard Award.

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• Continuing to support Powys teaching Health Board to lead by example and improve wellbeing at work. Through Public Health Wales, we will support Powys teaching Health Board to work towards “Platinum” Corporate Health Standard Award. (25)


4.8 INCREASING VACCINATION RATES TO RECOMMENDED LEVELS Why is it important? Immunisation and vaccination is the foundation for controlling the spread of many communicable, infectious diseases. The range of immunisations and vaccinations supported by the NHS are safe, effective and cheaper for society than dealing with the diseases they control. One of the key actions for preventing poor health and reducing health inequalities is to increase immunisations among children to eradicate the health problems caused by measles, mumps and rubella9. A recent outbreak of measles in North Wales has increased the impetus to improve MMR uptake, in order to protect individuals and the community. What is the current situation? Powys teaching Health Board has increased uptake of childhood vaccines in recent years. From being well below the Welsh national average on a number of vaccines, Powys is now at similar levels to the rest of Wales for most childhood vaccines. Immunisation and vaccination of very small children has improved considerably, and Powys is reaching Welsh Government (and World Health Organization) levels which ensure community immunity. Vaccine uptake data for children in Powys shows10:

• Coverage of immunisations for children at their 1st and 2nd birthdays are reaching 95%, a significant improvement on previous years.

9 Welsh Government. Programme for Government 2011 10 Vaccine Uptake in Children in Wales. October to December 2011. COVER 101: Wales February 2012. Public Health Wales.

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• Uptake of vaccinations for pre-school children (MMR2 and 4 in 1) have

shown marked improvement on previous years.

• HPV data shows that uptake amongst girls aged 15, 16 and 17 years was lower than Wales uptake rates.

• Uptake of teen ‘boosters’ amongst 16 year olds is lower in Powys than

across the rest of Wales. MMR1 uptake is 86% (91.5% for Wales), MMR2 uptake is 73.4% (83.4% for Wales) and 3 in 1 Teenage Booster uptake is 73.7% (76.3% for Wales).

• In 2011-12, seasonal influenza immunisation uptake for people over 65

improved to 66.9%, although this was slightly lower than uptake across Wales (67.3%).

• In 2011-12, seasonal influenza immunisation was 49.3%, for people under 65 in clinical at risk groups. This was a slight improvement compared with uptake in previous years, although still slightly lower that uptake across Wales (50.1%).

What are our 2011-14 priorities? We will:

• Develop an MMR ‘catch-up’ programme. • Ensure that the need for information management, recording and reporting

is communicated to primary care teams. • Comprehensive systems are put in place within primary care and Powys

teaching Health Board to ensure a child’s vaccination status is readily available.

• Develop and agree with primary care methods for recording and reporting refusals to be vaccinated.

• Consider the capacity to deliver vaccination programmes in Powys and, if necessary, develop a case for increased capacity. Explore the contribution that school nurses can make to delivering vaccine programmes.

• Increase the number of health and social services staff who take up vaccinations.

• Increase the number of over 65’s and people under 65 in clinical at risk groups who take up seasonal influenza vaccinations.

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• A MMR “catch-up” programme for teenagers is being planned and remains a priority action.

• Areas requiring further development include improving information management, having comprehensive systems to improve availability of vaccination status and developing methods of recording refusals to be vaccinated. These areas are being reviewed as part of an updated Powys Immunisation Group Action Plan.

• Capacity has been increased in Powys with the appointment of an Immunisation Co-ordinator and a Head of Children’s Public Health Nursing.

• Flu vaccination uptake amongst Healthcare staff has increased year on year, with a marked increase between 2010-11 and 2011-12. This continues to be a priority action.

• There has been an increase in flu vaccination uptake rates amongst both those over 65 years and people under 65 in clinical at risk groups. Continuing to improve flu vaccination uptake rates remains a priority both nationally and locally.


• Achieving and maintain immunisation targets for children in Powys. (2)

• Developing and implementing an MMR catch up campaign for teenagers. (2)

• Improving flu vaccination uptake rates for Health and Social care staff, those aged over 65 years and those in at risk groups. (25, 35)


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5 DEVELOPMENT OF ACTION PLANS The Strategic Health Improvement Group is in the process of overseeing the development of specific action plans regarding each of the OHF priority areas. It is identifying the service or work groups responsible for implementation of the strategy for each priority area and actions. The “Results Based Accountability Framework” is a tool that is being considered as a tool to help achieve this. It is based around a simple framework: -

• What do we want for the population?

• How would we recognise it in measurable terms?

• What will it take to get there? The diagram below shows the elements of Results Based Accountability (RBA):

RBA distinguishes between two types of accountability: -

• Population accountability – results for whole populations such as all children, all older people or all citizens

• Performance accountability – results for the customers or clients of a

particular programme, project, agency or service

What do we want for

the population?

How would we recognise it in

measurable terms?

What will it take to get

there?

Outcomes

Indicators

Programmes / Services

Performance Measures

Population Accountability Partnerships)

(

Performance Accountability (Organisations)

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In RBA, population accountability cannot be assigned to any one individual or organisation, at this level responsibility must be shared. Only at the performance accountability levels can individuals or organisations be held accountable. Within these 2 types of accountability, RBA also sets out four levels: -

• Outcomes – Conditions of well-being for people or the environment in which they live, work or visit.

• Indicators – Measures that help quantify the achievement of outcomes.

• Programmes / Services – Actions that will be taken either by

organisations independently or in partnership to achieve the outcomes.

• Performance Measures – Measures of how well the actions are being delivered in terms of: -

o How much did we do? o How well did we do it? o Is anyone better off?

A key guiding principle will be that activities are focused primarily on those communities (defined geographically or as a vulnerable group) with the lowest health indicators currently.

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6 MONITORING IMPLEMENTATION The monitoring of individual action plans within this strategic framework is guided by the following local service board arrangements:

• In the Powys Public Health Strategic Framework 2011-14, it was stated

that agreed outcomes and indicators would be monitored by the Powys Local Service Board and relevant thematic partnerships. This monitoring arrangement may change in view of the review of partnerships that is underway.

• The agreed services and performance measures are being monitored by

the partner organisations as required. This will complement the monitoring arrangements used within the partner organisations.

Governance and decision making powers remain with the various organisations. However, organisations are considering the potential benefits of adopting more collaborative models for governance and scrutiny for the One Powys approach. Monitoring will need to be adapted to reflect outcomes that have been highlighted as part of Together for Health:

• Gap in life expectance between most and least affluent • % of population who are obese • % of adults who smoke • % who report drinking above recommended guidelines • % of live births with birth weight of less than 2500g

Indicators

Programmes / Services

Performance Measures

Outcomes

Population Accountability

Performance Accountability

Partnerships • Powys LSB • Thematic

partnerships

Organisations

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• % of population who are physically active In developing the One Powys plan the LSB became aware of a lack of useful information to underpin prioritisation of objectives and to guide implementation. Work is underway to improve collection and sharing of information, although this is an iterative process.

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Options Review of Sexual Health Services for Powys


Agenda Item 2.8

BOARD MEETING


OPTIONS REVIEW OF SEXUAL HEALTH SERVICES FOR POWYS

Report of

Consultant in Public Health/ Acting Director of Public Health

Paper prepared by

Consultant in Public Health Head of Midwifery and Sexual Health Services

Purpose of Paper

To provide the Board with an overview of Sexual Health services in Powys, highlight gaps and concerns with current services and recommend options to the Board for consideration.


The Board is asked to:- NOTE Sexual Health services currently provided

in Powys and the different options available for improving services; and

review the options discussed in this paper and SUPPORT the recommended option for developing Sexual Health services.




Promotes Health & Wellbeing Ensuring the right access


Powys teaching Health Board (PtHB) Public Health (PH) Genito-Urinary Medicine (GUM) Long Acting Reversible Contraceptive (LARC) Emergency Hormonal Contraception (EHC) Patient group directive (PGD) Minor Injury Units (MIUs) Termination of pregnancy (ToP) Sexually transmitted infections (STI) Blood Borne Viruses (BBV) General fertility rate (GFR) Locally Enhanced Service (LES) Intra uterine device (IUD)

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Agenda Item 2.8

OPTIONS REVIEW OF SEXUAL HEALTH SERVICES FOR POWYS

Executive Summary This purpose of this paper is to provide the Board with an overview of Sexual Health services in Powys, highlight gaps and concerns with current services and recommend options to the Board for consideration. The aim is to provide residents of Powys with a Sexual Health service that is in line with national standards, that can meet Powys teaching Health Board Genito-Urinary Medicine (GUM) access targets and that will address identified sexual health needs. Current services in Powys consist of:

Contraceptive services that are provided solely through GP Practices. Patients may attend Family Planning clinics out of county; there is no such service provision within Powys.

Emergency Hormonal Contraception is available through pharmacists, Minor Injury Units and GP Practices.

No medical termination of pregnancy services are provided in Powys, although there are a small number of surgical terminations at Brecon Hospital.

Genito-urinary medicine consultant led sessions are held once a week in Builth and Newtown Hospitals (both sessions are held on the same day).

HIV and Blood Borne Viruses are managed through accessing specialist services based in hospitals outside Powys, as there are no specialist / consultant led sessions held in Powys.

The Network Psychosexual Partnership Cymru provides psychosexual counselling sessions in Powys.

Data shows that teenage conception rates in Powys are lower than national rates and the prevalence of HIV is lower than national rates. It is difficult to estimate Powys’ rates of sexually transmitted infections, as many patients are diagnosed at GUM clinics out of county. The concerns with current service provision are:

GUM and contraceptive services are not integrated, with no clear pathways for patients to access both

There is a lack of a clinical governance framework and leadership, particularly for contraceptive services.

GUM services currently fail to meet AOF 24 / AQF targets of providing access to core sexual health services within 2 working days.

Access to services is problematic in terms of geography (GUM services are only available in Builth and Newtown), setting (contraceptive services are only available through GP Practices) and timing (GUM services are only available once a week).

There is a lack of multi-disciplinary team approach, with the skills of GPs, Practice Nurses, School Nurses, Specialist Nurses, GPs with Specialist Interests, Consultant Physicians not being harnessed and joined up, leading to a fragmented service.

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Agenda Item 2.8

There is a lack of choice of services, with GUM services only being available through GUM clinics and contraceptive services only being provided through GP practices.

Six options are appraised for Sexual Health service provision in Powys. These are: 1. No change in current services 2. Changing systems working 3. Increasing the number of GUM consultant sessions 4. Developing a nurse led GUM clinic 5. Having a GP Locally Enhanced Service 6. Developing an Integrated Family Planning and GUM clinic

The option recommended to the Board is Option 2 (Change systems working), with the aim of improving current service integration, access to services and governance within the current financial envelope for sexual health. In addition, it is recommended that discussions are continued with Hywel Dda Health Board to better understand current funding arrangements for Sexual Health services to Powys in order to try and release funding for further service development. If this process is successful, it is recommended that an Integrated Family Planning and GUM clinic (Option 5) is developed. This model will provide an integrated Sexual Health services that can be accessed within two working days, as well as enabling Powys to have:

• A comprehensive governance system that will include tertiary support and teaching

• Provide an alternative setting for patients to access Sexual Health services in Powys, which is of particular relevance to young people

• A cost effective use of expertise within primary care via GP sessions and nurses

• Provide a holistic approach to Sexual Health in Powys Recommendation The Board is asked to:-

NOTE Sexual Health services currently provided in Powys and the different options available for improving services; and

review the options discussed in this paper and SUPPORT the recommended option for developing Sexual Health services.

Report prepared by: Presented By: Consultant Local Public Health Team Dr Sumina Azam Head of Midwifery and Sexual Health Services


Background Papers Options review of Sexual Health Services for

Powys Consultees Powys Sexual Health Forum

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Agenda Item 2.8

OPTIONS REVIEW OF SEXUAL HEALTH SERVICES FOR POWYS 1 Purpose of Paper The purpose of this paper is to provide the Board with an overview of current Sexual Health (SH) services in Powys and highlight any gaps or concerns. This paper will describe a range of options for the provision of future SH services, summarising the advantages and disadvantages of each option. Overall, the aim will be to ensure that future SH services in Powys are:

• In line with national standards and recommendations for sexual health services

• Can help meet Powys teaching Health Board (PtHB) Genito-Urinary Medicine (GUM) access targets

• Can help to address sexual health needs that have been identified in Powys. 2 Background National standards for sexual health services have been described in the following documents:

o Welsh Government - Sexual Health and Wellbeing Action plan for Wales 2010-15

o Providing seamless services for the sexual health needs of people living in Wales (2011)

o Providing for the needs of people with HIV / AIDS in Wales – National care pathways and service specifications for testing, diagnosis and supportive care (2009)

In addition, PtHB needs to ensure that all patients are able to access GUM services within 48 hours as part of the AOF/AQF. These standards have been incorporated into Powys Sexual Health Forum’s vision, which is “To provide effective, safe, quality and integrated sexual health services within a community setting, utilising General Practice, community pharmacies, school nursing and nurse led clinics with effective and timely pathways to secondary services.” 3 Current services in Powys 3.1 Contraceptive services In Powys, contraceptive services are provided solely through GP Practices. Patients can access services either via their own GP Practice or attend another GP Practice if the service is not provided by their own practice. Contraceptive services are provided as part of GMS contract service requirements and include:

• Provision of sexual health promotion advice and condoms • Emergency contraceptive care, signposting and onward referral • Sexual and contraceptive history taking • Free pregnancy testing • Contraceptive advice and access to all methods in Wales formulary (there is

currently ongoing work to have all Wales prescribing guidelines / formulary)

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Agenda Item 2.8

and unrestricted access to all Long Acting Reversible Contraceptive (LARC) methods (in house / by referral).

• Information on all LARC methods • Initiation of bridging contraception • Cervical screening • Initial advice and referral for Termination of Pregnancy • Referral for male / female sterilisation • Referrals to psychosexual services. Although referrals to erectile dysfunction

services is part of the GMS contract, this service is not offered, as no erectile dysfunction services are currently provided in Powys.

• Safeguarding and promoting welfare of vulnerable groups In addition, patients may access these services outside of Powys e.g. through Family Planning Clinics in neighbouring Health Boards or English providers. Emergency Hormonal Contraception (EHC) is available via Minor Injury Units (MIUs), GP practices and pharmacists in Powys. Patients aged over 16 years can access EHC as an over the counter medicine. Patients aged over 13 years can access free EHC through a patient group directive (PGD), which is a part of a National Enhanced Service. Of the 23 community pharmacies in Powys, 21 are eligible to register to provide EHC under a PGD and 16 pharmacies are currently offering the service. Table 1 below shows the number of women presenting to Powys pharmacies for EHC between April 2010 and March 2011. Table 1: Age profiles of those accessing EHC services in pharmacies in Powys

Age Number of consultations 30+ 119 25 to 30 82 17 to 24 190 13 to 16 58

Source: Powys Medicines Management Team

3.2 Termination of Pregnancy (ToP) Prompt access to termination of pregnancy (ToP) services is important in helping to reduce the risk of associated complications, with national guidelines recommending that women should not wait longer than 3 weeks from referral to termination. Most patients access medical and surgical ToP services out of the county, although a small number of surgical ToP are carried out at Brecon Hospital. Although this paper does not include the provision of ToP services within the proposed service model options, there will need to be a pathway developed to ensure “seamless” services. This will involve ensuring that services can be accessed through numerous routes e.g. GP Practices, GUM clinics, any Community Sexual Services commissioned. Data on abortion rates is provided in Section 4. 3.3 GUM Services Genito-urinary medicine (GUM) services are provided through two weekly consultant led sessions. These sessions are held on the same day, which means that GUM services in Powys can only be accessed once a week. The sessions are held in Builth and Newtown Hospitals. The current funding for this service is unclear. The

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Agenda Item 2.8

service was originally developed following a Dyfed Powys Sexual Health Advisory Group grant bid in 2003 but the current funding route for this service requires clarification. No services are provided if the consultant is unable to attend the clinic. Table 2 below shows activity levels for these clinics since 2006/07. There are no Enhanced Service agreements in place for GPs to provide GUM services in Powys. Table 2: Activity at GUM consultant clinics held in Builth and Newtown between 2006/07 and 2011/12 2006/07 2007/08 2008/09 2009/10 2010/11 2011/12

(data for 26 weeks only)

Builth 257 235 204 195 212 102 Newtown 198 218 205 198 189 77 Powys total

455 453 409 393 401 179

The table below gives an indication that as well as seeing patients at clinics, the GUM services in Powys also have extensive telephone contact with patients. Table 3: GU clinic activity (KC60 data) 2009 Incoming telephone

calls for clinical advice or results

First attendances Of which are new patients

Builth 203 169 130 Newtown 182 182 138 Source: Public Health Wales Communicable Disease Surveillance Centre. HIV and STI trends in Wales: Surveillance Report, March 2011. Cardiff: Public Health Wales.

GPs also assess and refer patients with sexually transmitted infections (STI) symptoms as part of the GMS contract. However this does not usually include:

• STI testing and treatment of asymptomatic and symptomatic men and women • Testing for Blood Borne Viruses and syphilis • Treatment of STIs • Facilitation of client based partner notification

Powys residents can also access GUM services out of county e.g. at hospital or community GUM clinics. As these can be accessed anonymously, it is not possible to ascertain how much activity originates from Powys. At present, Powys tHB are not charged for services accessed by its residents. 3.4 HIV and Blood Borne Virus services Patients can be tested and diagnosed in a variety of settings e.g. at a GP surgery, GUM clinics and at substance misuse clinics. The management of patients with HIV and Blood Borne Viruses (BBV) is through specialist services based in hospitals outside Powys, as no specialist / consultant lead sessions are held in Powys.

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Agenda Item 2.8

3.5 Psychosexual counselling Although there are no statistics on the prevalence of psychosexual health problems, there is anecdotal evidence from health professionals that these are common. National guidelines state that psychosexual services should be provided to “anyone who has a sexual problem, concern or dysfunction”, with care pathways in place to enable access to them1. Within Powys, this service is provided by The Network Psychosexual Partnership Cymru, which is funded through Powys tHB’s Women and Children’s directorate. This service is based in Builth Hospital and there are approximately 36 sessions per year (216 appointments available in total). In 2010, 88% of referrals to the service were from GPs. Referrals to the services are for a wide range of sexual problems e.g. sexual dysfunction as a primary problem or as a result of medical or psychiatric condition, sexual pain disorders, psychological disorders as a result of sexual or reproductive health, sexual aversion, concerns about sexual orientation or gender. The service provides counselling to patients with erectile dysfunction, although it is not involved with its medical management. In the service’s 2010 Annual Report2, it was noted that patients using the service regularly describe clinics in Builth Wells as difficult to access by public transport, particularly from the North of the county. 3.6 Erectile Dysfunction services Erectile dysfunction is a common condition, with approximately 26% of men aged 18 to 75 years being affected3. As part of seamless sexual health service1, there needs to be a pathway in place for the referral of patients with erectile dysfunction. No erectile dysfunction services or pathways are available in Powys, although the psychological aspects can be managed through psychosexual counselling services that are available. Medical management of erectile dysfunction is undertaken either by GPs or patients are referred to specialists out of county. 3.7 Services for children and young people Children and young people have particular needs that should be considered when developing SH services. Children of school age may not be able to access services that are only provided in school hours and young people are likely to find lack of transport a barrier. Currently, sexual health services for children and young people are provided through GPs, school nurses and Powys Information Service, which provides relationship information through Powys Youth Clubs and is leading on the introduction of the C-card Scheme. The limited sexual health service provision may not provide an adequate choice that young people are comfortable accessing. This is of particular importance as young people are likely to find accessing out of county GUM / Family Planning Clinics more problematic than adults.

1 Providing seamless services for the sexual health needs of people living in Wales 2011 2 Annual Report of Psychosexual Counselling Services in Wales. 2010. The Network of Psychosexual Partnership Cymru. 3 Guidelines on the Management of Erectile Dysfunction. British Society for Sexual Medicine. 1998.

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Agenda Item 2.8

3.8 Funding of current services Item Cost Notes GU consultant sessions (2 sessions / week in total)

Approx £10,000

Unable to identify audit trail – funding may not be from Powys (historic funding was through a grant bid from Dyfed Powys)

Laboratory testing £8,471 Payment to Hywel Dda (SLA in place). Tests undertaken by other providers are paid for as part of Long Term Agreements

0.2 wte nursing support (Band 7) to GUM Clinic

£9,878.00 Midwifery budget. N.b. this does not include running clinic sessions

0.2 wte admin support (Band 2) to GUM Clinic

£4,182.00 Child Health Services budget

Psychosexual counselling sessions £7,000 Sexual health budget Additional contraceptive services primary care

part of GMS Primary Care

Enhanced contraceptive services primary care

£80,580.68 Primary Care

Out of county GUM services currently not billed for

Termination of Pregnancy (ToP) services – cost of English providers

~£50,000

TOTAL excluding ToP services and GUM consultant

£110,111

Funding of Sexual Health Services in Powys is complex, due to the numerous historic funding streams and the changes that have taken place to these. As an overview, sources of funding have been from:

• Previously ring fenced money for sexual health services from WG (£32,000 for Sexual Health and £48,000 for Integrated Sexual Health Services). This money has not been ring fenced since 2010-11. Previous work was undertaken in 2008-09 to clarify where this money was allocated. Estimations at the time were:

o £13,219 – Powys providers o £10,000 – Hywel Dda o £23,392 – ABMU o £16,000 – Gwent o £16,249 – Hereford

• Grant funding application by Dyfed Powys in 2003 to pay for a GUM service for Ceredigion and Carmarthen. It is unclear how the GUM service in Powys continued to be funded once this grant money ceased.

• There may also have been funding from WG to Hywel Dda to cover aspects of sexual health services in Powys such as the GUM services. However, no confirmation of this has been found through discussions with Hywel Dda and Public Health Wales, who were involved in advising WG about sexual health service funding.

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Agenda Item 2.8

4 Health Needs in Powys Levels of sexual health need are explored using data related to demography, sexual health related morbidity, current health service activity and the use of national data to ascertain potential levels of activity for different service models. 4.1 Demographic data 4.1.1 Population projections Between 2008 and 2023, it is estimated that the population of Powys will increase by 8%. The population growth is mainly due to 52.1% increase in the 65+ year olds (from 28,700 to 43,700). Over this time frame, it is estimated that there will be a small decline in the number of people aged under 65 years. Table 4: Powys population changes 2008 2013 2018

2023

Children 23,420 22,461 22,328 22,426 16 – 64 years 79,556 78,770 77,361 76,111 65+ years 28,701 34,142 39,208 43,661 Total 131,677 135,373 138,896 142,197 Source: Local Authority Population Projections for Wales (2008 based). Local Authority report. Welsh Assembly Government. 2010 For service planning purposes, this means that the needs of the elderly population need to be considered. Analysis of data from a STI surveillance system between 1996 and 20034 showed that although the relative number of people aged over 45 who were diagnosed with an STI was small, there was a greater increase in STIs diagnosed in this population compared with those aged under 45 years (127% increase in over 45s v 97% increase in under 45s). 4.1.2 General Fertility Rate The General fertility rate (GFR) is a measure of current fertility levels and is the number of live births per 1,000 women aged 15-44. Data from 2007 shows that the GFR for Powys (61.4) is higher than for Wales (59.4) and higher than any other Health Board area5. 4.1.3 Teenage conceptions Reducing the number of unintended pregnancies, particularly among teenage girls is one of the key objectives of WG’s Sexual Health and Wellbeing Action Plan for Wales 2010-2015 (2010). Teenage conception rates in Powys are lower than national rates and are consistently amongst the lowest compared with other Local Authorities in Wales. For example, the conception rates for those aged under 16 years are 5.8 / 1,000 for Powys, compared with 8.1 / 1,000 for Wales (ONS, 2007). Figure 1 shows that Powys has relatively low teenage conception rates compared with other Local Authorities.

4 Trends in Sexually transmitted infections (other than HIV) in older people: analysis of data from an enhanced surveillance system. Bodley-Tickell et al. Sex Transm Infect 2008 84: 312-317. http://sti.bmj.com/content/84/4/312.full.pdf 5 Office for National Statistics

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Agenda Item 2.8

Figure 1: Conception rate for under 18s by Unitary Authority (2007-2009 average). Rates per 1,000 female residents aged 15 to 17.

Source: Statistics for Wales. Statistical Bulletin. 29 November 2011. 4.1.4 Legal abortions Data from 2010 shows that there were 267 abortions in women who are Powys residents (15.1 per 1,000 resident women aged 15 to 44 years). This is similar to Wales abortion rate of 15.2 per 1,000 resident women aged 15 to 44 years. Figure 2 below shows the abortion rate for different age groups of women resident in Powys. Abortion rates are highest for women aged 20 to 24 years. Figure 2: Abortion rate for women resident in Powys

Abortion rate for women resident in Powys

0

5

10

15

20

25

30

Under18

18 to19

20 to24

25 to29

30 to34

35+

Age group

Rate

per

1000 w

om

en (

15-4

4

years

)

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4.2 Sexual health related morbidity - disease prevalence data 4.2.1 HIV prevalence HIV is of significance due to its associated serious morbidity, mortality and high costs of treatment. National Wales data shows increasing prevalence of HIV, with 383 residents receiving care for HIV in 2001 compared with 1,321 in 20106. The increased prevalence is related to the increase in incidence as well as treatment resulting in longer survival. Figure 3 below illustrates how prevalence of HIV in Powys has remained unchanged at 20-29 cases / 100,000 between 2009 and 2010. Figure 3: HIV prevalence in Wales by Local Health Board of Residence.

Source: Public Health Wales Communicable Disease Surveillance Centre. HIV and STI trends in Wales: Surveillance Report, January 2012. Cardiff: Public Health Wales. DRAFT

HIV prevalence in Powys in 2010 was 28.2 / 100,000, compared with a prevalence of 43.7 / 100,000 for Wales overall. Across Wales, most cases were seen in those aged 35 to 44 years. Transmission of HIV was through various routes: men who have sex with men (52.3%), heterosexual transmission (40.5%), via blood / blood products (1.7%), injecting drug users (2.3%) and mother to child transmission (2%). 4.2.2 Blood Borne Virus (BBV) prevalence Wales has a very low prevalence of Hepatitis B virus, although some communities in Wales have a higher prevalence e.g. minority ethnic communities, injecting drug users, commercial sex workers and men who have sex with men (MSM). In 2010, 19 new cases were diagnosed in GUM clinics in Wales. Over this time period, 515 Hepatitis B vaccinations were administered in GUM clinics7. Hepatitis C virus infection is most common in those who are injecting drug users, with 23% - 26% of injecting drug users having evidence of the infection8. In 2010, there were 33 new patients diagnosed with Hepatitis C through GUM clinics in Wales7. 4.2.3 Sexually transmitted infection (STI) prevalence

6 Survey of Prevalent HIV Infections Diagnosed (SOHPID) data 7 Communicable Disease Surveillance. HIV and STI trends in Wales. Surveillance Report. January 2012. DRAFT 8 Welsh Assembly Government. Blood Borne Viral Hepatitis Action Plan for Wales 2010-2015. February 2010.

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Agenda Item 2.8

Rates of STI are highest amongst those aged under 24 years. Nationally, there is an increasing trend in the number of STIs diagnosed, particularly Chlamydia9. Data is available on the number of cases of STIs that are diagnosed in GUM clinics in Powys. This does not include Powys residents who attend GUM clinics out of county. Table 5: New episodes of STI by GUM clinic (KC60 data)

Syphilis Gonorrhoea Chlamydia NSU (male)

Trichomoniasis

Anaerobic/ bacterial vaginosis

Candidosis Herpes Warts HIV

2009 Builth 0 1 18 7 0 1 6 1 20 0 Newtown 0 0 18 1 1 13 9 2 23 0 2010 Builth 1 0 14 1 0 2 6 0 21 0 Newtown 0 0 14 0 0 7 8 1 22 0 2011 Builth 0 0 11 1 0 3 9 1 27 0 Newtown 0 1 9 0 0 7 10 1 16 1

Source: GU Clinic Data collation

This shows that the number of STIs diagnosed within Powys is low, with the most common infections being warts, Chlamydia, Candidosis and bacterial vaginosis. Only two cases of gonorrhoea have been diagnosed between 2009 and 2011 in Powys, which is different to the national picture, where gonorrhoea is the second most common sexually transmitted infection. Of note, there has been a diagnosis of HIV at the GUM clinic. 4.3 Health service activity data 4.3.1 Primary care QoF data NICE guidelines10 recommend that all women requiring advice on contraception should be offered a choice of all contraception, including long acting reversible contraceptive (LARC) methods. LARC contraception methods are more cost effective than the combined oral contraceptive pill and will reduce the numbers of unintended pregnancies. Of the LARC devices, intrauterine devices (IUDs) and intrauterine systems (IUS) are more cost effective that injectable contraceptives e.g. Depoprovera. Powys primary care QoF data shows that between 01/04/10 and 31/03/11, 8,312 women were prescribed an oral or patch contraceptive method and 92% were provided with information about LARC. Over the same timeframe, of the 478 women prescribed emergency hormonal contraception at least once in the last year by their GP, 89% were provided with information from the practice about LARC at the time of / within 1 month of prescription (Appendix 1) 4.3.2 Primary care payment data Data is also available for payments to GP Practice for providing sexual health contraceptive services. 9 Providing seamless services for the sexual health needs of people living in Wales. June 2011. Draft. 10 National Institute for Health and Clinical Excellence. Long acting reversible contraception. NICE clinical guideline 30. London. October 2005.

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Agenda Item 2.8

Comparisons of practice level claims for LARCS for 2010/11 are available in appendix 2. Overall, the data shows that there is a large variation amongst practices for claims for LARCs. This could be due to variation in services provided by practices or may reflect different levels of need in different localities. Brecon Medical Practices had the largest number of claims related to IUCDs and Implanon, Welshpool had the largest number of claims for Nexplanon and Newtown had the largest number of claims for Depoprovera. Compared with Hywel Dda, Powys has higher rates of both Implanon fitting and Depoprovera claims (see appendix 3). 4.4 Projected levels of activity for different service models 4.4.1 Community Contraceptive Services Potential levels of need for community contraceptive services for Powys patients could be ascertained by calculating activity to these services from national data sources. Such data shows that in 2009, 6.4% of the female population in Wales aged between 12 and 49 years attended community contraceptive clinics11. If these figures were applied to Powys, this would equate to approximately 1,920 women. The following table summarises the age distribution of those accessing community contraceptive clinics, with 36% of females and 73% of males being below 20 years of age. Table 6: Age at first contact at community contraceptive clinics, 2008-09 Age Female Male Under 16 8% 27% 16-19 28% 46% 20-34 46% 20% 35+ 18% 7% Source: KT31 statistical returns. NHS Community Contraceptive Services in Wales, 2008-09. National Statistics. Nov 2009. http://wales.gov.uk/docs/statistics/2009/091111sdr1812009en.pdf The reasons for accessing community contraceptive services is shown in table 7 below. Table 7: Reasons for first attendance at community contraceptive clinics, 2008-09 Females Males Routine contraception 45% 51% Sexually transmitted infections - 19% Counselling 21% 21% Other 13% 9% Emergency contraception 3% - Cervical screening 14% - Pregnancy testing 4% - This shows that patients access contraceptive clinics for a variety of reasons and highlights the need for a provision of integrated contraceptive and GUM services.

11 NHS Community Contraceptive Services in Wales, 2008-09. National Statistics. Nov 2009. http://wales.gov.uk/docs/statistics/2009/091111sdr1812009en.pdf

FOR APPROVAL



Agenda Item 2.8

Concerns / Issues with Current Services 5.1 Lack of integrated services The provision of integrated sexual health services underpins both Welsh Government’s Sexual Health and Wellbeing Action plan for Wales 2010-15 and Providing seamless services for the sexual health needs of people living in Wales 2011. At present, there is no integrated contraceptive and GUM service provision, which means that patients are required to access the two services separately. This is of concern as an individual requiring one of these services is likely to require the other. At present there are no clear pathways for patients who need to access both GUM and contraceptive services. In addition, there are no pathways in place for the management of erectile dysfunction in Powys.

5.2 Lack of clinical governance framework There is a need to have both leadership and governance arrangements in place in order to have “seamless” sexual health services. At present, there is no clear overall leadership for contraceptive services. GPs providing contraceptive services in primary care do not have prompt access to expertise and support if required. For example, problems arising as a result of insertion of Intra-Uterine Devices or LARCs are referred to specialist services in hospitals out of Powys, with advice potentially not being available in a timely manner. Although there is GUM leadership provided by a GUM consultant, this needs to be strengthened as the consultant is only in Powys once a week. Any concerns raised by GPs at other times are referred to clinicians who may not be able to provide advice and support promptly. 5.3 Failure to meet AOF 24 / AQF targets. There is a requirement for all patients to have access to core sexual health services (HIV and sexually transmitted infection testing and routine contraception advice) provided by appropriate specialists within 2 working days. However, Powys is not meeting targets as GUM services are only provided once a week in Powys. In order to meet this target, services need to be provided on at least 3 days of the week. In additions, urgent cases should be able to access appropriate services within 24 hours.

5.4 Access to services Access issues are due to a number of factors: a) Geography. GUM services can only be accessed in Powys in Builth and

Newtown. This limits access to those who are able to travel to these locations. In particular, this has a bigger impact on younger people who may not be able to travel to these venues or out of county.

b) Setting. Contraceptive services are provided in GP practices. Although this allows the services to be geographically accessible, younger patients are less likely to access such services. National data shows that 6.4% of women aged 12 to 49 years access community contraceptive services. This suggests that if such services were available in Powys, they could be accessed by approximately 1,920 women.

FOR APPROVAL



Agenda Item 2.8

c) Timing. GU services are only available once a week. This greatly reduces the accessibility of the service.

5.5 Lack of multi-disciplinary team approach Aspects of contraceptive and GUM services can be provided by a variety of professionals e.g. GPs, Practice Nurses, School Nurses, Specialist Nurses, GPs with Specialist Interests, Consultant Physicians. At present, the different skills from all these groups are not being harnessed and joined up, leading to a fragmented service. 5.6 Lack of choice of services The present service model means that there is limited choice in accessing contraceptive services. Although the provision of contraceptive services in Primary Care is important, national data shows that approximately 20-25% of contraceptive services are provided outside of the Primary Care setting. This provides an indication of the level of demand there could be in Powys if alternative service models were used. Low levels of GUM service provision also reduces the choices available to Powys patients. 5.7 Failure to be responsive to the changing health needs of the local population Powys Sexual Health services need to be able to meet challenges such as rising STI levels and rising blood borne virus and HIV levels. As services are already unable to offer GUM appointments in a timely matter, this is likely to be an increasingly important issue in future. 5.8 Timeliness of GUM service provision In addition to patients not being able to access GUM services within 48 hours, there are concerns that test results at GUM clinics are not provided to patients in a timely manner. Results from laboratories can take up to 4 weeks and patients are able to only access their results either by attending clinic or by phoning whilst a clinic is running i.e. during a 2 hour window. 6 Options review The following section will describe potential options for provision of contraceptive and GUM services in Powys. These options do not include altering the provision of termination of pregnancy services, HIV and blood borne virus services and psychosexual counselling. Each option is appraised taking into account the following considerations:

1. Will the service model result in an integrated contraceptive and GUM service? 2. Will the service model result in improved access to Powys residents in terms

of timing, location and setting? 3. Will the service model be better able to address changes in health needs of

the Powys population? 4. Will the service model enable Powys tHB to reach its AOF / AQF targets? 5. Will the service model provide an adequate clinical governance framework? 6. What are the additional cost implications to Powys tHB

FOR APPROVAL



Agenda Item 2.8

OPTION 1: No change This involves continuing service delivery as described in section 4. Contraceptive services would continue to be provided mainly by GP Practices, although some patients may attend Family Planning clinics out of county. GPs would provide services as per the GMS contract (appendix 5, “Core primary care services”). GUM services would be accessed through GUM consultant sessions held once a week in Powys or via out of county services. The location of GUM clinics in Powys could be altered e.g. to Brecon or Llandrindod, to improve geographical coverage of the service.

a) Service model Psychosexual

counselling Contraceptive

services GUM Services

GUM access

M T W T F S S

b) Advantages and disadvantages of proposed service model


Minimal increase in costs, except for annual uplifts for SLAs

Community hospital based GUM services

Contraceptive services are accessible both geographically and in a timely manner

Continued non compliance with GUM access targets (AQF)

Lack of integration of contraceptive and GUM services

Lack of clinical governance framework for contraceptive services. GPs currently obtain advice for complex GUM and contraceptive cases out of county.

Lack of multi disciplinary working

Limited geographical accessibility to GUM services due to clinics being held in two locations only

Limited access to acceptable / accessible services

Welsh Psychosexual

Network Builth hospital,

36 sessions / year

GPs Part of GMS

GUM consultant 1 session Builth

1 session Newtown (clinics could be provided in other

localities)

Pharmacy EHC service

Out of County Family Planning

Clinics

Out of County GUM Clinics

FOR APPROVAL



Agenda Item 2.8

for younger population (contraceptive and GUM)

No GUM services are provided when the lead consultant is on leave

The cost of English GUM services may rise in future if providers use PbR. (Postcodes may be used to identify patient source)

c) Estimated costs of service Service Sessions Cost Funding stream

GUM consultant 2 sessions £? Unable to identify audit trail – funding may not be from Powys

Nurse B7 0.2 wte £9,878 Midwifery budget Admin B2 0.2 wte £4,182 Child health admin and

MCI admin Psychosexual counselling No change £7,000 Sexual health budget SLA tests Hywel Dda HB £8,471 Sexual health budget Additional contraceptive services primary care


Enhanced contraceptive services primary care 2010/11

£80,580 Primary Care


Total cost of service £110,111

Additional costs of service model £0

d) Appraisal of options using criteria Will the service model result in an integrated contraceptive and GUM service?

No GUM services will be provided separately to contraceptive services.

Will the service model result in improved access to Powys residents in terms of timing, location and setting?

No Within Powys, GUM will only be accessed once a week at 2 locations (Builth and Newtown Community Hospitals) Contraceptive services will only be provided through GPs, which may not be acceptable to all sections of the population e.g. young people

Will the service model be able to address health needs of the Powys population e.g. rising STI rates?

No The current GUM service would not be able to increase its capacity.

Will the service model enable PtHB to reach its AOF / AQF targets?

No GUM services can only be accessed once a week within Powys.

Will the service model provide an adequate clinical governance framework?

No At present, GPs need to seek advice out of county from District General Hospitals for contraceptive services and GUM services, although complex GUM cases can be referred to the GUM clinic.

What are the additional cost implications to PtHB?

£0

FOR APPROVAL



Agenda Item 2.8

OPTION 2: Change systems working This option involves changing current ways of working in order to provide a more integrated service. At present, a variety of Health and education professionals in Powys are involved in or could be involved in the provision of different aspects of sexual health care, either directly or indirectly. In addition to those who are mentioned in option 1, this includes:

• School nurses – provide sexual health advice to children and young people • Health visitors – in contact with women post birth and could signpost women

to appropriate sexual health service providers • Midwives - in touch with women during the post-natal period and could

signpost women to appropriate sexual health service providers • GPs and Practice Nurses – currently mainly provide contraceptive services

and signpost to GUM services • Community pharmacies – currently involved in C-Card scheme and EHC

provision. • Healthy Schools Team – advise and support schools on the Healthy Schools

Scheme, which includes a Personal Development and Relationships module. The team are also involved in the delivery of the APAUSE (Added Power and Understanding in Sex Education) programme within secondary schools.

• Professionals involved in the distribution of condoms, either as part of the C-Card scheme (pharmacists, youth workers across the county, professionals from the substance misuse agency (CAIS), Youth Offending, Leaving care team) or as a part of their service (Terrance Higgins Trust and specialist nurses for looked after children

• Theatre nurses, who currently undertake cervical smears as part of colposcopy.

This model would involve the GUM consultant and GUM clinic nurses using a proportion of their clinic session to develop and deliver Powys wide teaching and governance for healthcare professionals on GUM. The aim of this would be to enhance knowledge and skills of health professionals related to sexually transmitted infections and ensure that there is signposting to current services within Powys and out of Powys. In addition, the consultant and nurses providing the GUM services could be involved with aspects of sexual health care e.g. being involved in teaching, training and developing care pathways for Sexual Health in Powys. In addition, to improve access to GUM services, the GUM clinic location could be altered across Powys. This systems change could be accelerated by having initial additional capacity to engage with services, develop networks, training and pathways, allowing continuity of service provision.

FOR APPROVAL



Agenda Item 2.8

a) Service model

Psychosexual counselling

Contraceptive services

GUM Services GUM access

M T W T F S S

b) Advantages and disadvantages of proposed service model Advantages Disadvantages

Minimal increase in costs, except for annual uplifts for SLAs

Community hospital based GUM services, with locations varying to improve accessibility

Contraceptive services are accessible both geographically and in a timely manner

Continued non compliance with GUM access targets (AQF)

Access to acceptable / accessible services for younger population (contraceptive and GUM) will still be limited

No GUM services are provided when the lead

Welsh Psychosexual


36 sessions / year

GPs Part of GMS


1 session Newtown (clinics to be

provided in other locations)



Clinics

Health & other professionals to be empowered, skilled &

knowledgeable about sexual health and be able to signpost

to services available

GUM service involved with teaching & governance of GUM and in aspects of sexual health

services e.g. signposting to contraceptive services and

developing pathways of care.

FOR APPROVAL



Agenda Item 2.8

Improved integration of contraceptive and GUM services

Improved clinical governance framework for GUM and aspects of contraceptive services.

Improved multi disciplinary working

Better signposting of services available, including to younger people

consultant is on leave

The cost of English GUM services may rise in future if providers use PbR. (Postcodes may be used to identify patient source)

a) Estimated costs of service Service Sessions Cost Funding stream

GUM consultant 2 sessions £? Unable to identify audit trail – funding may not be from Powys

Nurse B7 0.2 wte £9,878 Midwifery budget Admin B2 0.2 wte £4,182 Child health admin and

MCI admin Nurse B7 for 6 months for accelerated change

£24,696 (non recurrent)

Additional capacity from within PtHB

Psychosexual counselling No change £7,000 Sexual health budget SLA tests Hywel Dda HB £8,471 Sexual health budget Additional contraceptive services primary care


Enhanced contraceptive services primary care 2010/11

£80,580 Primary Care


Total cost of service £110,111 + £24,696 non-recurrent

Additional costs of service model £0 recurrent + additional capacity met within PtHB

b) Appraisal of options using criteria Will the service model result in an integrated contraceptive and GUM service?

Partially GUM services will mainly be provided separately to contraceptive services. Other aspects of sexual health services could be provided by the GUM team e.g. cervical smears. Improved training / teaching will improve signposting between GUM and contraceptive services and health and other professionals.


Partially Within Powys, GUM will only be accessed once a week. However, altering the location will improve accessibility to residents across the county Contraceptive services will continue to be provided through GPs, with some aspects provided by GUM in addition


No The GUM service capacity will not be increased. However, better knowledge and skills related to barrier contraception and better signposting to GUM services may help to mitigate this.

FOR APPROVAL



Agenda Item 2.8


No GUM services can only be accessed once a week within Powys.


Partially The training and governance role of the GUM team will help to improve clinical governance of GUM and aspects of contraceptive services. GPs will still need to obtain external support for complex contraceptive concerns.


£0 + 6 months of Nursing staff time to be met within PtHB

FOR APPROVAL



Agenda Item 2.8

OPTION 3: Increase GUM capacity and no change to contraceptive services GUM capacity could be increased by either:

1. Increasing the number of GUM consultant sessions 2. Recruiting additional medical staff e.g. Staff grade, GPwSI 3. Recruiting additional nursing staff or using current nursing staff helping at the

clinic to run an additional clinic In order to meet GUM access targets, sessions will need to be provided on 3 days each week (Monday / Wednesday / Friday) as a minimum. In this model, there would be four sessions held over 3 days. In addition, to have increased GUM accessibility, the sessions would need to be held in different parts of the county and in Community settings.


counselling



M T W T F S S



Could achieve GUM access targets (AQF)

Retaining current GUM consultant is likely to be a cost effective option

Community settings will help increase accessibility of GUM services

GUM services will be more sustainable, with services still being provided in the absence of the GUM consultant

Increased cost implications

GU and contraceptive services will still not be integrated

Contraceptive services will not be changed, resulting in continued concerns about whether General Practice is adequate to provide services to all sections of the population e.g. to teenagers

Welsh Psychosexual


36 sessions / year

GPs Part of GMS



localities)



Clinics

2 additional GUM sessions

Increase capacity through having

nurse led clinics in tandem

FOR APPROVAL



Agenda Item 2.8

c) Estimated costs of service

Service Sessions Cost Funding stream

GUM consultant

2 additional sessions (4 total)

£37,496 for 2 additional sessions to be found

Nurse B7 0.4wte £19,757 to be found Admin B2 0.4wte £8,365 to be found Psychosexual counselling no change £7,000 sexual health budget SLA tests HDHB no change £8,471 sexual health budget

Additional contraceptive services primary care part of GMS Primary care

Enhanced contraceptive services primary care £80,580 Primary care


Total costs of service model £161,669

Additional costs of service model £51,557 Nb. If additional medical services were to be provided by either a GP with Specialist Interest or Staff Graff clinician rather than a GUM consultant, the costs are likely to be lower.


No GUM services will be provided separately to contraceptive services.


Only for GUM services The service will mean that within Powys, GUM services can be accessed in a timely way. The locations can be varied to improve access. However, contraceptive services will only be provided through GPs, which may not be acceptable to all sections of the population e.g. young people


Partially This model will help to address trends such as treating rising STI rates. However, it does not address issues such as increasing the detection rate of STIs by conducting screening of those who are asymptomatic.


Yes GUM services will be accessible within 48 hours within Powys.


No GPs will continue to need to seek advice out of county from District General Hospitals for contraceptive services and GUM services, although complex GUM cases can be referred to the GUM clinic.


£51,557

FOR APPROVAL



Agenda Item 2.8

OPTION 4: Additional provision of nurse led GUM and contraceptive clinics. Additional nursing capacity could be used to provide community based GUM and contraceptive services. Additional clinics will need to be held to ensure that they are accessible within a 48 hour time frame for all patients and also that they are geographically accessible. GUM expertise will be provided either through referral to GUM medical consultant or through external providers.


counselling


GU and contraceptive services

GUM Services GU access

M T W T F S S


Integrated GUM and contraceptive service provision

Could achieve GUM access target (AQF)

Community settings will help increase accessibility of GUM and contraceptive services

GUM services will be more sustainable, with services still available in the event of leave etc

Increased cost implications.

GUM and contraceptive expertise will only be available remotely for nursing staff, which has clinical governance issues.

External Clinical Governance support may have cost implications

Welsh Psychosexual


36 sessions / year

GPs Part of GMS



localities)


Out of County Family

Planning Clinics

Nurse led GUM and contraceptive

clinics

Governance via GUM consultant

and external providers or

external providers alone

Onward referral

FOR APPROVAL



Agenda Item 2.8


Service Sessions Cost Funding stream

GUM consultant 2 £?

Unable to identify audit trail – funding may not be from Powys

Nurse B7 0.6 £29,636 to be found Nurse B6 0.6 £25,230 to be found Admin B2 0.6 £12,548 to be found Psychosexual counselling no change £7,000 sexual health budget SLA tests HDHB £8,471 sexual health budget

Additional contraceptive services primary care part of GMS Primary care

Enhanced contraceptive services primary care £80,580 Primary care


Total costs of service model £163,465

Additional costs of service model £53,353

This costing model excludes any set up costs of clinics and the cost of any clinical governance arrangements.


Yes GUM services will be provided together with contraceptive services.


Yes The service will mean that within Powys, GUM and contraceptive services can be accessed in a timely way in a variety of locations. There will be increased choice in the setting of contraceptive services, potentially making the services more acceptable to all sections of the population e.g. young people

Will the service model be able to address health needs of the Powys population e.g. rising STI rates ?

Yes There will be increased capacity to manage rising levels of STIs. There will be increased detection of STIs by conducting screening of those who are asymptomatic




No Nurses would be working in isolation, without immediate advice and support.


£53,353

FOR APPROVAL



Agenda Item 2.8

OPTION 5: GP Locally Enhanced Service A Locally Enhanced Service (LES) model could be used to enable GPs to provide both sexual health (including emergency contraception) and GUM services. A description of the range of services provided is available in appendix 5 (“Locally enhanced primary care service”). As a minimum, 3 practices would be required in Powys to ensure accessibility. There would need to be continued provision of GUM consultant services in Powys in order for there to be a route for onward referral. The LES agreement would include arrangements for clinical governance and skills maintenance. In addition, a LES to provide an Erectile Dysfunction Service should be considered.


counselling


GUM and contraceptive services


M T W T F S S


Advantages Disadvantages Will help to meet GUM access target (AQF)

Contraceptive and GUM services will be integrated

Accessing GUM and contraceptive services in GP Practices is likely to make the service more geographically accessible

GUM services will be more sustainable, with services still available in the event of leave

Greatly increased cost implications

There will still be continued concerns about whether younger people will access contraceptive or GUM services through GP practices.

Participating GPs could have different Clinical Governance arrangements.

GPwSI Builth hospital, 36 sessions /

year

GPs Part of GMS



localities)



Planning Clinics

GP LES with 3+ Practices to

provide GUM and contraceptive

services

Governance via GUM consultant

and external providers or

external providers alone

Onward referral

GP LES for Erectile

Dysfunction

FOR APPROVAL



Agenda Item 2.8


Sessions Cost

Cost for Minimum service

Cost for Ideal service

Funding stream

GUM consultant 2 sessions £? £? £?

Nurse B7 0.2 wte £9,987 £9,987 £9,987 Midwifery budget

Admin B2 0.2 wte £4,182 £4,182 £4,182

Child health and MCI admin

Psychosexual counselling No change £7,000 £7,000 £7,000 SH budget

SLA tests Hywel Dda HB £8,471 £8,471 £8,471 SH budget

Additional contraceptive services primary care No change Part of GMS Part of GMS Part of GMS Primary care

Enhanced contraceptive services primary care No change £80,580 £80,580 £80,580 Primary care

Out of county GUM services Currently not billed for

Currently not billed for



GUM LES Cost per practice 3 practices 4 practices

GP Retainer cost £2,000 (annual) £6,000 £8,000

To be found (annual uprating 3.255%)

Cost of GP session

3 or 4 sessions a week across county

£780 (per session) £112,320 £149,760 To be found

Cost for patients seen (400 pa with current model) £100 / patient £40,000 £40,000 To be found Cost per HIV +ve patient seen pa (1 pt in 2011) £200 £200 £200 To be found

LES erectile dysfunction (1 practice) GP retainer cost £2,000 £2,000 £2,000 To be found

Cost of GP session 2 per month £780 (per session) £18,720 £18,720 To be found

Cost per patient seen (72 pa) £100 / patient £7,200 £7,200 To be found Total costs of service model £296,661 £336,101 Additional costs of service model £186,550 £225,990

N.b. Aspects of this service could be provided at reduced cost e.g. retainer fees, cost of a GP session. However, this will need to be negotiated locally. Costs quoted are an Upper estimate of anticipated costs.

FOR APPROVAL



Agenda Item 2.8




Yes, in main The service will mean that within Powys, GUM and contraceptive services can be accessed in a timely way in a variety of locations. However, the setting of contraceptive services will be unchanged and will only be available through GPs. This limited choice could potentially have a negative impact on young people wishing to access contraceptive services


Yes GPs capacity could be increased if there was a rise in the number of people wishing to access contraceptive or GUM services.


Yes GU services will be accessible within 48 hours within Powys


Yes GPs will need to be able to access advice and support in a timely manner. This model will involve GPs arranging their own clinical governance framework. However, participating GPs may chose different arrangements that are linked to their location and onward referral routes.


£186,550 (3 GP model) - £225,990 (4 GP model) This excludes the cost of clinical governance support

FOR APPROVAL



Agenda Item 2.8

OPTION 6: Integrated Family Planning and GUM Clinic This model would involve setting up a community based Family Planning and GUM service. Services would be integrated and would include contraceptive services e.g. condoms, LARCs, emergency contraception and IUD. Also provided would be opportunistic smears, opportunistic STI screening and opportunistic sexual health advice /contraception. Examples of the range of services available can be found in appendix 5 (“Integrated community sexual health clinics”). Sessions for erectile dysfunction could also be provided as part of this model. In addition, psychosexual counselling services could be integrated into the model to provide a holistic Sexual Health service. The service would be provided by nurse and GP sessional work. GUM consultant input would be required in order to provide an onward referral route and clinical governance. The clinics could be held in different community hospitals to increase the accessibility of the service.


counselling


GUM and contraceptive services


M T W T F S S M T W T F S S

Welsh Psychosexual

Network – could be integrated with GUM &


Builth hospital, 36 sessions / year

GPs Part of GMS



localities)



Planning Clinics

Integrated Community Clinic to provide GUM, contraceptive &

erectile dysfunction services

via GP & Nurse

sessions

Governance via GUM consultant & external providers

or external providers alone

Onward referral

FOR APPROVAL



Agenda Item 2.8


Could achieve GUM access target (AQF)

GUM consultant provides tertiary support, clinical governance and teaching

Cost effective use of expertise within primary care allowing good governance arrangements

Provision of an integrated contraceptive and GUM service, with opportunities to incorporate and erectile dysfunction service and psychosexual counselling

Increased choice of settings e.g. in community hospitals would increase acceptability of the services to patients and young people in particular

Increased cost implication, with set up costs

Specialised service, which is contrary to the ethos of having more services within primary care

There may be a need for external clinical governance arrangements for contraceptive services


Sessions

Cost of 4 additional sessions

Cost of 2 additional sessions

Funded stream

GUM consultant

2 / week and additional session per fortnight for teaching / governance £5,000 £5,000 To be found

Nurse B7 0.6 £29,635 £19,757 To be found Nurse B6 0.6 £25,230 £16,820 To be found Admin B2 0.6 £12,547 £8,364 To be found

GP sessions 4 a week (£250 a session) £48,000 £24,000 To be found

Psychosexual counselling no change £7,000 £7,000 SH budget SLA tests HDHB no change £8,471 £8,471 SH budget

Additional contraceptive services primary care part of GMS part of GMS Primary care

Enhanced contraceptive services primary care £80,580.68 £80,580.68 Primary care


currently not billed for

Total costs of service model

£216,463 (excluding set up costs)


Additional costs of service model



FOR APPROVAL



Agenda Item 2.8




Yes The service will mean that within Powys, GUM and contraceptive services can be accessed in a timely way in a variety of locations. Contraceptive services will be available in both a community hospital setting with continued enhanced contraceptive services available through GPs.


Yes The increase in capacity will mean that issues such as increasing STIs can be addressed. There is also an opportunity for screening for asymptomatic STIs.




Yes The GUM consultant will be able to provide clinical governance oversight to GPs and Nurses doing sessional work at the clinics. There will still need to be governance arrangements for contraceptive services.


£59,881 to £106,351 This excludes set up costs and costs of contraceptive clinical governance support

FOR APPROVAL



Agenda Item 2.8

SUMMARY

Option 1 No change to current services

Option 2 Change systems working

Option 3 Increase GUM consultant sessions

Option 4 Nurse led GUM and contraceptive clinics

Option 5 GP LES

Option 6 Integrated family planning and GUM Clinic

Will the service model result in an integrated contraceptive and GUM service?

No Partially No Yes Yes Yes


No Partially Only for GUM services

Yes Yes, in main Yes

Will the service model be able to address changes in health needs of the Powys population?

No No Partially Yes Yes Yes


No No Yes Yes Yes Yes


No Partially No No Yes Yes


£0 £0 + 6 months Nursing time from within PtHB

£51,557 £53,353 (excluding set up costs)

£186,550 (3 GP model) to £225,990 (4 GP model)

£59,881 to £106,351 (excluding set up costs)

FOR DISCUSSION AND DECISION

Powys Public Health Update Report Page 33 of 40 Board Meeting 27 June 2012

Agenda Item 2.8

6 Conclusion and Recommendations The current service model in Powys is currently not meeting national standards - of particular concern is that contraceptive and GUM services are not integrated. The level of provision of GUM services means that patients are not able to access care within 48 hours, which is a key PtHB AOF / AQF target. Six service models have been proposed that could to varying degrees:

• Provide integrated sexual health services • Improve access to services • Address changes in health needs of the population • Enable PtHB to meet its AOF / AQF GUM access targets • Be affordable

Any services that are developed will need to be done so in the context of ensuring there is a pathway of care for patients that will meet all their sexual health needs. Three of the options (Options 4,5 and 6) will result in a fully integrated sexual health service and one option (Option 2) will partially result in integrated services. Two options (Options 5 and 6) are able to meet most of the above criteria. However, the costs associated with both these models mean that unless funding is released from elsewhere, these models are unlikely to be affordable at present. Of note, Integrated Family Planning and GUM clinic costs are lower than for a GP Locally Enhanced Service. The option recommended to the Board is Option 2 (Change systems working), with the aim of improving current service integration, access to services and governance within the current financial envelope for sexual health. In addition, it is recommended that discussions are continued with Hywel Dda Health Board to better understand current funding arrangements for Sexual Health services to Powys in order to try and release funding for further service development. If this process is successful, it is recommended that an Integrated Family Planning and GUM clinic (Option 5) is developed. This model would meet the above criteria, as well as enabling Powys to have:

• A comprehensive governance system that will include tertiary support and teaching

• Provide an alternative setting for patients to access Sexual Health services in Powys, which is of particular relevance to young people

• A cost effective use of expertise within primary care via GP sessions and nurses

• Provide a holistic approach to Sexual Health in Powys Authors: Dr Sumina Azam, Consultant in Public Health/ Acting Director of Public Health, Powys Public Health team Cate Langley, Head of Midwifery and Sexual Health Services



Agenda Item 2.8

Appendix 1 GP Practice QoF data – LARC contraception April 2011 Practice Number of women

prescribed an oral or patch contraceptive method who have also received information from the practice about LARC in the previous 15 months

Number of women prescribed an oral or patch contraceptive method

% of women prescribed an oral or patch contraceptive method who have also received information from the practice about LARC in the previous 15 months

Montgomery 395 417 94.7 Ystradgynlais 703 778 90.4 Brecon 998 1026 97.3 Knighton 192 278 69.1 Llanidloes 486 514 94.6 Rhayader 144 177 81.4 Builth 401 438 91.6 Llanfair Caereinion 252 272 92.6 Welshpool 575 610 94.3 Cemmaes Road 94 105 89.5 Llanfyllin 596 655 91.0 Llandrindod 451 533 84.6 Machynlleth 275 301 91.4 Newtown 1014 1079 94.0 Crickhowell 447 490 91.2 Haygarth 446 483 92.3 Presteigne 146 156 93.6 TOTAL 7615 8312 91.6 Source: QOF, Primary care directorate, PtHB



Agenda Item 2.8

Appendix 2: GP Practice LARC claims 2010/11

0 20 40 60 80 100 120 140

Montgomery

Newtown

Presteigne

Rhayader

Welshpool

Ystradgynlais

Brecon

Builth Wells

Cemmaes Road

Crickhowell

Haygarth

Knighton

Llandrindod Wells

Llanfair Caereinion

Llanfyllin

Llanidloes

Machynlleth

IUCD fitting

IUCD review

0 20 40 60 80 100 120

Montgomery

Presteigne

Welshpool

Brecon

Cemmaes Road

Haygarth

Llandrindod Wells

Llanfyllin

Machynlleth

ImplanonfittingImplanonreview



Agenda Item 2.8

0 5 10 15 20 25 30 35 40

Montgomery

Newtown

Presteigne

Rhayader

Welshpool

Ystradgynlais

Brecon

Builth Wells

Cemmaes Road

Crickhowell

Haygarth

Knighton

Llandrindod Wells

Llanfair Caereinion

Llanfyllin

Llanidloes

Machynlleth

Nexplanonfitting

Nexplanonreview

0 50 100 150 200 250 300 350 400

Montgomery

Newtown

Presteigne

Rhayader

Welshpool

Ystradgynlais

Brecon

Builth Wells

Cemmaes Road

Crickhowell

Haygarth

Knighton

Llandrindod Wells

Llanfair Caereinion

Llanfyllin

Llanidloes

Machynlleth

Depoproveraclaims



Agenda Item 2.8

Appendix 3: Total LARC claims for 2010/11for Powys, compared with claims made in Hywel Dda Health Board for a 4 month period in 2009 Powys 2010/11

(12 month data) Ceredigion Sept – Dec 2009 (4 month data)

Pembrokeshire Sept – Dec 2009 (4 month data)

Carmarthenshire Sept – Dec 2009 (4 month data)

IUCD fitting 482 79 86 IUCD review 889 100 57 IUCD 112 Implanon fitting 455 84 31 133 Implanon review 275 Implanon removal 48 15 87 Nexplanon fitting 82 Nexplanon review 34 Depoprovera claims 2168 421 633 957 Comparison of claims for Implanon and Depoprovera fittings for Powys and Hywel Dda (crude) Implanon Fitting Depoprovera claims Powys Hywel Dda Powys Hywel Dda Female population aged 10-49 years (2007)

30,000 91,900 30,000 91,900

Number of claims over 12 months (Powys actual, Hywel Dda estimates)

455 744 2168 6033

Claims per 1,000 female population aged 10-49 years (crude)

15.2 8.1 72.3 65.6



Agenda Item 2.8

Appendix 4: GP Practice QoF performance related to EHC Practice Number of women

prescribed EHC at least once in the last year by the practice, who have received information from the practice about LARC at the time of / within 1 month of prescription

Number or women prescribed EHC at least once in the last year

% of women prescribed EHC at least once in the last year by the practice, who have received information from the practice about LARC at the time of / within 1 month of prescription

Montgomery 23 24 95.8 Ystradgynlais 46 50 92 Brecon 44 47 93.6 Knighton 8 15 53.3 Llanidloes 22 24 91.7 Rhayader 1 13 7.7 Builth 27 29 93.1 Llanfair Caereinion 15 17 88.2 Welshpool 27 29 93.1 Cemmaes Road 5 5 100 Llanfyllin 48 54 88.9 Llandrindod 22 29 75.9 Machynlleth 23 23 100 Newtown 57 60 95 Crickhowell 24 25 96 Haygarth 24 26 92.3 Presteigne 8 8 100 TOTAL 424 478 88.7 Source: QOF, Primary care directorate, PtHB



Agenda Item 2.8

Appendix 5: Providing seamless services for the sexual health needs of people living in Wales. June 2011.



Agenda Item 2.8

FOR APPROVAL

Scheme of Delegation April 2012

Page 1 of 3 Board Meeting 27 June 2012

Agenda Item 2.9


AGENDA ITEM 2.9

BOARD SCHEME OF RESERVATION AND DELEGATION OF POWERS

Report of

Chief Executive

Paper prepared by Corporate Governance Manager

Purpose of Paper

The purpose of this paper is to provide the Board with a revised Scheme of Reservation and Delegation of Powers for consideration and approval, if appropriate.


The Board is asked to CONSIDER and APPROVE, if appropriate, the revised Scheme of Reservation and Delegation of Powers.


1. Governance and accountability framework


Promotes Health & Wellbeing Continuously Improves Safety, Effectiveness &

Patient Experience Captures the Benefit of Integration Empowers our Staff Lives within our Means


Standing Orders (SOs) Standing Financial Instructions (SFIs) Welsh Government (WG)

FOR APPROVAL



Agenda Item 2.9

BOARD SCHEME OF RESERVATION AND DELEGATION OF POWERS

Introduction As set out in the organisation’s Standing Orders, the Board – subject to any directions that may be made by Welsh Ministers – shall make appropriate arrangements for certain functions to be carried out on its behalf so that the day to day business of the Health Board may be carried out effectively and in a manner that secures the achievement of the organisations aims and objectives. Background At its meeting on 06 October 2010, the Board approved its Scheme of Reservation and Delegation of Powers which reflected changes to the Executive Team as a result of NHS Wales’ reorganisation in October 2009. The Board has recently established its substantive Executive Team, which includes the Medical Director; Director of Nursing; Director of Therapies & Health Sciences; Director of Workforce & Organisational Development; Director of Public Health & Strategic Planning and Director of Finance. All appointments have now been made with the exclusion of the Director of Public Health and Strategic Planning which will be re-advertised shortly. In light of the appointment of a substantive Executive Team, there has been a need to review and realign the portfolios of Executive Directors to ensure clarity of accountability and facilitate organisational capacity and capability to enable delivery of the organisation’s strategic objectives (Annual Plan). This includes the need to release the capacity of the Director of Nursing to enable her to lead the Health Board’s clinical change programme. The proposed changes and the rationale for these is summarised in Annex A. Scheme of Delegation The revised Scheme of Reservation and Delegation of Powers is attached at Annex B for the Board’s consideration. The proposed changes are summarised below:- Board Committees

Current Scheme Proposed Scheme Audit Committee Quality & Safety Committee

o Risk Management Committee o Improving Patient Involvement &

Experience Committee o Clinical Effectiveness Committee o Safeguarding Committee o Infection Prevention & Control

and Environment of Care Committee

Audit Committee Quality & Safety Committee

o Mental Health Act sub-Committee o Information Governance sub-

Committee Integrated Governance Committee Charitable Funds Committee Remuneration & Terms of Service

Committee Pharmaceutical Applications Committee

FOR APPROVAL



Agenda Item 2.9

Mental Health Committee o Hospital Managers Power of

Discharge Committee Information Governance Committee Integrated Governance Committee Charitable Funds Committee Remuneration & Terms of Service

Committee Pharmaceutical Applications Committee

The Board is asked to note that detailed proposals in respect of its Committee Structure will be presented in a separate paper for consideration at its meeting on 18 April 2012. Recommendation The Board is asked to CONSIDER and APPROVE, if appropriate, the revised Scheme of Reservation and Delegation of Powers.

Report prepared by: Presented By: Rani Mallison Andrew Cottom Corporate Services Manager Chief Executive

Background Papers WAG Model Standing Orders/Standing Financial

Instructions Financial Consequences N/A

Other Resource Implications N/A

Consultees Executive Team

ANNEX A

REALIGNMENT OF EXECUTIVE PORTFOLIOS

1 INTRODUCTION

The tLHB has recently established a substantive Executive team with appointments to five out of six of the vacant positions that were previously held by secondees or individuals on temporary contracts. The new executive team has identified the need to realign some portfolios at executive and tier 3 levels to ensure clarity of accountability and organisational capacity to deliver, especially in the face of the tLHB’s failure to meet its financial target for 2011/2012. In addition to the sixth Executive Director vacancy, there are now a number of vacancies at tier 3 and below. The Board has signalled its approval to proceeding with an organisation wide clinical change programme to stabilise the financial position and address the underlying deficit. An urgent need to resolve the organisational structure gaps and alignments prior to embarking on the clinical change programme was identified, to enable the release the Director of Nursing to lead this programme.

2 BACKGROUND/DRIVERS FOR CHANGE

The tLHB was established in 2009 and inherited a management structure which separated the services within its provider arm and the externally commissioned services. In its first two years, much success has been achieved, particularly in terms of building relationships of trust with our communities and the local GPs. Additionally there is a growing belief in Powys and expectation of significant service change. A key achievement of the tLHB has been to establish a clear strategy that improves services and reduces cost. Some key elements of this strategy now have community wide agreement at a local level which will enable the tLHB to visibly move away from hospital care (Builth and Bronllys projects). The Annual Plan for 2012/13 to support delivery of this strategy, has been developed through an engagement process. Following assessment of the organisational capacity to deliver the objectives prioritised within the Annual Plan, the following priorities were identified :

• an urgent need to recruit to the two vacant Locality General Manager posts;

• a need for the realignment of some Executive Director responsibilities to ensure clarity of accountability and alignment with corporate objectives; specifically to enable executive directors to focus on strategic leadership and design thus allowing the localities and

directorates to concentrate on working with their communities on service design and operational delivery.

• the organisation’s information infrastructure and alignment to its core business needs to be assessed for its fitness for purpose

• The responsibilities of the former Associate Director of Performance need to be reassigned or reappointed to.

• the remaining Executive Director vacancy, the combined Director of Planning and Public Health role which the tLHB failed to appoint to in January will need to be re-advertised.

The key elements of the tLHBs financial strategy are:

• System management to reduce volume and length of stay in secondary care.

• Providing day cases and outpatients locally and undercut PBR tariffs • Maximising operational efficiency of our own provider services • Implementing best practice from prescribed drugs • Ensuring best value from our secondary care contracts • Developing an efficient platform of back office functions through

efficient working practice and shared services

As a strategy – this remains valid as has been confirmed by the independent review recently commissioned by Welsh Government. The issue is one of pace and depth and the tLHB has determined the need for an organisation wide clinical change programme to stabilise the financial position and address the underlying deficit. There is a need to resolve these organisational structure gaps to maximise the tLHB’s capacity to deliver the Annual Plan and clinical change programme. The locality model is our accepted direction and there is a need to now demonstrate our commitment to this model by ensuring the right leadership, capacity and capability is in place. The current appointment processes for the two LGMs has resulted in the appointment of a high calibre general manager for the South who will commence on 16th July 2012, with a strong shortlist of five candidates being interviewed for the North locality post on19th June 2012. However, localities need to be strengthened to enable them to ‘manage the whole system’ for their communities. This requires review and realignment of corporate functions which will mean change for the centre which includes a mind set of transferring responsibility. Additionally, locality and directorate clinical leadership needs clarification and the local GPs in both the north and the south localities have actively sought to take an increasingly prominent clinical leadership role and accountability for their localities. What we currently term as “commissioning” in Powys is not wholly fit for purpose, has been under significant strain and requires very urgent attention. The WAO have worked with us on some preliminary diagnosis of the issues, but the need to address

the current fragmentation and lack of clarity about accountabilities within our planning, commissioning and contracting activities is at the root of the problem and needs to be addressed. Aligned to this the ambitions of the tLHB will not be achieved without better information and clear accountability for the information ‘function’. NWIS have been working with us to address this and have commissioned an independent review of our information capacity and capability which will commence on 20 June 2012. This review will include recommendations on improving our information governance function including Data Protection and FOI. In addition executive accountability for information technology (IT) requires identification to reduce the number of direct reports to the CEO and minimise his direct reports below tier 2. There is also a need for the tLHB to increase its capacity to participate in and influence the all Wales implementation of Together for Health, the South East Wales strategic plan and the individual Health Board and Trust service change planning through release of the time of the CEO and Medical Director. Finally, education and development is fragmented across the tLHB and has diminished since it was split up in 2010. The requirement for a coherent approach to multi-disciplinary education and training is apparent and frequently cited as a fundamental issue for the tLHB. PROPOSED CHANGES TO EXECUTIVE PORTFOLIOS Following review and discussion with each executive directors and other colleagues, the following realignment of portfolios has been considered and agreed by the executive team to address the issues identified above and to enable the Director of Nursing to undertake the role of clinical change programme manager. In addition to these proposals, both within the clinical change programme and aligned to core objectives in the Annual Plan, there will be dedicated executive leadership for specific workstreams. These roles will be clarified under the Annual Plan delivery arrangements and within the clinical change programme governance arrangements. Proposed changes to existing portfolios

CEO

CHANGES TO CURRENT NEW - REALIGNED Transfer accountability for IT and IT

governance Strategic partnerships and engagement –

supported by Director of Planning and Public Health

Transfer accountability for performance Accountable for locality clinical leads

management Community partnership agreements–

supported by Director of Planning and Public Health

EXECUTIVE DIRECTOR DELEGATIONS

Medical Director

CHANGES TO CURRENT NEW - REALIGNED Transfer of 1000 Lives Information Technology

Director of Finance

CHANGES TO CURRENT NEW - REALIGNED Service contracting and monitoring

Director of Nursing

CHANGES TO CURRENT NEW - REALIGNED Transfer of quality and safety functions Clinical change programme leadership Transfer of health and safety and risk

management 1000 Lives

Transfer of patient experience function Transfer of infection control

Director of Therapies

CHANGES TO CURRENT NEW - REALIGNED Accountability for quality and safety

functions Accountability for health and safety and

risk management Accountability for patient experience

function Accountability for infection control Accountability for IT and IT governance

Director of Public Health and Planning

CHANGES TO CURRENT NEW – REALIGNED Transfer strategic partnerships and

engagement Accountability for information function

Transfer communication


CHANGES TO CURRENT NEW – REALIGNED Accountability for Transfer communication

function Accountability for muti-professional

education Accountability for performance

management Further detail is contained in Appendix 1 NEXT STEPS - IMPLEMENTATION

• Completion of recruitment process to existing gaps and new roles/gaps identified by diagnostic phases.

• Transition plan for each area of transfer to be developed and agreed by the two Directors to include :

o Agree timeframes for transfer including phasing o Agreement over transfer of resources and budgets (including staff) o Communication plan for informing staff affected and other

stakeholders.

APPENDIX 1

Medical Director Director of Finance Director of Nursing Director of Therapies Director of Public Health and Planning


• Professional leadership and accountability for medical strategy, staff and service governance including primary care

• Clinical Governance (shared with DoTH and ND)

• Pharmacy Contract & Medicines Management

• Medical revalidation and fitness to practice

• Clinical information strategy/informing healthcare

• Custodian of Health Records

• Caldicot Guardian Information Technology

• Research & Development

• Individual Patient Commissioning

• Clinical Audit • Implementation of NICE

guidelines • Inspections by external

bodies – Royal colleges, Deanery etc

• General Medical Services

• Professional Leadership for Finance Staff, Accounting standards & Financial Governance

• Strategic Financial Planning (Revenue & Capital)

• Business Intelligence • Financial Management • Financial Reporting • Financial Systems • Financial Control • Financial Services • Charitable Funds Accounting • Community Health Councils

Accounting • Asset Accounting • Annual Accounts Production • Statutory Financial Duties

Compliance • External and Internal Audit

Compliance • Counter Fraud • NWSSP lead plus specific

liaison for Internal Audit, PPV, P2P

• Powys County Council shared services

• Contracting and Contract Monitoring

• External (Financial) Audit Liaison

• Professional leadership and accountability for nursing, midwifery and health visitor strategy, staff and service governance

• Clinical governance (shared with MD and DoTH)

• All Wales Continuing Care

• Continuing NHS Care (tHB)

• Children & Young People Planning

• Delayed Transfers of Care

• Women and Childrens

• Mental Health Services

• Leadership of clinical change programme Protection of Vulnerable Adults

• Safeguarding Children/ Child Protection

• 1000 Lives

• Professional leadership and accountability for therapies and health science strategy, staff and service governance

• Leadership for Quality and safety

• Clinical governance (shared with MD and ND)

• Standards for Health Care • Patient Safety/ Clinical

Standards • Risk Management • Corporate Health &

Safety • Patient experience • Redress • Infection Prevention &

Control • Medical Devices • Information Governance

- FOI - Data protection

• Professional accountability for Public Health

• Health improvement strategy

• PH monitoring and surveillance

• DPH Annual report • Cat 1 PH Response • Professional advice for

environmental issues • Performance Information

and health intelligence

• Estates • Strategic Planning (local,

regional commissioning and national to include WHSSC and Third sector)

• Joint planning including: - LSB - HSCWB - Community Safety - Sustainable

development - Civil contingencies Act

• Capital planning

• Professional leadership and accountability for HR and OD staff and service governance.

• Workforce and OD strategy

• Workforce planning • HR policy and practice • Workforce Change • Equality & diversity • Welsh Language Scheme • Employee health and

wellbeing/Occupational health

• Multi-disciplinary workforce education and development

• Library services • Communications • Employee engagement • Partnership working • Staff competence • Payroll (SS liaison) • Recruitment and retention • Employee record

management • Performance management

(corporate) and External Audit Liaison

Reservation and Delegation of Powers for Powys tHB Date: April 2012 Page 1 of 20

ANNEX B

Scheme of Reservation and Delegation of Powers for Powys teaching Health Board

April 2012


Schedule 1

SCHEME OF RESERVATION AND DELEGATION OF POWERS

This Schedule forms part of, and shall have effect as if incorporated in the

Local Health Board Standing Orders Introduction As set out in Standing Order, the Board - subject to any directions that may be made by the Welsh Ministers - shall make appropriate arrangements for certain functions to be carried out on its behalf so that the day to day business of the LHB may be carried out effectively, and in a manner that secures the achievement of the organisations aims and objectives. The Board may delegate functions to:

i) a Committee, e.g., Quality and Safety Committee;

ii) a sub-Committee, e.g., a locality based Quality and Safety Committee taking forward matters within a defined area. Any such delegation would, subject to the Boards authority, usually be via a main Committee of the Board;

iii) a joint-Committee or joint sub-Committee, e.g., with other LHBs

established to take forward matters relating to specialist services; and

iv) Officers of the LHB (who may, subject to the Board’s authority, delegate further to other officers and, where appropriate, other third parties, e.g. shared/support services, through a formal scheme of delegation)

and in doing so, must set out clearly the terms and conditions upon which any delegation is being made. These terms and conditions must include a requirement that the Board is notified of any matters that may affect the operation and/or reputation of the LHB. The Board’s determination of those matters that it will retain, and those that will be delegated to others are set out in the following:

Schedule of matters reserved to the Board; Scheme of delegation to Committees and others; and Scheme of delegation to Officers.

all of which form part of the LHB’s SOs.


DECIDING WHAT TO RETAIN AND WHAT TO DELEGATE: GUIDING PRINCIPLES The Board will take full account of the following principles when determining those matters that it reserves, and those which it will delegate to others to carry out on its behalf:

Everything is retained by the Board unless it is specifically delegated in accordance with the requirements set out in SOs or SFIs

The Board must retain that which it is required to retain (whether by

statute or as determined by the Welsh Ministers) as well as that which it considers is essential to enable it to fulfil its role in setting the organisation’s direction, equipping the organisation to deliver and ensuring achievement of its aims and objectives through effective performance management

Any decision made by the Board to delegate functions must be

based upon an assessment of the capacity and capability of those to whom it is delegating responsibility

The Board must ensure that those to whom it has delegated powers

(whether a Committee, partnership or individuals) remain equipped to deliver on those responsibilities through an ongoing programme of personal, professional and organisational development

The Board must take appropriate action to assure itself that all

matters delegated are effectively carried out

The framework of delegation will be kept under active review and, where appropriate, will be revised to take account of organisational developments, review findings or other changes

Except where explicitly set out, the Board retains the right to decide

upon any matter for which it has statutory responsibility, even if that matter has been delegated to others

The Board may delegate authority to act, but retains overall

responsibility and accountability

When delegating powers, the Board will determine whether (and the extent to which) those to whom it is delegating will, in turn, have powers to further delegate those functions to others.


HANDLING ARRANGEMENTS FOR THE RESERVATION AND DELEGATION OF POWERS: WHO DOES WHAT The Board The Board will formally agree, review and, where appropriate revise schedules of reservation and delegation of powers in accordance with the guiding principles set out earlier. The Chief Executive The Chief Executive will propose a Scheme of Delegation to Officers, setting out the functions they will perform personally and which functions will be delegated to other officers. The Board must formally agree this scheme. In preparing the scheme of delegation to officers, the Chief Executive will take account of:

the guiding principles set out earlier (including any specific statutory responsibilities designated to individual roles)

their personal responsibility and accountability to the Chief Executive, NHS Wales in relation to their role as designated Accountable Officer

associated arrangements for the delegation of financial authority to equip officers to deliver on their delegated responsibilities (and set out in SFIs).

The Chief Executive may re-assume any of the powers they have delegated to others at any time. The Board Secretary The Board Secretary will support the Board in its handling of reservations and delegations by ensuring that:

a proposed schedule of matters reserved for decision by the Board is presented to the Board for its formal agreement;

effective arrangements are in place for the delegation of LHB functions within the organisation and to others, as appropriate; and

arrangements for reservation and delegation are kept under review and presented to the Board for revision, as appropriate.

The Audit Committee The Audit Committee will provide assurance to the Board of the effectiveness of its arrangements for handling reservations and delegations.


Individuals to who powers have been delegated Individuals will be personally responsible for:

equipping themselves to deliver on any matter delegated to them, through the conduct of appropriate training and development activity; and

exercising any powers delegated to them in a manner that accords with the LHB’s values and standards of behaviour.

Where an individual does not feel that they are equipped to deliver on a matter delegated to them, they must notify the Board Secretary/Chief Executive of their concern as soon as possible in so that an appropriate and timely decision may be made on the matter. In the absence of an officer to whom powers have been delegated, those powers will normally be exercised by the individual to whom that officer reports, unless the Board has set out alternative arrangements. If the Chief Executive is absent their nominated Deputy may exercise those powers delegated to the Chief Executive on their behalf. However, the guiding principles governing delegations will still apply, and so the Board may determine that it will reassume certain powers delegated to the Chief Executive or reallocate powers, e.g., to a Committee or another officer. SCOPE OF THESE ARRANGEMENTS FOR THE RESERVATION AND DELEGATION OF POWERS The Scheme of Delegation to officers referred to here shows only the "top level" of delegation within the LHB. The Scheme is to be used in conjunction with the system of control and other established procedures within the LHB.


SCHEDULE OF MATTERS RESERVED TO THE BOARD1

THE BOARD AREA DECISIONS RESERVED TO THE BOARD 1 FULL GENERAL The Board may determine any matter for which it has statutory or delegated authority,

in accordance with SOs2

2 FULL GENERAL The Board must determine any matter that will be reserved to the whole Board in accordance with statutory and Welsh Assembly Government guidance.

3 FULL OPERATING

ARRANGEMENTSAdopt the standards of governance and performance (including the quality and safety of healthcare, and the patient experience) to be met by the LHB, including standards/requirements determined by professional bodies/others, e.g., Royal Colleges

4 FULL OPERATING ARRANGEMENTS

Approve, vary and amend:

SOs; SFIs; Schedule of matters reserved to the LHB; Scheme of delegation to Committees and others; and Scheme of delegation to Officers.

In accordance with any directions set by the Welsh Ministers.


Approve the LHB’s Values and Standards of Behaviour framework

1 Any decision to reserve a matter, and the manner in which that retained responsibility is carried out will be in accordance with any regulatory and/or Assembly Government requirements 2 Except for those decisions delegated to the Welsh Health Specialised Services Committee (WHSSC)



Approve the LHB’s framework for performance management, risk and assurance


Approve the introduction or discontinuance of any significant activity or operation. Any activity or operation shall be regarded as significant if the Board determines it so based upon its contribution/impact on the achievement of the LHB’s aims, objectives and priorities


Ratify any urgent decisions taken by the Chair and the Chief Executive in accordance with Standing Order requirements


Ratify in public session any instances of failure to comply with SOs


Approve arrangements relating to the discharge of the LHB’s responsibility as a bailee for patients’ property


Approve policies for dealing with complaints and incidents


Approve individual compensation payments in line with SFIs


Approve individual cases for the write off of losses or making of special payments above the limits of delegation to the Chief Executive and officers


Approve proposals for action on litigation on behalf of the LHB


Authorise use of the LHB’s official seal

16 FULL ORGANISATION STRUCTURE &

STAFFING

Ratify appointment and manage appraisal, discipline and dismissal of the Chief Executive


Approve the appointment, appraisal, discipline and dismissal of the Executive Directors and any other Board level appointments and remuneration levels outside of


STAFFING WAG approved limits

18

FULL ORGANISATION STRUCTURE &

STAFFING

Require, receive and determine action in response to the declaration of Board members’ interests, in accordance with advice received, e.g. From Audit Committee


STAFFING

Approve, [arrange the] review, and revise the LHB’s top level organisation structure and corporate policies


STAFFING

Appoint, [arrange the] review, revise and dismiss Board Committees, including any joint-Committees directly accountable to the Board


STAFFING

Appoint, equip, review and (where appropriate) dismiss the Chair and members of any Committee, joint-Committee or Group set up by the Board


STAFFING

Appoint, equip, review and (where appropriate) dismiss individuals appointed to represent the Board on outside bodies and groups


STAFFING

Approve the terms of reference and reporting arrangements of all Committees, joint-Committees and groups established by the Board


STAFFING

Approve the arrangements relating to the discharge of the LHB’s responsibilities as a corporate trustee for funds held on trust

25 FULL STRATEGY & PLANNING

Determine the LHB’s strategic aims, objectives and priorities


Approve the LHB’s Corporate and Annual Operating/Delivery Plans


Approve the LHB’s Risk Management Strategy and plans

28 FULL STRATEGY & Approve the LHB’s citizen engagement and involvement strategy, including


PLANNING communication


Approve the LHB’s partnership and stakeholder engagement and involvement strategies


Approve the LHB’s key strategies and programmes related to: The development of clinical services Quality and patient safety Workforce and Organisational Development Infrastructure, including IM &T, Estates and Capital (including major capital

investment and disposal plans)


Approve the LHB’s budget and financial framework (including overall distribution of the financial allocation and unbudgeted expenditure)


Approve new contracts for the LHB to provide, or to secure provision from providers for Personal Medical; Dental; Pharmacy; Optometry services to some or all of the LHB’s population Services


Approve individual contracts (other than NHS contracts) above the limit delegated to the Chief Executive set out in the SFIs

34 FULL PERFORMANCE & ASSURANCE

Approve the LHB’s audit and assurance arrangements


Receive reports from the LHB’s Executive on progress and performance in the delivery of the LHB’s strategic aims, objectives and priorities and approve action required, including improvement plans


Receive assurance reports from the Board’s Committees, groups and other internal sources on the LHB’s performance and approve action required, including


improvement plans 37 FULL PERFORMANCE

& ASSURANCE Receive reports on the LHB’s performance produced by external regulators and inspectors (including, e.g., WAO, HIW, etc) that raise issue or concerns impacting on the LHB’s ability to achieve its aims and objectives and approve action required, including improvement plans, taking account of the advice of Board Committees (as appropriate)


Receive the annual opinion of the LHB’s Chief Internal Auditor and approve action required, including improvement plans


Receive the annual management letter from the LHB’s external auditor and approve action required, including improvement plans


Receive the annual opinion on the LHB’s performance against Healthcare Standards for Wales and approve action required, including improvement plans

41 FULL REPORTING Approve the LHB’s Reporting Arrangements, including reports on activity and performance locally, to citizens, partners and stakeholders and nationally to the Assembly Government

42 FULL REPORTING Receive, approve and ensure the publication of LHB reports, including its Annual Report and annual financial accounts


DELEGATION OF POWERS TO COMMITTEES AND OTHERS3 Standing Order 2 provides that the Board may delegate powers to Committees and others. In doing so, the Board has formally determined:

the composition, terms of reference and reporting requirements in respect of any such Committees; and the governance arrangements, terms and conditions and reporting requirements in respect of any delegation to others

in accordance with any regulatory requirements and any directions set by the Welsh Ministers. The Board has delegated a range of its powers to the following Committees and others:- Audit Committee Quality & Safety Committee

o Mental Health Act sub-Committee o Information Governance sub-Committee

Integrated Governance Committee Charitable Funds Committee Remuneration & Terms of Service Committee Pharmaceutical Applications Committee

The scope of the powers delegated, together with the requirements set by the Board in relation to the exercise of those powers are as set out in i) Committee Terms of Reference, and ii) formal arrangements for the delegation of powers to others. Collectively, these documents form the Board’s Scheme of Delegation to Committees.

3 As defined in Standing Orders


SCHEME OF DELEGATION TO EXECUTIVE DIRECTORS, OTHER DIRECTORS AND OFFICERS The LHB SOs and SFIs specify certain key responsibilities of the Chief Executive, the Director of Finance and other officers. The Chief Executive’s Job Description, together with their Accountable Officer Memorandum sets out their specific responsibilities, and the individual job descriptions determined for Executive Director level posts also define in detail the specific responsibilities assigned to those post holders. These documents, together with the schedule of additional delegations below and the associated financial delegations set out in the SFIs form the basis of the LHB’s Scheme of Delegation to Officers. This scheme only relates to matters delegated by the Board to the Chief Executive and their Executive Directors, together with certain other specific matters referred to in SFIs. Each Executive Director is responsible for delegation within their department. They shall produce a scheme of delegation for matters within their department, which shall also set out how departmental budget and procedures for approval of expenditure are delegated.


Executive Director Delegations:

Medical Director Director of Finance Director of Nursing Director of Therapies Director of Public Health and Planning


• Professional leadership and accountability for medical strategy, staff and service governance including primary care

• Clinical Governance (shared with DoTH and ND)

• Pharmacy Contract & Medicines Management

• Medical revalidation and fitness to practice

• Clinical information strategy/informing healthcare

• Custodian of Health Records

• Caldicot Guardian Information Technology

• Research & Development

• Individual Patient Commissioning

• Clinical Audit • Implementation of NICE

guidelines • Inspections by external

bodies – Royal colleges, Deanery etc

• General Medical Services

• Professional Leadership for Finance Staff, Accounting standards & Financial Governance

• Strategic Financial Planning (Revenue & Capital)

• Business Intelligence • Financial Management • Financial Reporting • Financial Systems • Financial Control • Financial Services • Charitable Funds Accounting • Community Health Councils

Accounting • Asset Accounting • Annual Accounts Production • Statutory Financial Duties

Compliance • External and Internal Audit

Compliance • Counter Fraud • NWSSP lead plus specific

liaison for Internal Audit, PPV, P2P

• Powys County Council shared services

• Contracting and Contract Monitoring

• External (Financial) Audit Liaison

• Professional leadership and accountability for nursing, midwifery and health visitor strategy, staff and service governance

• Clinical governance (shared with MD and DoTH)

• All Wales Continuing Care

• Continuing NHS Care (tHB)

• Children & Young People Planning

• Delayed Transfers of Care

• Women and Childrens

• Mental Health Services

• Leadership of clinical change programme Protection of Vulnerable Adults

• Safeguarding Children/ Child Protection

• 1000 Lives

• Professional leadership and accountability for therapies and health science strategy, staff and service governance

• Leadership for Quality and safety

• Clinical governance (shared with MD and ND)

• Standards for Health Care • Patient Safety/ Clinical

Standards • Risk Management • Corporate Health &

Safety • Patient experience • Redress • Infection Prevention &

Control • Medical Devices • Information Governance

- FOI - Data protection

• Professional accountability for Public Health

• Health improvement strategy

• PH monitoring and surveillance

• DPH Annual report • Cat 1 PH Response • Professional advice for

environmental issues • Performance Information

and health intelligence

• Estates • Strategic Planning (local,

regional commissioning and national to include WHSSC and Third sector)

• Joint planning including: - LSB - HSCWB - Community Safety - Sustainable

development - Civil contingencies Act

• Capital planning

• Professional leadership and accountability for HR and OD staff and service governance.

• Workforce and OD strategy

• Workforce planning • HR policy and practice • Workforce Change • Equality & diversity • Welsh Language Scheme • Employee health and

wellbeing/Occupational health

• Multi-disciplinary workforce education and development

• Library services • Communications • Employee engagement • Partnership working • Staff competence • Payroll (SS liaison) • Recruitment and retention • Employee record

management • Performance management

(corporate) and External Audit Liaison


Delegations within Standing Financial Instructions:

LHB SFIs Ref (Sept ‘10)

Description

Board

Chief Exec

Dir of Finance

Dir of Nursing

Medical Director

Dir of Workforce & OD

Dir of PH& Planning

Dir of Therapies

1 STANDING FINANCIAL INSTRUCTIONS

1.1 General – interpretation/application of SFIs

√

1.2 Non-compliance with SFIs – consideration & proposals for action in the event of

Audit Committee

√

1.3 Compliance with Financial Duties & Resource Limits of LHBs

√ √

2 RESPONSIBILITIES & DELEGATION

2.1 Financial Supervision – formulate financial strategy/approval of budgets/approving policies & financial systems/defining responsibilities as per Scheme of Delegation

√

2.2 Accountable for Overall Financial Control through system of delegated responsibility

√ √

2.2 Responsible for overall internal control – ensuring all members of the organisation are notified of the requirements of SFIs

√

2.3 Implementing Financial Policies, maintaining and effective system of internal financial control incl. detailed financial procedures/recording systems & ensuring ongoing training & communication re. SFIs

√

2.5 Contractors & their employees – compliance with SFIs

√

3 AUDIT, FRAUD & CORRUPTION, &

SECURITY MANAGEMENT

3.1 Independent check on effective internal control arrangements

Audit Committee

3.2 & 3.3 Effectiveness of internal financial control & establishment of internal audit function & processes

√

3.4 Consider & Review External Audit Strategy

Audit Committee

3.5 Fraud & Corruption – Monitoring & ensuring compliance with WAG directions

√ √


incl. nomination of a Local Counter Fraud Specialist

3.6.1 Post Payment Verification – consideration of recommendations

√

3.6.3 Post Payment Verification strategy Audit Committee

3.7 Security Management – compliance with WAG directions

√

4 ALLOCATIONS & RESOURCE LIMIT

4.0.2 Responsibility for the LHBs activities and to the Board for ensuring it stays within National Assembly for Wales allocated Capital & Resource Limit

√

4.0.3 Obtain Board approval for budget-setting in accordance with Allocations received

√

5 FINANCIAL PLANNING

5.2 Submission to Board of Annual Local Delivery Plan

√

5.2 Approval of Annual Local Delivery Plan which includes an annual balanced financial plan or sustainable recovery plan

√

6 BUDGETARY CONTROL

6.1, 6.3 & 6.4 Budget Setting/monitoring/providing timely financial information & training to budget-holders

√

6.2 Budgetary Delegation √ 6.3 Identifying/implementing cost efficiency

improvements & income generation initiatives

√

6.4 Monitoring Returns submitted in accordance with published guidance & timescales to WAG

√ √

7 ANNUAL ACCOUNTS & REPORTS

7.0.2 Sign off of Annual Accounts on behalf of Board

√ √

7.0.3 Preparation of Annual Accounts √

8 SHARED & HOSTED SERVICES ARRANGEMENTS

Use of shared or hosted services provided by other NHS organisations – arrangements for SLAs

√ √ √ √ √ √ √


9 BANKING ARRANGEMENTS

9.1 Approval of Banking Arrangements √ 9.2 Establishing Government Banking Service

Accounts √

9.3 Operation of Government Banking Service Accounts

√

9.2 Establishing Other Bank Accounts √ 9.3 Operation of Other Bank Accounts √

10 INCOME, FEES & CHARGES & SECURITY OF CASH, CHEQUES AND OTHER NEGOTIABLE INSTRUMENTS

10.2 Income Systems incl. systems for banking of monies received

√

10.3 Fees & Charges – approving & reviewing level of all fees & charges other than those determined by statute or WAG

√

10.4 Debt Recovery – Recovery Action & Losses Procedures

√

10.4 Debt Arbitration – adherement to guidance √ √ 10.5 Security of Cash, Cheques & Other

Negotiable Instruments √

11 PROCUREMENT & CONTRACTING

FOR GOODS & SERVICES

11.1 Policies & Procedures √ 11.2 & 11.3 Procurement Principles/EU Directives

Governing Public Procurement √ √ √ √ √ √ √

11.4 Sustainable Development Strategy √ 11.6 Procurement Procedures:

11.6 & 11.7 Issue Tenders as per Procurement Thresholds

√

11.6 Single Tender Action/Approval to waive tender/quotation procedure

√ √

11.6 Receive Tenders √ (PA) 11.6 Open Tenders √ (PA) 11.6 Post Tender negotiation √ √ 11.6 Accept Tender √ √ √ √ 11.6 Dealing with Arbitration & conciliation

issues relating to contracts √ √ √

11.8 Delegation of Contract Management √


12 CONTRACTS FOR HEALTH CARE

SERVICES

12.1 Responsibility for Healthcare Agreements with Service Providers for health care services

√

12.2 Statutory Provisions 12.2 GMS Contracts √ 12.2 GMS OOH √ 12.2 Dental Contract Payments √ 12.2 Pharmacy Contract √ 12.2 Individual Patient Commissioning √ 12.2 Local Authority Service Level Agreements √ √ 12.2 LTA Payments √ 12.2 Voluntary Sector Arrangements √ 12.2 Operational Continuing Health Care &

FNC √

12.2 Continuing Health Care & FNC Policy & Legal Framework

√

13 PAY EXPENDITURE

13.2 Funded Establishment – delegation of authority to vary

√

13.3 Staff Appointments up to approved budget & funded establishment

√ √ √ √ √ √ √

13.4 Payroll – department/operational √ 13.4.2 Payroll – internal controls/independent

audit review √

13.4.3 Payroll – timesheets/termination forms/sick leave notification etc

√ √ √ √ √ √ √

13.5 Contracts of Employment √

14 NON PAY EXPENDITURE 14.1 Delegation of Authority – approval of non-

pay expenditure & operational scheme of delegation & authorisation to budget-holders & managers

√

14.1.3 Authorisation processes within electronic procurement systems

√

14.2 Requisitioning √ √ √ √ √ √ 14.3 Process & systems for Accounts Payable √


incl. listing of officer Board members & employees (incl. specimen signatures) authorised to certify invoices

14.4 Prepayments – ensuring all items due under a prepayment contract are received

√ √ √ √ √ √

14.5 Official Orders – authorised use √ 14.5 Official Orders – format & security √

14.6 (14.6.1 (e) – gifts & hospitality) to be read in conjunction with SO 7.5

Budget holders & managers to comply with guidance & limits specified by the Director of Finance in regard to non-pay expenditure

√ √ √ √ √ √

15 CAPITAL INVESTMENT. FIXED ASSETS

REGISTERS & SECURITY OF ASSET

15.1 NHS Capital Investment – appraisal & approval processes & availability of financial resources (incl. revenue consequences)

√ √

15.1 NHS Capital Investment – reporting procedures & procedures governing financial management of capital investment projects

√

15.3 Asset Registers √ √ 15.4 Security of Assets – overall control √ 15.4 Security of Assets – control procedures

(incl. fixed assets, cash, cheques & negotiable instruments)

√

16 STORES & RECEIPT OF GOODS

16.2 Control of Stores, Stocktaking, condemnations & disposal

√

16.3 Goods Supplied by an NHS supplied Agency – delegation of authority to requisition & accept goods

√

17 DISPOSALS & CONDEMNATIONS,

LOSSES & SPECIAL PAYMENTS

17.1 Disposals & Condemnations – processes & procedures

√

17.2 Losses & Special Payments – procedures for recording of & accounting for

√

18 INFORMATION MANAGEMENT &

TECHNOLOGY

18.1 IM&T Strategy √


Delegated Limits for All Requisitions: Delegated Limit Authorised Signatory Over £100,000 Chairman Up to £100,000 Chief Executive Up to £50,000 Executive Directors/Locality General Managers Up to £10,000 Third Tier Officers Up to £1,000 Delegated Budget Holders

Notes Third Tier Officers and Delegated Budget Holders – Budget holders delegated by Executive Directors and Locality General Managers

18.2 & 18.5 IM&T – Executive Director operational responsibility & risk assurance

√

18.3 IM&T – Development of Financial Systems

√

18.4 Contracts for Computer Services with other health bodies or outside agencies

√

19 PATIENTS PROPERTY

19.1 & 19.3 Arrangements for safe-keeping & recording of patients property

√

19.2 Patient information in regard to patients property

√

20 CHARITABLE FUNDS

20.1 Corporate Trustee Charitable Funds Committee

20.2 Accountability to Charity Commission & the Assembly Government

Charitable Funds Committee

20.3 Applicable of Standing Financial Instructions to funds held on Trust

Charitable Funds Committee

21 RETENTION OF RECORDS 21.1 Responsibility for retaining archives for all

records in accordance with WAG guidance, data protection & FOI

√

FOR APPROVAL

Board Associate Member June 2012


Agenda Item 2.10


AGENDA ITEM 2.10

BOARD ASSOCIATE MEMBER: POWYS GP

Report of

Chief Executive

Paper prepared by Corporate Governance Manager

Purpose of Paper

The purpose of this paper is to outline to the Board a proposal to request Ministerial agreement for a Powys GP to be appointed as an Associate Member of the Board to support strengthened primary care involvement and advice.


The Board is asked to CONSIDER and APPROVE, if appropriate, a proposal to request Ministerial agreement to appoint a Powys GP as an Associate Member of the Board.






Standing Orders (SOs) Welsh Government (WG)

FOR APPROVAL



Agenda Item 2.10

BOARD ASSOCIATE MEMBER: POWYS GP

Membership of the Local Health Board As set out in Powys Health Board’s constitution, the Board shall include no more than 20 members comprising the Chair and Vice Chair, the Chief Executive and officer and non officer members, referred to as Executive Directors and Independent Members respectively. All such members have full voting rights. Membership of the Board will also include Associate Members who do not have voting rights. Associate Members As required within the organisation’s Standing Orders, the following Associate Members, appointed by the Minister for Health and Social Services, will attend Board meetings on an ex-officio basis, but will not have voting rights:-

Director of Social Services (County Council Chief Executive appointed for Powys Board)

Chair of the Stakeholder Reference Group (appointed) Chair of the Healthcare Professionals’ Forum (Forum yet to be established).

The Board may appoint an additional Associate Member to assist in carrying out its functions, subject to the agreement of the Minister for Health and Social Services. Any Associate Member appointed by the Board will be for a period of up to one year, with a maximum term of four years if re-appointed. Proposal to Appoint an Additional Associate Member The Health Board’s principal role is to ensure the effective planning and delivery of the local NHS system, within a robust governance framework, to achieve the highest standards of patient safety and public service delivery, improve health and reduce inequalities and achieve the best possible outcomes for its citizens, and in a manner that promotes human rights. The nature of Powys is such that Primary Care plays a significant role in achieving the Board’s aims. The geographical spread and isolated nature of the population means that much of the agenda of the Board’s role centre around GP Practices. This includes our public health role, the ownership and provision of local services, the engagement of the population and securing access the right access to secondary care. For this reason it is considered that additional input from the GP community into the Board would be appropriate. The proposal to the Board is to invite Dr D Paton to join the Board as an Associate Member. Dr Paton is chair of the Powys Local Medical Committee. Whilst the invitation is to Dr Paton because of his role with the LMC, it would not be a representative role but rather, providing the Board with additional Primary Care input. A pen portrait for Dr. Doug Paton is attached at Annex A.

FOR APPROVAL



Agenda Item 2.10

Recommendation The Board is asked to CONSIDER and APPROVE, if appropriate, a proposal to request Ministerial agreement to appoint a Powys GP as an Associate Member of the Board.

Report prepared by: Presented By: Rani Mallison Andrew Cottom Corporate Services Manager Chief Executive

FOR APPROVAL



Agenda Item 2.10

Profile Principal in General Practice LMC Negotiator for Powys South Powys Locality Team Member Experience Chair of total purchasing project south Powys This pilot involved Brecon ,Haytalgarth and Crickhowell practices holding a devolved budget for all health care commissioning with providers including a budget for all community and paramedical staff. Project ended in 1997 with the change of government.

Chair of Powys local health group The precursor of Powys LHB. A group including gps, reps of paramedical staff, pharmacists, dentists and voluntary sector set up by WAG.

18 Board members and a small executive team

WAG persuaded to treat Powys as a "pathfinder" and allow it to function as a primary care trust and not to be subsumed into a large acute trust as the rest of Wales

Local commissioning groups/locality groups Since the advent of LHB, I have been interested in developing services locally. We have integrated a social service department in the practice, commissioned GP beds in a local nursing home and have now a community resource team based in the practice. We have an ethos of a "one stop shop" for Health and Social Care.

Powys LMC Chair/ Negotiator This involves discussion with the LHB on the development of local enhanced services to allow GPs to take on work in primary care that has been done historically in secondary care. It is crucial to bringing services closer to patients I also act as a resource for issues around the GP contract

Education Edinburgh Academy Edinburgh University MB.ChB 1983 MRCGP 1989

Dr Douglas Paton ANNEX A

FOR APPROVAL

NHS Wales Shared Services Governance Framework


Agenda Item 2.11


AGENDA ITEM 2.11

NHS WALES SHARED SERVICES: GOVERNANCE FRAMEWORK

Report of

Director of Finance

Paper prepared by


Purpose of Paper

The purpose of this paper is to outline to the Board the use of Urgent Chair’s Action taken, in-line with the organisation’s Standing Orders, in respect of the NHS Wales Shared Services Governance Framework and amendments to the Health Board’s Standing Orders and Standing Financial Instructions.


The Board is asked to RATIFY the use of Urgent Chair’s Action taken, in-line with the organisation’s Standing Orders, in respect of the NHS Wales Shared Services Governance Framework and amendments to the Health Board’s Standing Orders and Standing Financial Instructions.


1. Governance & Accountability




NHS Wales Shared Services Partnership (NWSSP) Velindre NHS Trust (VNHST) Welsh Government (WG)

FOR APPROVAL



Agenda Item 2.11

NHS WALES SHARED SERVICES: GOVERNANCE FRAMEWORK

Introduction The Board will be aware that, following consultation, Welsh Government issued new regulations to establish a Shared Services Committee and for the NHS Wales Shared Services Partnership (NWSSP) to be hosted by Velindre NHS Trust (VNHST). This arrangement came into effect from 01 June 2012. In light of this arrangement there was a need for all Boards to approve the NHS Wales Shared Services Governance Framework prior to the Regulations being enacted on 01 June 2012. NHS Wales Shared Services Governance Framework The NHS Wales Shared Services Governance Framework consists of:-

Standing Orders for the Shared Services Committee (including Scheme of

Delegation) for inclusion in Velindre NHS Trust’s Standing Orders as a schedule

Memorandum of Cooperation Accountability Agreement between the Chair of Shared Services Committee

and Director of Shared Services Interface Agreement between the Chief Executive/Accountable Officer of

Velindre NHS Trust and the Director/Accountable Officer of Shared Services Hosting Agreement: Shared Services Partnership Committee.

Copies of these documents are available upon request. Health Board Standing Orders In light of the revised arrangements in respect of NHS Wales Shared Services, Welsh Government took the opportunity to issue Health Boards and NHS Trusts with a summary of amendments required to Model Standing Orders and Model Standing Financial Instructions, to be effective from 01 June 2012. The amendments required cover:-

The new Shared Services arrangements from 1st June 2012 - amendments required to both the respective SOs and SFIs.

Grant funding - a commitment was given to the Minister to add a new section in the respective SFIs.

Other amendments in the respective LHB SOs as follows: Chair's action on urgent matters - to bring the LHB SOs into line with

the Trusts SOs LHB meetings with CHCs - to bring the LHB SOs into line with the CHC

Regulations.

A full summary of required changes is attached at Annex A.

FOR APPROVAL



Agenda Item 2.11

Use of Urgent Chair’s Action In order that both the NHS Wales Shared Services Governance Framework and amendments to the Health Board’s Standing Orders and Standing Financial Instructions could be approved by 31 May 2012, as required, a meeting was arranged to support the use of Urgent Chair’s Action. In-line with the organisation’s Standing Orders, the use of Urgent Chair’s Action was taken on 30 May 2012, in consultation with two Independent Members (Andrew Leonard and Gloria Jones Powell). The tHB Chair approved the NHS Wales Shared Services Governance Framework and amendments to the Health Board’s Standing Orders and Standing Financial Instructions and no issues of concern were recorded. As required within the organisation’s Standing Orders, the use of Urgent Chair’s Action must be reported to the Board for formal ratification. Recommendation The Board is asked to RATIFY the use of Urgent Chair’s Action taken, in-line with the organisation’s Standing Orders, in respect of the NHS Wales Shared Services Governance Framework and amendments to the Health Board’s Standing Orders and Standing Financial Instructions.

Report prepared by: Presented By: Rani Mallison Rebecca Richards Corporate Governance Manager Executive Director of Finance

ANNEX A This document, extracted from the respective LHB and Trust Standing Orders and Standing Financial Instructions, has been amended to reflect the changes that will need to be made to the Standing Orders and Standing Financial Instructions of each Local Health Board and NHS Trust from 1st June 2012 to reflect:

• the new Shared Services arrangements from 1st June 2012 (SOs and SFIs);

• Guidance on Grant funding (SFIs); and • Other amendments to LHB SOs to bring them into line with NHS Trusts.

Where the Standing Orders and Standing Financial Instructions of the relevant Local Health Board or NHS Trust are not based on this model form document, please note that additional/other changes may be required. Note: Text in red should be deleted

Text in green should be inserted

LHB / TRUST STANDING ORDERS [For Velindre NHS Trust] 1. THE TRUST 1.0.1 The Trust’s principal role is to: [delete as appropriate]

[For Velindre – (a) to own and manage Velindre Hospital, Velindre Road, Whitchurch,

Cardiff CF4 7XL and associated hospitals and premises, and there to provide and manage hospital accommodation and services;

(b) to own and manage Welsh Blood Service Headquarters, Ely

Valley Road, Talbot Green, Pontyclun CF72 9WB and associated premises, and there to provide and manage services relating to the collection, screening and processing of blood and its constituents and to the preparation and supply of blood, plasma and other blood products;

(c) to manage and provide to or in relation to the health service in

Wales a range of information technology systems and associated support and consultancy services, desktop services, web development, telecommunications services, healthcare information services and services relating to prescribing and dispensing;

(d) to manage and provide Shared Services to the health service in

Wales; and

(e) to own or lease the premises associated with the provision of the services in paragraph (d).]

2. RESERVATION AND DELEGATION OF LHB / TRUST FUNCTIONS [For LHBs & Trusts] 2.0.4 NHS Wales Shared Services

Background Information - The Welsh Assembly Government has led the development of a new model for shared services that are used by the NHS in Wales (“Shared Services”). Shared Services are non-clinical business functions provided for NHS Wales’ organisations, including Welsh Health Estates, legal services, internal audit, health supplies (including procurement, supply chain, accounts payable services) and payroll and recruitment services. Most of these Shared Services are hosted by individual Local Health Boards and NHS Trusts, with the intention that all NHS Wales organisations can make use of their expertise. A Senior Management Team will be responsible for the delivery of Shared Services. The Senior Management Team will be led by the Director of Shared Services. The Director of Shared Services shall hold Accountable Officer status, and shall retain overall accountability in relation to the management of Shared Services. The Director of Shared Services will report to the Chair of the Shared Services Partnership Committee which is a sub committee of the National Delivery Group, and on which the LHB / Trust will be represented.

[For LHBs]

Statutory Powers - Section 12(3) of the NHS (Wales) Act 2006 provides that the Welsh Ministers may give directions to a LHB about its exercise of any functions. By virtue of Section 13 of the NHS (Wales) Act 2006, functions may be exercised jointly between LHBs and other bodies, including NHS Trusts, where directions are given to that effect. In accordance with Directions issued by the Welsh Ministers on [insert date] entitled [insert name of Directions], and in accordance with Standing Order 2.2.2 below, the Board formally resolved on [insert date] that the functions of the LHB relating to the management and provision of the Shared Services would be delegated to the Director of Shared Services. The Director of Shared Services will retain overall accountability for ensuring the management and provision of the Shared Services. The Director of Shared Services shall be permitted to arrange for members of the Senior Management Team to carry out day to day management of the Shared Services. For example, in relation to staff appraisal processes. [For Trusts] Statutory Powers - Paragraph 18 of Schedule 3 to the National Health Service (Wales) Act 2006 (the “2006 Act”) provides that an NHS Trust may enter into arrangements for the carrying out, on such terms as the NHS Trust considers appropriate, of any of its functions jointly with any Local Health Board or other NHS Trust. Section 19 of the 2006 Act provides that the Welsh Ministers may give directions to any NHS Trust about its exercise of any functions. In accordance with Directions issued by the Welsh Ministers on [insert date] entitled [insert name of Directions], and in accordance with Standing Order 2.2.2 below, the Board formally resolved on [insert date] that the functions of the Trust relating to the management and provision of the Shared Services would be delegated to the Director of Shared Services, an officer of Cwm Taf Local Health Board. The Director of Shared Services will

retain overall accountability for ensuring the management and provision of the Shared Services. The Director of Shared Services shall be permitted to arrange for members of the Senior Management Team to carry out day to day management of the Shared Services. For example, in relation to staff appraisal processes. [For LHBs & Trusts] Powers delegated to the Director of Shared Services – In accordance with the Board resolution referred to above, the following powers are delegated by the LHB / Trust to the Director of Shared Services to be exercised in accordance with the strategy documents approved by NHS Wales on the recommendations of the Shared Services Committee:

• the preparation of the annual NHS Wales Shared Services Business Plan based on the policies and strategy set by the NHS Wales Shared Services Partnership Committee;

• overall management of the delivery Shared Services via the Senior

Management Team;

• day-to-day management of the [Shared Service Staff]1 employed by the LHB / Trust on the basis of their existing contractual terms and conditions of employment with the LHB / Trust. Such management functions to include grievance procedures, appraisal, recruitment and termination of employment (subject to any appeal rights contained in the existing contractual terms and conditions of employment);

• authority to undertake any competitive tender exercise required in

relation to the Shared Services or to new services which will become part of the Shared Services;

• authority to execute any legally binding documents relating to the Shared Services on behalf of the LHB / Trust in accordance with the delegated authority limits;

• overall accountability for the Shared Services to the Chief Executive of

NHS Wales, through Accountable Officer status for the Shared Services.

[For LHBs & Trusts] 2.0.4 NHS Wales Shared Services

Background Information In 2011 the NHS bodies in Wales, together with the Welsh Assembly Government (as it then was) decided to bring together various support services functions across the NHS in Wales under a single management team as a “virtual” Shared Services entity.

1 Shared Service Staff to be identified and listed in Board resolution or accompanying document.

In September 2011 the Welsh Ministers gave authority to proceed with the transfer of responsibility for the provision of Shared Services from the virtual model to an NHS body in Wales.

Following an invitation to all NHS bodies to express an interest in becoming the host organisation, Velindre NHS Trust was confirmed as the host organisation on 22nd November 2011.

Arrangements from 1st June 2012

From 1st June 2012 the function of managing and providing Shared Services to the health service in Wales will be given to Velindre NHS Trust. The Trust’s Establishment Order has been amended to reflect the fact that the function of managing and providing shared services to the health service in Wales has been conferred on it.

The Velindre National Health Service Trust Shared Services Committee (Wales) Regulations 2012 (the Shared Services Regulations) require the Trust to establish a Shared Services Committee which will be responsible for exercising the Trust’s Shared Services functions. The Shared Services Regulations prescribe the membership of the Shared Services Committee in order to ensure that all LHBs and Trusts in Wales have a member on the Shared Services Committee and that the views of all the NHS organisations in Wales are taken into account when making decisions in respect of Shared Services activities. The Director of Shared Services will be designated as Accountable Officer for Shared Services.

These new arrangements also necessitate putting in place a new Memorandum of Co-operation and a Hosting Agreement between all LHBs and Trusts setting out the obligations of NHS bodies to participate in the Shared Services Committee and to take collective responsibility for setting the policy and delivery of the Shared Services to the health service in Wales. The Shared Services Committee is to be known as the Shared Services Partnership Committee for operational purposes.

2.1 Chair’s action on urgent matters [For LHBs] 2.1.2 Chair’s action may not be taken where either the Chair or the Chief Executive

has a personal or business interest in an urgent matter requiring decision. In this circumstance, the Vice-Chair or the Executive Director acting on behalf of the Chief Executive will take a decision on the urgent matter, as appropriate.

2.2 Delegation of Board functions [For Velindre NHS Trust] 2.2.0 The Trust shall delegate its Shared Services functions (that is, the provision

and management of Shared Services to the health services in Wales) to the Shared Services Partnership Committee which they are required to establish

and confer such functions on in accordance with the Shared Services Regulations.

2.2.1 Subject to Standing Order 2.2.0, the Board shall agree the delegation of any of

their functions to Committees and others, setting any conditions and restrictions it considers necessary and following any directions given by the Welsh Ministers. These functions may be carried out:

2.2.1 The Board shall agree the delegation of any of their functions to Committees

and others, setting any conditions and restrictions it considers necessary and following any directions given by the Welsh Ministers. These functions may be carried out:

[For LHBs]

i by a Committee, sub-Committee or officer of the LHB (or of another LHB or Trust); or

ii by another LHB; NHS Trust; Strategic Health Authority or Primary Care Trust in England; Special Health Authority; or

iii jointly with one or more bodies including local authorities through a joint-Committee, sub-Committee or joint sub-Committee.; or

iv by the Director of Shared Services in accordance with Standing Order 2.0.4.

[For Trusts]

i by a Committee, sub-Committee or officer of the Trust (or of another Trust); or

ii by another LHB; NHS Trust; Strategic Health Authority or Primary Care Trust in England; Special Health Authority; or

iii with one or more bodies including local authorities through a sub-Committee.; or

iv by the Director of Shared Services in accordance with Standing Order 2.0.4.

2.2.2 [For LHBs]

The Board shall agree and formally approve the delegation of specific executive powers to be exercised by Committees, sub-Committees, joint-Committees or joint sub-Committees which it has formally constituted, or to the Director of Shared Services.

2.2.2 [For Trusts]

The Board shall agree and formally approve the delegation of specific executive powers to be exercised by Committees or sub-Committees which it has formally constituted, or to the Director of Shared Services.

2.3 Delegation to Officers [For LHBs] 2.3.1 The Board will delegate certain functions to the Chief Executive. For these

aspects, the Chief Executive, when compiling the Scheme of Delegation to Officers, shall set out proposals for those functions they will perform personally and shall nominate other officers to undertake the remaining functions. The Chief Executive will still be accountable to the Board for all

functions delegated to them irrespective of any further delegation to other officers.

2.3.2 This must be considered and approved by the Board (subject to any

amendment agreed during the discussion). The Chief Executive may periodically propose amendment to the Scheme of Delegation to Officers and any such amendments must also be considered and approved by the Board.

5. WORKING IN PARTNERSHIP 5.1 Community Health Councils (CHCs) [For LHBs] 5.1.5 The Board shall make arrangements for regular joint meetings between the

CHC members and the Board, to be held at least twice yearly and ensuring attendance of at least one third of the Board’s members.

5.1.5 The Board shall make arrangements for regular joint meetings between the

CHC members and the Board, to be held not less than once every three calendar months and ensuring attendance of at least one third of the Board’s members.

6. MEETINGS [For LHBs] Voting 6.5.1 The Chair will determine whether Board members’ decisions should be

expressed orally, through a show of hands, or by a paper ballot. The Chair must require a paper ballot if the majority of voting Board members request it. Where voting on any question is conducted, a record shall be maintained showing how each Board member voted or abstained. Associate Members may not vote in any meetings or proceedings of the Board.

6.5.1 The Chair will determine whether Board members’ decisions should be

expressed orally, through a show of hands, by secret ballot or by recorded vote. The Chair must require a secret ballot or recorded vote if the majority of voting Board members request it. Where voting on any question is conducted, a record shall be maintained. In the case of a secret ballot the decision shall record the number voting for, against or abstaining. Where a recorded vote has been used the Minutes shall record the name of the individual and the way in which they voted. Associate Members may not vote in any meetings or proceedings of the Board.

8. SIGNING AND SEALING DOCUMENTS [For LHBs & Trusts] 8.0.3 Where as part of the functions delegated to him in accordance with Standing

Order 2.0.4, the Director of Shared Services is entering into a contract, lease or other legally binding document on behalf of the LHB / Trust, the Director of Shared Services shall arrange for the signature and completion of the document in accordance with the Standing Orders of the organisation of which he is an officer.

8.2 Signature of Documents [For LHBs & Trusts] 8.2.1 Subject to Standing Order 8.0.3, where a signature is required for any

document connected with legal proceedings involving the LHB / Trust, it shall normally be signed by the Chief Executive, except where the Board has authorised another person or has been otherwise directed to allow or require another person to provide a signature.

9. GAINING ASSURANCE ON THE CONDUCT OF LHB BUSINESS [For LHBs & Trusts – no change] 9.0.3 Assurances in respect of the Shared Services shall be primarily be achieved

by the reports of the Director of Shared Services to the Shared Services Partnership Committee, and reported back to the Chief Executive (or his nominated representative). Where appropriate, and by exception, the Board may seek assurances direct from the Director of Shared Services. The Director of Shared Services and the Shared Services Committee shall be under an obligation to comply with any internal or external audit functions being undertaken by or on behalf of the LHB / Trust.

[END OF AMENDMENTS TO THE LHB & TRUST STANDING ORDERS]

LHB / TRUST STANDING FINANCIAL INSTRUCTIONS [For LHBs] 8. SHARED AND HOSTED SERVICES ARRANGEMENTS 8.0.2 A Service Level Agreement must be in place between the LHB and the shared

services host organisation specifying the services, cost, quality and performance management arrangements of the functions provided by the shared services function.

8.0.3 All arrangements shall clearly set out details of accountability, responsibilities

and authority of the respective parties to the agreement. The agreement should also set out the framework by which the LHB and its auditors can gain assurance and the timescales by which this will be provided.

8.0.2 From 1st June 2012 the functions of managing and providing Shared Services

to the health service in Wales will be given to Velindre NHS Trust. The Trust is required to establish a Shared Services Committee (to be known for operational purposes as the Shared Services Partnership Committee) which will be responsible for exercising the Trust’s Shared Services functions. However, responsibility for the exercise of the Shared Services functions will not rest primarily with the Board of Velindre NHS Trust but will be a shared responsibility of all NHS bodies in Wales.

8.0.3 A Senior Management Team, led by the Director of Shared Services will be

responsible for the delivery of Shared Services in accordance with an Annual Business Plan agreed by the Shared Services Partnership Committee. The Director of Shared Services shall hold Accountable Officer status, and shall retain overall accountability in relation to the management and delivery of Shared Services.

8.0.4 A Memorandum of Co-operation and a Hosting Agreement must be in place

between the LHBs and Trusts within Wales setting out the obligations of NHS bodies to participate in the Shared Services Partnership Committee and to take collective responsibility for setting the policy and delivery of the Shared Services to the health service in Wales. The hosting agreement will provide the terms upon which Velindre NHS Trust provides the legal framework for the management and provision of shared services to the NHS in Wales.

[For Trusts] 7 SHARED AND HOSTED SERVICES ARRANGEMENTS 7.0.2 From 1st April 2011, a Senior Management Team will be responsible for the

delivery of NHS Wales Shared Services (“Shared Services”). The Senior Management Team will be led by the Director of Shared Services. The Director of Shared Services shall hold Accountable Officer status, and shall retain overall accountability in relation to the management of Shared Services.

7.0.3 A Memorandum of Co-operation must be in place between the LHBs and

Trusts within Wales setting out the arrangements for the delivery and strategic planning of Shared Services and the governance framework for the reporting and monitoring of performance of Shared Services by the Shared Services Partnership Committee.

7.0.4 All arrangements shall clearly set out details of accountability, responsibilities

and authority of the respective parties to the Memorandum of Co-operation. The Memorandum of Co-operation should also set out the framework by which the Trust and its auditors can gain assurance and the timescales by which this will be provided.

7.0.2 From 1st June 2012 the functions of managing and providing Shared Services

to the health service in Wales will be given to Velindre NHS Trust. The Trust is required to establish a Shared Services Committee (to be known for operational purposes as the Shared Services Partnership Committee) which will be responsible for exercising the Trust’s Shared Services functions. However, responsibility for the exercise of the Shared Services functions will not rest primarily with the Board of Velindre NHS Trust but will be a shared responsibility of all NHS bodies in Wales.

7.0.3 A Senior Management Team, led by the Director of Shared Services will be

responsible for the delivery of Shared Services in accordance with an Annual Business Plan agreed by the Shared Services Partnership Committee. The Director of Shared Services shall hold Accountable Officer status, and shall retain overall accountability in relation to the management of Shared Services.

7.0.4 A Memorandum of Co-operation and a Hosting Agreement must be in place

between the LHBs and Trusts within Wales setting out the obligations of NHS bodies to participate in the Shared Services Partnership Committee and to take collective responsibility for setting the policy and delivery of the Shared Services to the health service in Wales . The hosting agreement will provide the terms upon which Velindre NHS Trust provides the legal framework for the management and provision of shared services to the NHS in Wales.

[For LHBs/Trusts but note Trusts paragraph numbering will be 10 and not 11] 11 PROCUREMENT AND CONTRACTING FOR GOODS AND SERVICES 11.1 Policies and procedures 11.1.1 The LHB / Trust shall maintain detailed policies and procedures for all aspects

of procurement including tendering and contracting processes. The policies

and procedures shall comply with these SFIs and the supplementary guidance included at Schedule 1.

11 GRANT FUNDING, PROCUREMENT AND CONTRACTING FOR GOODS

AND SERVICES Procurement or Grant Funding 11.0.1 It is a matter for LHBs / Trusts to determine whether individual activities should

be procured, or are eligible to receive grant funding, seeking legal advice as necessary.

Grant Funding 11.1 Policies and procedures 11.1.1 The LHB /Trust shall maintain detailed policies and procedures for all aspects

of grant funding. The policies and procedures shall comply with these SFIs, and where appropriate the Welsh Government’s Code of Practice to funding the third sector:

http://wales.gov.uk/topics/housingandcommunity/voluntarysector/publications/code/?lang=en

11.1.2 The Chief Executive is ultimately responsible for ensuring that the LHB’s /

Trust’s grant procedures:

• are kept up to date; • conform to statutory requirements; • adhere to guidance issued by the Welsh Government; • are consistent with the principles of sustainable development; and • are strictly followed by all Executive Directors, Independent

Members and staff within the organisation. 11.1.3 All grant guidance issued by the Welsh Government should have the effect as if

incorporated in these SFIs. 11.2 Corporate Principles underpinning Grants Management 11.2.1 While there is a need to make the financial arrangements for awarding funding

as simple and streamlined as possible, LHBs / Trusts should also ensure that taxpayers’ money is spent appropriately and that it provides good value for money.

11.2.2 The overarching principles for managing public resources in Wales are set out

in Managing Public Money .The document states that the award of funding should be made in accordance with the law and the requirements of propriety, regularity and value for money.

11.2.3 Regularity requires compliance with appropriate authorities, regulations and

legislation. Propriety requires both public authorities and funded bodies to

deliver appropriate standards of conduct, behaviour and corporate governance. In addition, the public expects official decisions to be made fairly and impartially with public money spent wisely and appropriately, delivering value for money and ensuring that best use is made of resources.

11.2.4 The corporate principles of grants management are:

• the development of grant management processes and procedures that are transparent, accountable, proportionate and consistent;

• delivery of a high quality regulatory framework that responds to demands but does not place unnecessary administrative burdens on LHBs / Trusts or funded bodies;

• a regulatory framework that will take into consideration the need for proportionality; balancing the need for governance with the burden of administration. Thus striking an appropriate balance between accountability and simplicity;

• an effective grant management process to ensure funded bodies spend the funding efficiently, transparently and for the purpose intended, with a view to maximising the impact and outcome from budgets;

• appropriate evidence-based approach to underpin the design and development of all new funding programmes to ensure efficient and effective use of public funds. Ensuring that the funding programme is the optimal solution and that funding is targeted where it is most needed and where it can have most impact;

• a consistent framework that will reinforce respect and effectiveness of the rules for both administrators and funded bodies.

11.3 Grant Procedures 11.3.1 It is vital that money is put to use in a way that delivers the maximum benefit

to the people of Wales. Grants funding programmes need to be managed as efficiently and cost effectively as possible to make sure that every penny is spent appropriately and in an accountable manner. Information on grants management is available on the WAO website at:

http://www.wao.gov.uk/goodpractice/1821.asp 11.3.2 LHBs / NHS Trusts are responsible for ensuring that appropriate procedures

exist in relation to all the grants and funding for which they are accountable. They are also responsible for ensuring that any grant provided to an entity that engages in economic activity complies with the State aid rules.

11.3.3 LHBs / NHS Trusts are required to undertake due diligence checks on all

potential delivery organisations to determine the economic and financial viability of any organisation(s) to administer public funds, and the reliability of the organisation(s).

11.3.4 The LHB / NHS Trust must enter into legally binding funding agreements with

all delivery organisations. Guidance is available on the WAO website at:

http://www.wao.gov.uk/goodpractice/1898.asp#q10 11.3.5 The LHB / NHS Trust is responsible for ensuring that all third party delivery

organisations comply with and adhere to the terms and conditions of the Funding Agreement.

Procurement 11.4 Policies and procedures 11.4.1 The LHB / Trust shall maintain detailed policies and procedures for all aspects

of procurement including tendering and contracting processes. The policies and procedures shall comply with these SFIs and the supplementary guidance included at Schedule 1.

[Subsequent paragraphs in this section need to be renumbered]

[END OF AMENDMENTS TO THE LHB & TRUST STANDING FINANCIAL INSTRUCTIONS]

FOR DISCUSSION

Annual Plan 2012-13 Page 1 of 13 Board Meeting 27 June 2012

Agenda Item 3.1


AGENDA ITEM 3.1

ANNUAL PLAN / MAKING IT HAPPEN 2012-13

Report of

Chief Executive

Paper prepared by

Chief Executive

Purpose of Paper

To update the Board on progress in securing arrangements for achieving transformational change by the rapid implementation of the Annual Plan.


The Board is asked to DISCUSS and NOTE this paper for information.


The annual plan incorporates the actions required to make progress across the Standards for Health Services.


The paper supports the delivery of the organisation’s Annual Plan 2012/13.


NLIAH – National Leadership and Innovation Agency for Healthcare

FOR DISCUSSION


Agenda Item 3.1

ANNUAL PLAN 2012-13

BACKGROUND At its last meeting, the Board received and approved its Annual Plan 2012/13. The Plan was the culmination of a process that engaged the Board and the organisation and led to the articulation of the Board’s priorities for implementation in 2012/13. One of the features of the plan was a recognition by the Executive that in order to properly achieve the aspiration of the Annual Plan, a clinically led and Organisational Development based programme of transformation was required. At the time of the last Board, the approach and shape of this programme was embryonic. In addition, the Health Board had been subject to an external, independent financial review, the outcome of which was awaited. The purpose of this paper is to update the Board on the development of this programme of transformational change. Accelerated Clinical Change for Excellence At the heart of the programme of transformation articulated in the Annual Plan, is the development of a programme of clinical change for excellence. In essence it is a programme to implement with more pace and more depth the programme of change already articulated in the Annual Plan, some of which, on honest reflection, were carried forward from last year’s plan. There has been recognition however that the conditions under which this programme is being developed are more favourable than in previous years following the permanent appointment of the Executive Team. In addition, the platform for building the programme includes:-

• A clearly articulated vision and ambition by the Board. This was approved in the Annual Plan as to ensure:-

‘Truly integrated care, centred on the individual’ by

• Improving health and well-being (health) • Ensuring the right access (services) • Striving for excellence (delivery) • Involving the people of Powys (people) • Making every pound count (money)

A programme of transformation must seek to achieve this ambition.

• Confirmation that the direction of travel is right. Most recently, this is confirmed by the external review of the Health Board’s financial

FOR DISCUSSION


Agenda Item 3.1

position that was commissioned by the Welsh Government. The issue is one of pace and depth.

• Increasing evidence and enthusiasm for the concept that improving quality and reducing cost are natural bed fellows. The Health Board’s own programme of improvement in primary care prescribing is evidence of this. The concept is particularly relevant to our programme of transformation, as reducing the overall cost of care for the people of Powys must be a key outcome.

• Developing clinical leadership particularly from Primary Care together with an improved confidence and trust from key stakeholders.

Over the past couple of months, some time has been taken to ensure that the approach to launching the programme of accelerated clinical change is such as to maximise effect, secure organisational and key stakeholder buy in and remains true to the aspirations set out in the Annual Plan. Consideration has included detailed discussion with the external support the Health Board commissioned to support the programme, visit to a “turnaround” site, reflection on the report of the independent financial reviewer and some support from NLIAH who have supported these initiatives across Wales. The outcome has been:-

• Selection of a limited number of pathfinder projects where it is known that there is potential for improvement and that progress has been hampered by a range of issues. One reason for selecting a limited number of projects is to avoid overload and spreading input so thinly that it is not as effective. The projects chosen are:-

o Emergency/non-elective pathways in South East Powys (Annual

Plan improvement actions 44-47) o Maximising elective services in Powys (Annual Plan

improvement actions 48-54) o Maternity day care repatriation (Annual Plan improvement action

67) o Implementing the Builth & District Health and Social Care model

(Annual Plan improvement action 38) The areas selected also provide good coverage across the areas of priority of the Health Board and will inevitably touch on the significant technical support areas such as information; contracting and finance. They do therefore provide a good basis on which to initiate the clinical change programme.

• On each of these programmes, undertake a facilitated “Deep Dive methodology”. The methodology which is supported by NLIAH, uses an approach that focuses on creative problem solving. There is a level of preparatory work that requires an analysis of the organisation’s information and provides some description around the “problem”. The method actively engages a wide range of stakeholders, frees up thinking and gains a higher level of commitment. In essence, it works

FOR DISCUSSION


Agenda Item 3.1

on the assumption that the answer is in the room – that the expertise available simply needs to be captured in a structured way. The approach was selected over employing external consultancy because of its inclusive approach which helps with ownership. In addition, NLIAH have tried and tested this elsewhere in Wales and secured positive results.

The first Deep Dive event is planned for 5th July.

• Implementation and spread – in terms of the programme for

accelerating clinical change for excellence, the expectations of the Deep Dive events are high and will include:-

o A blueprint at a detailed clinical level for securing significant

improvement. This is anticipated to go beyond the fairly high level strategic direction that the Health Board has articulated and be at a level where implementation can proceed.

o It will also provide the basis for modelling our three year plan as the key elements of service change will be covered.

o A clear programme of implementation with clear timeframes and expected benefits. In this context, programme management will be critical (see below) and use of quality improvement techniques promoted by 1000 Lives is anticipated.

o Identification of the organisational development and training needs in order to secure the implementation on a sustainable basis.

o A basis upon which engagement strategies are developed which are focussed on local communities and with a deliberate intent to gain support for changes.

o Sufficient information to provide the basis for modelling a three year plan that meets the requirements of the Health Board’s financial discussion with Welsh Government.

Given the anticipated benefits of the initial deep-dive exercise, a key part of the programme for Clinical Change for Excellence will also be developing a method that ensures spread as quickly as possible. The approach to this has yet to be developed.

Accelerated Organisation Development Whilst the paper has identified that the organisational context for undertaking this programme is good, we have also recognised that there are some mission critical organisation issues that need to be addressed immediately. It is also recognised that the Deep Dive and improvement programmes will inevitably identify more, one in particular being the development of effective teams. This was identified as a priority in last year’s Corporate Plan and whilst some progress has been made, is likely to be another area of accelerated development.

FOR DISCUSSION


Agenda Item 3.1

The immediate OD issues and their progress are as follows:-

Issue Progress Executive alignment – to improve effectiveness and release capacity for MIH programme

Paper for approval by Board – 27 June; included within this are changes that release time for the Nursing director to lead on the Clinical Change for Excellence programme.

Information – to significantly improve accessibility and use of relevant information in support of business management and service improvement

Support provided by NWIS due to start on 20th June with a 10 working days turnaround for identification capacity and capability gaps and includes agreement from NWIS to continue secondment of senior information officer.

Local General Managers Reverted to three LGM posts in order to ensure appropriate transformation capacity. South – recruitment complete; start date 21st July North – interviews 19th June These were identified as critical appointments in the independent financial review.

Commissioning / contracting – to ensure the function is properly aligned and resourced.

Appropriate alignment is described in the Executive Directors’ Scheme of Delegation paper.

Effective Teams Executive Director development programme in hand; team development programme through Aston University to be launched 9th July.

Programme management Secured initial professional advice with development in hand (see below).

Programme / project management – to initiate the overall implementation of the Annual Plan, an action grid is being used by Executive Directors to ensure that the early stages of the programme are advanced with appropriate pace. A copy of the grid completed on 13th June is attached as Appendix 1. The approach is rudimentary and by no means fit for the purpose of ensuring the implementation of the Annual Plan, developing and implementing accelerated clinical change for excellence programme and ensures the implementation of the Health Board’s cost reduction programme. Programme Management was a significant theme in the independent financial review which focussed particularly on our existing cost reduction programme but concluded in general that - “The Health Board lacks the experience and capacity to support and drive the substantial change and there is no programme management resource or approach in place”. And it is clear that in order to achieve the focus and pace that are features of a turnaround across the annual plan, clinical change programme and financial plan, that the Health Board needs to invest in this area.

FOR DISCUSSION


Agenda Item 3.1

From initial research into securing this resource, it is also clear that programme management is profession in its own right and that to be sure of its effect; the Health Board needs to secure professional advice. The specific approach suggested in the Independent Financial review was through the employment of a Board level Turnaround Director plus programme office. However, in reality, it is the programme office and professional programme management input that is missing. Sufficient Board level leadership already exists and which can be made more effective through the support of an appropriate programme office. Work is in hand therefore to secure this type of professional input by the end of June. Financial Programme The Board will receive separately and be asked to approve a supplementary financial plan. The plan provides the basis for securing break even, the main components of which are:-

• Full implementation of savings plans, thereby avoiding the use of contingencies and reserves.

• Managing growth – thereby avoiding the use of monies set aside for this purpose.

• Indentifying new opportunities through the accelerated clinical change for excellence programme.

• Seeking to secure agreement that the early draw down of funding from last year is “repaid” over a three-year period from April 2013.

The Board has also had sight of the report of independent financial review commissioned by Welsh Government. Whilst the report confirmed our reported financial position and risks and, supported the approach for resolution, it did also identify three key issues for the Executive to specifically address. 1) Turnaround – the report indicated that it is imperative that the Health

Board achieve the characteristics of turnaround in terms of pace and focus; in terms of a structured sense of drive and urgency and high level of support to those seeking to implement cost savings. To a large extent this imperative has been addressed through a process of financial review led by the Finance Director. The process was outlined in full to the Integrated Governance Committee at its meeting in May. It involves weekly progress review between the FD and principal budget holders, with any issues of concern being escalated to the Executive team who can direct appropriate leadership and support. This process has matured since the visit as implementation progresses. However, it is clear that in order to really secure the structured drive and urgency, it will benefit from the programme office support discussed above.

FOR DISCUSSION


Agenda Item 3.1

In addition, to provide further assurance and improvement, a review of the HB’s financial regime has been commissioned. Its purpose is to review our overall approach to financial management (inc delivery of savings plans). This review will be looking for confirmation that the organisation has the right financial regime to deliver a complex and challenging programme. This would include looking at behaviours, policies, information, budgeting cycle and monitoring and reporting arrangements. In terms of method – the main vehicle will be structured questionnaire; group discussion, and review of information. As well as key members of the finance team, interview will include some Executives; principle budget holders; GP leads (and maybe clusters) and possibly some key partners – probably limited to Wales and including Welsh Government. Our approach to contracting will be included in this, supported by some additional expertise from an English commissioning and providing environment. The review will take around 6 days of the high level financial support already commissioned and will report in the first week of July.

2) Confirming the appetite of Welsh Government to support challenging within the welsh system including the agreement of tariff deflators, the management/imposition of contract terms which and creation of a currency that enables Powys to properly challenge efficiency and take advantage of strategies that reduce demand on hospitals. To take this forward:-

a) The FD has written to the FD of all Powys’s welsh providers to inform

them of our intention to impose a deflator of 1.8% and to manage activity strictly within contract terms. This enables non payment of some activity on efficiency grounds.

b) At a national level, the creation of a more appropriate regime of payment between HBs is being developed and supported by all Chief Executives.

c) In response to the report on Powys’s financial position both the Health Board’s original and supplementary financial plans have made clear to Welsh Government that its support in our approach to contract management is necessary. To date, explicit confirmation of support has not been received, but neither has the Health Board been discouraged to take this approach. The Health Board will continue with this approach with all Welsh providers unless informed otherwise by Welsh Government. In the meantime, its support will be pursued.

3) Ensuring a number of infrastructure issues are dealt with promptly. This

has been covered within the accelerated OD section of this paper, the specific issues being Locality General Manager appointments; information and realigning executive director roles.

4) Integrating workforce plans with savings proposals. This is being achieved

as the detail behind savings proposals are developed through the processes led by the Finance Director with the support of the Workforce and OD Director.

FOR DISCUSSION


Agenda Item 3.1

Conclusion In summary, this paper describes the process and actions taken to ensure that the programme of transformational change described in embryonic form at the meeting in April, is now moving forward. At this stage, the programme has three main elements to it:-

• Accelerated Clinical Change for Excellence • Accelerated Organisational Development • Financial Programme

Leadership of these is within the Executive Team, which is where it is best placed. Programme design and support is being secured to ensure this leadership achieves best effect. Recommendation The Board is asked to DISCUSS and NOTE this paper for information. Report prepared by: Presented By: Andrew Cottom Andrew Cottom Chief Executive Chief Executive

FOR DISCUSSION

Annual Plan Action Grid Page 9 of 13 Board Meeting 27 June 2012

Agenda Item 3.1

POWYS TEACHING HEALTH BOARD ANNUAL PLAN / MIH ACTION GRID – UPDATED 13 JUNE

APPENDIX 1

Action Number

Item Action Lead Timeframe Deadline

Progress Review

Progress

Note – numbers in brackets ( ) reference to the Improvement Actions in Annual Plan

Annual Plan

Performance Framework

Sign off Chief Executive objectives

ME/AC

31 May

6 June

Complete. Based on Annual Plan

Agree & sign off Executive Directors objectives

AC/All Mid-June 30 May 121 meetings being arranged 20 June

Locality Directors / Teams All Mid-June 30 May North & mid to be set via meeting on 1 June; South tba

13 June Templates to be circulated. Objectives final sign off 11 July 2012

11 July Individual appraisal system – ensure fit for purpose(99)

JD Mid-June 13 June Further work required re: KSF and profile data.

20 June Locality / Division performance review JD End of

June 30 May Noted 20 June

Reporting to Integrated Governance Committee

AC End of June

24 May Basic framework agreed with IG; need to agree mechanism for reporting to IG

20 June Communication Public / organisation facing version BW 30 May 30 May In hand – circulate to Execs and

staff side reps 6 June Drafted – to be agreed via AC &

reviewed 13th June 13 June BW to circulate paper for Exec -

comments due in 19/6/12.

FOR DISCUSSION


Agenda Item 3.1

Action Number


Progress Review

Progress

Note – numbers in brackets ( ) reference to the Improvement Actions in Annual Plan 20 June

Develop and implement communication programme for Annual Plan (inc Making it Happen) – 107/108

BW/JD 6 June 6 June Process of internal communication to be designed & agreed

13 June Deferred 20 June

Meetings & Business structure

To redesign executive meetings structure to ensure appropriate governance and efficient working and decision making

RM

13 June

30 May

Purpose noted. Will need Exec support

13 June Deferred

20 June

Accelerated OD

Executive Directors

Agree revised Executive portfolios (97) JD 23 May Completed Implementation of revised Exec portfolios (97)

JD/All 20 June 30 May Proposal to manage handover with timeframes to be circulated

20 June Executive Director development programme – design & agree implementation

JD/All 13 June 30 May Proposal to be sent to Execs; 1st date to be set

13 June JD arranged for Alan Carpenter to attend next Informal meeting

20 June

Information & performance (inc “Commissioning”)

Information Service

BW End of June

30 May NWIS starting next week. Review progress at 20 June 2012

20 June “Commissioning/Contracting (72) BW End of

June 13 June BW to bring paper to next Exec

meeting re: the process of this action.

20 June

Performance arrangements (100) JD End of June

20 June

FOR DISCUSSION


Agenda Item 3.1

Action Number


Progress Review

Progress

Note – numbers in brackets ( ) reference to the Improvement Actions in Annual Plan Locality Recruit LGM – North & South JD 30 May 30 May South completed

North – rerun 19 June 20 June

Locality Director development programme JD Sept 20 June

Project Management Skills

JD Sept 20 June

Accelerated

Clinical Change

Deep-Dive “Performance gaps & opps)

Design & agree approach

CS/JD

30 May

30 May

Approach agreed

Agree implementation plan CS/JD 30 May 30 May To be achieved via projects – see below

Implementation CS/JD TBA --- ditto ----- Projects Maximising elective services in Powys(48-

54) • Design & agree approach • Implementation Plan

CS

13 June

23 May Agreed need to have more focussed/narrower objective. Theatres was initial suggestion

30 May Deep dive = 1st phase; date needs to be set asap

13 June Deep dive confirmed 05 July 2012 with NILAH. Invitee list to be confirmed. CS requested Deep dive questions to be forwarded prior.

20 June Emergency / non-elective pathways – SEPowys (44-47)

• Design & agree approach with implementation time frames

CS

30 May 30 May Deep dive = 1st phase; date

needs to be set asap

Builth & district health & social care system(38)


CS

13 June

13 June

20 June

FOR DISCUSSION


Agenda Item 3.1

Action Number


Progress Review

Progress

Note – numbers in brackets ( ) reference to the Improvement Actions in Annual Plan Maternity Day Care repatriation plan(67)


CS

13 June

30 May Deep dive = 1st phase; date needs to be set asap

13 June 20 June

Programme Office

Design & agree purpose CS 30 May 30 May Deferred 13 June Deferred 20 June

Secure appropriate skills CS TBA 13 June Ensure Spread Design & agree purpose TBA 20 June

Planning Develop 3 – year plan

Agree approach and timetable(110) BW/SA 20 June 20 June

Financial Delivery of existing plans

Design & implement recovery programme (109)

RR 23 May 23 May Design completed Agreed fortnightly to Execs

Review progress against Financial Plan / Budget setting checklists

RR 23 May 24 May Agreed fortnightly to Execs 6 June Progress noted. AC to send

checklist to principal budgetholders to remind of need to make progress

20 June Check process against A Lord letter RR/AC 6 June 6 June

Three year plan Agree process and timetable for costing (110)

RR 20 June 20 June

Undertake review of financial regime

Agree ToR for review via C Hurst & timetable for completion

AC/RR 6 June 13 June RR to circulate Terms of Reference. Timetable to be agreed and completed by 15 June 2012

20 June

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Agenda Item 3.1

FOR DISCUSSION

Bridging the Gap Action Plan 2011/2012 Page 1 of 4 Board Meeting 27 June 2012

Agenda Item 4.1

BOARD MEETING


BRIDGING THE GAP – ACTION PLAN 2012-13

Report of

Director of Therapies and Health Sciences

Paper prepared by

Planning Manager

Purpose of Paper

To summarise recent developments/discussions relating to work with the Third Section. To present the Board with the Bridging the Gap Action Plan which will act as the main focus for joint work with the Third Sector in 2012-13.


The Board is asked to APPROVE the Bridging the Gap Action Plan 2012.

Link to ‘Standards for Health Care’

3. Health Promotion, Protection and Improvement 5. Citizen Engagement and Feedback 6. participating in Quality Improvement Activities 7. Safe and Clinically Effective Care 8. Care Planning and Provision




WG – Welsh Government PAVO- Powys Association of Voluntary Agencies WCVA – Wales Council for Voluntary Action HSCF – Health and Social Care Facilitator DNS – Director of Nursing Services Director of HR – Director of Human Resources CHC – Continuing Health Care PQASSO-Practical; Quality Assurance Systems for Small Organisations

FOR DISCUSSION


Agenda Item 4.1

BRIDGING THE GAP – ACTION PLAN 2012-13

Background Powys tHB commissions a range of services which are delivered by the Third Sector. Most of these agreements have been in place for a number of years, and their funding has been built on the historic value of the agreement including any annual uplift as directed by WG. The Health Board has directly funded c£1.0m to the Third Sector through its discretionary allocation and a further c£0.279m through funding that was formerly directly granted, by WG, through WCVA, to Third Sector Mental Health Services providers. The total funding for Third Sector agreements for 2012-13 is c£1.4m. Many of the services are targeted at reducing hospital admissions, supporting independent living and effective hospital discharge. In 2011 a collaborative document “Bridging the Gap” was published (http://www.gavowales.org.uk/file/Bridging_The_Gap.pdf) aimed at addressing the challenge to fully utilise the Third Sector contribution in the management of complex care.. It makes a significant contribution to the potential for NHS bodies, the Welsh Government and the Third Sector to build additional capacity in caring for those with complex conditions and to be able to measure progress Bridging the Gap – Addressing the Challenge to Fully Utilse the Third Sector Contribution in the Management of Complex Care The report was published jointly by the WCVA and the Continuing NHS Healthcare National Programme. In addition to developing and implementing effective efficient, flexible service models for those eligible for Continuing NHS Healthcare, the programme, linked to “Setting the Direction”, sought to identify ways in which the NHS could support and maximise all opportunities to maintain independent living, to support people with complex healthcare needs to remain in their usual place of care and prevent dependency on higher levels of care. The report contained 12 recommendations which aim to ensure engagement with the Third Sector is systematic and strategic in nature. The recommendations are accompanied by key actions enablers and proposed outcome indicators. The Draft Action Plan Powys tHB’s response, which has been drawn up in conjunction with the Powys Association of Voluntary Organisations (PAVO), is attached at Appendix 1. This represents a comprehensive plan of action for joint work with the Third Sector in 2012-13. It is proposed that actions required will form the main focus for monitoring progress and will be the foundation of the 2012-13 work-plan for the Health and Social Care Facilitator. The Director of Public Health and Planning is the Executive Lead for Third Sector liaison and will be responsible for monitoring progress against the plan.

FOR DISCUSSION


Agenda Item 4.1

Highlights of Progress to date Considerable progress has been achieved already against some of the actions, as shown below Contracting processes and review .(relvant to recommendations 1, 2 and 4) Historically contracts with third sector providers were “rolled over” each year often without the benefit of robust reviews and clinical input . In September 2011, the Board of Directors agreed a more detailed review process for 2012-13 which aimed to ensure that performance against voluntary sector contracts became an integral part of the Third Sector agenda. It agreed that the reviews should be led by relevant clinicians and were to be based on proformas developed by the Welsh Council for Voluntary Action. All current Third Sector SLAs have now been reviewed by key clinicians in the first phase of the process. A list of these is attached at Appendix 2. Information obtained from the reviews will be used to inform the 2012-13 contracting process. Standards for Health Services (Recommendation 6) – PAVO’s Continuing Health Care Link Officer work on Safe and Equitable Tier 1 services. has resulted in a high level of awareness of Standards for Health Care. In response to requests for additional support from smaller local (Tier 1) organisations in respect of Standards for Health Services, PAVO has developed a Powys Toolkit that raises awareness and signposts Third Sector organisations to local resources and support. This is attached as Appendix 3 PAVO is also working with the sector to map existing quality assurance standards (e.g. PQASSO, Investors in Volunteers) against Standards for Health Services to reduce the need for duplicate improvement plans. Over the last two years, PAVO has worked with WCVA and Welsh Government Clinical Governance Support Unit to develop and pilot training for Standards for Health Services for the Third Sector. This training will now be rolled out across Wales with two training sessions being planned for 2012-13 in Powys. Reciprocal arrangements are being developed with Health and Social Care Facilitators in Hywel Dda to enable Third Sector organisations to attend training sessions across Powys / Hywel Dda area. PAVO is collecting data on enquiries relating to Standards for Health Services and is working with tHB to establish baseline data and performance outcomes in respect of these. It has also developed a Healthcare Standards Toolkit for use by the Third Sector in Powys which is attached as Appendix 4. Revised Process for Small Health Grant Scheme in Powys (Recommendation 4) a revised process has recently been agreed to ensure that the allocations are directed towards those interventions which are likely to have the greatest impact.

FOR DISCUSSION


Agenda Item 4.1

Conclusion An Action Plan has been developed in response to the 12 recommendations contained in the Bridging the Gap report. This will be the main focus of joint work with the Third Sector during 2012-13. Progress has already been made against several of the recommendations and formal monitoring of the Action Plan will take place on a quarterly basis Recommendation The Board is asked to APPROVE the Bridging the Gap Action Plan. Report prepared by: Presented By: Pat Tempest Amanda Smith Planning Manager Director of Therapies and Health

Sciences Background Papers Bridging the Gap Action PlanFinancial Consequences No direct consequences although achievement of

the Action Plan is aimed at making best use of available funding

Other Resource Implications No direct implications Consultees PAVO

Gloria Jones Powell

Bridging the Gap Action Plan Report – Appendix 1

BRIDGING THE GAP ACTION PLAN 2012-13

Recommendation 1 –STANDARDISING THIRD SECTOR PROVISON ACROSS POWYS WHEREVER POSSIBLE AND APPROPRIATE

Key Actions Outcome indicators Current Position Planned activity Timescale Lead Establish a baseline Capture information on all 3rd sector services delivered in Powys

Schedule in place of all 3rd Sector Providers funded by tHB Information held by communication hubs

Schedule in place currently under review (May 12)

Complete review and identify gaps in provision

August 12 Interim Director of Planning

Local compact to be established

Compact in place Current compact (established 2006) under review

Agree new compact March 13 PAVO Chief Officer

Ensure involvement of 3rd sector in development of communication hubs

Number of 3rd sector organisations in mid Powys communications hub database. Number and percentage of 3rd sector referrals Percentage of 3rd sector organisations registered on NHS Direct and/or local communications hub compared to initial stocktake

Mid Powys communications hub established as pilot. Referrals into 3rd sector limited

Contribute 3rd sector perspective to evaluation of Hub, making appropriate recommendations Identify gaps and promote and support registration of 3rd sector on NHS databases and INFO Engine

July 12 March 13

HSCF

Based on benchmarking exercise identify evidence based services that would provide benefits if rolled out

Regular reports on effectiveness of current 3rd sector support e.g. through reviews of contracts.

Evidence base being developed incrementally. Process for review of contracts is being refined

Continue to develop evidence base Continue to develop robust review process for current 3rd sector contracts

March 13 Interim Director of Planning


Recommendation 2 – EXPLOIT ALL OPPORTUNITIES TO ENABLE THE THIRD SECTOR TO CONTRIBUTE TO TRANSFORMATIONAL CHANGE

Key Actions Outcome indicators Current Position Planned activity By Lead Identify 3rd sector inputs within One Powys Plan, Levering Service Change Compendium, Setting the Direction, Powys Joint Maturity Matrix and Bridging the Gap Report

Percentage of services with 3rd Sector inputs compared to initial stocktake

Data available but not yet collated

Collate date into standardised format for defined service areas and in different geographical localities

Dec 12 Interim Director of Planning

Disseminate and promote good practice


Disseminated through 3rd sector networks, PAVO e briefings and tHB planning groups

Increase dissemination of good practice through multi-sectoral training and workshops and incorporate routinely into service planning, commissioning and development Audit of health teams in Crickhowell to investigate strength of third sector links

Mar. 13 Interim Director of Planning

Consideration of added value of 3rd Sector inputs in all new and revised service models


Joint Performance Monitoring (JMT) provides some information on added value. tHB directs CHC funding towards projects shown to add value e.g. PURSH and RRAP

Collate current data on added value through JMT reports and feedback to 3rd sector providers Further develop JPMT with measure of added value based on Social Return on Investment

Dec 12 Director of Human Resources Director of Human Resources HSCF


Recommendation 3 – THIRD SECTOR MUST BE ABLE TO CONTRIBUTE TO FORMAL ASSESSMENT AND CARE PLANNING PROCESSES

Key Actions Outcome indicators Current Position Planned activity Timescale Lead 3rd Sector to be formally linked into tHB Unified Assessment (UA) processes in those circumstances where 3rd Sector organisations are providing part of the service response or acting in an advocacy role for either/both service user and/or carer tHB approach to UA will reflect this requirement and ensure processes are in place to formally link 3rd Sector partners into the assessment and care planning process

percentage of 3rd sector staff providing inputs into a care package that formally links into the UA process or other shared assessment process

Unified Assessment Processes Minimal involvement to date of 3rd Sector in place with dedicated teams such as reablement and on project sites There is a review on nurse documentation on an all Wales basis and an ongoing local review of the current UAP application

Work with 3rd sector providers, social services etc. to identify key pathways for 3rd sector involvement including carers. Establish baseline activity and monitor progress

Mar. 13 DNS

Work with 3rd Sector Provider Forum to agree consistent reporting on added value


Recommendation 4 - COMMISSIONING STRATEGIES MUST PROACTIVELY EMBRACE THIRD SECTOR

Key Actions Outcome indicators Current Position Planned activity Timescale Lead 3rd Sector to be included within appropriate service planning processes to ensure appropriate consideration of inputs is available at an early stage

Percentage of service planning processes which regularly include 3rd Sector inputs Percentage of new/increased 3rd Sector services commissioned

Many service planning groups do include 3rd Sector representatives however this needs to be kept under review as the structures within the tHB change 8% of SLAs allocated in 11/12

Audit existing service planning processes for 3rd Sector involvement review current services to allow for new service development

Mar. 13 Interim Director of Planning Director of HR

Social clauses to be recognised in SLAs where appropriate and contracts grants to reflect outcomes

Percentage of SLAs with social clauses

Standard SLA in use with all providers

Review current SLA for social clauses

Aug 12 Director of HR

Where appropriate establish a 3rd Sector Key Fund with CVCs to enable small local interventions that have a high impact in complex care

Introduction of a Key Fund Small health grant scheme in place Thb has directed its Continuing Health Care (CHC) Funding towards specific schemes aimed to prevent hospital admissions e.g. PURSH and

Develop robust criteria for small grant scheme to ensure funds allocated to schemes having high impact. Ensure synergy with PCC independent living programme. Consider use of charitable funds to augment small health grant

June 12 Dec 12

HSCF Interim Director of Planning

Local Compact Code of Practice for Funding 3rd Sector principles reflected in local commissioning and procurement processes

Level of Compliance with Code of Practice

Commissioning Strategy reflects principles in Designed to Add Value

Make explicit links between PtHB commissioning strategy and Code of Practice for Funding 3rd Sector

Dec 12 HSCF

A register to be established of current third sector providers with grant agreements/contacts

Register in place Register in place Review and update Mar. 13 Director of HR


Recommendation 5 – THIRD SECTOR PROVIDERS ARE MEMBERS OF THE MULTI-DISCIPLINARY TEAM (MDT)

Key Actions Outcome indicators Current Position Planned activity Timescale Lead 3rd Sector representation to be included as part of the care planning process when it is determined they will contribute towards the overall care package and to support service user and carer voice an choice

Percentage of MDTs with 3rd Sector representation when appropriate

Some service specification require attendance at MDT meetings. Communications hub pilot is highlighting opportunities to clarify and strengthen the role of the 3rd Sector in MDTs and the need to develop shared governance arrangements Carers and advocacy organisations have evidence of variable involvement of carers in MDTs and discharge arrangements

Audit current service specifications and levels of involvement Agree good practice with 3rd Sector providers and MDT leads and disseminate Establish reporting system for 3rd sector providers and MDT good practice Develop good practice protocol for involvement of carers and advocated in discharge planning and monitor

Mar 13 Mar.12

Director of HR DNS

CHC programme MTD development work to include 3rd Sector representation


CHC programme in place Audit current arrangements. Secure 3rd sector representation for MDT development workstream Engage service providers in dialogue re 3rd Sector provider and support roles in MDT.

Mar.13 Interim Director of Planning

MDT development work to include reference to 3rd Sector roles as part of MDT where appropriate


Ensure that good practice is incorporated into MDT development work

Dec 12 Interim Director of Planning

Utilisation of local Communications Hub directory of services in order to sign post patients to 3rd Sector services

Number of referrals to 3rd Sector services

INFO engine (signposting) under development Directory of ‘funded’ services from 3rd Sector available Interim evaluation of hub indicates low number of referrals to sector

Further technical development of INFO engine Development of protocols to signpost referrals to 3rd Sector

Dec. 12 HSCF


Recommendation 6 – THIRD SECTOR MUST WORK TOGETHER TO DEMONSTRATE THE QUALITY OF SERVCIES USING STANDARDS FOR HEALTH CARE IN WALES

Key Actions Outcome indicators Current Position Planned activity Timescale Lead 3rd Sector Board members to develop and implement a pan-Wales Support Programme to enable third sector organisations to use the Standards for Health Services through the “How to Guide” with joint learning nd support resources for both the 3rd Sector and tHB staff

Percentage increase I n 3rd Sector organisations with completed self assessment portfolio

PtHB Board member and 3 PAVO staff trained on use of the “How to guide and delivery of Training Sessions. Dedicated resource produced by PAVO for awareness raising and use with small organisations. Understanding of Standards for Health Services relevance to groups embedded across PAVO staff.

Develop a shared understanding of proportionate levels of compliance for small organisations with PtHB, Welsh Government and Wales Council for Voluntary Agencies. Establish baseline data and performance indicators Provide training and support to 3rd Sector provider

Mar. 13 HSCF


Recommendation 7 – BETTER UTILISE NEW AND EXISTING OPPORTUNITIES TO IMPROVE KNOWLEDGE ABOUT AND SKILLS WITHIN THE THIRD SECTOR AND ABOUT THE THIRD SECTOR

Key Actions Outcome indicators Current Position Planned activity Timescale Lead Third sector included in appropriate training and development opportuntities provided by the tHB. These opportunities are in addition to core training available via CVCs

Percentage of 3rd Sector staff accessing joint training opportunities

Third sector is made aware of training and development opportunities on an ad hoc basis - PCC integrated training programme is widely circulated to the sector New requirement under Carers Measure to support carers will impact upon this outcome

Continue to identify training/development opportunities relevant for different types of 3rd organisation and to proactively promote these Establish baseline data, monitoring systems and to set targets for improving 3rd Sector participation in relevant training Strengthen joint health/ social care training via Integrated HSC training Incorporate training requirements in new contracts/ SLA for 3rd Sector

Dec.12 Interim Director of Planning

Percentage of tHB staff receiving training on role of 3rd Sector

Ad hoc training opportunities

Organise awareness raising sessions for tHB staff to better understand 3rd Sector as providers and supporters of statutory agencies.

Monitor attendance and impact on signposting/referral to 3rd Sector

Develop presentation/induction/e-learning pack

Further development of INFO Engine and train tHB staff on its use

Mar.13 HSCF


Recommendation 8 – ACTIVELY INCREASE AND IMPROVE SUPPORT FOR CARERS

Key Actions Outcome indicators Current Position Planned activity Timescale Lead With reference to the Carers’ Strategy Measure and work under ‘Sustainable Social Services: A Framework for Action’, contribute to and support the development of the communications hubs using the community resources model of primary care delivery. Build on the approach of existing carers’ centres in Wales in order to provide access to information; training for the unpaid carer such as manual handling and infection control; and emotional support.

Agree universal service standard

Consultation on Carers’ Measure is underway. Carers currently access PCC integrated training

Raise awareness of universal service standards for carers ensure that carers, key tHB staff and external provider organisations understand what constitutes good practice an and how to report breaches.

Work with training partners to improve access to training for carers, monitor carers attendance and obtain feedback on relevance of training provided

Mar. 13 DNS

Work to agree and establish universal access for carers to these comprehensive services in Powys

Percentage of Powys residents accessing services that comply with the universal standard

Carers and advocary organisations have evidence of differing levels of support across NHS services.and differing involvement of carers in discharge

Develop baseline data, identify priority areas and performance targets Establish accessible reporting systems for breaches of good practice .

Dec.12 DNS

Work to support the involvement of carers in Unified Assessment and Multi-disciplinary Teams

Percentage of MDTs/UA and discharge processes involving carers

Implement universal standards and monitor breaches of good practice Prioritise involvement of carers and advocates in discharge planning Identify gaps in support for carers through communications hub.

Dec.12 DNS


Recommendation 9 – UNDERSTAND AND IMPROVE THE USE OF THE THIRD SECTOR IN THE CARE OF PEOPLE WITH SPECIALIST CONDITIONS

Key Actions Outcome indicators Current Position Planned activity Timescale Lead THB to undertake a gap analysis to determine how it uses 3rd Sector organisations when planning and providing services for people with specialist conditions

Increased use of Third Sector organisations in the planning an provision of care for those with a specialist condition

PAVO study of national HSC organisations highlights challenges for Third Sector organisations not based in Powys providing support to Powys residents

Access to specialist 3rd Sector support not equitable across powys

Development of action learning set to improve access for rural residents to advice on specialist conditions. Promotion of INFO Engine as a mechanism for 3rd Sector providers not based in Powys to advertise services Strengthen links between national and local information and advice networks and tHB staff supporting people with specialist conditions

Complete gap analysis involving users carers and providers

Mar. 13 HSCF

Identify 3rd Sector inputs in supporting people with specialist needs during the transition process from children and young people to adult services

Increased use of Third Sector organisations in the planning an provision of care for those with a specialist condition

Further information required on current processes

Clarify current transition process and audit 3rd Sector involvement

Mar.13 HSCF


Recommendation 10 – IMPROVED ACCESS AND PROACTIVE DISCHARGE PLANNING

Key Actions Outcome indicators Current Position Planned activity Timescale Lead 3RD Sector to link to discharge planning training and development within tHB as route to inform operational practitioners of 3rd Sector roles in effective, timely discharge plans

Percentage of discharges that have 3rd Sector input as part of on-going care plan

Further information required on involvement of 3rd Sector in discharge planning

identify baseline activity , agree good practice with 3rd Sector and discharge planning teams, - support training to implement

Dec. 12 Locality General Managers

THB to have a strategy in place re access to 3rd Sector services available in Powys.

Percentage of discharges that have 3rd Sector input as part of on-going care plan

Strategy not yet developed

Develop Strategy Mar.13 HSCF


Recommendation 11 – PEOPLE AND FAMILIES HAVE GREATER KNOWLEDGE AND AWARENESS OF THIRD SECTOR SERVICES AND HOW TO ACCESS THEM

Key Actions Outcome indicators

Current Position Planned activity Timescale Lead

THB to work with Health and Social Care Facilitator to collate information held on 3rd Sector inputs and ensure the information is easily accessible

Percentage of 3rd Sector organisations on NHS Direct and/or Communications Hubs

Service provider organisations in Mid Powys on Communications Hub database. Limited data available on 3rd Sector inputs due to low level of formal referral. Continued commitment to development of INFO Engine

Additional support being provided for development of INFO Engine and registration of providers

Dec.12 HSCF

THB to explore ways in which 3rd Sector inputs can be highlighted with Primary Care Practitioners to support community based access to 3rd Sector inputs via Communications Hubs

Increased referrals to 3rd Sector support through Communications Hubs

As above Establish good practice in 3rd Sector referral with Service Provider Forum and key tHB and PCC staff involved in the Communications Hub and integrated referral pathways

Dec.12 HSCF

Communications Hub information to be reviewed to ensure it remains up to date and provides access details

Increased referrals to 3rd Sector support through Communications Hubs

Formal evaluation of Mid Powys Hub being undertaken

Undertake joint training for tHB, PCC and 3rd Sector Providers and establish regular review of information

Mar.13 HSCF


Recommendation 12 – INCORPORATE THIS ACTION PLAN INTO THB ORGANISATIONAL PERFORMANCE PLANNING AND DEVELOPMENT PROCESSES

Key Actions Outcome indicators

Current Position Planned activity Timescale Lead

THB to link actions recommended in this action plan to work undertaken as part of the Compact development

Total value of commissioned 3rd Sector services in Powys

Contracts and value identifed

Develop matrix of 3rd Sector providers/ commissioned services in each locality. Ascertain the nature of current funded services and involvement by service providers in key priorities of Bridging the Gap including Communications Hub; Multidisciplinary team , Unified Assessment and Discharge Planning, carer support , registration on info Engine ; support for chronic conditions and evidence of compliance with Standards for Health Services. As part of annual review, develop longer term indicators for tHB, HSCF and Third Sector provider

Mar.13 Director of HR HSCF

Quarterly updates on progress to be provided to Powys and 3rd Sector through dissemination by WCVA

Total number of people with complex needs receiving commissioned 3rd Sector services

PAVO provides information to WCVA on request but system for collection of appropriate date needs to be agreed

Regularly feed in quarterly monitoring information to Welsh Government and WCVA. Agree systems for quantifying and reporting on number of people with complex conditions and their carers receiving commissioned 3rd Sector services through primary care, Community Resource Team, Communications Hubs and District General Hospitals

June 12 Mar.13

HSCF

Bridging the Gap Action Plan Report ‐ Appendix 2

Summary of Third Sector SLAs May 2012

NB: Further work is required to finalise the list of contracts, sums and budget location.

Organisation:

2011/12 budget £

3 Counties Cancer Network 3,023

Beacon of Hope 0 Bobath 49,231 Bobath - Cost per Case 13,264 Bracken Trust 14,000 Crossroads Mid and West Wales 42,783 Crossroads Mid and West Wales 6,112 Brecon and District Contact Association 29,190 Brecon and District Contact Association 91,841 Brecon and District Contact Association 16,662 Community Safety Partnership Cruse 18,884 Hope House Childrens Respite Hospice 6,750 Mid Powys Mind 17,986 Mid Powys Mind 55,991 PAVO - H & S S co-ord 62,587 PAVO - Community Transport PAVO - Small Grants 10,491 PAVO - Continuing Health Care Pont Hafren Association 50,550 Pont Hafren Association 22,608 Powys Agency Mental Health (Mont/Info) 25,823 Powys Agency Mental Health (Mont/Info) 72,507 Powys Carers 16,781 Kalediscope 219,556 Powys Mental Health Alliance 12,351 Powys Mental Health Alliance 19,593 Relate 2,659 Severn Hospice 67,584 Severn Hospice - Hospice at Home St Michaels Hospice 28,779 Stroke Association 31,415 Tros Gynnal 20,982 Ty Hafan 6,446 US Machynlleth 3,368 St. Davids Foundation Hospice Care 15,617


Vol Bureau Community Support Groups 16,011

Ystradgynlais Mind 28,068

Organisation:

Barnardos (accomodation) IMHA 15,983

IMCA (CHC) 37,996 Powys Advocacy (CHC) 60,039 Powys Advocacy (CHC) 10,681 Powys Citizens Advice Bureau 2,764 Powys Health Forum PPI 20,982 Substance Misuse Police 25,612 Total

Vol Bureau Community Support Groups Builth Wells Community Support Brecon Volunteer Bureau Community Action Machynlleth and District (CAMAD) Crickhowell Volunteer Bureau Hay and District Community Support Knighton and District Community Support Llandrindod Wells and District Volunteer Bureau North Montgomeryshire Volunteer Bureau Presteigne Norton Community Support Rhayader & District Community Support South Montgomeryshire Volunteer Bureau Ystradgynlais Volunteer Centre

Other SLAs (notified by Localities etc)

Women and Children’s Services

Psychosexual Counselling Services Cymru contact value £7200


Mental Health Services ‐ mental health grant scheme (LMHGS) as follows

Organisation LMHGS PTHB Total

Brecknock and Radnor Community Health Council £10,681 £10,681

Brecon and District Contact Association £91,841 £29,193 £121,034

Crossroads Mid & West Wales ‐ Brecon Area Office £6,112 £6,112

Mid Powys Mind £55,991 £17,988 £73,979

Ponthafren Association £22,608 £50,556 £73,164

Powys Agency for Mental Health £72,507 £25,825 £98,332

Powys Mental Health Alliance £19,593 £12,351 £31,944

Cruse £18,886 £18,886

Relate £2,659 £2,659

US Machynlleth £3,368 £3,368

Ystradgynlais Mind £28,071 £28,071

The Standards for Health Services in Wales:

A toolkit for the third sector in Powys

Introduction to the Standards for the Third Sector in Powys 1. About this toolkit 2. What are the Standards for Health Services in Wales? 3. How are the Standards useful? 4. Making the Standards appropriate and proportional for the third sector 5. An introduction to the Standards for third sector organisations 6. Where to go for training and support in Powys

May 2012

The Standards for Health Services in Wales: A toolkit for the third sector in Powys Introduction to the Standards

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INTRODUCTION TO THE STANDARDS FOR THE THIRD SECTOR IN POWYS

1. About this toolkit: This toolkit has been designed by PAVO: to raise awareness and understanding of the Standards

for Health Services in Wales and its relevance to the third sector in Powys

to embed the adoption of the Standards for Health Services in Wales within a wider commitment to developing good governance and quality assurance mechanisms

to flag up examples of good governance and good practice relevant to the third sector in Powys

to signpost the third sector to appropriate resources, training and support

Third sector organisations in Powys have been able to pilot the How to Guide and to feedback third sector views about the adoption of the Standards to PAVO, WCVA and the Welsh Government. PAVO is currently working with local and national partners to: ensure that quality assurance priorities within health and

social care are aligned together encourage local commissioners and other funders to

formally endorse the Standards ensure appropriate support is available for third sector

organisations using the Standards for Health Services in Wales

encourage the development of a quality mark or other form of external validation

2. What are the Standards for Health Services in Wales? The Standards for Health Services in Wales are a set of 26 governance standards which provide a framework for quality and safety in health services. They were published in April 2010. All NHS services and NHS funded services, as well as those required to register with Healthcare Inspectorate Wales should use and meet the Standards for Health Services in Wales and/or the National Minimum Standards for Independent Health Care Services in Wales. For ease, we will refer in this toolkit to the Standards for Health Services in Wales simply as “the Standards”.


2. Equality, diversity and human rights

3. Health promotion, protection and improvement

4. Civil contingency and emergency planning arrangements

5. Citizen engagement and feedback

6. Participating in quality improvement activities

7. Safe and clinically effective care

8. Care planning and provision

9. Patient information and consent

10. Dignity and respect

11. Safeguarding children and vulnerable adults

12. Environment

13. Infection prevention and control and decontamination

14. Nutrition

15. Medicines management

16. Medical devices, equipment and diagnostic systems

17. Blood management

18. Communicating effectively

19. Information management and communication technology

20. Records management

21. Research, development and innovation

22. Managing risk and health and safety

23. Dealing with concerns and managing incidents

24. Workforce planning

25. Workforce recruitment and employment practices

26. Workforce training and organisations development


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3. How are the Standards useful? It is necessary for ALL organisations or services funded by NHS Wales to demonstrate their use of the Standards. In addition, using the Standards can also be an important way for organisations receiving referrals from NHS services or wishing to work with the NHS to demonstrate the safety and quality of their standards in a way that is consistent with the NHS. The Standards can also be particularly useful for organisations and services who do not use other standards or quality assurance systems.

The Standards can help you to improve and develop services:

review services and promote honest discussion about strengths and weaknesses in your organisation

assess where you are doing well and have good practice to share and where you could do better and have areas for improvement

develop improvement plans to address the weaker areas

identify opportunities to develop and extend services

The Standards can help you to improve engagement and participation:

improve team working within your organisation

involve your board/trustees in the process of assurance and monitoring

involve your clients and service users in assessing the services they receive

improve joint working with other third sector organisations

promote open dialogue with the Health Board and other funders

Statement from Powys teaching Health Board (2012): The Standards for Health Services, April 2010 are embedded within Powys teaching Health Board at all levels; all staff are aware of the standards and see them as a quality framework which helps contribute to service improvement. It is important that all partner organisations are aware of the standards and understand it is not a “tick box” exercise that you either meet or don’t meet. The standards provide a framework for quality and safety which enables you to understand how you are performing against the standards in your everyday work. We appreciate that using them for the first time might be daunting, particularly for smaller organisations. The templates provided in the “how to guide” should help you carry out your own self assessment against the standards. It will help you develop a self assessment portfolio (Powys teaching Health Board will not expect a folder of evidence as the location of evidence should be recorded on the self assessment and improvement templates) to plan for continuous review, learning and service improvement to demonstrate how your service meets the standards and ensures effective provision for the people of Powys.


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4. Making the Standards appropriate and proportional for the third sector:

The Standards have been designed for all NHS Wales funded services – from your local GP’s surgery to the Accident and Emergency ward to a local befriending project. This means that some standards will be more or less relevant to some services and organisations than to others.

How do you “meet” the Standards? The Standards are not a “tick box” exercise that you either meet or don’t meet. However, you must still comply with the appropriate laws and regulations governing your organisation and services. Some of these laws and regulations are referred to within the Standards for Health Services in Wales and compliance with these is compulsory. Providing assurance of the quality of your services through use of the Standards may give NHS organisations greater confidence to work closely with your organisation and fund your services. The Healthcare Inspectorate Wales (HIW) also assess how well individual health service organisations perform in relation to the Standards.

We already use other professional and regulatory standards. Do the Standards replace them? No. The Standards for Health Services in Wales have been designed to be used alongside other standards – both voluntary and compulsory. They are not intended to replace them or to add wholesale to them. To make things easier, PAVO is cross-referencing the Standards for Health Services in Wales with some of the other standards commonly used within the voluntary sector in Powys. We will continue to examine more sets of standards and put information up on our website at http://www.pavo.org.uk/support/standards-for-health.html

Although we are funded by NHS Wales, we do not provide medical care. Are the Standards really that relevant to us? Yes. Some of the Standards are specifically focused on developing and maintaining a high level of medical care. However, many of the Standards relate to ensuring general good governance (i.e. running your organisation effectively and legally) which is relevant to your organisation whatever your size or focus of your activities. For example, the Standards can help you reflect on your current practices relating to communication, use of data, employment, joint working, health and safety, and business planning. You need to examine all 26 of the standards although it is up to you to decide which order you examine them in. If any standard does not apply to your organisation (e.g. 17: Blood Management is unlikely to apply if you do not deal with blood products), you can note this down with a clear short statement explaining why, when you build your self-assessment portfolio.

What will we need to do to demonstrate that we are using the Standards? The simplest way to demonstrate that you are using the Standards is to build a self-assessment portfolio. The How To Guide, developed by WCVA, provides a suggested step by step approach to building your self-assessment portfolio and includes templates to help you in the process.


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5. An introduction to the Standards for third sector organisations:

This section tells you a little bit about each standard and asks some initial questions to get you thinking about how well you are currently doing. This section also signposts you to some of the relevant guidance and other resources available for you to use as you work on improving your services against the standards. In the next section you can find more details about where to go for further training and other support available if you want to know more about and these topics and boost your skills.

If you want to know more about the Standards themselves, you should go to the NHS Wales Governance E-manual. Here you can download the Supporting Guidance to the Standards which goes through the Standards in a lot more detail and signposts to a comprehensive range of relevant legislation and guidance. You can also download an Easy-Read leaflet about the Standards which is aimed at anybody who uses health services. Links to these resources are all available from the Standards for Health online toolkit on the PAVO website: http://www.pavo.org.uk/support/standards-for-health.html

Standard 1: Governance and accountability framework

This standard is about making sure that you have effective systems and processes in place so that your organisation is running properly and you can provide high quality services and support.

What are your organisation’s values and objectives? Do your trustees, staff and volunteers know and understand them?

Are you complying with all the relevant regulations, accreditation and requirements? How do you know what they are?

How can you ensure that you are not wasting money and time?

How do you identify and manage risks?

Are you working well with other organisations or teams?

Standard 2: Equality, diversity and human rights This standard is about making sure that everybody is treated fairly no matter their identity, background, position or age, and about adopting policies and practices which try to reduce health inequities.

How does your organisation ensure it takes account of different people’s needs (including clients, carers, staff and volunteers)?

How do you challenge discrimination?

Do you actively seek to reduce health inequities? How can you demonstrate this?


6

Standard 3: Health promotion, protection and improvement This standard is about making sure that your organisation supports staff and volunteers to stay safe and healthy and that you are able to play your part in supporting clients and other citizens to maintain and improve their health, wellbeing and independence.

What policies or schemes does your organisation have and use to promote and protect the health and wellbeing of staff and volunteers?

How do you support clients and other citizens to maintain and improve their health, wellbeing and independence?

Supporting staff to stay healthy and get through ill health: Healthy Working in Wales has been developed to support employers, employees and health professionals to improve health at work, prevent ill health and to support return to work following ill health. It includes the Corporate Health Standard, run by the Welsh Government, which is the quality mark for workplace health promotion in Wales. It also includes the Health at Work Advice Line Wales, a pilot service providing managers and employees of small businesses with easy access to professional occupational health advice over the telephone. For more information on this support go to http://www.healthyworkingwales.com/

Your organisation may also wish to sign up to The Mindful Employer Charter. This is aimed at increasing awareness of mental health at work and demonstrates that you are working towards supporting staff with their own mental health issues. There is an administration charge. For more information http://www.mindfulemployer.net/

Standard 4: Civil contingency and emergency planning arrangements This standard is about making sure your organisation is prepared for emergencies so that you can still deliver services.

What risks and emergencies could stop your organisation from delivering services as usual?

Have you got emergency plans? Have you tested them?

Do all your staff understand their roles and responsibilities in the event of an emergency?

How would you warn or inform service users and other citizens in an emergency?

Standard 5: Citizen engagement and feedback This standard is about making sure that your organisation asks clients, carers and other stakeholders about their experiences and views, and that you show how you are using this feedback to improve the delivery of services and plan new services.

How does your organisation collect feedback from clients and other stakeholders?

Are there any stakeholder groups who are reluctant to feedback or who have difficulty doing so? What could you do to make it easier for them?

How can you demonstrate that you are acting appropriately on feedback received and sharing it with the relevant people inside and outside your organisation?


7

Standard 6: Participating in quality improvement activities This standard is about making sure that your organisation works towards improving services (reducing waste, variation and harm) in a thorough and consistent way, for example by using recognised methodologies and reliable recording and measuring systems and by making sure that everybody is on board.

How do you identify where your organisation needs to improve? How do you decide how you are going to do it and what things you are going to tackle first?

Are there particular methodologies or systems that could help make recognising and tackling areas for improvement easier?

Do managers and team leaders support staff and volunteers to identify and address improvements?

How do you measure and record improvements?

How do you share learning?

1000 Lives Plus 1000 Lives Plus is the national improvement programme, supporting organisations and individuals, to deliver the highest quality and safest healthcare for the people of Wales. The programme is focussed on building capacity and spreading and embedding best practice in order to make sustained improvements in care. To find out more, visit http://www.1000livesplus.wales.nhs.uk/

Standard 7: Safe and clinically effective care This standard is about making sure that your organisation is providing people with safe and effective care by following best practice and supporting staff to keep up to date with their knowledge and skills.

How does your organisation hear about and receive best practice guidance? How do you assess its relevance and move forward with implementing or acting on it?

How do you record and learn from incidents when best practice has not been followed?

Standard 8: Care planning and provision

This standard is about making sure that people are treated in the right way, at the right time, in the right place and with the right staff.

How does your organisation take into account the individual needs of clients?

How long does it take for your organisation to provide support or services to a client or to point them to the right type of support for them? Is this timescale appropriate?

How do you promote and support self-care, rehabilitation and re-enablement?

Do you have effective working relationships with partners? What steps should be taken to improve them?


8

Standard 9: Patient information and consent This standard is about making sure that your organisation provides appropriate information and opportunities to people so that they can make decisions on their condition, care, medication and support arrangements, and also that you treat people’s information confidentially unless it is appropriate to share.

How do you ensure that the information your organisation gives to clients about their condition, care, medication and support options is easy to understand? Are you sure that they find it useful?

Do all your staff and volunteers understand what information needs to be kept confidentially and what that entails?

Are you up to date with current patient consent legislation and best practice?

Could the Mental Capacity Act (2005) have implications on your work and responsibilities?

Standard 10: Dignity and respect This standard is about making sure that clients, carers, volunteers and staff are treated with dignity and respected for their differences.

Do the services your organisation provides offer dignity to clients and carers? How do they compare with the 10 challenges from the SCIE Guide on Dignity in Care?

Is the environment that people use or work in pleasant and appropriate to their needs? Does it allow appropriate privacy?

How would you deal with a complaint that a staff member’s dignity and respect was being compromised?

The SCIE Guide on Dignity in Care The Social Care Institute for Excellence (SCIE) has produced a practice guide to support organisations to drive up standards of dignity in care and meet the Dignity Challenge. The Dignity Challenge is a clear statement of what people can expect from a service that respects dignity.

The Dignity Challenge:

High quality care services that respect people’s dignity should:

1. have a zero tolerance of all forms of abuse 2. support people with the same respect you would want for yourself or a member of your family 3. treat each person as an individual by offering a personalised service 4. enable people to maintain the maximum possible level of independence, choice and control 5. listen and support people to express their needs and wants 6. respect people’s right to privacy 7. ensure people feel able to complain without fear of retribution 8. engage with family members and carers as care partners 9. assist people to maintain confidence and a positive self-esteem 10. act to alleviate people’s loneliness and isolation.

The Guide is available at http://www.scie.org.uk/publications/guides/guide15/files/guide15.pdf and further information is available at http://www.scie.org.uk/publications/guides/guide15/index.asp


9

Standard 11: Safeguarding children and vulnerable adults

This standard is about making sure that children and vulnerable adults are kept safe and protected from abuse, neglect and exploitation by conforming to legislation and guidance, providing training and support, sharing good practice, and by working effectively with other organisations.

What legislation applies to your organisation? How can you demonstrate that you are complying with it?

Do you have a child protection or vulnerable adult safeguarding policy? Is it up-to-date and do your trustees, staff and volunteers know about it?

Have staff and volunteers had appropriate, up-to-date training in child protection and/or the protection of vulnerable adults?

Do staff and volunteers know when to report concerns and who to?

Who else should you be working with to ensure children and vulnerable adults are kept safe? Are your referral and communication processes effective?

How would you manage an allegation of abuse? Do you need a system in place to help you deal with it appropriately?

Protecting vulnerable people in Powys: Powys Local Safeguarding Children Board (LSCB) is responsible for co-ordinating local arrangements to safeguard and promote the welfare of children across Powys. Powys LSCB includes representatives of all statutory and voluntary agencies in Powys which work with children and their families. Children and young people in Powys are represented on the Board through a group called “Eat Carrots. Be safe from Elephants” which meets during school holidays. More information on the Powys LSCB is available at http://www.powys.gov.uk/index.php?id=2253&L=0 The Powys Area Adult Protection Committee (AAPC) is a joint forum responsible for providing a strategic lead in protecting vulnerable adults within Powys; for example through monitoring and reviewing local adult protection policies, auditing specific cases and promoting awareness. For further information, visit http://www.ssiacymru.org.uk/index.cfm?articleid=3172 PAVO has developed safeguarding resource packs for the third sector in Powys. The “Safeguarding Children and Young People Resource Pack” is available on CD and includes an introduction to the topic, key documents and useful links. The “Protection of Vulnerable Adults Pack” contains definitions, information on roles and responsibilities, guidance on policies and procedures plus links to further resources. These packs are available by contacting the PAVO Helpdesk: 0845 009 3288 or [email protected]

Standard 12: Environment This standard is about making sure that your organisation’s premises are safe, clean, accessible, comfortable and sustainable.

Are your organisation’s premises accessible to all clients, carers, volunteers and staff? Are they safely accessible for people with a disability or sensory loss?

Do you have a system for undertaking repairs and maintenance work?

Do your premises protect the privacy of clients and staff?

What are you doing to reduce utility bills, promote recycling and reduce waste?


10

Standard 13: Infection prevention and control and decontamination

This standard is about making sure that your organisation supports and enables clients, visitors and staff to achieve and maintain high standards of hygiene so that the risk of infection is reduced.

How can your organisation demonstrate that high standards of hygiene are maintained in your premises?

Do your staff or volunteers work in clients homes? How can you maintain high standards of hygiene there?

How do you assess the risks posed by and to individual clients?

Standard 14: Nutrition This standard is about making sure that the food and drink your organisation provides is appropriate to clients’ individual needs, that food and drink is safely prepared and stored, and that support with feeding and drinking is provided if necessary.

Does your organisation provide food or drink to clients, staff or visitors? How do you monitor whether this is safely prepared and provided?

How do you know that the food you provide meets the nutritional, therapeutic, religious and cultural needs of clients?

What support do you offer to those who cannot eat or drink independently?

Supporting good nutrition in community settings In 2011 the Welsh Government published an All-Wales Pathway for the Management of Malnutrition in the Community in response to high rates of malnutrition amongst older people. The pathway may be used by anybody who comes into contact with people who would benefit from help and support with nutrition, particularly older people, who are living in the community (such as their own homes or in a care home). It provides guidance on how to support awareness raising and information sheets with tips to help eating and drinking, as well as information on when and how to access further support. The pathway and resource pack and further resources are available from http://wales.gov.uk/topics/health/publications/socialcare/guidance1/nutrition/?lang=en

Standard 15: Medicines management This standard is about making sure that any medicines your organisation stores or administers is managed effectively, efficiently and safely, and that advice or information about medicines is appropriate.

What legislation, licensing and good practice guidance should your organisation be complying with? How do you monitor compliance?

Is the place where you store medicines safe, secure and appropriate?

What advice and information do you provide on medicines? How do you make sure that it is up-to-date and relevant?


11

Standard 16: Medical devices, equipment and diagnostic systems This standard is about making sure that the equipment your organisation uses is safe, clean, in good working order and that staff and users know how to use it properly.

What system does your organisation have to know when to replace equipment? What happens when equipment is no longer fit for purpose?

How do you make sure that equipment is maintained, cleaned and stored appropriately?

How do you identify the training needs of staff, volunteers and users? What training do you provide? How do you know it is working?

What do you do when a fault is reported?

Standard 17: Blood management This standard is about making sure that people have a safe supply of blood and blood products when they need them. It is relevant if your organisation offers a service where blood, blood products and blood components are produced or used.

Standard 18: Communicating effectively

This standard is about making sure that your organisation communicates with service users, carers, staff, volunteers and others in a way that is appropriate for them.

What training does your organisation provide to staff and volunteers to help them communicate effectively with colleagues, service users and carers?

Do you have a communications strategy or plan?

What is your policy on sharing information about service users and carers?

How do you respond when faced with people with different communication or language needs?

Standard 19: Information management and communications technology

This standard is about making sure that your organisation uses safe and secure information management and communications technology systems to support care and improve services.

How does your organisation manage information and data?

Is the data you keep reliable, accurate and up-to-date? How do you know?

How do you use the information that you collect to review, assess and improve services?

What information do you share with partners? How can you demonstrate that the way you share information is appropriate?

Standard 20: Records management This standard is about making sure that records within your organisation are kept safe and are easily found and that they are clear and up-to-date.

What arrangements does your organisation have for creating, maintaining and destroying records?

How do you ensure all records are accurate, complete and understandable?

Do staff know and understand the need for safe record keeping as well as their roles and responsibilities associated with it?


12

The Wales Accord on the Sharing of Personal Information (WASPI): The Wales Accord on the Sharing of Personal Information (WASPI) provides a framework for providers of health, education, safety, crime prevention and social wellbeing services in Wales which hold information about individuals on how to share that information with others legally, safely and with confidence.

The WASPI framework is recognised as one of the key elements of the Welsh Government's Sharing Personal Information programme. The WASPI framework sets out agreed requirements and mechanisms for the exchange of personal information between different partner organisations and complies with the Information Commissioner’s 'Data Sharing Code of Practice'. For more information and to sign up, visit http://www.waspi.org/

Standard 21: Research, development and innovation This standard is about promoting research, development and innovation that benefits service users and improves service delivery whilst following appropriate research rules and frameworks. It is relevant to services participating in research, development and innovation.

Are you aware of the Research Governance Framework for Health and Social Care?

How do you involve service users and carers, as appropriate, in the design, conduct and reporting of research?

How do you share results and learning?

Standard 22: Managing risk and health and safety This standard is about making sure that your organisation looks after the health and safety of all staff and volunteers and anybody who uses your services.

How does your organisation assess risks?

How do you protect the health, safety and wellbeing of service users, carers, staff and the public? What do you do to review and improve these arrangements?

What happens when you receive a safety notice or alert? How do you know who to send it to and when appropriate action has been taken?

Standard 23: Dealing with concerns and managing incidents This standard is about making sure that your organisation responds effectively and deals fairly, openly and proactively with concerns raised, including through giving support to service users or staff and through demonstrating that lessons have been learned.

Does your organisation have a comments, complaints or incidents procedure? What is it based on?

Do staff and volunteers know what your procedure for dealing with concerns is? Do they need more training?

How do you work with and support staff or volunteers involved in a concern?


13

Standard 24: Workforce planning This standard is about making sure that your organisation has enough staff with the right skills to provide safe services.

Does your organisation have enough staff to deliver the services you offer safely?

Do you make plans for how you will continue to provide safe services when there are staff shortages?

Does your workforce reflect the demographic and communication needs of the local population?

How do you support and develop new staff and trainees?

Standard 25: Workforce recruitment and employment practices

This standard is about making sure that the right people are attracted to work for your organisation and that they are appropriately recruited and supported at work.

How does your organisation make sure that staff are regularly CRB-checked, have other necessary employment checks and are registered with the relevant bodies?

How do you ensure that staff act and are dealt with in accordance with relevant standards and codes of conduct?

Do you have a whistle-blowing policy?

What supervision do you give to staff? How can you demonstrate that it is effective?

Standard 26: Workforce training and organisational development This standard is about making sure that your organisation gives staff the opportunity to develop their knowledge and skills so that they can undertake their roles and meet the current and future needs of your organisation.

How does your organisation ensure that staff and volunteers maintain and develop the skills and knowledge needed to do their jobs?

Do you offer an induction or training programme? Do all staff participate in this?

Do you conduct annual personal appraisals? How do these link in to your organisation’s objectives?

How do you help collaborative practice and team working?


14

6. Where to go for training and support in Powys:

For more information on the Standards – and how to use them:

http://www.pavo.org.uk/support/standards-for-health.html

The Standards for Health Services section on PAVO’s website has copies and links to the key Standards for Health documents listed below. This website will be regularly updated as resources are developed and further information and support becomes available.

The Standards for Health Powys Third Sector Online Toolkit: The toolkit contains introductory information on the Standards and how they are appropriate to third sector organisations, with Powys-based information and guidance as appropriate. Also available is information mapping the Standards against other standards used commonly within the third sector such as PQASSO.

The How to Guide: Helping You to Use “Doing Well, Doing Better, the Standards for Health Services": A "How to Guide" for Third Sector Organisations has been designed to support you to create a Self Assessment Portfolio which will help you plan for continuous review, learning and service improvement.

The NHS Wales Governance E-Manual: The Doing Well, Doing Better: Standards for Health Services in Wales section contains a full list of the Standards. The E-manual also contains the Supporting Guidance document which includes comprehensive links to relevant legislation and technical guidance and documents mapping the Standards against other professional standards, regulations, and other quality requirements used within the NHS. The NHS Wales Governance E-Manual can also be accessed directly at http://www.nhswalesgovernance.com/

For information on training:


15

http://www.pavo.org.uk/support/pavo-training-courses.html

PAVO offer regular courses on a range of topics including:

Staff Development

Introduction to Tendering

Supervision and Appraisal

Volunteer Recruitment, Selection and Induction

Introduction to Trading

Roles and Responsibilities of Trustees and Management Committee Members

Business and Strategic Planning To find out more about upcoming training sessions offered by PAVO and other training providers in Wales, visit http://www.pavo.org.uk/support/pavo-training-courses.html. PAVO can also offer bespoke courses for your organisation.

For support with specific enquiries and troubleshooting:

PAVO Helpdesk: 0845 009 3288 [email protected]

The PAVO Development Team can signpost you to appropriate training and resources and can offer you further support with adopting the Standards within your organisation and putting together the self-assessment portfolio. We can also support you with addressing any quality improvement issues that using the Standards might raise, such as developing new policies or helping mediate conflict within your organisation.

PAVO’s development services include:

Funding advice

Individual hands-on help

Citizen & community engagement

Governance & trusteeship advice

Development & promotion of volunteering

PAVO also create and facilitate opportunities for you to network and work with other third sector organisations providing services as well as communicate and collaborate with statutory service providers such as Powys teaching Health Board and Powys County Council.

Contact the PAVO Helpdesk to see how PAVO can help you: 0845 009 3288 or [email protected]

FOR DISCUSSION

Powys Scheme for the Mental Health Measure Wales


Agenda Item 4.2

BOARD MEETING


MENTAL HEALTH – PROCESS FOR THE DEVELOPMENT OF THE POWYS SCHEME FOR THE MENTAL HEALTH MEASURE WALES

Report of

Director of Nursing

Paper prepared by

Director of Nursing

Purpose of Paper

The paper outlines the approach being taken to develop a Scheme for Powys that will comply with the Mental Health measure (Wales).


The Board is asked to NOTE the approach prior to Scheme presentation for approval in its September meeting.


This paper support standards: 1. Governance and accountability framework 2. Equality, diversity and human rights 5. Citizen Engagement and Feedback 6. Participating in Quality Improvement Activities 7. Safe and Clinically Effective Care 8. Care Planning and Provision 9. Patient Information and Consent 10. Dignity and respect 11. Safeguarding Children and Safeguarding Vulnerable Adults


All


N/A

FOR DISCUSSION



Agenda Item 4.2

MENTAL HEALTH – PROCESS FOR THE DEVELOPMENT OF THE POWYS SCHEME FOR THE MENTAL HEALTH MEASURE WALES

Introduction This paper outlines the way in which Powys teaching Health Board with its key statutory partner Powys County Council are developing a Scheme for Powys in relation to implementing the Mental Health Measure (Wales). The Measure comes into full effect from October 1st 2012 and the Board will be asked in its meeting in September to sign off the Scheme being submitted to Welsh Ministers. The component parts of the Mental Health Measure (Wales) The Mental Health measure (Wales) will bring about important changes to the way in which people are assessed and treated for mental health issues in Wales. The Measure is all-age and therefore includes children and young people. The Measure is divided into four core parts (although there are two other parts and schedules): a) Part 1 – Local Primary Mental Health Support Services b) Part 2 – Coordination of and Care and Treatment Planning for Secondary Mental Health Users c) Part 3 – Assessments of Former Users of Secondary Mental Health Services d) Part 4 – Mental Health Advocacy Part 1 – Local Primary Mental Health Support Services There is recognition that primary care plays a crucial role in delivering effective mental health care and treatment. The aim of the Measure is to strengthen that role so that throughout Wales there will be local primary care mental health support services. These will be delivered by Health Boards and Local Authorities in partnership, and it is expected that these services will operate within or alongside existing GP practices. Part 2 – Care Coordination and Treatment Planning The Measure places duties on service providers (Health Boards and Local Authorities) to act in a coordinated manner to improve the effectiveness of the mental health services they provide to an individual. The Measure will require there to be a care and treatment plan for service users of all ages who have been assessed as requiring care and treatment within secondary mental health services. Part 3 - Assessments of Former Users of Secondary Mental Health Services The aim of this part of the Measure is to enable adults who have been discharged from secondary mental health services, but who subsequently believe that that their mental health is deteriorating to such a point as to require such care and treatment again, to refer themselves back to secondary services directly, without necessarily needing to first go to their general practitioner or elsewhere for a referral.

FOR DISCUSSION



Agenda Item 4.2

Part 4 - Mental Health Advocacy Evidence suggests that advocacy can lead to an improved experience of mental health services for individuals, including the potential for advocacy to create choice, improve involvement in decision making, and promote access to a range of different services. The Measure provides for an expanded statutory scheme of independent mental health advocacy, both for patients subject to compulsion under the Mental Health Act 1983, and for those in hospital informally (in other words, not subject to the 1983 Act). Developing a Scheme/Implementing the Measure Powys teaching Health Board and Powys County Council are the key statutory partners that are required to develop the Scheme and implement the Measure, with the Health Board in the lead. This is being coordinated via the joint Mental Health Planning and Delivery Group. Good progress is being made in relation to the development of the scheme. Appendix 1 outlines some of the key requirements and critical tasks that need to be achieved. This is taken from the Welsh Government Guidance for Health Boards and Local Authorities. The implementation plan for the Measure developed in partnership between the teaching Health Board and the County Council is included as Appendix 2. This indicates confidence in achieving the requirements prior to October 1st. Specifically focused attention has been given in relation to the working arrangements for children’s services (including education, health and children’s social services) and in relation to provider Health Boards progress with Care and Treatment Planning including the performance reporting and assurance arrangements. There remain some outstanding issues in relation to the cross border arrangements and further formal guidance is being sought from Welsh Government on this issue. The full Scheme will be developed and presented to the Board at its meeting in September. Conclusion The Mental Health Measure is a significant development for the population in relation to accessing services including assessment and treatment. Its focus is on developing primary care, a position of strength for Powys, and reducing over-reliance on secondary care services. Good progress is being made toward full compliance with the Measure in Powys and positive partnership working is taking place in this regard. The full Scheme and a further update report will be presented to the Board in September 2012 for Approval. Report prepared by: Presented By: Carol Shillabeer Carol Shillabeer Director of Nursing Director of Nursing

FOR DISCUSSION



Agenda Item 4.2

Appendix 1: Extract from Welsh Government Guidance on the requirements of Health Boards and Local Authorities. (p10 – 13) Local Health Boards and Local Authorities – joint working Much of the Measure requires LHBs and Local Authorities to work together to effectively meet their duties under the legislation. It will be important that existing relationships between the two bodies for an area are effectively utilised, so as to effectively and efficiently deliver the new requirements. Below are details of a number of actions that will need to be considered by LHBs and Local Authorities to prepare for the new legislative framework. This is not intended to be an exhaustive list, but rather a prompt for further consideration. Actions required for Part 1 of the Measure Under Part 1 of the Measure, the following actions will need to be considered by the two partners – • Preparing, and putting into writing, a joint scheme for local primary mental health support services for the area of the local authority; • Ensuring that the services are accommodated, and can operate within (or close to) GP settings; • Appointing appropriate staffing in terms of skills, experience and numbers; • Ensuring strong clinical and management supervision is established to support primary mental health workers; • Ensuring suitable clinical governance, performance management and budgetary control structures are in place to support and monitor the operation of the local primary mental health support services; • The scheme under Part 1 of the Measure is included in the Children and Young People’s Plan for the local authority area • Appropriate referral mechanisms are put in place for general practitioners, and (where applicable) practitioners in secondary mental health services, to refer individuals to the new services; • Ensuring that strong relationships are developed between the new services and the general practitioner services that they will be supporting; • Where relevant, appropriate arrangements are made for local primary mental health services to be delivered in prisons5; • Use is made of existing local and national6 services, including those provided by the third sector or voluntary organisations, which enable effective information to be held to allow patients to be signposted to other support (as part of the local primary mental health support service); • Effective arrangements are put into place to support advice and information on mental health, and mental health services, being given to GPs and their staff; • Effective links operate between local primary mental health support services and secondary mental health services to accommodate referrals into/from both services, to ensure that service users (of either service) are seen quickly and duplication of effort is reduced.

FOR DISCUSSION



Agenda Item 4.2

Actions required for Part 2 of the Measure Under Part 2 of the Measure, the following actions will need to be considered by Local Health Boards and Local Authorities – • Effective roll-out of the new learning resources for CPA, to ensure that existing and prospective care coordinators are clear about their functions both under the Measure, and under the wider CPA framework; • Establishing and maintaining lists of eligible care coordinators7; • Establishing and maintaining records of relevant patients (within the meaning of section 12 of the Measure), which will include patients receiving secondary mental health services secured by the LHB or Local Authority but provided by another agency/organisation (eg in an independent hospital in England); • Ensuring systems enable the correct relevant mental health service provider to be identified in accordance with section 15 of the Measure, and then to appoint a care coordinator for a relevant patient; • Making sure that electronic and other case record management systems are updated to meet the requirements of Part 2 of the Measure, including use of the new prescribed care and treatment plan8; • Appropriate revisions are made to audit tools to accommodate the new provisions of Part 2 of the Measure, and associated subordinate legislation and Code of Practice; • Effective systems are put in place to support review and revision of care plans, in line with the intended relevant subordinate legislation, and appropriate recording systems are utilised to enable compliance to be monitored. Actions required for Part 3 of the Measure Under Part 3 of the Measure, the following actions will need to be considered by the LHB and Local Authority partners – • Preparing, and putting into writing, arrangements for the carrying out of assessments and the making of referrals under Part 3 of the Measure; • Developing written information to be given to service users on their discharge from services, explaining eligibility under Part 3, and the local arrangements for accessing such assessments; • Ensuring staff understand when service users should be provided with information about eligibility, and how to respond when such a request for assessment is made; • Developing/amending electronic and other case record management systems so that discharge from secondary mental health services is clearly recorded (so as to assist determining future eligibility); • Systems are established that will allow disputes regarding determination of usual residence to be effectively and quickly resolved9; • Adapting existing referral systems within secondary mental health services, if necessary, to accommodate self-referral; • Adapting arrangements for writing reports to service users following assessment, if necessary; • Ensuring that information sharing arrangements with other secondary mental health services are updated to take account of need to provide/obtain information about eligibility under Part 3 when an individual (previously not known to local services) presents.

FOR DISCUSSION



Agenda Item 4.2

Actions required for independent mental health advocacy Part 4 of the Measure amends the Mental Health Act 1983, therefore under new sections 130E to 130L of the 1983 Act (and associated subordinate legislation) LHBs10 should consider – • the existing independent mental health advocacy provision, preferably as part of a more strategic review of wider mental health advocacy services in their area; • identifying the potential numbers of qualifying informal and detained patients in their area, and where such patients are located (ie the hospitals, units and wards); • ensuring sufficient provision of independent mental health advocates (IMHAs), and where applicable entering into appropriate contracts with advocacy providers for the provision of such IMHAs; • developing robust engagement protocols for all relevant hospitals and registered establishments (including working with the relevant managers of registered establishments) where arrangements are made with advocacy providers; • ensuring that there are suitable facilities within their own hospitals/units/wards for IMHAs to meet with qualifying patients; • securing a programme of awareness raising for staff within their own hospitals, as well as within registered establishments, about the role and functions of IMHAs, as well as how to contact IMHAs (it is expected that delivery of such awareness raising may well be undertaken by advocacy providers, where such arrangements have been included in contracts) • developing appropriate patient information leaflets and posters, which explain the independent mental health advocacy scheme and how to contact IMHAs. Fuller information and support for LHBs on independent mental health advocacy is set out in ‘Delivering the Independent Mental Health Advocacy Services in Wales: Interim Guidance for Independent Mental Health Advocacy Providers and Local Health Board Advocacy Service Planners’ (Welsh Assembly Government, January 2011).

FOR DISCUSSION



Agenda Item 4.2

Appendix 2 Implementation Plan for Mental Health Measure (Wales) Green = on course Amber = some delay/difficulties Red = not on course

WG Date Action PTHB

Adult PTHB Child

PCC Adult SS

PCC Child SS

PCC CYPP

PCC Ed

Progress/ comment

Part 1 By December 2011

Appointment of LHB Primary Care Implementation Leads to support the work required to establish the local primary mental health support services.

SM CL

S O’G CT JD AT TD

CS (Lead Director for Children and Mental Health) Part 1 Implementation lead appointed for all-ages (Jan 2012)

By December 2011

Local project management arrangements in place with all key interests represented

Multiagency Children and Young People’s Emotional Health and Wellbeing Group. All-age planning and implementation chaired by DNS. (Membership includes Strategic Director for Education & Director of Social Services)

December 2011 onwards

Establish dialogue with local GPs and GP bodies to ensure that strong relationships develop between the new services and the general practitioner services that they will be supporting

SM CL KD

SO’G CT JD AT TD

A Part 1 Support Officer was appointed. However, the postholder was successful in securing a permanent post, so alternative arrangements until October are now being made. PMHWs for children are working with GPs. Counsellors for adults are working in each GP practice. Presentations have been made to some GP practices. The Head of Clinical Strategy and General Manager for Women and Children Services have met with Practice Managers. The DNS and Head of Mental Health have met with the LMC.


Establish dialogue with third sector organisations to ensure that all local services are taken into account in the development and delivery of the new service model

SM CL SO’G CT JD AT TD

Engagement and communication through the Children and Young People’s Partnership Emotional Health and Wellbeing Group.

December 2011 Publicity and awareness raising materials SM CL SO’G CT JD AT The CYPP referral criteria for emotional wellbeing and

FOR DISCUSSION



Agenda Item 4.2

onwards developed and disseminated KD TD mental health already cover all tiers and a range of agencies i.e. the guidelines for NHS referrals already start with a range of multiagency alternatives. These will be slightly amended to take account of the final Part 1 Scheme. Material circulated by WG did not make clear that the part 3 entitlement can only be accessed after 18. It is understood the material will be revised for a number of reasons.

March 2012 i) Local/regional service model(s) agreed to confirm, inter alia:

• the pattern of local service delivery, ensuring that local primary mental health support can operate within, or close to GP settings; • arrangements for delivery of services to “additional persons” (i.e. those not registered with a GP and/or not usually living within the local authority area), including, where relevant, appropriate arrangements for local primary mental health services to be delivered in prisons.

SM CL SO'G CT JD The elements of the all-age scheme covering children and young people were formally agreed by the CYPP in April 2012. The Scheme will be formally approved by the PtHB on the 26th June and then by PCC.

April 2012 Analysis of required staffing for Part 1 services in terms of skills, experience and numbers, and required posts identified

SM CL &KD

SO’G JD Additional £35k from allocation to further strengthen PMHWs and integrated counselling for children from 1.6.12 Arrangements in hand to strengthen bereavement counselling. PMHW capacity will increase from 2.6 WTE – 3.2 WTE – however there will be alternative temporary arrangements due to acting up and sick leave over the summer. Arrangements also being made in adult services. Finance call-down arrangements to be agreed.

April 2012 Part 1 schemes included in the Children and Young People’s Plan for the local authority area (see section 11 of the Measure)

CL CT JD The Mental Health Measure was included in the One Powys Plan. The children and young people’s element of the Part 1 scheme was considered at CYPOG on 4th April; and approved by the CYPP on 16th April

FOR DISCUSSION



Agenda Item 4.2

It will be submitted to PtHB Board on the 27th June and then to PCC for formal approval.

May 2012 Job descriptions for primary care practitioners evaluated and grades assigned

CL & KD

JD Primary care counsellors already in place for adults. Primary mental health workers in place for children (although some of the additional capacity will be based on temporary arrangements through the summer). Integrated counselling arrangements for children in place through the CYPP and being retendered, with counselling services.

May 2012 Local schemes (including regional schemes) agreed and in place for all local authority areas or regions

SM CL S’OG CT JD AT TD

Agreed CYPOG 4th April Approved CYPP 16th April PTHB Board 27th June PCC

April – September 2012

Processes for recruitment of additional staff required to deliver Part 1 services in place

Please see above PMHW capacity will expand from 2.6WTE to 3.1WTE (but there will be some temporary arrangements over the summer due to sick leave). Arrangements also being made in adult services.

Part 2 & 3

By December 2011

The identification of an individual with responsibility for reporting and overseeing implementation of Part 2 and Part 3 on behalf of Local Authorities and Local Health Boards for each LHB area. This may also involve the establishment of multiagency implementation groups.

SM CL SO’G CT JD AT TD

CS (Lead Director for Children and Mental Health) Consolidated Implementation Group with Director of Social Services Strategic Director for Education/Lead Director for Children

December 2011 Development of implementation plans to help provide assurance of being prepared for commencement

Implementation dates revised in line with WG guidance of Dec 2011. Implementation Plan updated in February, April and June.

By January 2012 Engage with Information Technology providers to ensure that electronic and other case record management systems are updated to meet the requirements of Part 2 of the Measure, including use of the new prescribed care and treatment plan.

SM KD SO’G CT JD TD CYPP multiagency workshops took place in March and May to ensure PCC Education, Children’s Services and PtHB NHS CAMHS are making appropriate arrangements. There have also been additional meetings of the key leads. The Care and Treatment Plan should be available on MIP, together with the reassessment entitlement letter. With regard to performance reports where information is already available on MIP reports can be generated. However, new information may require manual

FOR DISCUSSION



Agenda Item 4.2

collection in the interim until IT changes are made. (Social Services have made the necessary changes to Draig, however there may have been some slippage in education due to sick leave.) JD to check cross-over with children with disability. No slippage reported for adult services. ABHB implementation assurance plan received.

By January 2012 Engage with Information Technology providers to develop or amend electronic and other case record management systems, so that discharge from secondary mental health services is clearly recorded (so as to assist determining future eligibility)

SM KD SO’G CT JD TD As above

January 2012 onwards

Roll-out of the new learning resources for care coordination and care and treatment planning, to ensure that existing and prospective care coordinators are clear about their functions and duties under Part 2 of the Measure

SM KD SO’G CT JD TD Training and multiagency workshops took place in March 2012 May 2012 Cascade now taking place within teams. Children’s Social Services have also made all-Wales presentations. Due to sick-leave there may be slippage within the Education Department. The NHS CAMHS Manager, Children’s Social Services and the CYPP lead will work with the Head of Educational Psychology to ensure all the necessary action is in place. No slippage reported for adult services. ABHB action plan received.

By March 2012 Draft arrangements for the carrying out of assessments and the making of referrals under Part 3 of the Measure in anticipation of the making of Regional Provision Regulations. These arrangements should allow for disputes regarding determination of usual residence to be effectively and quickly resolved.

SM CL & KD

SO’G CT JD TD There will be a common letter for Powys (adjusted for age) setting out the entitlement for those over the age of 18. The letter can be then saved as part of health, social care and education IT systems. No slippage reported for adult services. ABHB action plan received.

By March 2012 Develop and agree formal processes for appointing care coordinators, including temporary appointments – for LHBs and local authorities that meet the requirements of the Measure and adhere to the Code of

SM CL& KG

SO’G CT JD TD Meetings involving education, social care and CAMHS have taken place, with workshops in March and May. The LEA is identifying the cases to which this may apply and has sought legal advice to clarify the position of children admitted to a school named in their SEN statement.

FOR DISCUSSION



Agenda Item 4.2

Practice to Parts 2 & 3. This is likely to cover the identification of which organisation is responsible for appointment, any agreements for appointing care coordinators that are employed by another organisation and consideration of skills, experience and training in appointing an appropriate care coordinator.

Identified and processes in place for children’s social services and NHS CAMHS. The three key leads will meet regularly and are identifying a process for cases if it is not clear which agency should appoint the co-ordinator or the agency changes. There will be a formal protocol. There will be a meeting with the Head of Educational Psychology so that the NHS and Children’s Social Services can assist them as there has been slippage due to sick leave. No slippage reported for adult services. ABHB action plan received.

Part 4 By December 2011

Identification of potential qualifying informal and detained patients in each LHB area, and where such patients are located (i.e. NHS and private hospitals, mental health units and wards, and registered establishments)

SM SO’G No children or young people are admitted within Powys, so arrangements will be made by other providers. However, the arrangements made for adults, will cover the eventuality of young people subject to a community order. No slippage reported for adult services. ABHB action plan received.


Programme of awareness-raising for staff within hospitals, units and registered establishments, regarding the role and functions of IMHAs, as well as how to contact IMHA service providers

SM SO’G No slippage reported for adult services. ABHB action plan received.


Development of appropriate patient information leaflets and posters, which explain the independent mental health advocacy scheme and how to contact IMHAs, and distribution to all relevant inpatient settings


December 2011 LHBs and IMHA providers to have developed and produced new patient information leaflets/posters etc explaining expanded IMHA scheme and wider range of qualifying patients


December 2011 New or revised IMHA contract arrangements SM SO’G No slippage reported for adult services. ABHB action plan received.

FOR DISCUSSION



Agenda Item 4.2

agreed in all LHB areas and arrangements for the provision of expanded IMHA service by independent advocacy provider(s) in place

December 2011 Developing robust engagement protocols for all relevant hospitals and registered establishments (including working with the relevant managers of registered establishments) where IMHA-qualifying patients may be located


By December 2011

Recruitment, induction and training of new IMHAs for expansion of service to sections 4 and 5 patients complete


By December 2011

Ensuring that there are suitable facilities within all relevant hospitals/units/wards for IMHAs to meet with qualifying patients


By March 2012 Recruitment, induction and training of new IMHAs for expansion of service to informal inpatients complete


By April 2012 All IMHA providers expected to have attained Action for Advocacy Quality Performance Mark


The Mental Health (Wales) Measure 2010 is a new law made by the Welsh Government which will help people with mental health problems in four different ways.

The Mental Health (Wales) Measure 2010

Local Primary Mental Health Support ServicesThe Measure will make sure that more services are available for your GP to refer you to if you have mental health problems such as anxiety or depression. These services, which may include for example counselling, stress and anxiety management, will either be at your GP practice or nearby so it will be easier to get to them.

You will also be told about other services which might help you, such as those provided by groups such as local voluntary groups or advice about money or housing.

Care Coordination and Care and Treatment PlanningSome people have mental health problems which require more specialised care and support, (sometimes provided in hospital). If you are receiving these services then your care and treatment will be overseen by a professional such as a psychiatrist, psychologist, nurse or social worker. These people will be called Care Coordinators and will write

you a care and treatment plan – working with you as much as possible. This plan will set out the goals you are working towards and the services that will be provided by the NHS and the local authority and other agencies to help you reach them. This plan must be reviewed with you at least once a year.

Assessment of people who have used specialist mental health services beforeIf you have received specialised treatment in the past and were discharged because your condition improved, but now you feel that your mental health is becoming worse, then you can go straight back to the mental health service which was looking after you before and ask them to check whether you need any further help or treatment. You don’t need to go to your GP first, although you may wish to talk it through. You can ask for this up to three years after you are discharged from the specialist team.

Independent Mental Health AdvocacyIf you are in hospital and you have mental health problems you can ask for help from an Independent Mental Health Advocate (IMHA). An IMHA is an expert in mental health who will help you to make your views known and take decisions in relation to your care and treatment (but will not take decisions on your behalf!)

If you have any questions about the Mental Health Measure and what it means for you then please contact us at:[email protected]

WG14213 © Crown Copyright

Gwasanaethau Cymorth Iechyd Meddwl Sylfaenol Lleol

Local Primary Mental Health Support Services

O 1 Hydref 2012 gall eich Meddyg Teulu eich helpu i ddefnyddio gwasanaethau newydd fydd ar gael yn lleol er mwyn helpu pobl gyda phroblemau iechyd meddwl fel gorbryder, iselder, colli cof, ac anawsterau ymddygiadol ac emosiynol

Ewch i weld eich Meddyg Teulu os ydych yn credu y gallai’r gwasanaethau hyn eich helpu

From 1 October 2012 your GP can support you to access new services which will be available locally to help people with mental health problems such as anxiety, depression, memory loss and behavioural and emotional difficulties

Please see your GP if you think that these services could help you

Mae mwy o fanylion ar gael yn/ More information is available from:

[email protected]

neu ffoniwch/or telephone: 02902 370011

FOR DISCUSSION

Business Case: Builth Wells Page 1 of 4 Board Meeting 27 June 2012

Agenda Item 4.3

BOARD MEETING


BUILTH WELLS: PROJECT UPDATE

Report of


Paper prepared by

Senior Partnership Manager

Purpose of Paper

To consider progress with the Builth Wells Integrated Health and Social Care Centre with reference to the revenue consequences and project management arrangements.


The Board is asked to:- NOTE the revised Business Justification Case

for the Builth Wells Health and Social Care Centre;

NOTE the revenue assumptions of the service model described in the Business Justification Case; and

NOTE the Revised Project Governance Structure.


This paper supports the following standards: 7. Safe and Clinically Effective Care 8. Care Planning and Provision 24. Workforce Planning


Delivery of the Builth Wells Project relates to all five key elements of the Health Board’s Annual Plan: Improving Health & Well-Being Ensuring the Right Access Striving for Excellence Involving the People of Powys Making Every Pound Count


WG – Welsh Government

FOR DISCUSSION


Agenda Item 4.3

BUILTH WELLS: PROJECT UPDATE

1. Introduction Significant progress has been made recently in the delivery of the joint Powys teaching Health Board (PtHB)/Powys County Council (PCC) Project: Integrated Health and Social Care Services for Builth Wells. On the basis of the draft Business Justification Case, together with detailed discussions between officers of PCC and PtHB with the NHS Shared Services Division, Welsh Government (WG) has now allocated a total capital grant of £5.2m to Powys County Council to build the new facility. A final Business Justification Case is required by WG to support the allocation of capital to PCC. The business case is based on the Five Case Model as required under WG guidance. As the majority of the service model delivered directly in the facility is NHS services the revenue assumptions within the business case are being presented to the tHB Board as part of the formal approval process. With the WG capital grant secured, and construction of the new facility now under way, the focus of the PtHB/PCC Builth Wells Project must shift towards the implementation of a new model of integrated health and social care. In order to ensure that this work is co-ordinated effectively a review of the Project Governance Structure has been undertaken and this also is presented to Board Members for approval. 2. Business Justification Case The “Business Justification Case: Integrated Health and Social Care Services for the Communities of Builth Wells” is attached at Appendix 1. This document builds on the earlier version submitted to WG in September 2010. It responds to the detailed feedback provided by officers within WG to the original document as is normal practice. As Powys County Council is the recipient of the capital, responsibility for formal submission of a compliant business case rests with PCC.

FOR DISCUSSION


Agenda Item 4.3

The revenue model is based on the following service assumptions that will be further tested as delivery of the scheme progresses

• The new Builth facility will be registered as a care home • The tHB will contract with a provider for residential care including facilities

management services and hotel services • The business case indentifies the preferred option is to maintain continuity of

service through an extension to the Council’s contract for residential care. This approach is currently under review

• Clinical services will be provided through an in-reach model from an integrated and strengthened community team

The revenue section of the business case is based on these assumptions and demonstrates that the estimated revenue savings accrued from the closure of Builth Wells Community Hospital is £924K offset by investment in the new models of care estimated at £492K The net saving achieved from the implementation of the Integrated Service Model for Builth Wells is therefore estimated to be £431K per annum. A further saving of £47K is estimated from changes in capital charges. These estimates are based on the service model assumptions to date for the purposes of the BJC and will be reviewed as the project progresses through the implementation phase. This modelling does however demonstrate the revenue affordability of the scheme. 3. Future Project Management Arrangements PCC have now secured a formal agreement with BUPA to release the land surrounding the Brynhyfryd Care home for construction which has commenced. Completion is envisaged to be at the end of May 2013. Whilst this construction work takes place, priority must be given to the implementation of the innovative new model of integrated health and social care community services. The Builth Project structure must now be reviewed to ensure this is managed and co-ordinated effectively. The revised Project Structure is attached at Appendix 2. The following key features are worthy of note:

• Decision making arrangements from the Builth Wells Project Board to PtHB Board of Directors and Board.

• The Project Board continues to be chaired by the PCC Cabinet Portfolio Holder for Adult Social Care, recognising the level of capital funding and associated risk, and the contribution of PCC of the land for the development

• PtHB Project Sponsor (Lead Director): Interim Director of Planning, and PCC Project Sponsor, Head of Adult Services

• Service Implementation Workstream Lead: Locality General Manager, Mid-Powys.

• Project Manager: Senior Partnership Manager (PCC/PtHB)

FOR DISCUSSION


Agenda Item 4.3

Overall, these new arrangements will ensure effective collaboration between PtHB and PCC, clear decision making and effective management of what is to become a complex service transformation project, 4. Conclusion Good progress has been made in the delivery of the design and construction element of the Builth Wells Health and Social Care Facility. Council and tHB colleagues have worked well together to design a building with an innovative, flexible functionality. Successful negotiations with WG have resulted in an enhanced capital grant of £5.2m being awarded to PCC and work has commenced on site with the scheme. Further work is underway to agree the detailed service model and implement the required developments in preparation for the handover anticipated to be May 2013. A revised Business Justification Case has been prepared that includes the capital and revenue consequences of the scheme. The revenue consequences of the schemes are affordable to the Health Board. Strengthened project governance arrangements have been developed to ensure that an innovative model of integrated health and social care can be implemented to coincide with the completion of the new facility. 5. Recommendation The Board is asked to:-

NOTE the revised Business Justification Case for the Builth Wells Health and Social Care Centre;

NOTE the revenue assumptions of the service model described in the Business Justification Case; and

NOTE the Revised Project Governance Structure. Report prepared by: Presented By: Gerry Davidson Bruce Whitear Senior Partnership Manager Interim Director of Planning Background Papers N/a

Financial Consequences As described in the paper

Other Resource Implications N/a

Consultees N/a

Appendix 1

Integrated Health and Social Care Services for the

Communities of Builth Wells

BUSINESS JUSTIFICATION CASE

Version No : 4 Issue Date : 31st May 2012

2

Figure 1. Builth Wells Project Area

3

Version History

Version Date Issued

Brief Summary of Change Owner’s Name

2.1 18.11.11 First redraft with enhanced Economic Appraisal, Procurement Route and Financial Case

CT/GD

2.1.2 23.12.11 Redraft Section 4.2 MG/CP 2.2 25.01.12 Adjustments to reflect changes

in service model. Further additions in response to WG comments

GD

3 10.02.12 General content update and editing. Revised capital and revenue assessments. Revised Risk Sharing Agreement. Revised appendices to include Risk Register and Construction Programme.

GD

4 31.05.12 Revised Project Management arrangements.

GD

Signed off by: A Cottom Acting Chief Executive Powys Teaching Health Board J Patterson Chief Executive Powys County Council

4

Contents Executive Summary .................................................................................................................................. 7 1 Introduction..................................................................................................................................... 10

1.1 Purpose.......................................................................................................................................... 10 1.2 Introduction and Purpose .............................................................................................................. 10

2 The Strategic Case .......................................................................................................................... 12

2.1 Introduction................................................................................................................................... 12 2.2 Organisational Overview .............................................................................................................. 12 2.3 Health and Social Care Strategies................................................................................................. 16 2.4 Existing Arrangements.................................................................................................................. 17 2.6 Potential Scope and Services ........................................................................................................ 24 2.7 Potential Benefits .......................................................................................................................... 28 2.8 Potential Risks............................................................................................................................... 29 2.9 Constraints and Dependencies ...................................................................................................... 30

3 The Economic Case ........................................................................................................................ 31

3.1 Critical Success Factors ................................................................................................................ 31 3.2 Service Scope................................................................................................................................ 32 3.3 Site Solution.................................................................................................................................. 36 3.4 Capital Funding............................................................................................................................. 39 3.5 Service Implementation ................................................................................................................ 42 3.6 Service Delivery/Procurement ...................................................................................................... 44 3.7 The Short Listed Options .............................................................................................................. 45 3.8 Qualitative Appraisal .................................................................................................................... 45 3.9 Economic Appraisal ...................................................................................................................... 47 3.10 Overall Findings.......................................................................................................................... 49 3.11 Preferred Option.......................................................................................................................... 50

4 The Commercial Case..................................................................................................................... 51

4.1 Introduction................................................................................................................................... 51 4.2 Procurement Strategy.................................................................................................................... 51 4.3 Proposed charging mechanisms for construction.......................................................................... 55 4.4 Potential for risk transfer during construction.............................................................................. 55 4.5 Proposed Key Contractual Clauses - construction........................................................................ 57 4.6 Implementation Time-scales ......................................................................................................... 57

5. The Financial Case............................................................................................................................. 58

5.1 Introduction................................................................................................................................... 58 5.2 Capital Costs ................................................................................................................................. 58 5.3 Impairment .................................................................................................................................... 59 5.4 Revenue Costs............................................................................................................................... 60 5.5 Overall Affordability..................................................................................................................... 63

5

6 The Management Case.................................................................................................................... 66 6.1 Introduction................................................................................................................................... 66 6.2 Programme Management Arrangements ...................................................................................... 66 6.3 Project Roles and Responsibilities................................................................................................ 68 6.4 Project Milestones......................................................................................................................... 71 6.5 Use of Special Advisors................................................................................................................ 72 6.6 Contingency Plans......................................................................................................................... 72

Appendix 1 Health, Social Care and Well Being Needs Analysis, 2007. Appendix 2 Risk Sharing Agreement Appendix 3 Project Risk Register Appendix 4 Project Team Workshop – November 2009 Appendix 5 Capital Costs – Do Minimum Appendix 6 Capital Costs – New Build Appendix 7 Revenue Costs – Do Minimum Appendix 8 Revenue Cists – New Build Appendix 9 Construction Programme

6

Making a Difference to Local Residents. Mr and Mrs Jones were excited to be moving into their new apartment in the Builth Wells Health and Social Care Centre. Mrs Jones felt that it was already a very familiar place. She had attended a stop smoking class there some years ago, and when her husband was first diagnosed with Diabetes they both attended a course that had helped them greatly with the confidence to know that they could manage his problem. And of course they always visited their NHS dentist there regularly and were members of the over fifties club that meet there every Thursday. Mr and Mrs Jones had occasionally talked with their two children that eventually they would need to move out of their house as it would probably be too big for them to manage. It was also out of the town so they always needed to drive for even the most basic of shopping. They had discussed moving to the Health and Social Care Centre after a friend of theirs had moved to a room there following a stroke. They visited her regularly and were impressed by the lovely bright rooms and the friendly atmosphere. Their friend was very happy there and really appreciated the sense of security she gained from the staff. She also told them how sociable it was there, although Mr and Mrs Jones always felt that they would personally prefer a little more privacy. After Mr Jones had his heart attack it became very clear that they needed to find somewhere smaller to live, and all on one level. The paramedics had arrived quickly at their home on the morning of his heart attack and Mr Jones was admitted to Hereford Hospital after having clot busting drugs in the ambulance. He could have died if they had not been quick enough. They were very impressed when he was also offered rehabilitation at the health and social care centre after his discharge from hospital. Their GP mentioned the extra-care apartments in the Health and Social Care Centre. Mr and Mrs Jones had visited their friend often at her care home there, however they had never really seen inside these other parts of the building. Her mother had died in the old Builth Wells hospital several years before it closed. She could not fault the care, but always felt it a shame that mum could not have died at home as she had wished, and that she and the family were unable to have the privacy of a private room when the end came. Mrs Jones was amazed at how homely the Health and Social Care Centre was compared to the old hospital. There were fantastic views over the river, and they would still have their own front door, safe in the knowledge that help was on hand if they needed it. Although they had been offered some changes to their house to help Mr Jones manage, they decided it was time to move. Sadly Mr Jones’s health deteriorated quite quickly, and while Mrs Jones was able to look after him to some extent, she began to rely on the carers available from the Centre to help to wash and dress her husband and look after some of his more basic needs. After her husband died Mrs Jones’ children were concerned how she was going to cope. They had been married for over 50 years and never separated. As it turned out though it seemed that the Health and Social Care centre helped her through it. Mrs Jones was able to stay in her apartment – no need to move. There were other people in the building she could talk to in a similar position, and lots of activities she could join in with if she wanted. And sometimes she wanted to be on her own with her thoughts. Mrs Jones outlived her husband by five years. She died one night in her sleep after having kept the confidence to look after her self for all those years.

7

Executive Summary This Business Justification Case describes the service transformation that is planned for and currently being implemented in the Builth Wells area of Powys. The use of the Business Justification Case has been recommended by the WG CEF Team in order to expedite the scheme. Powys County Council (PCC) and Powys teaching Health Board (PtHB) have worked together with local stakeholders to develop a new model of health and social care. This new model will replace current outdated services that are unable to meet current and future challenges in the need for health and social care for the local population. This scheme is for Phase 1 of the development of integrated health and social care services for the communities of Builth Wells. Phase 1 enables the closure of the existing Builth Wells Community Hospital by the transfer of facilities to an extension of the care home at the Brynhyfryd site, where the following services will be provided:

• Integrated health and social care team comprising the current district nursing, domiciliary social care and reablement teams

• Third sector advisory service • Outpatient and therapy suite for dietician, physiotherapy, OT, paediatric physiotherapy, • Outpatients suite supporting tele-health and in-reach (from services outside of Powys)

consultant-led outpatients • Minor surgery suite in support of the local GP practice • Three chair general dental service • Ambulance service and paramedic base • Well-being suite for group based health education, therapy, reablement and day

support services • 12 en-suite units residential intermediate care with in-reaching nursing and reablement

services. The BJC proposes that Phase 2 would include for an additional 40 beds of residential care to be provided after completion of Phase 1. The BJC does not seek funding for Phase 2 but discuses a preferred option of funding by third party capital. This new model will replace current outdated services that are unable to meet current and future challenges in the need for health and social care for the local population. Though primarily a community based service model, the plans include a modest capital investment estimated at £5.37M. This investment will provide a base for community based services in the area, and the first phase of a new range of care options that will lead to the closure of the present Builth Wells Hospital. This investment will release £0.43M of revenue funding on an annual basis to the NHS. The new model of care draws on both the Setting the Direction and the Rural Health Plan to develop local health and social care that are focused on:

8

• A single point of contact and an integrated model of delivery through a service and

communication hub • Providing new options for care that enable people to remain in their own homes for as

long as possible, including the provision of new accommodation options such as extra-care, and nursing home care that is currently not available to residents in Builth Wells

• Strengthening the role of community services including the third sector, to reduce the need to escalate care away from people’s homes

The business case describes the specific service developments that are planned and currently being implemented to build on existing community heath and social care services. Specific investments include:

• Extended community nursing hours into the evenings, extending the options for care at home especially palliative care that is mostly currently provided in Powys hospitals

• A reablement service that will provide domiciliary physiotherapy and occupational therapy to assist people to adapt to remaining at home after illness

• Faster access to domiciliary social care services to provide a rapid response care service for people in urgent need

• Provision of a minimum framework of third sector Tier 1 services in line with a model of services being developed

• Hospice at home services provided by the third sector The BJC describes the case for the capital that is required to support service transformation in the Builth Wells area using the Five Case Model in line with WG requirements for capital business cases. The strategic case provides the detailed needs assessment, national and local strategic context and the proposed service model for the Builth Wells. The current Builth Wells hospital is a 12 bed facility that has a low occupancy rate, and hence a high cost per bed to run. Additionally the facility is becoming increasingly difficult to operate as the ability to recruit staff to a small unit requiring a relatively low level of professional skills is proving challenging. It does however provide a range of valued community services that need to be retained and strengthened to better support people in the community. Similarly, PCC recognises that the current provision of care options in the Builth Wells area requires considerable development to meet the needs of an ageing population into the 21st Century. The economic case describes the detailed option appraisal that has been considered and evaluated to deliver the proposed service model. Important to note is that maintaining the status quo is not a realistic option. Working together therefore PtHB and PCC can not only strengthen the community options but also jointly commission a range of care through bringing together provision of health and social care. This will include a facility that will provide, once both phases are completed, the spectrum of options from extra-care housing, residential care, nursing home care and GP managed care in a single health and social care centre. This will provide a seamless range of options for local residents that enable them to stay in their own community and also achieve economies of scale through bringing together all care options within a single facility. The

9

chosen site also has the added benefit of being located as part of an overall campus that includes the GP practice and sheltered housing provision, adding to the ability to provide flexible services into the future. The financial case describes the capital requirement to build Phase One of the development which will provide the base for health and social care services for the community and an initial 12 bed unit. It is demonstrated that this can be achieved on a cost neutral basis for PCC and will achieve significant revenue savings for PtHB through the closure of the current Builth Hospital. The commercial case describes how PtHB and PCC will secure a strategic partner in the housing association sector to build the second phase of the facility that is likely to include extra-care, nursing home care, residential care and dementia care provision for those not able to remain at home, and/or who choose to move to the centre. This section also describes the procurement process through which PtHB and PCC will engage a strategic partner as the provider of care services. Finally the management case outlines the management accountability for the capital scheme through to the Council’s Board, as it is proposed that the capital funding for this scheme will be in the form of a capital grant from WG to Powys Council, who will procure the building through their existing capital Construction Framework. This proposal maps out an exciting future for services in Builth Wells that also forms the exemplar for future health and social care service provision across Powys.

10

1 Introduction

1.1 Purpose This Business Justification Case (BJC) provides the case to support the development of integrated health and social care services for the community of Builth Wells. Fundamental to this service development is the transformation of health and social care services to an integrated, pre-emptive service which has, as its starting point, the premise that individuals belong to, identify with, and should be cared for, within their local communities. The (BJC) makes the case for future investment in support of the Builth Wells Model for Integrated Health and Social Care Services and seeks approval to proceed to the development of Phase 1 of the capital element of the scheme at a capital cost of £5.37M. It is proposed that Phase 2 will proceed based on the engagement of strategic third party partners for both the capital and service elements of this part of the scheme.

1.2 Introduction and Purpose PtHB, in partnership with PCC, Powys Association of Voluntary Organisations and a range of other stakeholder groups has developed a combined proposal for the development of the Builth Wells Model for Integrated Health and Social Care. The model has been developed with local stakeholders from health, social care and the community, and is designed to maximise the level of care and support that can be provided to people in their own homes and in care settings. The model will provide for enhanced health and social care services, working more effectively, through integrated working, improved communication and information sharing, and appropriate risk management of clients. This will work to maximise the availability of local services and minimise the need to engage services out of the area and out of Powys in line with both ‘Setting the Direction’, the delivery programme for Primary and Community Services, and the Rural Health Plan. Implementation of the model is key to the delivery of the Service Workforce and Financial plans in the Builth Wells area of Powys. The model forms a key deliverable as part of the programme of service modernisation and integration required in Powys to deliver PtHB and PCC’s vision for New Models of Health and Social Care as set out in our Common Vision Statement. A key driver is the delivery of high quality, accessible services which contribute to revenue efficiencies. The community led service model is supported by the requirement for a facility that provides a base for community services integrated with a care home/housing facility that meets local need. This development has been planned in two Phases: • Phase 1 comprises the implementation of the community based model including the base

for community services that support the model, and a 12 bed intermediate care unit.

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• Phase 2 comprises further phases of the development to provide a range of care environments from extra-care and residential care options through to care options that include nursing care. Phase two will be completed following competitive dialogue exercises to appoint strategic partners for provision of the building and for the provision of care.

This document is primarily concerned with Phase 1 of development in the context of the overall scheme and fulfils the core requirements of a BJC to secure capital for the development of Phase 1. Phase 1 will have a capital requirement of £5.37M which is being sought from the WG NHS Capital Programme. The entire scheme is currently estimated to be valued at around £15M to be sourced through partnering arrangements with a housing association. Delivery of Phase 1 of the scheme will enable the closure and disposal of the current Builth Hospital, and will achieve recurrent revenue savings for the Health Board of £0.43M per year. The BJC has been prepared using the standards and format for Business Cases, as set out in Welsh Health Circular WHC (2006) and subsequent guidance including: • The Strategic Case section. This sets out the strategic context and the case for change,

together with investment objectives for the scheme and the proposed service model.

• The Economic Case section. This demonstrates that the partnership has selected a preferred way forward, which best meets the existing and future needs of the service and is likely to optimise Value for Money.

• The Commercial Case section. This outlines the way in which the service might be commissioned and delivers the service within the resource constraints.

• The Financial Case section. This highlights likely funding and affordability issues and the potential balance sheet treatment of the scheme.

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2 The Strategic Case

2.1 Introduction The purpose of this section is to confirm how the scope of the proposed service model fits with existing service and business strategies at both the national and local levels. It maps out a compelling case for change in terms of the current and future operational needs of health and social care organisations in Powys. PtHB, in partnership with PCC, Powys Association of Voluntary Organisations, and a range of stakeholder groups has developed, in partnership, a combined proposal for the development of an Integrated Health and Social Care Community Service for the citizens of Builth Wells. The implementation of an integrated health and social care service for the population within the Builth Wells area represents the response from the Powys Health, Social Care and Wellbeing Partnership to a series of concurrent strategic drivers both at the national and local levels. As a pilot programme for the delivery of integrated health and social care in a defined community this will be the blueprint for the delivery of this strategic vision across the rest of the County.

2.2 Organisational Overview

2.2.1 The County of Powys Powys had an estimated population in mid-2008 of 132,598 and covers a quarter of Wales, making it the most sparsely populated county in England and Wales, with just 26 persons per square kilometre. (Wales: 144 persons per square kilometre). The proportion of people aged 75 and over in Powys has increased from 9% in 1998 to 10.3% in 2008 (Wales: 8% in 1998 to 8.6% in 2008), due to national trends in longer life expectancy and falling birth rates accentuated by the net out-migration of young adults from Powys. It is estimated that there were 58,654 households in Powys in 2007. It is estimated that 32.3% of Powys households were single persons (Wales: 30.9%), 35% were couples with no children (Wales: 31.5%), 5.3% were single parent families (Wales: 7.7%), and 20.1% were two adult families (Wales: 20.9%). 26% of the current Powys population is over 60 years against the Welsh average of 23%. By 2016, population projections for Powys show that 31% of the population will be aged over 60 years and that the number is set to increase by a quarter representing an additional 8,264 people. The working age population is static but will start to decline. This is of significance because the 35 – 55 year old females are the group traditionally available for caring, or for employment as carers. This shift towards an older population is happening faster in Powys than the Welsh average. Even a 10% shift from institutional care to home based care will not be enough to counteract the ageing population and an increase in institutional care is still

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required. By 2016, the numbers of service users aged over 50 years in receipt of social services is likely to increase by 900, half of whom will be aged 85 years and over. Between 2006 and 2016, it has been estimated that the number of older people in Powys with dementia requiring care is likely to increase by 303 – 410. This represents a rise of between 16 and 18%. Chronic conditions are a cause of a large proportion of emergency hospital admissions. By 2014, there will be a 20% increase in those aged 65 and over with at least one chronic condition.

2.2.2 Powys County Council PCC has 73 councillors, elected every four years. The Council is currently controlled by a coalition called the Administration made up of members of the Powys Independent Alliance and the Welsh Liberal Democrats. Since May 2011 the Council has an Executive Cabinet made up of the Leader, appointed by Council, and 9 members of the Administration appointed by the Leader. The Council provides an extensive range of services to the residents of Powys. Services may be delivered by the council’s own employees or by contracting out the delivery of services to another body or organisation. At 1st March 2009, the council employed 8,732 people full and part-time (5,077 FTE). Statutory officer appointments are: Head of Paid Service (Chief Executive), Monitoring Officer (Head of Legal, Scrutiny and Democratic Services), Head of Finance and Corporate Performance, Director of Social Services (shared with Ceredigion) and Chief Education Officer. The council's net budget for 2011/12 was £233 million. More than three-quarters (77%) is provided by the Welsh Assembly Government, with £54 million raised locally through Council Tax. Approximately 19% of the budget is spent on adult services and 7% on children’s services.

2.2.3 Powys teaching Health Board (PtHB) PtHB was established in 2009. The Board is responsible for commissioning secondary health care and hospital services and coordinating the delivery of primary care services. It also directly delivers community care services such as district nursing, child health, midwifery and community services in ten local community hospitals. The Health Board has recently moved to a locality based management system. PtHB employs 2,137 people (1,312 whole time equivalent). In 2011/12, the WG allocated funding of £245million to PtHB. Approximately 48% of this budget was spent on purchased services and 24% on directly provided services.

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2.2.4 The Builth Wells Catchment For the purpose of this project, the Builth Wells catchment area is defined as the Builth Wells Local Community Forum area and Builth Wells Medical Practice area. A map of the Local Community Forum Area which roughly coincides with the Medical Practice area is shown in Figure 1. The Powys Local Public Health Team undertook a comprehensive assessment of the needs of this community in early 2007. The full analysis can be found in Appendix 1 with a summary of the main findings as follows: In population terms the number of people living in the Builth Wells area is relatively small at around 7,000 but in geographical terms the area covered is quite substantial. With the exception of Builth Town the population is sparse. The communities of Builth Wells and the surrounding area experience a below-average level of deprivation, low economic inactivity and low reliance on benefits. All of these factors contribute to good health in the longer term. However, income levels are relatively low and access to services can be difficult due to the rurality of the area. Educational attainment in schools in the area is above the national average. Health related behaviour, although better than Wales as a whole, is a potential problem for the future. Almost a half of the population is overweight or obese, increasing the risk of long term conditions in the future such as diabetes and heart disease. Self reported levels of health within the population are generally good with the number of people with limiting long-term illness being less than the Welsh average. Death rates overall are slightly lower than the Welsh average, however, for some conditions such as stroke, heart and circulatory disease, rates are above the Welsh average. Death rates for cancers and respiratory illnesses are below the Welsh average. Housing Table 2.1 shows the results of a House Condition Survey1 commissioned by Powys County Council and undertaken in 2004 for the housing stock within the Builth Project area.

1 Powys County Council, ‘Report of Private Sector House Condition Survey 2004’, David Adamson & Partners Ltd, Sept 2006

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Table 2.1

The survey reports a total of 3301 dwellings, the vast majority of which are owner-occupied (87%). Almost half of the housing stock is old housing of pre-1919 construction. Such housing is typically harder to heat and to retain heat and also more costly to physically alter in terms of disabled adaptations. The survey also shows a high proportion (31.5%) of the dwellings are in an unsatisfactory condition being in either poor repair or classed as exhibiting category 1 hazards as defined by the Housing Health and Safety Rating System introduced under the Housing Act 2004. Over 40% of the dwellings are occupied by households defined as elderly. This finding is supported by the figure of 38% of Head of Households reporting their employment status as pension only. Almost a quarter of dwellings are occupied by one person only and it would be

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fair to assume that the majority of these single person households will be occupied by elderly people. Without their closest family support, such households can become increasingly dependent upon support from their friends, communities and statutory services. Meeting Health and Social Care Needs Populations of the size of Builth Wells are sufficient to support and sustain a range of level 1 services. “Designed for Life: Creating World Class Health and Social Care for Wales”, describes Level 1 services as those provided in the home, in the local community or in supported housing, and include primary care, social care services and continuing care. The most frequently used Level 2 acute services such as out-patients, some diagnostic tests, rehabilitation and day surgery, can also be provided locally but need to be planned and managed on a shared basis in conjunction with neighbouring communities, within mid Powys and external provider organizations. For Builth Wells these services are largely provided at Llandrindod Wells Hospital. Higher level services for the most part are provided outside of Powys, for this community primarily in Hereford. The predicted change in population structure, with an increase in the elderly (75+) has the potential to have a significant impact on health and social care provision, most significantly social care, as dependence increases with age.

2.3 Health and Social Care Strategies Modernisation and integration of health and social care services in Builth Wells is an exemplar project for the county in meeting the service modernisation and financial targets set out in the tHBs’ Service Workforce and Financial Framework and within the Council’s Change Plan. The development of this scheme is in line with a wide range of National Strategies. In particular, it supports Rural Health Planning – Improved Service Delivery Across Wales – which stresses the importance of improved access to services, the need for community cohesion and engagement and more integrated service models; and the Primary and Community Service Strategic Development Programme – Setting the Direction – which reinforces the need for a whole system change in health and social care policy frameworks and the need for integrated care. “Better Support at Lower Cost” sets the agenda for Adult Social Care Services in the context of an integrated whole-system approach to health and social care which intervenes early and promotes independence. In response to National Strategies, Powys has formulated the Health Social Care and Well Being Strategy 2008/11, which is now in its implementation phase and of which the proposed scheme – the Builth Wells Model for Integrated Health and Social Care - is an integral part.

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2.4 Existing Arrangements In the Builth Wells area primary and secondary health care services are currently provided by PtHB and social care services are currently provided by PCC, together with third sector services as follows: General Medical Services (GMS) - The area is served principally by the Builth Wells Medical Practice, which has a GMS contract with PtHB to provide NHS General Medical Services. These services include those provided by the GPs, and those provided by the Practice Nurses whom the practice employs. The practice is located in the surgery at Glandwr Park, Builth Wells. This building was constructed as a purpose-built surgery in the early 1990s, with a later extension providing additional meeting room and office accommodation. It is in good condition, but has little capacity to provide services beyond General Medical Services. There is insufficient space to accommodate members of the wider Primary Care Team, for example the District Nursing Team, and no space for expansion or extension. The practice undertakes its minor surgery activity at Builth Wells hospital due to the lack of space in its practice. The practice hosts some community clinics provided by PtHB services. Community Nursing Services - People living in the area have access to Community Nursing Services provided by PtHB. The District Nursing Team has an administrative base in Builth Wells Hospital. This joint team serves the population registered with the Builth Wells Medical Practice and also those registered with the Rhayader Medical Practice. The Nursing Service delivers care predominantly to patients in their own homes. There are, however, occasions when District Nurses will see patients elsewhere, for example, in a surgery. There are also Specialist Nurses working in the area who see patients from a much wider area than that covered by the Project. These nurses cover areas such as Diabetes, Coronary Heart Disease, Respiratory Disease and Psychiatry. They also work in partnership with other specialist service providers such as Macmillan. They work in support of the GPs and those working in the District Nursing Team. They also liaise with clinical teams involved in the delivery of the package of care from secondary care, for example, Hereford Hospital. Midwifery - Powys Midwifery services provide antenatal care through a weekly antenatal clinic and quarterly antenatal classes in Builth Wells Hospital. There are named midwives for the Builth Wells caseload who are well received by the community. Low risk pregnant women have a choice of homebirth, or the Llandrindod Wells or Brecon Birth Centres for local birth or may choose to travel to birth at a neighbouring acute hospital. There has been a notable increase in local births especially homebirths from the Builth Wells caseload. Allied Health Professionals and the wider medical t eam- People living in the area have access to a range of Therapy Services. These include Occupational Therapy, Physiotherapy, Podiatry, Dietetics, and Speech & Language Therapy provided either at home or in Builth Wells Hospital on an outpatient basis. General Dental Services (GDS) - There are two practices in Builth Wells providing dental services. The practice based in Builth Wells Hospital is a two-chair facility providing NHS General Dental Services under a GDS contract with PtHB. The practice is based on the

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ground floor of the hospital and has access for patients with limited mobility. The second practice provides NHS services only to children. Community Pharmacy Services - There are two community pharmacies operating in the area. The first is a branch of Boots, operating from a store in Builth Wells. The second is a small independent pharmacy operating from accommodation within Llanwrtyd Wells Health Centre. The vast majority of people accessing GMS from the Builth Wells Medical Practice will have their drugs dispensed by one of these two community pharmacies. General Optometric Services - There is one optometrist providing General Optometric Services in the area, based in Builth Wells. The majority of services provided from the premises in Builth Wells are to people living locally. Community Hospital Services – Builth Hospital currently has 12 beds in use, with a nominal complement of 17 beds, under the clinical medical management of the GPs at the Builth Wells Medical Practice. Bed occupancy stands at 68.4% of which 8.6% is delayed transfers of care. Implementation of the community service model in the area has already contributed to the decline in demand for the in-patient beds. There are no consultant beds in Builth Hospital. There are clinic facilities that provide 16 consultant led outpatient sessions per month on an outreach basis from Neville Hall and Hereford Hospitals across 8 specialties. An Ultrasound service is provided at the hospital on an outreach basis from Hereford Acute Hospital, overseen by a consultant and provided on two days per month. Domiciliary Social Care Services - A snapshot in 2009 shows 55 clients receiving domiciliary care in their own homes in the Builth Wells area. 75% of this care is provided by Powys County Council domiciliary care service, while 25% is provided by the independent sector. Of the 55 care packages received by these clients, 7 have 4 calls a day involving two carers to a total of 90 hours a week. 30 clients receive a morning call, 6 clients receive tea time calls and 11 clients are visited late evening (7pm – 10.30pm). 1 client receives a sitting service of 5 hours, 4 days a week. Day Care - General day care provision is based currently in Llandrindod Wells. 31 people travel from Builth Wells to Llandrindod for day care. Transport is provided for people to attend. When at the day centre, people are supported with bathing, showering, personal needs, and a hot meal is provided. For one day a week, the day centre provides a dementia day service. Residential Care - There are two residential homes in the Builth area, Brynhyfryd and Tynygraig. As of January 2012, social services block purchase 11 units in Brynhyfryd with the remaining 19 units in this home privately marketed. In Tynygraig, social services spot purchase 12 units with the remaining 15 units privately marketed. Housing Warden – Builth has one warden who works 19 hours per week supporting 22 clients. Nursing Home Care - There are no nursing homes in the Builth area. The nearest provision is Crossfield House in Rhayader, Brookside in Brecon and Nursing Homes in Herefordshire.

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Currently 28 people from the Radnorshire and Builth area are funded in nursing care. In addition many people (the largest proportion) self fund. Meals Service – As of December 2009, there were 14 clients receiving meals which are provided from Builth Wells High School and Brynhyfryd residential home. Care Management Services - Social workers often work with people who are experiencing difficulty or crisis. Their aim is to provide support to enable service users to help themselves. They maintain professional relationships with service users and their families, acting as a guide, advocate or critical friend. Within the care management role are specialist areas of work, including Approved Social Workers (ASW’s) who work with service users who have mental health difficulties. There are also specialist teams, based in Llandrindod, who work with adults with a learning disability, and children and families. The Social Workers in Area Teams are supported by Community Service Officers who undertake less complex assessment of need, set up packages of care, and support families and carers. There were 418 open referrals for the social service in 2009 for adults resident in the Builth project area. 173 of these were new referrals between 01.01.09 and 27.11.09. Adult Protection - All Social Service Departments in Wales are required to lead multi-agency work to protect vulnerable adults (over 18 years old) on the basis of guidance set out by the Welsh Assembly Government in the document ‘In Safe Hands’. These may include people who: • have learning disabilities or mental health problems, including dementia • are an older person with support/care needs • are physically frail or have a chronic illness • have a physical or sensory disability • misuse drugs or alcohol • have social or emotional problems. Adult protection work is divided into three main areas: prevention, investigation and follow up. These are delivered in partnership with other agencies such as the Police. In 2008/09 there were 173 completed adult protection investigations in Powys. Occupational Therapy (OT) - Occupational Therapists (OT’s) assess and treat physical and psychiatric conditions using specific, purposeful activity to prevent disability and promote independent function in all aspects of daily life. OT’s work with a range of people including those who have physical, mental and/or social problems, either from birth or the result of accident, illness or ageing. There are two OT’s based in the Llandrindod office who undertake assessments throughout Radnorshire and provide advice and information, which often includes the provision/recommendation of equipment and/or adaptations to promote independence or enable care to be sustained in the home. There were 111 OT assessments in the Builth Project area in 2009. Community Equipment and Adaptations – Occupational therapists employed by the Council or Health Board assess individuals for a range of equipment to support people to maintain their independence at home. The Council commissions an equipment storage,

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delivery and maintenance service form Nottingham Rehabilitation Supplies. The Council also issues disabled facilities grants to support people to make adaptations to their home to accommodate mobility requirements. During 2009 there were 11 disabled facilities grant completions, of which 7 were to private householders and 4 to council tenants. Also during this period, there were 59 additional adaptations undertaken and 77 packages of equipment delivered to clients within the Builth project area. Support for Carers - A number of services have been developed with the voluntary sector to provide information and advice, setting up of direct service support (carer breaks), respite care and specific support for young carers. Access to these services for the people of Builth and area is via social services or direct contact with the voluntary organisations. Within the Builth project area, 28 clients receive assistance from Crossroads totaling around 75 hours a month. Builth Wells Community Support - The voluntary sector provides a range of health and social care services across Powys. The most significant of these in relation to this business case is Builth Wells Community Support which was established in 1995 and is a registered charity. The aims of the organisation are to provide services which help local people to live healthy, independent lives within their community and to act as a focal point for volunteering and general information. The area served by the Community Support is more or less the same as the Builth Project area. The Community Support also operates a community car scheme which provides transport for essential journeys with the majority to health care facilities. 30 Volunteers use their own cars and are paid mileage expenses. In 2010/2011 this scheme provided 1174 return journeys and travelled 43837miles. Journeys are both local & long distance.

2.5 Business Needs This section provides a detailed account of the problems, difficulties and service gaps associated with the existing arrangements in relation to future needs. These issues are categorized against the Project’s Investment Objectives.

2.5.1 Quality or “Citizen Focus” By 2016, to provide a range of integrated seamless and equitable health and social care services which are felt by people in Builth Wells to have met their general and assessed needs (Citizen Focus). The capacity of services as currently configured to meet need is anticipated to become challenged over the next 10-25 years due to the projected demographic challenges and the lack of flexibility of options and choice from domiciliary care to housing, residential and nursing home options. Consequently as people age they face moving from one facility to another, and potentially outside of the area in which they may have lived all of their lives. It is recognized across stakeholders that the current model of health and social care does not meet the needs of citizens in providing an integrated seamless and equitable health and social care system. This is characterized by:

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• an over-reliance on out of county care for people with acute and chronic health needs, and • unacceptably high level of delayed transfers of care, associated with inappropriately long

hospital stays • extensive use of out of county placements leaving individuals in care environments long

distances from their family and community • inappropriate use of local hospital beds, as highlighted through the clinical governance

support unit review of Powys services • lack of community service capacity to meet local needs • lack of local modern housing, residential and care options for individuals • limited integration of health and social care services that support maintenance of

independence in the citizen’s home Domiciliary care services are not currently citizen focused as the service is not able to respond to the focus of promoting and maintaining independence, nor is it able to respond to acute changes in need. This is exacerbated by the lack of capacity available to provide all the care packages required resulting in significant financial challenges for the Council. The service is not focused on achieving outcomes for individuals, rather on meeting levels of activity. The Council is finding it increasingly difficult to find suitable and available placements at individuals’ establishment of choice. There is an acute shortage of nursing care placements in the north of the County and for people with dementia across the County. This, coupled with budget pressures, is leading to significant delayed transfers of care, with the associated human consequences. This lack of suitable and specialist accommodation forces the council and health board to purchase out of county placements which increases cost and disconnection of individuals from their families.

2.5.2 Efficiency or “Organisational Focus” By 2013, to provide health and social care services to people in Builth Wells through a single, combined and integrated working team with clear governance structures and a pooled budget (Organisational Focus). There are some examples of good joint working including social work staff placed with mental health teams, assessor nurses placed in older people’s social work teams and a pooled budget for NHS funded nursing care. Social work teams are increasingly involved with discharge planning but this needs to be consolidated. In particular resource and capacity pressures within social care services combine to cause delays in the allocation of new care packages and these go on to cause significant delayed transfers of care. A joint PCC PtHB programme for delivering integrated care pathways for older people was established in March 2010 with support from PricewaterhouseCoopers.

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Accessibility is a major challenge in Powys, with remote rural communities served by relatively small market towns. Historically, commissioners have made efforts to provide as broad a range of services as possible that are accessible to people in their locality. However the rurality of the population means that these services serve relatively small numbers of people. ‘Critical mass’ of potential customers and economies of scale are difficult to achieve, especially as services are provided on different sites. This emphasis on accessibility of services has effectively driven up their cost and adversely affects their quality.

2.5.3 Regulatory Compliance or “Standards Focus” By 2016, to provide health and social care services to people in Builth Wells which meet or exceed all regulatory standards (Standards Focus). In July 2007 and March 2008, the Welsh Assembly Governments’ Clinical Governance Support and Development Unit (CGSDU) produced reports into a range of clinical governance and patient safety matters in the former Powys Local Health Board. Several key issues were identified of specific relevance to Builth Wells Hospital:

• A wide variation in the seriousness of the conditions of patients admitted to community hospitals. They ranged from the acutely ill, to those who did not need to be in hospital

• In commenting on the fragility of services provided from the 10 community hospitals in

Powys, the Review recommended reducing the number of hospitals providing acute care, to two or three centres

• It was noted in the report that Community Hospital services in Powys cost

approximately £2000 per bed per week whilst the Wales average for a rehabilitation bed in a DGH was approximately £1,400, whilst a nursing home placement would cost approximately £700

• By working with Partners and stakeholders, the Review recommended that a model of

health and social care could be developed which provided the fullest range of services locally and also enable people to remain in their own homes as far as possible, with access to local care home units when needed.

The Council’s care home portfolio is generally dated and whilst currently it is not in breach of regulatory standards, the current buildings are not regarded as offering a high quality flexible and future-proof care environment. Significant capital investment is required in order to continue to reach a satisfactory safe functional standard.

2.5.4 Economy Focus By 2016 to optimise the use of resources to provide health and social care services through an integrated, sustainable, financial framework (Economic Focus).

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The council and health board both manage a portfolio of ageing buildings. A recent survey of the council’s care home portfolio indicated the need for £3.8m capital investment over the next 10 years simply to keep buildings fit for purpose. Increasing regulatory standards will require still further investment. In addition to the deterioration in the physical condition of the buildings, they also place limitations on service providers to offer a more flexible range of services within the establishments, for example the provision of nursing and dementia care. The Council currently has a care home in Builth Wells (Brynhyfryd). A condition survey of Brynhyfryd residential care home was undertaken by Capita Symonds in 2009. This 30 bedroom home was constructed in 1951. It is estimated that the investment requirement over a 10 year term would be in the region of £340,000 which includes an initial expenditure of some £103,000 required in year 1 to restore the property to achieve a satisfactory, safe functional standard. Some of the main items requiring urgent attention are rewiring, roof repairs, repair/renewal of passenger lift and work to ensure the fire integrity of the building. The Builth Wells Community Hospital building, originally Edwardian, has been much extended and modified during its life and the older main part of the building requires significant upgrade to meet latest standards, at an estimated cost of £406,000. Some 50% of the total buildings were erected prior to 1948 and consequently the buildings score badly in estate terms with a score of only 50% for space utilisation, functional suitability and availability of single rooms.

2.5.5 Replacement or “Procurement Focus” By 2016, to secure high quality capacity for residential and nursing home care in Builth and environs in line with local housing and care needs and demand (Procurement Focus). In September 2007, a report was presented to the Council’s Board entitled “Service Review of Residential Care Provision for Older People in Powys.” This review was undertaken by the National Care Forum (NCF). This report recognised the extent of future capital investment that will be required to ensure the portfolio will meet the new standards that are required for residential care provision. The NCF Review made an analysis of the value that had been achieved for the Council by the contract with the current provider and recommended that the service should “be retendered through a new competitive tendering exercise after the service configuration has been defined.” In January 2008, a project group was established to oversee the development of the future configuration of the residential care portfolio across the county. This was based on the emergent service model that was being developed for an integrated health and social care facility in the Builth Wells Community. This group concluded with a concept for the development of a variety of modernised facilities across the county ranging from larger multi-purpose health and social care facilities to smaller care home hubs and, in some cases, the closure or reconfiguration of care homes to provide more flexible extra-care housing schemes. Whilst this fits with the Council’s overall corporate goals, there continues to be a requirement to have regard to affordability and value for money. Through the Health, Social Care and Well-being Strategy this reconfiguration has been aligned with the Common Vision Statement for Integrated Models of Health and Social Care,

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which was approved by Council and Health Boards in July 2009. The proposed health and social care facility at Builth Wells represents the first stage in the implementation of that plan.

2.6 Potential Scope and Services The Builth Wells Project, of which the integrated health and social care facility is an integral part, has been scoped in response to the aforementioned strategies, programs and related business needs and extensive stakeholder engagement and emphasises the provision of low-level support to promote wellbeing and maintain independence.

2.6.1 The Service Vision In Powys, there is a shared understanding across the health and social care community of the strength of the case for service transformation. The vision for Powys is to transform health and social care services into an integrated, pre-emptive service which has, as its starting point, the premise that individuals belong to, identify with, and should be cared for, within their local communities. This is being achieved through working with the community to establish a network of services which enable people to: • Stay in their own homes and receive care in, or in settings close to their own homes, as

long as possible • Stay engaged in their local community for as long as possible • When necessary, to receive care in a care home environment supported by in-reach NHS

multi-disciplinary teams for short stay interventions where this is safe and appropriate • Acute care is provided in out of county hospitals with co-ordinated efforts to return people

to Powys services as soon as patients are medically fit • When their treatment/care has been completed, to return home (or live as independently

as possible) as quickly as they can, with whatever necessary support they require.

2.6.2 Service Principles The service model developed by Partners seeks to ensure the following key principles: • Promote independence and reablement • Engage communities in service transformation • Maximise the benefits of service integration across health, social care and the third sector • Promote co-location • Move away from institutional, bed-based models of care • Rationalises public sector care settings, including community hospitals and care homes • Provide a flexible, local, sustainable range of housing and care options • Delivers service and financial efficiencies

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2.6.3 The Service Model The development of the service model has been based on the following assumptions: • Service transformation must take place within a strong framework of local community

engagement. • PtHB and PCC will provide integrated leadership in the delivery of the model. • Services based in the community will need to be easily recognised and respected for their

accessibility, reliability and quality. • A whole system approach to care will be developed, underpinned by appropriate

information systems. • Service transformation must take place in the context of financial pressures. The service

will need to focus on the use of existing resources to maximum benefit and in the transformation process.

The model can be represented schematically as follows: Figure 2.1

The service delivery model is based on a recognition and systematic knowledge of the risks to independence of each member of the community. The model moves form a reactive crisis management approach to a proactive preventative one involving the early detection of increasing support needs, underpinned by planned health and social care interventions which avoid unnecessary and debilitating hospital interventions.

Tertiary Services (e)

District General Hospitals (d)

Local Rural Hospitals (c)

Community Based Care (Promoting Independence) (b)

Primary Care & Home-based Health & Social Services (a)

Car

e P

ath

way

Treatment out of Powys

Care at Home

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This business justification case describes the service model for Builth Wells and therefore focuses detail on a description of these first two levels of service. These are: • Primary Care and Home Based Health and Social Care Services • Community Based Care – Promoting Independence

2.6.4 Primary Care and Home Based Health and Social Care Services (Level (a) of Model). Services will be focused on developing and maintaining individuals’ independence through supporting the development of a strong community network and services at home. Primary care and home-based health and social services include all services to be provided locally, either in the client’s home, or within their local community. Services will be a mix of primary care led healthcare and jointly governed health and social care community resources. Outreach and community services will underpin the promoting independence model and include: • Information advice and support. – provided through a single point or the “Community Hub”

as identified in “Setting the Direction” helping members of the community, carers and care professionals to navigate through the health and social care system.

• Community Support and Engagement – enabling the early detection of risk factors. • Health and Wellbeing Services – ensuring local citizens have every opportunity to stay

healthy and maintain independence. • Volunteer support –providing practical support to citizens to prolong independence. • Carers Support – including information, advice, peer support and a flexible and accessible

range of respite services. • Housing Related Support. - ensuring that citizens’ homes continue to be appropriate

environments in which they can maintain their independence. • Telecare and Teleheath – supporting proactive responses from an appropriate range of

services. • Responsive Home Support Service – supporting people to continue to live at home based

on an outcome model. These services will enable local people to access locally a wide range of services in a way which ensures that their needs are met through the seamless provision of care. To achieve this there will be:

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• A single access point for patients to all locally provided health services. Over time this will include access to a range of social care services as partnership working develops.

• One information database so enabling seamless care to individuals. These services will be primarily community based and be provided to people in their own homes and through supported housing and care options.

2.6.5 Rural Health & Social Care Community-Based Se rvices (Level (b) of the Model) The provision of high quality primary and community care will enable more people to be cared for and treated at home, and key aims of the service will be to reduce admissions to secondary care (levels c and d of the Model) and facilitate early discharge from these care providers. These services will be jointly governed by PtHB and PCC to deliver an integrated and seamless overall service for citizens. This element of service delivery will include integrated services provided by the Primary Care Team, rehabilitation services, district nursing, community support, out-reach consultant-led services, locally based care home beds for short and longer term care and Voluntary Sector-led services.

• Flexible Care Home Accommodation – Rapid access to short term intermediate care accommodation, supported by GP and appropriately qualified staff (including nurses) in which assessments and step down interventions can be made whilst a service user at acutely high risk can be monitored prior to a return to a managed home environment.

• For those who are no longer safe to remain at home, a modern range of care home

accommodation which provides a satisfying environment, remaining closely linked to the local community. Such services are responsive to all residents’ needs including those suffering from dementia.

• An Integrated Community Therapies and Reablement Service – a home based service

that will support citizens experiencing planned or acute episodes who can be returned to as much independence as possible through a tailored package of therapies and social care support, typically a six week package of home support.

• Extended Community Nursing – Offering a greater range of nursing interventions over

an extended period to include twilight services to people in their own homes obviating the need for hospital admission, and extended home based palliative care.

• Hospital Transfer Co-Ordinator “in-reaching” to District General Hospitals out of County

to undertaking pre-discharge assessment and plan care and support to ensure timely discharge.

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• Integrated Community Equipment Service – a range of equipment to support people to continue to live at home with speedy access to support to adapt the home environment.

• GP services – the existing GP surgery is located extremely close to the development

site.

• Wellbeing Centre – to promote healthy lifestyles for support scheme residents, daycare users and community health and therapy programmes within the local community, including clinical outpatient and community services.

2.7 Potential Benefits The implementation of this service model is crucial to the transformation and development of community services in Builth Wells and to the wider Powys health and social care system. It will bring benefits to a wide range of stakeholders, who are set out in the table below, together with the associated benefit. Table 2.2 Project Benefits Stakeholder

Benefits

Service users • Increased and improved access to local services with less dependence on out of county acute hospital services

• Equity of service provision • Easier journey through health and social care system with a

single point of access • Greater promotion of health and wellbeing • Greater potential to avoid hospital admission and more home

and community based care • Significantly improved environments of care.

The Health Board and County Council

• Service integration and greater efficiency in the use of resources

• Revenue savings • Compliant facilities • Implementation of a key strategic goal • Delivery of several national policy drivers for this locality • Improved facilities for service users and staff. • Services resilient to demographic change

Staff • Better working conditions • Improved job satisfaction • Greater opportunity for training and to develop clinical

practice and service scope • Improved collaborative working. • Clear direction of travel

Public • Single point of access to information on all local health and social care facilities.

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2.8 Potential Risks In 2007, the National Audit Office and Office of Government Commerce (NAO/OGC) undertook a study of recent capital project schemes that were deemed unsuccessful in terms of cost, time overrun or delivery of benefits. One of the eight major reasons was the failure to identify properly and manage risks within projects. This section takes an early view of the high level key risks that are likely to impact upon the successful delivery of the Builth Wells Model and sets out the counter-measures that the Builth Wells Project Board will take in order to minimise and manage the associated risks. Table 2.3 Project Risks Risk Category

Risk Description Counter-measure

Funding risk – a reduction in the level /availability of capital or revenue funding due to the economic downturn or changes in health funding policy leads to delays and reduction in the scope of the project.

No contractual commitments will be made until firm assurances are given regarding the affordability and availability of capital.

Planning risk – issues relating to planning permission or planning constraints

Early engagement with planning department – Full planning permission obtained November 2011.

Demand and usage risk – the size and capacity of the scheme is not appropriate for the eventual needs of the population.

The preferred option will take into consideration future flexibility and opportunity to “right-size” through a phased approach to take account of emerging and changing needs

Project development and delivery

Build risk – the construction of the physical asset is not completed on time, to specification or within budget

Strong project management (appropriately resourced), and early engagement, robust contracts and a mature relationship with Construction Framework provider.

Lack of “buy-in” to new model of care

Full involvement of clinical heads and key stakeholders from other agencies is already occurring through the project governance arrangements and the wider programme management

Operational risk – the day-to-day operating costs cannot be contained within agreed budgets

Clear levels of accountability at local level for day-to-day budgetary management information systems and reporting

Service Delivery Risks

Affordability risk – the necessary realignment of budgets following the implementation of the new model of care does not provide the anticipated savings

Clear accountability with the overall programme for the systems-wide changes in resource allocation and service transformation.

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The Project Board have undertaken a detailed analysis of potential risks associated with the construction and ongoing management of the proposed health and social care facility and have developed a Risk-Sharing Agreement which is attached at Appendix 2. An on-going risk register is managed and reviewed by the project team (example attached at Appendix 3).

2.9 Constraints and Dependencies The Builth Wells Project is predicated on the following key assumptions: • Service transformation will be delivered in the context of financial pressures, maintain

service outcomes and deliver revenue savings across the health and social care system • Service transformation must take place within a strong framework of local community

engagement • PTHB and PCC will provide integrated leadership in the delivery of the model • Out of hospital services will need to be easily recognised and respected for their

accessibility, reliability and quality • A whole system approach to care will be developed, underpinned by appropriate

information systems • The Project will be in alignment with the Strategic Outline Programme for PtHB and

Change Plan of PCC.

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3 The Economic Case This section of the BJC records how the long list of options has been identified and appraised. It goes on to appraise a short list of options to arrive at the preferred way forward.

3.1 Critical Success Factors

The Critical Success Factors for the Builth Wells Project have been agreed as follows: • Strategic Fit - The consistency of the option with national and local strategy and policy: a

whole system approach to meeting the investment objectives • Potential Value for Money - How well the option maximises the return on the required

investment in terms of economy, efficiency and effectiveness, whilst minimising associated risks

• Potential Affordability - How well the option meets both organisations financial strategies, availability of funds and meets funding constraints

• Achievability - The practicality of delivering the option in terms of timeliness, the ability to adopt the new ways of working and the availability of sites, staffing and other resources

• Supply Side Capacity and Capability - How well the option appeals to the supply side and matches the ability of service providers to deliver required level of service.

These have been used, alongside the investment objectives agreed for the project, to appraise the long-listed options (SWOT analysis). An Options Workshop was held in December 2009 by the Project Team and included key personnel drawn from PtHB, PCC and WG. Membership of this workshop is supplied at Appendix 4. The long list of options for investment in the Integrated Health and Social Care Service was identified by the Workshop as follows and within the following 4 main categories of choice. • Service Scope – the potential coverage of services in relation to the Builth Wells Model • Service Solution – the potential range of options relating to the underpinning infrastructure • Service Delivery – the potential range of options relating to the delivery of supporting

services • Funding – the available choices for funding and financing the Builth Wells scheme.

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3.2 Service Scope

The main choices for service scope and components are as follows: Option 1.1 - Do Nothing

• Maintain Existing Community Health Services • Maintain Existing Community Social Care Services • Continue existing inpatient beds at Builth Hospital • Maintain Hospital building to provide safe environment • Existing care home capacity • Maintain both homes to provide safe environment.

Option 1.2 - Do Minimum

• Maintain Existing Community Health Services • Maintain Existing Community Social Care Services • Implement Mid Powys reablement scheme • Close Builth Hospital • Relocate bed based activity to Llandrindod Hospital • Relocate outpatients, therapies, X-Ray and outreach ultrasound activity to Llandrindod

Hospital • Denticare (Assist to relocate) • Ambulance Base (Relocate elsewhere in Builth) • Maintain existing care home capacity • Maintain both homes to provide safe environment.

Option 1.3 - Intermediate

• Close Builth Hospital • Relocate outpatients to Llandrindod • Relocate diagnostic imaging to Llandrindod • Enhanced Community Services:

o Extended hours rapid response – Twilight nursing o Reablement

• New Build Facility containing: o Integrated Health and Social Care Team comprising the current district nursing,

domiciliary social care and reablement teams o Third sector advisory service o Outpatient and therapy suite for dietician, physiotherapy, OT, paediatric

physiotherapy o Outpatients suite supporting tele-health and in-reach (from services outside of

Powys) consultant led outpatients o Minor surgery suite in support of the local GP practice o Three chair General Dental Service o Ambulance Service and paramedic base o Well Being suite for group based health education, therapy, reablement and day

support services

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o 52 units* comprising: � 12 en-suite units residential intermediate care with in-reaching nursing

and reablement services and additionally, for example : • 16 bed long term care home suite for older people • 16 bed long term care home suite for older people • 8 unit extra care facility

(*NB – Recent work undertaken by PCC and PtHB has evidenced the need to strengthen the provision of nursing home, dementia and extra care facilities in Mid Powys. At the time of completion of this BJC, this work is yet to be finalised. On completion it will form the basis for a full commissioning strategy upon which future capital requirements will be based). • Option 1.4 - Maximum

In addition to Intermediate: • Enhanced Community Services:

o 24/7 rapid response community service • New Build Facility:

o GP Surgery o Minor Injuries Centre o Pharmacy o Optician o Outpatients o Outreach and community laundry service o Base for outreach and Homecare support staff o Community café o Multi functional activities and community provision

Main Findings Option 1.1: The Status Quo – or “Do Nothing” This option has been included as the benchmark for value for money (VfM). As such, it was not found to support and further any of the investment objectives set for the scheme. It does however provide for essential repairs to the existing infrastructure, which would be affordable and achievable if phased over the long term. On this basis, it has been discounted as a realistic way forward and included as a benchmark for VfM. Option 1.2: The “Do Minimum” This option was found to meet most of the Investment Objectives in part. It enables the closure of the existing Builth Wells Hospital and the transfer of beds to Llandrindod Wells Hospital. This option does not provide strategic fit in relation to the Vision set for New Models of Health and Social Care and the Builth Wells Model or assist to rationalise residential and nursing home care in the run-up to PCC replacement of services. On this basis, it is not a tenable way forward but has been retained for comparison purposes.

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Option 1.3: Intermediate Scope This option meets all the Investment Objectives and CSFs set for the Builth Wells scheme. In addition to implementing the Vision set for New Models of Health and Social Care, it rationalises and makes best use of associated resources and enables the closure of Builth Wells Hospital with the replacement of a new Integrated Health and Social Care Facility. It does not however reflect the original vision set for the scheme inasmuch it does not provide for some important ancillary services - such as the multi-functional community space, GP Surgery, Pharmacy, Optician, – which in any event have not proven to be viable inclusions given the associated difficulties with relocating practitioners in practice, although the option will remain open to include some of these services should the difficulties with re-location be overcome. It is also recognized that the precise number and case-mix in the overall facility given the changing need of care requirements and the unknown impact of both self-funding placements and the right of residents to choose their care home. It should be noted however, that this option provides for limited Outpatient Treatment Facilities. On this basis, it represents a viable way forward. Option 1.4: Full Scope This option meets all of the Investment Objectives set for the Builth Wells scheme and provides for some important ancillary services – such as the Community (Village) Hall, GP Surgery, Dentistry, Pharmacy, Optician – which, as noted above do not constitute a realistic way forward in the immediate future. It was therefore found to be only partially affordable and not achievable in the short-term. Capital costs, revenue effects and asset appraisal associated with the closing of Builth Hospital or either of the Council Care Homes is not included within the BJC forms and option appraisal. On this basis, it has been discounted for the purposes of the BJC. Conclusion On the basis of the above analysis, the preferred way forward in relation to the potential service scope of the Builth Wells scheme was Option 1.3, and the adoption of the Intermediate Scope for service users. Option 1.2, “Do Minimum” whilst clearly not fulfilling the requirements for a modern integrated facility has been retained , but only as a baseline option in line with guidance, for comparison purposes. Table 3.1 summarises the assessment of each option against the investment objectives and CSFs.

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Table 3.1: Summary and assessment of scoping option s

Reference to: Option 1.1 Option 1.2 Option 1.3 Opti on 1.4 Description of Option

Do nothing

Do minimum

Intermediate

Full

Investment Objectives 1. Citizen focus X √ √√ √√√ 2. Organisational focus

X √ √√ √√

3. Standards focus

X √ √√ √√

4. Economy focus

X √ √√ √√

5 Procurement focus

X X √√ √√

Critical success factors 1. Strategic fit X X √√ √√ 2. Value for Money

X √ √√ √√

3. Affordability √ √ √√ √√ 4. Achievability √ √ √√ √ 5. Supply-side capacity & capability

n/a √√ √√ √

Summary

Discount VfM Benchmark

Preferred Discount – not realistic

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3.3 Site Solution In relation to the recommended scope above, the main choices for site solution were identified as:

• Option 2.1 – Do nothing/minimum - existing /sites with refurbishment • Option 2.2 - Existing Site with New Build Programme • Option 2.3 - New Site with New Build Programme

Main Findings Option 2.1 - Existing Site with Refurbishment Progr amme This option assumes that the vision for new Models of Health and Social Care could be implemented within the existing shared portfolio of sites within Builth Wells and the surrounding area. In reality, none of the residential care homes as they stand within the existing portfolio of PCC could accommodate the Integrated Health and Social Care Facility because of the limitations of the buildings. The only possible refurbishment based option, therefore, would be the re-development of Builth Wells Community Hospital. Whilst ostensibly an option, the refurbishment of this Victorian building would be unlikely to provide an economic, contemporary and viable infrastructure for the provision of high quality, flexible and effective services. This option therefore fails to provide for the organisational, standards and economic Investment Objectives set for the Project in addition to providing poor strategic fit, value for money and affordability in terms of the physical limitations of the existing buildings, their future configuration, and the related costs involved. On this basis, the refurbishment and upgrading of an existing site has been discounted as a realistic option but retained for comparison purposes. Option 2.2 - Existing Sites with New Build Programm e This option is predicated on the design and build of a modern, flexible facility on an existing site. PCC have undertaken a feasibility study of the available sites within the Builth Wells area including sites within the council and health board’s property portfolio. The Builth Wells Hospital site is not of sufficient size to accommodate the planned facility. The recommended site is to build on the existing site of the Brynhyfryd Care Home given its optimal location for the provision of service to the local community. Building an Integrated Health and Social Care Facility on this site would meet all the Investment Objectives and CSFs set for the Project, subject to funding and affordability

37

constraints. Indicative costs prepared at the outset of the Project would also indicate that this is likely to be the least-cost option, in comparison to refurbishment and upgrading of existing buildings. On this basis, this option was identified as an option for further consideration. Option 2.3 - New Site with New Build Programme A new-build on a new site ostensibly provides a sensible way forward. However, a comprehensive analysis of potential sites confirms that there is not a suitable site presently available in the Builth Wells area, let alone at an affordable price. On this basis, this option has been discounted from further consideration. Conclusion A structured review of available sites in Builth Wells concluded that there are no appropriate new sites upon which to embark upon a new-build programme (Option 2.3). Instead the analysis concluded that the optimum location for a new build programme was on the site of the PCC Brynhyfryd Care Home. On the basis of the above analysis, the preferred way forward in relation to the potential service solution for the Builth Wells scheme is to design, build and procure a modern, purpose built facility on the existing, publicly owned (PCC) site. Option 2.1; Existing Site with Refurbishment Programme - Whilst clearly not fulfilling the requirements for a modern integrated facility has been retained , but only as a baseline option in line with guidance, for comparison purposes. Table 3.2 summarises the assessment of each option against the investment objectives and CSFs

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Table 3.2: Summary and assessment of service soluti on options

Reference to:

Option 2.1 Option 2.2 Option 2.3

Description of Option

Existing site/s + refurb

Existing site + new-build

New site + new build

Investment Objectives

1. Citizen focus √ √√ √√

2. Organisational focus

X √√ √√

3. Standards focus

X √√ √√

4. Economy focus

X √√ √√

5 Procurement focus

√√ √√ √√

Critical success factors

1. Strategic fit √ √√ √√

2. Value for Money

X √√ √

3. Affordability X √ √

4. Achievability √ √√ X

5. Supply-side capacity & capability

√ √√ √√

Summary

Discount

(but retained for comparison purposes)

Preferred

Discount

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3.4 Capital Funding Four capital funding options have been identified:

• Option 3.1 - Public funding with WG supplying a capital grant. • Option 3.2 - Private funding with a not-for-profit partner raising capital. • Option 3.3 - Private funding with PCC taking responsibility for capital borrowing. • Option 3.4 - A combined approach which seeks to maximise WG Capital funding and

in parallel explore alternative capital sources in line with Options 4.1and 4.2 Option 3.1- Public funding with WG supplying a capi tal grant. This option is based upon WG funding for the totality of the facility in support of the Builth Wells Model for Integrated Health and Social Care with the associated revenue consequences being met through efficiency gains within the resultant service. The opportunity cost of WG funding will make the scheme more affordable over time and satisfies the CSF’s agreed for the Project. It is recognised that WG capital funding for the preferred scope is not currently available in totality. Option 3.2 - Private funding with a not-for-profit partner raising capital This option is predicated upon the Council procuring a service that provides care for 60 people in lieu of a service charge. The asset underpinning the service would be designed, built and maintained under the direction and ownership of the service provider, together with ownership of associated risks. Ostensibly, the advantage of this option would be that the public sector would not incur the initial capital charge for the facility. However it is likely that the service charge would outweigh the cost of public sector finance over time, unless it was offset by the value of associated risks. Option 3.3 - Private funding with PCC taking respon sibility for capital borrowing This option is predicated upon PCC borrowing the capital funding for the provision of the 60 unit Facility from the PWLB (Public Works Loan Board), as in the case of Prudential Borrowing for some other council schemes. The viability of this option is dependent upon the level of the Council’s existing borrowings and commitments and also the future ability of the Council to incur additional borrowing, which could potentially be limited by nationally imposed borrowing limits. This option has the advantage of deferring the cost of capital through lending whilst permitting retained ownership of the Facility in support of the service. Conversely, Prudential Borrowing does represent a significant liability to the Council, the cost of which would have to be repaid

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over time as an annual revenue stream. This cost needs to be taken into account as to the overall affordability of the project. Subject to VfM, it is a realistic option for the capital funding of the scheme and has therefore been carried forward on this basis and on the assumption that the revenue financing costs of the borrowing can be funded. Option 3.4 – A combined approach which seeks to max imise WG Capital funding and in parallel explore alternative capital sources in lin e with Options 4.1 and 4.2 It has become apparent that WG capital funding to support a single capital solution for the delivery of the service model is unlikely. Therefore there is a rationale to pursue a hybrid approach to funding. This approach would seek to take advantage of available WG capital support, but seeking to supplement this by exploring all other funding opportunities. This could legitimately be coupled to a phased approach to delivery and does not change the ultimate scope or likely capital requirement. Conclusion All four options are potential options to fund the scheme. In this context and that of the known WG capital envelope, option 3.4; a hybrid approach to capital funding is the preferred way forward. Table 3.3 summarises the assessment of each option against the investment objectives and CSFs.

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Table 3.3: Summary and assessment of capital fundin g options Reference to:

Option 3.1 Option 3.2 Option 3.3 Option 3.4

Description of Option WG funding

Private Funding

PCC Borrowing (eg Prudential)

Combined approach

Investment Objectives 1. Citizen focus n/a n/a n/a n/a 2. Organisational focus n/a n/a n/a n/a 3. Standards focus n/a n/a n/a n/a 4. Economy focus √ V √ √ 5 Procurement focus n/a n/a n/a n/a Critical success factors 1. Strategic fit √ √ √ √ 2. Value for Money √ √ √ √ 3. Affordability √ √ √ √ 4. Achievability √ √ √ √√ 5. Supply-side capacity & capability

√ √ √ √

Summary

Possible

Possible

Possible

Preferred way forward

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3.5 Service Implementation This section considers options relating to the approach to delivering the service scope. Options have been developed within the constraint of the available WG capital envelope:

• Option 4.1 – A single phased approach with all the necessary capital secured for the implementation of the preferred service scope.

• Option 4.2 – A two-phased approach, initially accessing available WG capital and subsequently exploring other sources of capital as described in Options 3.1, 3.2 and 3.3, above.

Option 4.1 – A Single Phased Approach This approach seeks to implement the preferred scope of a new-build health and social care facility in a single development programme. Such an approach assumes the availability of all necessary capital funding. In view of the known limit to the WG capital envelope that is currently available, this approach would require the co-ordination of funding from a variety of sources to deliver the project in a single development. Whilst there are obvious advantages in achieving the entire service model in a single programme, in reality this would necessitate a delay in its start until all necessary capital sources have been accessed. Such a delay is unacceptable in the context of the need to transform services. In this context this option has been retained , but only as a baseline option in line with guidance, for comparison purposes. Option 4.2 – A Two Phased Approach It has become apparent that a single capital solution to the delivery of the service model is unlikely and that a hybrid approach to funding, coupled with a phased approach to delivery would be appropriate to the delivery of this scheme. This does not change the overall scope or likely capital requirement, but does affect the operational implementation of the scheme which has been refined and defined into two phases as follows: Phase 1 The first phase relates to the implementation of community services including some re-provision of short stay GP managed care:

o Enhanced Community Services: o Extended hours rapid response – Twilight o Reablement

o New Build Facility containing: o Integrated Health and Social Care Team comprising the current district nursing,

domiciliary social care and reablement teams o Third sector advisory service

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o Outpatient and therapy suite for dietician, physiotherapy, OT, paediatric physiotherapy,

o Outpatients suite supporting tele-health and in-reach (from services outside of Powys) consultant led outpatients

o Minor surgery suite in support of the local GP practice o Three chair General Dental Service o Ambulance Service and paramedic base o Well Being suite for group based health education, therapy, reablement and day

support services o 12 en-suite units for short stay GP supervised care/continuing health care and

residential care with funded nursing care for people not able to be cared for in the community

Phase 2 Relates to the delivery of the flexible range of housing and care home options – the following is an example of how these may be configured.

o 16 bed care home suite: older people o 16 bed care home suite: dementia care o 8 unit extra-care facility

Conclusion On the basis of the available capital allocation, a two-phased approach is the preferred way forward with the first phase based on a WG capital application. Table 3.4 summarises the assessment of each option against the investment objectives and CSFs.

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Table 3.4: Summary and assessment of service delive ry/implementation options

Reference to:

Option 3.1 Option 3.2


Single-Phase Implementation

Two-Phased Implementation

Investment Objectives

1. Citizen focus √ √

2. Organisational focus √ √

3. Standards focus √ √

4. Economy focus √ √

5 Procurement focus √ √

Critical Success Factors

1. Strategic fit √ √

2. Value for Money √ √

3. Affordability √ √

4. Achievability X √


√ √

Summary

Discount But

retain for comparison purposes)

Preferred

3.6 Service Delivery/Procurement The provision of the bed-based elements of the Builth Wells model is considered in detail in Section 4.2. Conclusion On the basis of this analysis, the preferred way forward in relation to the service delivery for the Builth Wells scheme is to maintain continuity of service through an extension to the Council’s existing contract.

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3.7 The Short Listed Options The short listed options were drawn up following the strategic appraisal of the long list of options; this has a resulted in a single option that is considered deliverable and consistent with the investment objectives and critical success factors. Option 1: Do Minimum – included for comparison purposes only. Option 2: New build health and social care facility on the site of the council’s Brynhyfryd Care Home. Table 3.5

Option 1 – Do Minimum - Backlog maintenance issues addressed and limited internal refurbishment Scope Do minimum – Close Builth Hospital relocating bed-

based activity to Llandrindod Hospital and implementing no significant community services

Site Solution Existing sites with refurbishment programme Service Implementation

Single phase implementation

Funding Public finding Service delivery Provide the service through an extension of the

Councils current contractual arrangements. Option 2 – New build health and social care facility on the si te of the Council’s Brynhyfryd Care Home

Scope Enhanced community and bed-based services within a new-build facility.

Site Solution Existing site with a new-build programme Service Implementation

Two-phased approach with phase 1 being the subject of this BJC

Funding Public funding Service delivery Provide the service through an extension of the

Councils current contractual arrangements

3.8 Qualitative Appraisal A qualitative appraisal was undertaken against each of the agreed critical success factors: • Strategic Fit - The consistency of the option with national and local strategy and policy: a

whole system approach to meeting the investment objectives • Potential Value for Money - How well the option maximises the return on the required

investment in terms of economy, efficiency and effectiveness, whilst minimising associated risks

• Potential Affordability - How well the option meets both organisations financial strategies, availability of funds and meets funding constraints

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• Achievability - The practicality of delivering the option in terms of timeliness, the ability to adopt the new ways of working and the availability of sites, staffing and other resources

• Supply Side Capacity and Capability - How well the option appeals to the supply side and matches the ability of service providers to deliver required level of service.

Table 3.6

Critical Success Factor

Option 1:

Do Minimum - Backlog maintenance issues addressed and limited internal refurbishment

Option 2:

New build health and social care facility on the site of the Council’s Brynhyfryd Care

Home

Strategic Fit

This option does not give strong strategic fit. Whilst the closure of Builth Hospital and the relocation of some services to Llandrindod does offer some efficiencies, the limitation on reinvestment in community service is not strategically compliant.

This option supports the delivery of the PCC/PtHB integrated model of health and social care services in the Builth Wells area. As such it has strong strategic compliance.

Potential Value for Money

Whilst this option requires less initial capital investment, this will be to “shore up” an already dated portfolio. It does not support the development of a new model of care with associated efficiencies.

The injection of an initial public capital investment unlocks immediate savings and supports the delivery of a new model of care which maintains independence and transfers resources to more efficient forms of care.

Potential Affordability

Whilst this option requires negligible initial investment, whilst still delivering savings it is affordable. However it continues to commit PCC/PtHB to an outdated and inefficient model of care which, in the long term, has been shown to be unsustainable.

If supported by an initial public capital injection, this model delivers savings in the short term which through strategic reinvestment support a more sustainable model of care.

Achievability

Whilst in the short term and from a capital estates point of view, this option is relatively achievable, it impedes the development of integrated community health and social care services.

The Builth Project represents an initial component of an ambitious programme of change across health and social care services in Powys. This is challenging but must be undertaken in order to remain sustainable. A detailed programme management approach under shared governance arrangements ensure the achievability of this option.

Supply Side Capacity and Capability

The closure of Builth Hospital and relocation of some services to Llandrindod will present significant HR challenges to PtHB,

The development of integrated health and social care services will offer new and attractive alternatives to any potentially displaced staff. The existing service provider on the Brynhyfryd site is committed to expanding already exiting service into the new 12 bed unit.

In summary, having gone through the process of appraising a long list of options to establish feasible options, it is clear that there is only a single option which is capable of delivering the key investment objectives – the development of an integrated health and social care facility

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through a new build programme on the Powys County Council site of the Brynhyfryd Care Home. The preferred route for delivery is through a two-phased approach of which, the first of which accesses available WG capital funding.

3.9 Economic Appraisal

3.9.1 Introduction

This section describes the economic appraisal that has been undertaken to reassess the overall value for money, to the NHS. The capital and annual revenue costs of each option have been quantified and compared. Cash flows have also been compared over an indicative twenty five year period.

3.9.2 Capital Costs Capital costs for the shortlisted options net of any VAT recovery are as follows:

• Option 1 – Do Minimum: £3,501k • Option 2 – New build phased approach: £5,370k

A comprehensive breakdown of these costs is attached at Appendices 5 and 6.

3.9.3 Revenue Costs

Do Minimum The do minimum option allows for the transfer of services and staff operating from the Builth Hospital site to the Llandrindod Wells hospital site. Whilst a reduction in revenue costs will be achieved by operating from one site instead of two, given the very limited spare capacity in Llandrindod Wells, scope to absorb the services within the current footprint to achieve significant revenue reductions is minimal. Facility and Hospital services revenue reductions will be achieved, but not to the level where these services will be provided on a new build and operated by an external provider as is the case in the option 2. Preferred Option The revenue costs of the preferred option are detailed in the finance section of the BJC. Both options assume PtHB will receive strategic WG support for all non-recurrent impairment implications of this scheme.

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Table 3.7 Summary of Changes to Revenue Costs

Additional Costs

Option 1: Do Minimum

£’000

Option 2: New Build - Phase 1

£’000 Impairment on revaluation of BWCH 2,078 2,078 Funding for impairment -2,078 -2,078 Net Impairment 0 0 Net capital charges 33 -47 Net capital charges 33 -47 Estates Maintenance & Works -7 -42 Housekeeping & Domestics -29 -79 Energy and Utilities -21 -15 Business Rates 0 40 Catering and Portering -35 -116 Admin & Medical records -13 -23 Net Facilities costs -105 -234 District Nursing Services 0 0 Occupational Therapy 0 0 Pharmacy and Pathology 0 0 Evening District Nursing Team 93 93 Reablement 84 84 Hospital Services -210 -643 Nursing care beds 0 315 Net Clinical Service costs -33 -150 Net cost to Health Board -105 -431

A more detailed breakdown of these costs and the assumptions used in deriving them can be found in Appendices 7 and 8.

3.9.4 Lifecycle Costs The below table gives the net Capital and Revenue cash positions (excluding capital charges) over an indicative 25 year period, together with the estimated cash payback period of both options. Table 3.8

Option 1 Do minimum

£'000

Option 2 Preferred

£'000 Capital Costs 3,501 5,370 Incremental Cash Costs over 25 years -3,450 -9,618 Net Cash Position over 25 years 51 -4,248 Payback Period (years) 25.4 14.0

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3.9.5 Sensitivity Analysis

The degree of risk of an investment proposal has been assessed using switching values to test the outcome of an economic appraisal. It indicates how much each option would have to increase or decrease to affect the ranking of options and rank them in a different order. The technique of scenario planning looks at the effect on the success or otherwise of an option through the combination of different assumptions about the future. A scenario was tested to determine the percentage each variable would have to change to affect the ranking of the economic appraisal. Results of Switching Values The values (%) at which aspects of the options would change for the overall ranking of the options to change is shown below: Table 3.9

3.10 Overall Findings

The analysis of the short listed options has identified that Option 2 is the preferred option in terms of the risk and option appraisals as shown in the following table: Table 3.10

Evaluation Results Option 1: Do Minimum


Benefits Appraisal / Qualitative appraisal

2 1

Risk 2 1 Lifecycle Costs 2 1 Sensitivity Analysis 2 1 Overall Ranking 2 1

Changes in Costs (%) Option 1: Do

Minimum


Assuming re-provision of 6 beds, the cost per bed would have to increase by:

104%

Assuming re-provision of 12 beds, the cost per bed would have to increase by:

3%

Re-provision of services to Llandrindod in the Do minimum: The Non fixed and Staff costs associated with the current Builth Hospital provision would need to reduce by:

64%

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3.11 Preferred Option The economic and sensitivity analyses undertaken in this section demonstrates that the identification of Option 2 is robust. Table 3.11

Preferred way forward Option 2 – New build health and social care facility on the site of the Council’s Brynhyfryd Care Home Service Scope Enhanced community and bed-based services within

a new-build facility. Site Solution Existing site with a new-build programme Service delivery Provide the service through an extension of the

Councils current contractual arrangements Service Implementation

Two-phased approach with phase 1 being the subject of this BJC

Funding Public funding The preferred option therefore involves the construction of a new, purpose-built health and social care facility. This will facilitate the closure of the existing Builth Wells Community Hospital and the development of an integrated model of health and social care operating from within the new facility offering modern flexible intermediate care beds and facilities for a range of therapies and other out-patient services.

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4 The Commercial Case

4.1 Introduction This section of the BJC outlines the commercial arrangements for the development of an Integrated Health and Social Care Facility for the community of Builth Wells having regard to all capital sources and through the development of appropriate strategic partnerships with third party organisations.

4.2 Procurement Strategy This section considers the care service provision to the bed based elements of the Builth Wells model. In response to the chosen scope and method of service provision, the workshop identified the following options.

• Option 1 – Recognising the activities on the first floor of this 12 bed unit are broadly similar to those being carried out elsewhere on the Brynhyfryd campus, build upon the current arrangements and provide the service through an extension to the Council’s existing contract.

• Option 2 – Provide the service following the implementation of a compliant competitive

tender process i.e. seek bids from alternative providers in the private or third sector.

• Option 3 - Move responsibility for the management of all service provision to within the council and health board i.e. direct delivery of services by the Council and/or health board.

• Option 4 - Manage a “mixed economy” of service provision.

Staff employed by the existing service provider currently provide personal care and support to users within the Council’s residential care homes under an existing 10 year contract with an option to extend. The initial 10 year contract has been extended for a further 3 year period (to April 2014) which can be further extended for a further 2 years (to April 2016) and thereafter by a further 10 year period if required. This arrangement maintains the Councils relationship with the current provider and provides flexibility whereby the Council can, if necessary, approach the market when conditions are favourable. This extension also gives the Council the opportunity to deal with individual homes within its portfolio on a case by case basis. Main Findings

• Option 1 – Recognising the activities on the first floor of this 12 bed unit are broadly similar to those being carried out elsewher e on the Brynhyfryd campus, build upon the current arrangements and provide the service through an extension to the Council’s existing contract.

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This option is judged to be the least risky from a number of perspectives. Operationally, and in terms of continuity of service, it is advantageous to have one service provider on the site. This is especially important during the build phase, but also provides a seamless service going forward. From a resident’s view point, this option gives a certain reassurance at a time of upheaval and change. The current provider has a track record of delivering quality services within Powys which is an area which presents challenges in terms of workforce recruitment and retention. In addition the provider has experience in operating under a similar model in England and could therefore add value as the Council and the Health Board consider detailed design. The Council’s commercial relationship with this provider across a portfolio of eleven other sites provides sufficient leverage for the Council to secure reasonable pricing structures. The current contract provides some flexibility to take opportunities if and when phase two is considered, always remembering the timings of the contractual options referred to above. Whilst this option does not initially provide the opportunity to competitively tender the service, we shall be testing the market through benchmarking. It is agreed that competitive tendering would be more appropriate at phase 2 of the service development when alternative providers may be attracted offering vfm and potential capital injections against a proposal that could offer services across the whole Brynhyfryd campus. On this basis this remains the preferred option for Phase 1 of the service development.

• Option 2 – Provide the service through the implemen tation of a compliant competitive tender process i.e. seek bids from alternative providers in the private or third sector.

This option is predicated on a competitive procurement for an alternative service provider to support and care for the service users within the proposed facility. The nature of this procurement is such that a minimum of four months from the date the opportunity is advertised will be required to reach a position where a contract could be awarded. The current contract requires that the provider continues until 30th April, 2014, and unless appropriate notice is given for termination on that date, the contract automatically extends until the end of April, 2016. Therefore the current provider will be in place through the build phase and into ongoing operations. Therefore the scope of the opportunity would be limited to the activities undertaken in the 12 bed unit and would therefore be of limited interest to the market. In addition the contract term would need to be co-terminus with the contract and lease for the rest of the site in order that we could put together an attractive package as and when phase 2 is introduced. Therefore there is a risk that any tender exercise could result in a limited response, an unaffordable response, or, an award to a provider other than the current provider which would cause complications in terms of our ability to provide continuity of service and a clear exit strategy in terms of phase 2. In accordance with PCC’s existing policies for the provision of these services, it affords the opportunity to underpin the required standards of care home support through the competitive offerings of an established supply side and supply chain.

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Whilst this option remains viable it is felt that in terms of continuity for service it will be most appropriate to approach the market at Phase 2 of the service development. On this basis, this remains an option but at Phase 1, is discounted.

• Option 3 - Move responsibility for the management o f all service provision to within the council and health board i.e. direct delivery of services by the Council and/or health board.

This option presupposes that services would be delivered by a combination of PtHB and PCC staff albeit with staff currently employed by the residential care home provider being TUPE’d across and would be likely to incur significantly increased costs as a result of the council’s ongoing pay normalization process. In addition there may be issues arising from CSSIW registration e.g. enforce compliance with new standards in respect of the existing facility which may result in significant capital investment in order to bring that facility up to the required standards which in turn could compromise the business case. On the above basis, this option has been discounted.

• Option 4 - Manage a “mixed economy” of service prov ision This option is a hybrid of the procurement options 1, 2 and 3 above. Whilst ostensibly a feasible option, the employment of both contracted and council employed care staff would not engender synergies between the respective workforces, and would be likely to encounter motivational and operational difficulties. The staffing of the health and social care centre must be underpinned by a cohesive team of professionals. This option would not constitute best practice in terms of Human Resources (HR) management and be likely to run into higher cost for directly employed personnel. It has therefore been discounted as a tenable way forward on this basis. Conclusion On the basis of the above analysis, the preferred way forward in relation to the service delivery for the Builth Wells scheme is to maintain continuity of service through an extension to the Council’s existing contract. Table 4.1 summarises the assessment of each option against the investment objectives and CSFs.

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Table 4.1: Summary and assessment of service delive ry options Reference to:

Option 3.1 Option 3.2 Option 3.3 Option 3.4


Outsource (Extend current

contract)

Outsource OJEU

In-house Mixed economy

Investment Objectives 1. Citizen focus

√ x √ x

2. Organisational focus

√ x √ x

3. Standards focus

√ √ √ √

4. Economy focus

√ x X X

5 Procurement focus

√ √ x √

Critical success factors 1. Strategic fit

√ √ √ X

2. Value for Money

√ √ X X

3. Affordability

√ √ X X

4. Achievability

√ X √ √


√ X √ √

Summary

Preferred

Reject

Reject

Reject

4.2.1. Strategic Partner for the Brynhyfryd Site The Council and teaching Health Board committed to the principal of the redevelopment of the Brynhyfryd site to ensure the full range of care home and supported accommodation facilities is provided for the local community. In order to achieve this, additional available capital sources will be explored in detail including alternative not-for-profit private finance and prudential borrowing. This continued development will complement the NHS component of the facility and provide the additional elements of a full range of accommodation with appropriate support. In this context, extra care and other housing options are currently being considered alongside care home provision to ensure that an appropriate range of services are developed. Exploratory discussions have been undertaken with Housing Services and social landlord organisations already working in partnership with the Council in respect of profiling residents of existing social housing so that we might assess future housing and support requirements. Based on this, encourage bids from housing associations to undertake continued redevelopment of the site having regard to existing stock and service user profiles, needs information and on-site opportunities/constraints for development of extra care. In doing so it

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is envisaged that this strategic partnership will seek to access Welsh Assembly Government Social Housing Grant. The strategic partnerships described above will ensure that the initial capital injection for the health service component of the Builth Wells Project will deliver a service component which can realistically be developed further to provide a comprehensive range of services. The Council has an established track record of structured and collaborative strategic partnerships both with care home service providers and registered social landlord agencies. The Builth Project offers the opportunity to develop an innovative three-way partnership which can be developed and extended across the PCC and PtHB shared portfolio to deliver responsive and efficient services to each of the county’s rural communities.

4.3 Proposed charging mechanisms for construction The recent procurement review in Wales has concluded that a ‘collaborative working model’ should be adopted to replace the more traditional adversarial procurement approach. Both the Building for Wales and PCC’s Frameworks adopt this approach. They will require a target cost and will also stipulate the requirement for a staged payment mechanism, which would normally be monthly via valuation.

4.4 Potential for risk transfer during construction This section provides an assessment of how the associated risks might be apportioned between the council and the Supply Chain Partner. The general principle is to ensure that risks should be passed to “the party best able to manage them”, subject to value for money (VFM). For the purposes of the BJC a contingency of 15% has been applied as the further work is required to fully assess the construction risks associated with the project and to cost them fully. Table 4.2 outlines the allocation of responsibility for key risk areas:

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Table 4.2 - Risk Transfer Matrix

Potential allocation Risk Category

Public SCP Shared

1. Design Risk �

2. Construction & Development Risk �

3. Transition & Implementation Risk �

4. Availability and Performance Risk �

5. Operating risk �

6. Variability of Revenue Risks �

7. Termination Risks �

8. Technology & Obsolescence Risks �

9. Control Risks �

10. Residual Value Risks �

11. Financing Risks �

12. Legislative Risks �

13. Other Project Risks �

A risk sharing agreement between PCC and PtHB is attached at Appendix 2.

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4.5 Proposed Key Contractual Clauses - construction The form of contract will be the NEC 3 Option C with Target Cost that is utilised within the PCC Construction Framework.

4.6 Implementation Time-scales Implementation timescales will be dependent on the timing of WG capital grant allocation.

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5. The Financial Case

5.1 Introduction

This section describes the capital and revenue costs associated with phase one of the new build Health and Social Care Facility on the site of the council’s Brynhyfryd care home.

The redevelopment of the Brynhyfryd care home is predominately an extension of the current home, providing accommodation for the Integrated Health and Social Care Team, Dental, Outpatient and Therapy services, together with the provision of 12 en-suite units for both short stay GP supervised care and other forms of short-term health and social care. It will allow for the transfer of Ambulance, Dental, Outpatient and Therapy services from the current Builth Community Hospital site to the new facility, and allow for the closure of the hospital.

The revenue costs are based on full year costs for 2012/13. This business case assumes that the source of capital funding will be from the Welsh Government and will be in the form of a grant allocation direct to PCC, together with a Capital Resource allocation to PtHB for their element of equipment. Impairment funding will be required in early 2013/14 when the development is brought into use, and on the reclassification of Builth Wells Hospital. As an asset is not depreciated in the quarter it is brought in to use, it is assumed changes to capital charges will not take effect until the 2nd Quarter 2013/14 for Health Board’s equipment, whilst no capital charge funding will be required for the Local Authority which is subject to a different capital charge regime.

5.2 Capital Costs The capital costs of the development will be funded by WG and is summarised in the table below and detailed in Appendix 6 – Tendered cost forms. Table 5.1

Cost

(excluding VAT) £000

Cost (including VAT)

£000 Building costs (including fees etc.) 4,780 5,737

Non-works costs 101 122 Equipment 232 279 Contingency 256 307 VAT Reclaim -1,074 Total 5,370 5,370

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The phasing of planned capital costs and indicative funding profile is identified below.

Table 5.2

Year

Planned Capital Costs (PCC)

£'000

Funding £'000

2011/12 274 5,251 2012/13 1,994 0 2013/14 3,102 0 Total 5,370 5,251

5.2.1 VAT Treatment Independent VAT advisors have been appointed by PCC to confirm the treatment of VAT with HM Revenue and Customs. The current advice received from the advisors is that 100% of VAT will be recoverable. This is based on the Local Authorities’ current arrangements with HMRC whereby VAT is refundable for non-business functions where supplies and services are provided to service users against which no charge is made. Whilst this assumption is reasonable, it is not without risk, and will need to be tested with HM Revenue and Customs and the schedule of costs will be refreshed once firm and final advice in agreement with HMRC has been reached.

For the purposes of the cost schedules a VAT rate of 20% across the scheme has been assumed with full VAT recovery.

5.3 Impairment

The Health and Social Care Facility development once complete will be independently valued, which will result in impairment for PCC. Similar developments indicate this will likely result in an £1,343k non-recurrent impairment, however given the capital accounting regime within which the Local Authority operates, no impairment funding will be required. The revaluation of Builth Wells Hospital for sale or alternative use will also result in impairment due to change in asset value (as per International Accounting Standards 36) this AME (Annually Managed Expenditure) impairment will need to be funded based on actuals by WG. The Net Book Value of Builth Wells Hospital at the time of revaluation will be £2,328k and whilst the revaluation is yet to be confirmed, an independent valuation report supplemented by advice from NHS Wales Shared Services Partnership Facilities Services, gives an indicative selling price of £250k, which will result in an impairment of £2,078k. Under current accounting arrangements AME funding will only be required for the Non-Donated element of £1,263k. However these accounting arrangements are currently being reviewed whereby £816k impairment funding may be required in future years for the donated element of the site in addition to the £1,263k for non-donated elements. These figures are subject to amendment in 2012/13 after a revaluation of the Health Boards assets is due to take place.

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Table 5.3 Builth Wells Hospital

Builth Wells H&SC facility

£k Donated

£k Non-Donated

£k Total

£k

Capital costs 5,370 914 1,415 2,328 Valuation 4,028 98 152 250

Impairment 1,343 816 1,263 2,078 AME Impairment: 0 816 1,263 2,078

Should Builth Wells Hospital be sold, PtHB and PCC would wish to discuss with the Assembly the use of any net proceeds arising, should they exceed £500k for the non donated element.

5.4 Revenue Costs

5.4.1 Capital Charges Given the source and route of funding, capital charge costs related to the building will be incurred by PCC, however as a result of the Local Authority accounting regime there will be no revenue consequences, and therefore no costs would be levied by the Council to the Health Board in this regard.

Capital charges will be incurred by PtHB in relation to their equipment procured as part of this business case, this will be offset by a reduction in charges as a result of the change in asset value of Builth Wells Hospital. It is assumed that the site will be ‘held for sale’ and no depreciation costs will be incurred and that the reduction in capital charges will be retained by PtHB to offset charges from other capital investments.

The costs are shown in the table below. Table 5.4

Depreciation £k

PCC - Builth Wells H&SC Facility 0 PtHB - Builth Wells H&SC Facility 26 PtHB - Builth Wells Hospital -72 Reduction Capital Charges -47

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5.4.2 Other Revenue Costs Powys teaching Health Board In order to establish the revenue consequences of the preferred capital and service delivery model, PtHB has compared the current cost of services to the proposed new capital and revenue model. The net revenue saving to be achieved by the Health board is estimated to be £431k. This is predominantly achieved through closure of Builth Wells Cottage Hospital, with services being transferred to the new facility and some services being re-provided in Llandrindod Wells Hospital, offset by an investment in new models of care, which include short stay GP supervised care beds as well as Reablement and extended evening district Nursing services. Annual running costs of the new facility will be met by the Health Board, with other occupants of the facility contributing to their share of the running costs. For services transferred to Llandrindod Wells, it is assumed there will be no incremental running costs to the Llandrindod site and only direct costs of services transferring to Llandrindod have been included. For the purposes of financial modeling it has been assumed that PtHB will fund six of the new twelve beds through a joint commissioning arrangement with PCC. The average nursing home placement currently funded by PtHB costs £657 per week. However, given the small scale of care home beds to be provided, a prudent value of £900 per has been used for the purposes of this business case, together with £110 per week funded nursing care costs for the remainder of the beds. These values will need to be tested through a joint procurement process with the Council and maybe understated.

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The table below summarises the expected annual revenue consequences as a result of the development, this is further supplemented by a more detailed analysis in Appendix 8. Table 5.5

Annual Revenue Cost New

costs £k

Current costs £k

Net additional costs £k

Investment in new

models of Care £k

Total additional costs £k

Facilities Estates Maintenance & Works 14 -56 -42 0 -42

Housekeeping & Domestics 19 -97 -79 0 -79 Energy and Utilities 38 -53 -15 0 -15 Business Rates 57 -16 40 0 40 Catering and Portering 0 -116 -116 0 -116 Admin & Medical records 35 -58 -23 0 -23 162 -396 -234 0 -234 Clinical Services District Nursing Services 169 -169 0 0 0 Occupational Therapy 283 -283 0 0 0 Pharmacy and Pathology 39 -39 0 0 0 Evening District Nursing Team 0 0 0 93 93

Reablement 0 0 0 84 84 Hospital Services 201 -843 -643 0 -643 Nursing care beds 0 0 0 315 315

692 -1,334 -643 492 -150

Capital Charges 26 -72 -47 0 -47 Total 879 -1,803 -924 492 -431

Powys County Council It is anticipated that the 12 beds will be flexibly used for step in-step out care. The beds will be registered care home beds and the nursing, therapy and social care input will be through the reablement team, and community health and social care resource team “in-reaching” to support individuals. The introduction of this service will complement the services that are being developed to support a reablement approach to improve independence and reduce the need for acute hospital admission and enable more people to return home rather than being admitted to long term residential or nursing home care.

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To facilitate this it is planned to set up a pooled fund under a section 33 agreement. The PCC contribution will relate to estimated savings in long term care home placements. The funding for these beds will reflect the residential care rate, adjusted for the size of the unit and the requirement for care staff skilled in Reablement. Provision of a relatively small care unit of twelve beds may exert upward pressure on the unit costs, it is expected that the absence to the provider of capital charges will compensate for this.

5.5 Overall Affordability This business case demonstrates that the business model has evidenced reduction in costs to the PtHB of £0.4M after investment in additional community services and the commissioning of care home beds from the independent sector. This funding model assumes that there are economies of scale in joint commissioning of the bed capacity with PCC, and a provider can be secured who will provide care at these costs. The net savings to PtHB of £431k is predominantly achieved through the closure of Builth Wells Cottage Hospital, together with the investment in community services and the procurement of 6 GP supervised care beds. It is assumed funding will be retained by PtHB to offset its structural deficit.

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Table 5.6

Costs and Funding Summary £k Impairment on revaluation of BWCH 2,078 Funding for impairment -2,078 Net Impairment 0 Net capital charges -47 Net capital charges -47 Estates Maintenance & Works -42 Housekeeping & Domestics -79 Energy and Utilities -15

Business Rates 40 Catering and Portering -116 Admin & Medical records -23 Net Facilities costs -234 District Nursing Services 0 Occupational Therapy 0 Pharmacy and Pathology 0 Evening District Nursing Team 93 Reablement 84 Hospital Services -643 Nursing care beds 315 Net Clinical Service costs -150 Net cost to Health Board -431

5.5.1 Assumptions that Underpin Affordability The working assumptions in calculating the above costs are as follows;

• The estimated impairment as a result of the development due to change in asset value of Builth Wells Cottage Hospital will to be funded by WG on actuals

• It is assumed that Builth Wells Cottage Hospital will close and facilities costs associated with Builth Wells Cottage Hospital will offset the costs of the new development.

• Costs are based on standard rates at 2011/12 prices and are indicative. • The net reduction in costs of £431k will be retained by the PtHB to mitigate against its

recurrent deficit. • No redundancy or staff contract termination costs have been factored in. • TUPE regulations are being considered in respect of any new provider, any potential

costs associated with this have not been factored in. The prudent high Nursing care bed costs mitigate this to some degree, though this still needs to be tested.

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• Through the current active management of fixed term contracts and leading up to the commissioning of the new facility, staff costs will either be reduced through natural turnover or redeployment into other organisational vacancies. The above calculations assume there will be no staff remaining on the extended employment scheme.

• The current medical cover provided by the local practice for the hospital beds will continue to be paid to provide medical cover for the care home beds.

• Capital charges stated above are based on depreciation only. Once Builth Hospital is disposed of, the capital charge savings will be retained by PtHB and not returned to WG.

• One off costs associated with the transferring of services on the commissioning of the new facility have not been included in the annual cost comparisons above. These costs are not expected to exceed £20k.

• Service charges for the new facility are based on similar developments at today’s prices.

• The funding for the building will be in the form of a grant funded by the Welsh Government in which case, there would be no capital charges or levy by the Council to the Health board associated with the cost of capital or depreciation

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6 The Management Case

6.1 Introduction This section of the BJC addresses the ‘achievability’ of the Scheme. Its purpose, therefore, is to set out the governance arrangements that will be required to ensure the successful delivery of the scheme in accordance with best practice.

6.2 Programme Management Arrangements The Scheme is a core component of the Health Social Care and Wellbeing Partnership’s Common Vision for New Models of Health and Social Care Programme. This comprises a portfolio of projects to ensure the delivery of new models of health and social care across Powys, to time and within the resource envelope available. Responsibility for the leadership and programme management of this project will be taken by Powys County Council. It will sit within the Council’s Change Plan 2010-14. Within this, there are 4 improvement priorities:

• Adult living • Learning in the community • Regeneration • Climate Change.

It is proposed the Builth Project as described in this BJC will be a formal workstream within the Care and Wellbeing Programme and will sit within this governance and reporting framework. Within the teaching Health Board the capital programme is driven by the Strategic Outline Programme. There will be explicit links from the Builth Project governance structure to the tHB Strategic Outline Programme Board. The Builth Wells Project is a formal workstream within the joint PCC / PtHB programme for Integrated Care Pathways for Older People. Proposals are being developed to integrate the Council’s Care and Wellbeing Programme with the Health Board’s Strategic Outline Programme. This will ensure an effective integrated strategic and programme management framework within which the Builth Project will be delivered. The Builth Project Board has been in place since May 2007. It has reported to the Health Social Care and Wellbeing Partnership. Delivery of the proposed service and facilities reconfiguration will require strengthened project management arrangements with accountability and decision making facilitated through the Powys Change/Care and Wellbeing Programme. A newly constituted Project Board with executive level membership from PTHB and PCC will take responsibility for delivering the Builth Project. The proposed project structure is shown in Figure 6.1, below.

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Figure 6.1 Builth Wells Project Structure

Figure 6.2 Powys Change Plan Structure

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6.3 Project Roles and Responsibilities The following Key Role definitions comply with the agreed PCC arrangements for the delivery of the Powys Change Plan. They will require specific agreement form PtHB. 1. Project Lead Portfolio Holder PCC - Has cabinet accountability for the programme with personal responsibility for ensuring it meets its objectives and realises the agreed benefits. They will demonstrate political leadership to all elements that will make up the programme. Accountable to:

• Lead of the Executive Programme Board Accountable for:

• Programme Delivery. • Delivering Agreed Outputs. • Benefits Management.

Responsibilities:

• Agree a programme to meet the outcomes and set expectations for delivery. • Ensure the project reflects the political priorities and strategic direction of PCC/PtHB • Own the vision and purpose for the project, providing clear leadership and direction

throughout its life. • Secure the investment required to deliver the project so that the agreed benefits are

achieved. • Provide direction and leadership and accountable for the delivery and implementation

of the project at cabinet. • Represent the project at cabinet and work with other cabinet stakeholders with interest

in the selected project. • Take a lead role in directing the public face of the project.

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Project Sponsor PCC – Head of Adult Social Care PtHB – Interim Director of Planning Has executive accountability for the project, ensuring it meets its objectives and realises the agreed benefits. They will be a Strategic Director of the Council/Health Board and will be empowered to direct the project and take decisions. They will demonstrate leadership to all elements that will make up the project. Accountable to:

• Executive Project Board via the Project Lead Portfolio Holder Accountable for:

• Project Delivery - Successful delivery of the project objective. • Delivering Agreed Outputs – Ensuring that the project outcomes and outputs are

secured • Benefits Management - Enabling PCC/PtHB to benefit from the new capabilities

resulting from the project. Responsibilities:

• Form and chair the selected Project Board and account for the project’s governance arrangements, ensuring that the programme is managed within agreed Programme Office standards.

• Own the vision and purpose for the project, providing clear leadership and direction throughout its life.

• Ensure any investment required to deliver the project is understood and secured in order to achieve the desired benefits.

• Provide direction and leadership and be accountable for the delivery and implementation of the project.

• Agree the workstream briefs that form the project. • Appoint, manage and support Workstream Leads. • Manage the interface between key stakeholders, ensuring effective communication

and engagement that results in robust decision making. • Maintaining the project’s alignment with the PCC’s/PtHB’s strategic direction. • Work with the Project Team to provide documentation and evidence as requested and

to call on available support as required.

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Workstream Lead Is responsible for the workstream, ensuring it meets its objectives and realises the agreed benefits. They will be empowered to direct and deliver the workstream plan according to the remit and scope as agreed by the Project Board. They will demonstrate leadership to all elements that will make up the workstream. Accountable to:

• Project Sponsor Accountable for:

• Sub Programme Delivery – Delivering the required outputs to agreed time, cost and quality

• Benefits Management – Ensuring that the benefits are identified, measurable and delivered.

Responsibilities:

• Own the vision and purpose for the workstream, providing clear leadership and direction throughout its life.

• Understand and own the workstream brief and the tasks included within. • Identify and recommend new tasks. • Ensure appropriate background paperwork is complete and ready for submission to the

Project Board for consideration and decision. • Ensure workstreams are properly planned and resourced (Finance and Staff). • Ensure that dependencies and links with other workstreams are identified. • Approve and report on-going changes to workstream plans and finances within the

scope and tolerances set for each project. • Resolve issues and risks and identify change requests. • Escalate issues, risks and change requests when consideration by Project Board is

necessary. • Work with other Workstream Leads as necessary to ensure effective stakeholder

engagement and communication. • Work with the Project Team to provide documentation and evidence as requested and

to call on available support as required.

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Project Manager PCC/PtHB – Senior Partnership Manager Is responsible for the project, ensuring it meets its objectives and realises the agreed benefits. They will be a Senior Manager or Principal Officer of PCC/PtHB and will be empowered to direct and deliver the project according to the remit and scope as agreed by the Project Board. They will demonstrate leadership to all elements that will make up the project. Accountable to:

• Project Sponsor/s Accountable for:

• Project Delivery – Delivering the required outputs to agreed time, cost and quality Responsibilities:

• Understand and own project brief and the work streams included within. • Lead the planning, scheduling and implementation of project. • Manage and support work stream leads/project staff. • Maintain the project’s alignment with the strategic priorities of PCC/PtHB. • Approve on-going changes to plans and finances within the scope and tolerances set

for each project. • Resolve issues and risks and identify change requests. • Escalate issues, risks and change requests when consideration by Project Board / Sub

Programme Lead is necessary. • To ensure the project delivers the required products to the required standard of quality

and within the specified constraints of time and cost. • Monitor and report project progress. • Prepare project documentation in accordance with the approved model including PID,

Project Plans, Highlight Reports, Risk Log and Project closure and review reports. • Work with the Programme Office to provide documentation and evidence as requested

and to call on available support as required.

6.4 Project Milestones These are as follows:

• Feb 2012 – Begin on-site Pre Works (surveys, vegetation removal) • March 2012 – Begin Phase 1 works on site • Feb 2013 – Practical Completion of Works Phase 1 • March 2013 – End inspections and commence hand over works • May 2012 – New Build Handover - Facility opens with service provider

72

A detailed construction programme is shown in Appendix 9.

6.5 Use of Special Advisors The Project Team will oversee the appointment of specialist advisors in support of the independent and impartial assurance and advice required by the project. This will include expertise in the following areas.

• Legal • Procurement • Business Case • Commercial

6.6 Contingency Plans In the event that this project fails, the Council and Health Board will have to maintain the service within their existing facilities. However, these will not be able to meet current regulatory requirements and it will severely hamper the ability to deliver the wider benefits associated with the integrated service model agenda and also the wider capital and service redesign programme.

Appendix 2

Builth Wells Governance Arrangements May 2012

FOR DISCUSSION

Public Health Update Report Page 1 of 9 Board Meeting 27 June 2012

Agenda Item 5.1

BOARD MEETING


POWYS PUBLIC HEALTH TEAM BOARD UPDATE REPORT

Report of Consultant in Public Health / Acting Director of Public

Health Paper prepared by


Purpose of Paper

To provide the Board with an update of Public Health team structures. To highlight work undertaken by the Local Public Health Team on behalf of Powys teaching Health Board.


The Board is asked to NOTE this paper for information.




Promotes Health & Wellbeing


Powys teaching Health Board (PtHB) Public Health (PH)

FOR DISCUSSION


Agenda Item 5.1

POWYS PUBLIC HEALTH TEAM BOARD UPDATE REPORT

Background This report outlines the work currently being carried out by the Powys Public Health team. There is also an update of four work streams, giving a brief overview of the areas in which work is taking place:

• Powys Healthy Pre-School Scheme • Community Alcohol Partnership • Improving Young People’s Access to Condoms - C-Card • Powys- Molo Health Link: update

Recommendation The Board is asked to note this paper for information. Report prepared by: Presented By: Consultant / Acting Director of Public Health

Dr Sumina Azam

Principal Health Promotion Specialists Senior Public Health Practitioners


Background Papers Powys Public Health Team Board Update

Financial Consequences As determined by the report


Consultees n/a

FOR DISCUSSION


Agenda Item 5.1

1 SUMMARY The Acting Director of Public Health works closely with Public Health Wales and the local Public Health team, based in Bronllys Hospital. This report gives an overview of some of the work currently being undertaken by the local Public Health team. 1.1 Role and structure of the team The local Public Health team continues to undergo staffing changes:

• Our Director of Public Health left on 31 March 2012. A joint Director of Public Health and Strategic Planning post is being recruited to. • A Locum Consultant in Public Health has joined the team, whilst the substantive consultant acts in the Director of Public Health role. • One of our Principal Health Promotion Specialists is currently away on sickness leave. • Another Principal Health Promotion Specialist, who was seconded to our team and has recently retired, has had her time with us extended for 6 months on a 0.5wte basis to strengthen our team capacity.

Overall, there is a low level of capacity within the core Public Health Team, which currently consists of 1wte Consultant in Public Health, 1.2wte substantive Principal Health Promotion Specialists (0.6wte of whom is away with sickness leave), 1wte Senior Health Promotion Practitioner and 0.8wte Health Promotion Practitioner. 2 Work Streams 2.1 Powys Healthy Pre-School Scheme

Background A key theme of Our Healthy Future (Welsh Government, 2009) is health through the life course. Long term health and wellbeing can be supported through giving children and young people a good start in life. Disadvantage starts before birth and accumulates throughout the life course. However, “......tackling risk factors for lifelong health and wellbeing in the early years and building children’s resilience to adversity”, supports children and young people to achieve long-term health and wellbeing.

FOR DISCUSSION


Agenda Item 5.1

The Welsh Network of Healthy School Schemes was launched in September 1999 to encourage the development of local Healthy School Schemes within a national framework and criteria. The scheme aims to promote and influence the health of the whole school community through curriculum, leadership, ethos, and environment. The scheme is not an ‘add on’ initiative, but should pervade all aspects of school life and learning. The Healthy Schools awards enables schools to demonstrate their contribution to key national outcomes for children such as reducing and halting the increase in childhood obesity, promoting positive sexual health, reducing teenage pregnancy and reducing young people’s use of drugs, alcohol and tobacco. The Healthy Pre-Schools Scheme In 2011, Welsh Government (WG) announced that the Healthy Schools programme would be expanded to pre-school settings to improve the health and wellbeing of children in their early years. Powys Healthy Schools have been given additional funding (£15,000) for three years (2011-14) to achieve this. The scheme is being set up based on national guidance, and will work towards: • Recruiting a minimum of 10 settings within the first year (a further 5 – 10 in

subsequent years) • Working in partnership with Flying Start and others associated with pre-school

settings • Maintaining regular contact with recruited settings, through visits and other means

and providing local training, support and accreditation • Accrediting member settings within 18 months • Incorporating the scheme into the Children's Plan and other related strategic

plans

The Healthy Pre-Schools Scheme involves participating settings working on seven health areas: • Nutrition & Oral Health • Exercise / Active play • Environment • Safety • Hygiene • Mental & Emotional Health, Well Being & Relationships • Health Promoting Workplace Progress in Powys In Powys, the scheme is co-ordinated by the Healthy Schools Team based in the Public Health Team. The Powys Scheme has been set up through close working with the Children and Young People’s Partnership (CYPP), Dyfodol Powys Futures,

FOR DISCUSSION


Agenda Item 5.1

Wales Pre-school Providers Association and Mudiad Ysgolion Meithrin. These organisations have agreed to recruit a range of pre-school settings to the scheme. The Powys Healthy Pre-Schools Scheme provides resources and small grants for participating settings to help with Healthy Pre-School developments. The Powys Healthy Schools Team provide support and accreditation across Powys. Working with their partners, the Healthy Schools Team are supporting leaders, staff and carers from a participating settings to work through specific themed criteria in order to achieve a national award. This year (2012-13), accreditation will focus on two themes:

i) Nutrition and Oral Health ii) Physical activity and active play.

Accreditation criteria have been designed to complement the National Minimum Standards for Regulated Child Care and the basic principles and learning framework for Flying Start. Actions already undertaken to support the development of the scheme generally and these accreditation themes more specifically are:

• A ‘Spring into Action’ Powys wide conference was held in March for pre-school settings and associated professionals e.g. Health Visitors.

• A number of training sessions and meetings have been held with partners to enable the implementation of the scheme.

• Workshops for the pre-school settings and associated professionals on topics of ‘Nutrition and oral health’ and ‘physical activity and active play’ have been held during 2012.

To date, fourteen settings have been recruited. Six of these have already set accreditation dates for July and more will follow in the autumn. 2.2 Community Alcohol Partnership - A Local Initiative to Reduce Alcohol Related Harm Background The Brecon Community Alcohol Partnership (CAP) was officially launched at the end of April. This is the first such partnership in Wales. Over 35 CAPs already exist in 13 counties across England, Scotland and Ireland. About Community Alcohol Partnerships Community Alcohol Partnerships (CAP) use a multi sector approach to look at underage drinking and associated problems. They aim to bring together key local stakeholders including alcohol retailers, Trading Standards, youth services, police,

FOR DISCUSSION


Agenda Item 5.1

local authority licensing teams, schools and Local Health Boards to develop a Steering Group and Action Plan. CAP is unique in that it addresses both the demand and supply side of underage drinking through enforcement, education and public perception. Community Alcohol Partnerships in practice Retailers and local authorities commit to share information on problems with underage drinking e.g. information is shared if either become aware of problems in a local shop and work together to resolve issues. This work goes hand in hand with work such as:

• Joint confiscation operations between police and trading standards, in co-operation and communication with staff in local shops.

• Educational sessions for pupils in local colleges and schools highlighting the legal issues in attempting to purchase alcohol and raising awareness of proxy purchasing.

• Public awareness is reinforced through work with local media. • Retailers working together to support each other with shared training

programmes and best practice. Brecon Community Alcohol Partnership The Brecon CAP is a partnership between Powys County Council, Brecon Town Council, Dyfed Powys Police, Powys (teaching) Health Board, retailers, local schools and youth support groups. It is backed by Community Alcohol Partnerships Ltd. It is an excellent example of how public bodies, charities and private companies can work together to resolve community problems. The Brecon CAP will be going into schools and youth groups in the Brecon area to work with young people highlighting the health, social and legal consequences of drinking. Brecon CAP will continue to work with retailers, Police, Community Safety Partnership and Youth Service among others, to ensure that this initiative goes forward. 2.3 Improving Young People’s Access to Condoms - C-Card The Powys Sexual Health Forum, a multi-agency group made up of health professionals, youth service workers and other partner agencies has launched a Powys wide condom card scheme. The ‘Sorted’ C-Card scheme aims to provide young people aged under 25 years easy access to sexual health advice and support from trained health and youth workers and if appropriate, access to contraception.

FOR DISCUSSION


Agenda Item 5.1

In March 2012, youth workers across the county, along with other professionals from the substance misuse agency (CAIS), Youth Offending, Leaving care team, Terrance Higgins Trust and specialist nurses for looked after children, attended an Agored Cymru level 2 course in ‘Sexual Health and Young People’. The course was run by the Youth and Family Information team and school nurses and has enabled those taking part to become qualified assessors for young people wanting sexual health advice and condoms. The new C-Card scheme helps to ensure that when young people are ready to have sex, they do so safely using a reliable method of contraception which protects them from sexually transmitted infections as well as an unwanted pregnancy. The C-Card process means that the young person can see an assessor and, if under 16, have a confidential assessment to ensure that they understand the basics about safer sex and Sexually Transmitted Infections, the benefits of delaying sexual activity and how they should not feel pressurised into having sex. All young people accessing the service are encouraged to discuss sexual health matters with their parents / guardians. They are then able to join the scheme and receive a registration card with a unique reference number, which they can produce to receive condoms on eight occasions without the need for a further assessment. The Powys Sexual Health Forum is currently working towards accreditation in line with the All Wales C-Card Standards. Once accredited, young people will be able to utilise any other Welsh accredited C-Card scheme. 2.4 Powys- Molo Health Link: update Powys teaching Health Board Midwifery department and Powys Public Health team recently hosted colleagues from Molo, Kenya for two weeks as part of the Powys-Molo Health Link. The Powys-Molo Health Link is part of Brecon-Molo Community Partnership, which was established under the Welsh Assembly Gold Star scheme in October 2007. The Health Link is a partnership between Molo District and Powys (teaching) Health Board, supporting primary and secondary health care in the Rift Valley Province of Kenya, a district badly affected by post 2008 election violence. In 2009 the Molo District Health Director requested Public Health input to the Powys Molo Health link to help with implementing their new Community Strategy. The focus of the Molo Community Strategy is the assimilation and standardisation of ground level health staff to support and feed into clinic and district level staff. Community based volunteers are trained to become Community Health Workers, supported and supervised by paid Community Health Extension Workers.

FOR DISCUSSION


Agenda Item 5.1

Wales for Africa Grant In May 2011 an application was submitted to the Wales for Africa grant fund to cover the costs of exchange visits and training in Public Health approaches and techniques and also maternity service approaches. Maternity services in Kenya differ according to distance from a medical centre, with a focus on getting women to give birth in hospitals. A previous visit by Powys midwives had highlighted the fact that midwifery practice is highly medicalised in Kenya. This previous visit generated interest in a community-based maternity service. The aim of the Wales for Africa grant funding was to showcase Powys’ midwifery led maternity services as well as sharing of best Public Health practice between Powys and Molo. The successful grant application focused on the following four objectives:

1. Set up 2 two-week placements for Molo midwives to be attached to a Powys community-based midwifery team.

2. Set up a training programme for 2 members of the Molo Public Health team to visit and deliver training to the Powys Public Health team on the recruitment, selection, training and retention of volunteer community health champions to deliver a range of Health Promotion messages to the people they come into contact with.

3. Two Public Health workers from Powys will deliver further needs assessment, monitoring and evaluation training in Molo, as part of the follow up from the initial training.

4. Two midwives from Powys will deliver further maternity training in Molo. Exchange visits Unfortunately, due to escalating problems in neighbouring Somalia, the planned visits to Molo were delayed. However, April finally saw Powys Maternity services and the Public Health team hosting four Kenyan colleagues (two midwives and two Public Health officers) for two weeks. This was the first time these staff had been to the UK - their visit was a steep learning curve in our culture, as well as our different ways of working. The timetables for our Midwifery and Public Health colleagues were very full. The Public Health officers were able to gain a clear picture of the similarities and differences between Public Health operations in Powys and Molo, whilst the Midwives were able to shadow their Powys colleagues and gain firsthand experience of our community-based midwifery services. In addition, the Molo Public Health officers delivered a training session to Public Health Wales and Powys colleagues on the Kenyan Community Health Champions programme.

FOR DISCUSSION


Agenda Item 5.1

Key learning from the Powys-Molo Health Link Key learning points from their visit include: • An understanding that women can receive a high standard of midwifery care

without the need for highly technical equipment. • Effective use of time management to ensure efficiency in our working practice. • We have access to excellent equipment to support our working life, in contrast to

Molo’s lack of equipment and sometimes lack of office or desk. • Our good road and transport networks. • Our good ambulance service. Access to the ambulance service is not always

easy in Molo, with women and their families sometimes being required to pay for petrol.

• The importance of strong links with other organisations such as schools • The need for strong cordial relationships and good team working amongst

colleagues. The next step is to start planning a return visit to Molo to deliver further training. For Midwifery staff this includes training in obstetric emergencies e.g. shoulder dystocia, breech, pre-eclampsia and breastfeeding, advice regarding hare lip and other unusual conditions. For the Public Health staff, this includes training on data monitoring and evaluation, the Healthy Schools Scheme, including the APAUSE sex education programme.

FOR DISCUSSION

Financial performance Month 01/2012


Agenda Item 6.1


AGENDA ITEM 6.1

FINANCIAL PERFORMANCE TO MONTH 1 (APRIL 2012)

Report of

Director of Finance


Purpose of Paper

The purpose of this report is to inform the Board of the financial performance of the Powys Teaching Health Board (tHB) for 2012/13


The Board is asked to NOTE the financial performance of the tHB.


N/A


Making Every Pound Count.


tHB – teaching Health Board HR(W&OD) – Human Resources (Works and Organisational Development) NCL – Non Cash Limit M01 – Month 1 WG – Welsh Government CIPs – Cost Improvement Plans NHS – National Health Service

FOR DISCUSSION



Agenda Item 6.1

FINANCIAL PERFORMANCE TO MONTH 1 (APRIL 2012)

Background This paper presents the outturn financial performance of the organisation against the 2012/13 Interim Financial Plan approved by the Board in April 2012. Summary In summary this paper identifies that:

• The tHB has identified an overspend of £0.683M to month 1 • The tHB has projected an overspend of £8.1M to month 12 with associated

risks identified • The tHB is on track to achieve its capital resource limit target • The tHB is on track to achieve the Public Sector Payment Policy • The tHB is reporting savings achieved of £0.385M against a plan of £0.485M

in month 1 Annual Financial Plan The Board approved the Annual Financial Plan for 2012/13 in April 2012 and the performance information for month 1 that follows is against that plan. The Board will recall that the Annual Financial Plan contained two issues which had been brought to the Board’s attention as part of their consideration

• That the Health Board had been unable to identify savings to match the full extent of cost pressures identified of £15M, identifying savings of £11M leaving a £4.2M shortfall

• That the Health Board will receive a reduction in income from Welsh Government in 2012/13 of £3.9M as a result of an early drawn down in 2011/12 to break even

The two issues mean that the Health Board has been unable to produce a plan to break even by £8.1M. Subsequent to the April Board meeting whereby an interim financial plan was agreed, the Health Board was required to submit a further updated plan to Welsh Government during May 2012. There is a separate briefing to the Board on the revised plan. However for the purposes of month 1 reporting, the original plan remains extant. Revenue Resource Limit / Income (Annual Budget £230.671M) The main source of funding is received from the Welsh Government based on the annual resource allocation letter.

FOR DISCUSSION



Agenda Item 6.1

Expenditure The summary position to date is shown in Table 1 below which identifies an overspend at month 1 of £0.683M.

Directorate / Locality Annual

Budget £000 Budget to Date £000

Actual to Date £000

Variance to Date

£000 Mid Locality 30,228 2,602 2,599 3 North Locality 66,925 5,615 5,671 (56) South Locality 53,124 4,590 4,597 (7) Finance 796 66 68 (2) HR (W&OD) 904 75 79 (4) Performance 27,383 2,282 2,271 11 Corporate Services 1,411 118 117 0 Medical 5,413 455 450 6 Mental Health 17,990 1,641 1,642 (1) Nursing 4,881 415 369 45 Planning 6,594 554 544 10 Women & Children 12,169 1,014 1,021 (6) Therapies Management 1,741 145 146 (1) Comm Health Councils 3,783 316 319 (3) Shared Services 564 564 564 0 NCL (789) (66) (66) (0) Reserves 5,689 0 0 0 Reserves ‐ Gap (8,137) (678) 0 (678) Revenue Resource Limit (230,671) (19,709) (19,709) 0 Grand Total 0 (0) 683 (683)

(Brackets within the variance column denote overspend) The variance to date (£0.683M) can be broadly further broken down as follows;

1/12th of financial planning risk (£8.1M) (£0.678M) Other minor net operating variances (£0.005M

Total Month 1 position (£0.683M) The Board should note that a significant proportion of costs identified above are based on estimates given that actual information for primary and commissioned services for month 1 will not be available for upto 2 months. Costs identified in month 1 in these areas are based upon anticipated levels through profiling trends in 2011/12 or assuming that plans are on track where no other supporting information is available. Pleasingly, the directly provided services of the organisation have broken even in month 1, this after applying savings targets of £0.140M in month 1. Performance on workforce trends and non pay will continue to be tracked and monitored during 2012/12 to ensure costs are contained to within planned levels.

FOR DISCUSSION



Agenda Item 6.1

Performance against Savings plans The Board will recall that savings targets totalling £11M have been built into the 2011/12 financial plan. These planned savings are in addition to the recurrently achieved savings of £11.5M delivered in 2011/12. The position to date assumes that the majority of the savings planned to date are on track to be delivered with net slippage amounting to £0.1M occurring in month 1. A summary of performance against savings plans is included in Appendix 1. The main slippage reported on savings relates to commissioned services (£0.134M). The majority of savings are planned within the North and South Localities and hence it is in these areas where slippage is being reported. However, given the tHB has only recently received month 11 (2011/12) and in some cases month 12 data on commissioned services, there is very little information currently available to evidence savings achievement (or non achievement) in M01. Therefore, a high level of judgement has been applied in producing month 1 savings information for these aspects which will only be confirmed once month 1 commissioning information has been received and validated. Performance Management Process A slightly revised review process has been established for 2012/13 around the savings programme which includes individual weekly sessions between scheme holders and the Director of Finance to ensure robust plans are in place and are on track for delivery. A fuller briefing has been provided to the Integrated Governance Committee on this revised process. These sessions will also be the opportunity for scheme holders to raise areas of concern, or which require additional support to identify solutions and ensure pace in the delivery of savings. Forecast Outturn and Risks The tHB has reported a forecast an outturn overspend of £8.1M to the Welsh Assembly Government within the month 1 finance returns. This is based on the currently identified risk within the financial plan as approved by the Board. The tHB has also assessed further financial risks within the outturn position and these have been identified as shown in Table 2 below. “Most likely” representing the formally reported position to WG.

FOR DISCUSSION



Agenda Item 6.1

Table 2: Forecast Outturn Risk Analysis FORECAST YEAR END Worse Most Best Case Likely Case

£'000 £'000 £'000 Current Reported Forecast Outturn (8,122) (8,122) (8,122)

Non delivery of Saving Plans/CIPs (800) 0Withdrawal of MH funding from Welsh organisations (500) 0Deflator and contract terms not supported within NHS Wales (2,500) 0Potential Use of Reserves 0 2,000Potential Use of Balance Sheet 0 2,000Other Identified Savings 0 1,000

(3,800) 5,000 (11,922) (8,122) (3,122)

The worst case scenario of the outturn position for the year is built upon the following assumptions;

• The £8.1M risk within the financial plan will not be closed • There will be some underachievement of savings plans – based on previous

years experience • The use of a deflator and contract terms are not supported within NHS Wales • There will be other risks (as yet unidentified) which will necessitate the

deployment of currently held reserves / contingencies The performance management arrangements as outlined above are designed to identify risks facing the organisation and agree the mitigating actions which will need to be taken in order to reduce the level of financial risks being taken by the organisation. The best case scenario assumes that the tHB

Delivers in full the current savings programme

Secures good agreements with external providers for 2011/12 allowing the

release of balance sheet items

Improves the Management of our 5 healthcare systems, enabling growth to be

curtailed and remove the need to access tHB held contingency funding

Creates extended savings opportunities through the “Making it Happen”

Programme

FOR DISCUSSION



Agenda Item 6.1

Capital In line with Welsh Assembly requirements, no formal reports have been produced in month 1 for performance against capital expenditure. However internal reporting identifies that the tHB is on track to contain costs within capital resource limit for discretionary capital. Public Sector Payment Requirement In line with Welsh Assembly requirements, no formal reports have been produced in month 1 for performance against the Public Sector Payment Requirement. However internal reporting identifies that the tHB is on track to continue to achieve the 95% target against non NHS invoices. Conclusion In summary this paper has identified that:

• The tHB has identified an overspend of £0.683M to month 1 • The tHB has projected an overspend of £8.1M to month 12 with associated

risks identified • The tHB is on track to achieve its capital resource limit target • The tHB is on track to achieve the Public Sector Payment Policy • The tHB is reporting savings achieved of £0.385M against a plan of £0.485M

in month 1 Recommendation The Board is asked to note the financial performance of the tHB to month 1 2012/13.


FOR DISCUSSION



Agenda Item 6.1

APPENDIX 1 Analysis of performance against savings plans to date

Apr

£'000

Continuing Healthcare Plan 32

Actual 0

Variance (32)

Estates/Energy Plan 10

Actual 11

Variance 1

Commissioned Services to and from other organisations

Plan 245

Actual 111Variance (134)

Medicines Management (Primary & Secondary Care)

Plan 66

Actual 66

Variance 0

Procurement & Other Non Pay (excl. energy)

Plan 50Actual 38Variance (11)

Management Costs Reductions Plan 42Actual 37Variance (4)

Specialist Services Plan 0Actual 0Variance 0

Workforce Modernisation Plan 41Actual 121Variance 80

Total Plan 485Actual 385Variance (100)

FOR DISCUSSION

Financial performance Month 02 2012/13


Agenda Item 6.1b


AGENDA ITEM 6.1b

FINANCIAL PERFORMANCE TO MONTH 2 (MAY 2012)

Report of

Director of Finance


Purpose of Paper

The purpose of this report is to inform the Board of the financial performance of the Powys Teaching Health Board (tHB) for 2012/13


The Board is asked to NOTE the financial performance of the tHB.


N/A


Living within our Means.


CIP - Cost Improvement Programme EMAs – Emergency Medical Admissions HR - Human Resources MH - Mental Health PSPP - Public Sector Payment Policy tHB - teaching Health Board WHSSC – Welsh health Specialist Services Committee WOD – Workforce and Organisational Development

FOR DISCUSSION



Agenda Item 6.1b

FINANCIAL PERFORMANCE TO MONTH 2 (MAY 2012)

Background This paper presents the outturn financial performance of the organisation against the 2012/13 Interim Financial Plan approved by the Board in May 2012. Summary In summary this paper identifies that:

• The tHB has identified an overspend of £1.370M to month 2 • The tHB has projected an overspend of £4M to month 12 with associated risks

identified • The tHB is on track to achieve its capital resource limit target • The tHB is on track to achieve the Public Sector Payment Policy • The tHB is reporting savings achieved of £0.720M against a plan of £1.130M

in month 2 Annual Financial Plan The Board has been asked to approve an updated interim financial plan which identifies a remaining financial challenge of £4M. The following position is based upon the revised plan on the assumption that it is approved. Revenue Resource Limit / Income (Annual Budget £230.236M) The main source of funding is received from the Welsh Government based on the annual resource allocation letter. Expenditure The summary position to date is shown in Table 1 below which identifies an overspend at month 2 of £1.370M.

FOR DISCUSSION



Agenda Item 6.1b

Table 1 Income and Expenditure position to month 2

DIR / LGM Annual

Budget £000 Budget to Date £000

Actual to Date £000

Variance to Date £000

Mid Locality 30,232 5,205 5,210 ‐5 North Locality 66,926 11,229 11,608 ‐379 South Locality 53,152 9,184 9,351 ‐168 Finance 796 133 159 ‐27 HR (W&OD) 941 189 201 ‐13 Performance 27,245 4,541 4,631 ‐90 Corporate Services 1,411 235 248 ‐13 Medical 4,695 791 796 ‐5 Mental Health 17,018 2,976 3,054 ‐78 Nursing 4,919 834 771 62 Planning 7,594 1,275 1,280 ‐5 Women & Children 12,245 2,041 2,039 1 Therapies Management 1,741 290 292 ‐2 Comm Health Councils 3,783 627 627 0 Reserves Held 5,674 0 0 0 Reserves ‐ Planning Gap ‐8,137 ‐650 0 ‐650 Revenue Resource Limit ‐230,236 ‐38,898 ‐38,898 0

Grand Total 0 ‐0 1,370 ‐1,370

(Brackets within the variance column denote overspend) The Board should note that a significant proportion of costs identified above are based on estimates given that actual information for primary and commissioned services for month 2 will not be available for upto a further 2 months. Costs identified in month 2 in these areas are based upon anticipated levels through profiling trends in 2011/12 or assuming that plans are on track where no other supporting information is available. Variance Analysis to month 2 The £1.370M variance to date is made up of the following factors;

• Financial Planning gap At present, the financial plan assumes a £4M challenge which will need to be addressed in order to present a balanced financial plan. The year to date position includes 2/12ths of this planning gap, shown in the table above as £0.650M.

• Slippage on new year savings programme The Board approved the interim financial plan with a savings programme totalling £11M in April 2012. The supplementary financial plan assumes a further £1M of savings will be identified through the Making it Happen Programme. The overall savings programme has profiled in £1.130M of planned savings to month 2, actual performance has been assessed as £0.720M realising slippage to date on the plan by £0.410M. The following highlights the more significant issues slippage has occurred in the following areas

FOR DISCUSSION



Agenda Item 6.1b

o Continuing Healthcare A challenging target has been set by the organisation of £1.125M and covers both general and mental health continuing healthcare. Slippage to date amounts to £0.082M against a profiled plan of £0.131M. Executive support is being offered to Localities to assist them in identifying how savings can be generated o Commissioned services As identified above, no actual month 2 data is available as yet to test whether the results of actions taken by the localities and directorates responsible for commissioned services are achieving their desired effect. Therefore local intelligence has been applied to assess whether planned schemes are on track in their implementation, and/or assess the likely value of savings accumulated to date. This local assessment assumes that £0.353M of schemes have slipped to date. This slippage has occurred in the main as a result of the following;

Aneurin Bevan Health Board – the Health Board assumed savings in pricing beyond the 1.8% deflator in its savings programme with this provider. Based on local discussions, this is currently unlikely to be achieved (£0.160M slippage to date). Introduction of local referral management has not commenced with this provider and therefore slippage against planned savings is assumed (£0.022M to date)

Mental Health – The Mental Health savings plan assumes savings against other Health Boards delivering Mental Health services formerly provided by Powys tHB. Limited progress has been made to date in setting out how the savings will be delivered and therefore it is assumed that savings against these targets have slipped (£0.049M to date).

o Management cost reductions The Health Board set a target to reduce Headquarters costs by £0.5M. Slippage to date of £0.037M has occurred as a result of the plan at present being incomplete in identifying how the full £0.5M will be achieved and also because of slow turnover in staff in order to reduce posts.

• Slippage on old year savings plans The 2012/13 financial plan assumes the achievement of savings against the previous year’s savings programme, producing a cumulative savings plan of £22.6M. For the North Locality, the 2011/12 savings programme was acknowledged to be a challenging target and is still the case in 2012/13. To month 2, there is assumed slippage against savings targets set in 2011/12 around the Shrewsbury and Telford NHS Trust contract (£0.256M). The reasons for these are as follows

o The management of waiting lists by the Health Board for this provider did not fully achieved the targeted savings in 2011/12 and it is currently assumed that a similar performance will be achieved in 2012/13 (£0.084M slippage to date),

o Alternative pathways of care planned with other Health Boards have been slow to start, resulting in slippage to date (£0.114M),

o reduction in emergency medical admissions planning has not been fully worked through and it is assumed that there is slippage to date against target (£0.092M),

FOR DISCUSSION



Agenda Item 6.1b

• WHSSC The Welsh Health Specialist Services Committee whose membership is made up of the 7 Health Boards in Wales and secures specialist secondary care for NHS Wales currently does not have a balanced financial plan. Performance across each Health Board has been assessed by WHSSC and Powys tHB share of the overspend at month to is £0.099M.

Reserves and Contingencies As per the original plan to the Board, a number of reserves and contingencies are being held by the organisation which can be categorised into

• Funds held pending distribution to budget holders for known commitments • Funds held as a contingency for likely growth • Funds held as pure contingency for unknown events

The Health Board’s reserves have been analysed as follows in table 2. Table 2 Annual Reserves and contingencies held Reserves / Contingencies £M Held Pending Contingency for likely growth Contingency

2.018 3.098 0.558

Total 5.674 The supplementary financial plan assumes the health Board will be able to suppress growth to enable the use of the contingencies to release into the overall position to the value of £2M. In other words, only £3.674M will be required against the total reserves set aside. Balance Sheet Opportunities The supplementary plan assumes that upto £2M will be available through the write back of balance sheets items arising from 2011/12. Following the closure of the 2011/12 annual accounts and early analysis of the actual outturn position, it appears extremely likely that the £2M will be realised, although further analysis on the final position is currently being undertaken. Further review on provisions will take place throughout the year in preparation for the 2012/13 Annual Accounts. Forecast Outturn and Risks The tHB has reported a forecast an outturn overspend of £4M to the Welsh Assembly Government within the month 2 finance returns. This is based on the supplementary plan submitted to Welsh Government on 9th May and is due for discussion and approval by the Board on 27th June 2012. The Health Board has completed a risk assessment on the best, worst and most likely scenarios against the updated plan. This is set out in table 3 below

FOR DISCUSSION



Agenda Item 6.1b

Table 3 Risk Assessment against the forecast position FORECAST YEAR END Worse Most Best Case Likely Case £'000 £'000 £'000 Current Reported Forecast Outturn (4,000) (4,000) (4,000)Non delivery of Saving Plans/CIPs (1,800) 0Continuing Healthcare growth (500) 0WHSSC Performance (400) 0Growth in Commissioned services (1,600) 0Failure to Withdraw MH funding from Welsh organisations (500) 0Deflator and contract terms not supported within NHS Wales (2,500) 0Total (11,300) (4,000) (4,000)

The supplementary plan presented to WG on 9th May outlined that our strategy to break even is based on the following assumptions

• Full implementation of savings plans, thereby avoiding the use of contingencies and reserves

• Managing growth – thereby avoiding the use of monies set aside for this purpose

• Indentifying new opportunities through the accelerated clinical change for excellence programme

• Seeking to secure agreement that the early draw down of funding from last year is “repaid” over a three-year period from April 2013

However, this plan has many risks associated with it as follows;

• Our commissioning budgets were set on forecast outturn at month 10 given that was the latest available information at the time of budget setting. The first draft actual month 12 outturn position have indicated some deterioration in the last 2 months around Wye Valley NHS Trust and Shrewsbury and Telford NHS Trust. This means that the size of the challenge has potentially increased in terms of meeting delegated budgetary requirements in 2012/13.

• The £11M savings programme has significant risks associated with it, particularly around commissioned services and as noted above, requires the support of WG to enact the 1.8% deflator and other contractual requirements by the Health Board. In addition, the Health Board has received little support from other HBs in the deployment of additional consultant support to work within Powys’s premises to commence our repatriation programme

• The Health Board currently has two vacancies within our three local general manager positions. These positions are critical to delivering within budget.

• The Making it Happen programme assumes that further savings will be identified. The first deep dive exercise is due to commence on 5th July 2012 which puts at risk the likelihood of identifying additional savings to be delivered in-year

FOR DISCUSSION



Agenda Item 6.1b

The current forecast represents a view of the best case scenario given the risks outlined above and in this presentation assumes that slippage on the savings programme to date will be recovered throughout the remainder of the financial year. The worst case presents the outturn position if delivery against our annual plan does not materialise and / or if support for our approach to commissioned services is not supported by Welsh Government. Performance Management Processes The Chief Executive has further developed the and strengthened the approach already established in previous years with the following framework;

• Weekly/fortnightly performance meetings led by the Director of Finance are taking place to monitor progress against each scheme’s implementation, receive performance data on output results and agree any changes in actions against agreed implementation plans. Localities / Directorates and the Finance Director may, at their discretion, invite other members of the Executive Team to help provide specific advice and support.

• The Executive Team will receive a weekly account of progress against plans by exception from the Director of Finance, identifying areas that are off-track and mitigating actions. This will also be the opportunity to raise and resolve matters which require additional support or unblocking.

• Monthly meetings will be held between Locality General Managers / Directorate Managers and their respective teams with the Director of Finance or representative to review financial performance against expected results and to ensure that delegated budgets in their entirely are being contained within delegated limits. Escalation will take place in accordance with the Budgetary Control Policy

• Monthly meetings between the Executive Team and Locality / Directorate Team will review the performance of the locality/ directorate against the Annual plan

• The Board will retain oversight of the financial position at its Board meeting with further scrutiny taking place by exception at the Integrated Governance Committee as part of the oversight of the Annual Plan

The Health Board has established an accelerated clinical change programme – Making it Happen which is led by the Nurse Director and comprises of several work-streams around improving clinical quality and ensuring organisational effectiveness to deliver. As part of this programme, deep dive reviews are commencing on 5th July with a view to identifying how the tHB can further enhance its current savings programme through improved clinical practice. Capital The Health Board has been allocated £3.221M in capital funding from Welsh Government for 2012/13. Table 4 below summarises the allocations received, the planned expenditure and spend to date.

FOR DISCUSSION



Agenda Item 6.1b

Table 4 Annual Capital Programme and spend to date

• Discretionary Capital £0.342M

The discretionary capital limit has been set by Welsh Government at £0.342M for the year. From this allocation there is a requirement to allocate monies to All Wales Capital Programme schemes where discretionary capital schemes were brought forward to utilise slippage against these schemes in 2011/12. Consequently £0.088M has been allocated to Welshpool Renal and £0.113M for Orthopaedics Llandrindod from discretionary capital. The remaining £0.140M is being strictly prioritised given its small value, against essential works.

• AWCP Welshpool Renal £1.626M This scheme continues from 2011/12. The build is progressing well and it is anticipated that all funding will be utilised prior to December 2012. This includes monies allocated to the scheme from the tHB’s discretionary allocation as described above.

• AWCP Orthopaedics Llandrindod £0.400M This scheme continues from 2011/12. The work is progressing well and it is anticipated that all funding will be utilised prior to October 2012. This includes monies allocated to the scheme from the tHB’s discretionary allocation as described above.

• AWCP Orthopaedics Brecon £0.853M This scheme will commence during September 2012. The design phase is complete and the work will commence once works at Llandrindod concludes in order to avoid both theatres being closed at this same time. The same contractor is undertaking both schemes so there is a joined project plan of works for both schemes. It is anticipated that all monies will be expended prior to January 2013.

Scheme Capital Resource

Limit£M

Annual Planned Expenditure

£M

Expenditure to at 31st May 2012

£M

Discretionary Capital

0.342 0.140 0

AWCP Welshpool Renal

1.626 1.715 0.013

AWCP Orthopaedics Llandrindod

0.400 0.513 0.010

AWCP Orthopaedics Brecon

0.853 0.853 0

TOTAL

3.221 3.221 0.023

FOR DISCUSSION



Agenda Item 6.1b

Public Sector Payment Requirement The tHB is required to pay 95% of non-NHS suppliers within 30 days and is currently on track to meet this target. The tHB currently achieves a cumulative position of 95% of non NHS invoices paid within 30 days by value and 98% by number of invoices. Table 5 Public Sector Payment performance to month 2 Cumulative Performance at 31st May 2012 30 days 10 daysValue of invoices 95% 77%Number of invoices 98% 90% Conclusion

• The tHB has identified an overspend of £1.370M to month 2 • The tHB has projected an overspend of £4M to month 12 with associated risks

identified • The tHB is on track to achieve its capital resource limit target • The tHB is on track to achieve the Public Sector Payment Policy • The tHB is reporting savings achieved of £0.720M against a plan of £1.130M

in month 2 Recommendation The Board is asked to NOTE the financial performance of the tHB to month 2 2012/13.


FOR DISCUSSION

Audit Committee Briefing May 2012

Page 1 of 4 Board Meeting18 April 2012

Agenda Item 7.1a


AGENDA ITEM 7.1a

REPORT FROM THE CHAIR OF THE AUDIT COMMITTEE MAY 2012

Report of

Audit Committee Chair

Paper prepared by


Purpose of Paper

The purpose of this paper is to provide the Board with an update on the key issues discussed and any decisions made by the Audit Committee at its meeting in May 2012.


The Board is asked to RECEIVE this update for information and DISCUSS any issues arising.






N/A

FOR DISCUSSION



Agenda Item 7.1a

REPORT FROM THE CHAIR OF THE AUDIT COMMITTEE MAY 2012

PURPOSE The role of the Audit Committee is to advise and assure the Board and the Accountable Officer on whether effective arrangements are in place to support them in their decision making and in discharging their accountabilities for securing the achievement of the organisation’s objectives, in accordance with the standards of good governance determined for the NHS in Wales. Therefore, the purpose of this paper is to provide the Board with a summary of the discussions held and any issues arising from two meetings of the Audit Committee held in May 2012. INTERNAL AUDIT Internal Audit Plan 2011/12 The Committee received an update from the Director of Audit & Assurance, NHS Wales Shared Services, which advised that the final three audits identified in the Powys Operational Plan for 2011/12 had been completed and final reports issued:-

Communications – Adequate Assurance IT General Controls – Limited Assurance Arrangements for the commissioning and management of funded placements

of vulnerable individuals on non-NHS settings – Limited Assurance The Committee received a response from the Director of Nursing (Executive lead for Nursing Home Governance), in respect of the audit of commissioning and management of funded placements in non-NHS settings which had concluded limited assurance. The Committee was advised of the work underway to ensure recommendations arising from the audit were addressed and improvements made. The Committee was assured that the work underway would deliver improvements within the area of nursing home governance. The Committee requested that a response and assurances in respect of the IT General Controls audit report (limited assurance) be provided to the Committee at a future meeting by the Joint Head of IM&T. Annual Internal Audit Report and Opinion 2011/12 The Committee received the Annual Internal Audit Report and Opinion 2011/12 on the overall adequacy and effectiveness of the organisation’s risk management, control and governance processes. The opinion was that “the Board could take some assurance that the arrangements, upon which the organisation relies to manage risk, control and governance within those areas under review, and the operational compliance noted, are suitably designed and applied effectively. However, management need to address the exposure to significant risks in several areas”.

FOR DISCUSSION



Agenda Item 7.1a

The Committee noted that this Opinion would contribute to the Board’s assessment of the effectiveness of the organisation’s system of internal control and to the completion of the Annual Governance Statement. EXTERNAL AUDIT The Committee received an update from the Wales Audit Office (WAO) in respect of progress against the Audit Outline 2011, noting that fieldwork was underway in respect of a follow-up of Adult Mental Health Services. The Committee received the following Wales Audit Office Reports:- Review of Internal Audit This report advised the Committee that the tHB’s Internal Audit Services had complied with the aims of the Internal Audit Standards for the NHS in Wales but there were some key areas where improvements were required. The Committee agreed that these improvements should be given consideration by the tHB and NHS Wales Shared Services. The Committee therefore agreed to include key improvement areas in its workplan for 2012/13, including: the development of an Internal Audit Charter, in-line with the expectations of the Internal Audit Standards; and clarity on links between the Head of Internal Audit, Accountable Officer and the Board should be reviewed to ensure that arrangements meet the expectations of the Internal Audit Standards. Information Management and Technology (IM&T) Governance – Follow-up Summary Report This report concluded that the tHB is making progress implementing the previous recommendations identified in the original audit of IMT&T Governance, however progress was slow and this would limit the extent to which technology could be used to enable modern, efficient healthcare services. The Committee requested that a response and assurances in respect of the audit be provided to the Committee at a future meeting by the Joint Head of IM&T. Data Quality This report concluded that, from a low baseline, the tHB has improved arrangements for ensuring data is valid and accurate, however it needs to become more formalised and include approaches to provide assurance. The Committee was assured by the Chief Executive that improvements in respect of information/data had been included as an objective in the Board’s Annual Plan 2012/13 to ensure improvements were made to support delivery of the organisation’s vision. The Committee noted that the tHB had secured additional resource from NWIS to support a review of the work needed to ensure improvements were made. GOVERNANCE AND ASSURANCE The Committee received the Audit Committee Annual Report 2011/12, prior to presentation to the Board. This Annual Report was developed to provide the Board and the

FOR DISCUSSION



Agenda Item 7.1a

Accountable Officer with assurance in respect of the adequacy and effectiveness of the organisation’s functions and systems to maintain a sound system of internal control. The Annual report outlined areas for further development to enhance governance and assurance which included development and use of the organisation’s Assurance Framework and implementation and assurance reporting in respect of the organisation’s Risk Management Strategy. ANNUAL ACCOUNTS 2011/12 The Committee received the tHB’s Annual Accounts 2012/13 for consideration, prior to presentation to the Board for approval. The Committee reviewed a number of documents, including:-

the tHB’s Financial Statements for 2011/12; the tHB’s Annual Governance Statement; the Audit of Financial Statements Report ( 2011/12) from the Wales Audit Office; the tHB’s Letter of Representation; and the tHB’s Remuneration Report.

The Audit Committee confirmed that it was not aware of any matters of significant that should be drawn to the Board’s attention which were not included in the reports to be presented to the Board in respect of the annual accounts 2011/12. Therefore, the Audit Committee recommended to the Board that it approved: the Annual Accounts 2011/12, including the Annual Governance Statement; the Letter of Representation; and the tHB’s Remuneration Report. RECOMMENDATION The Board is asked to RECEIVE this update for information and DISCUSS any issues arising.

Report prepared by: Presented By: Rani Mallison Gareth Jones Corporate Governance Manager Chair of Audit Committee

FOR DISCUSSION

Integrated Governance Committee Briefing May 2012


Agenda Item 7.1b


AGENDA ITEM 7.1b

REPORT FROM THE CHAIR OF THE INTEGRATED GOVERNANCE COMMITTEE MAY 2012

Report of

Integrated Governance Committee Chair

Paper prepared by


Purpose of Paper

The purpose of this paper is to provide the Board with an update on the key issues discussed and assurances in respect of the delivery of the organisation’s Corporate Plan, as discussed by the Integrated Governance Committee at its meeting in May 2012.


The Board is asked to RECEIVE this update for information and DISCUSS any issues arising.






N/A

FOR DISCUSSION

Integrated Governance Committee Briefing May 2012


Agenda Item 7.1b

REPORT FROM THE CHAIR OF THE INTEGRATED GOVERNANCE COMMITTEE MAY 2012

PURPOSE The role of the Integrated Governance Committee is to: maintain an oversight of the work of the Board’s Assurance Committees, ensuring integration of governance work across all business of the tHB and all issues which fall outside or between the work of the Committees are addressed; and review the tHB’s Assurance Framework, in-line with performance against achievement of organisation’s Corporate Plan, ensuring there is an accurate reflection of existing risks, key controls and assurances. Therefore, the purpose of this paper is to provide the Board with an update on the key issues discussed and assurances in respect of the delivery of the organisation’s Corporate Plan, as discussed by the Integrated Governance Committee at its meeting in May 2012. ANNUAL PLAN 2012/13: PERFORMANCE MANAGEMENT ARRANGEMENTS The Committee held discussion regarding the need to improve on the performance arrangements established for 2011/12, ensuring that performance information was presented in an integrated way. It was agreed that a revised performance management framework would be developed for consideration by the Committee at its next meeting, including the development of a Committee Workplan for 2012/13. FINANCIAL MANAGEMENT ARRANGEMENTS The Committee received a report of the Director of Finance, outlining the actions being taken in respect of delivering £11M savings as identified in the Board’s Interim Financial Plan for 2012/13. The Committee was advised that, following conclusions reached by an external review, a revised process for monitoring financial savings had been established. The Committee noted that the revised process had identified that there was a lack of granularity behind many savings programmes and therefore these programmes were being given priority for focus to assure the Board that savings were on track to be delivered. The Committee noted that, in establishing the revised process, a number of risks to delivery of the savings programme had been identified and actions were being taken to address these. RECOMMENDATION The Board is asked to RECEIVE this update for information and DISCUSS any issues arising.

Report prepared by: Presented By: Rani Mallison Roger Eagle Corporate Governance Manager Chair of Integrated Governance

Committee

FOR DISCUSSION

Q&S Committee Annual Report 2011/12


Agenda Item 7.2

BOARD MEETING


QUALITY & SAFETY COMMITTEE ANNUAL REPORT 2011/12

Report of

Committee Chair

Paper prepared by


Purpose of Paper

To provide the Board with the Quality & Safety Committee Annual Report 2011/12 for discussion.


The Board is asked to RECEIVE the Quality & Safety Committee Annual Report 2011/12.


1.Governance and accountability framework


Promotes Health & Wellbeing Continuously Improves Safety, Effectiveness &

Patient Experience Captures the Benefit of Integration Empowers our Staff Lives within our Means


N/A

Quality & Safety Committee Annual Report 2011/12

Page 1 of 11

QUALITY & SAFETY COM MITTEE

ANNUAL REPORT 2011/12

JUNE 2012


Page 2 of 11

Introduction As required in the teaching Health Board’s Standing Orders and the Committee’s Terms of Reference, the Quality and Safety Committee is required to issue annually a Report of the Committee Chair. The purpose of this report is to provide the Board and the public with assurance that the organisation has effective arrangements in place for the delivery of safe and high quality services for its population and that, where these arrangements are not effective, action is identified to make the required improvements. The Chair of the Quality and Safety Committee (hereafter known as ‘the Committee’) is an Independent Member of the Board, Gloria Jones Powell, and is also the organisation’s Board Champion for Children and Young People. The role of the Committee Chair is to report formally, regularly and on a timely basis to the Board on the Committee’s activities and to bring to the Board’s specific attention any significant matters under consideration by the Committee. The Purpose of the Quality and Safety Committee The Quality and Safety Committee is one of the key ways in which the organisation seeks assurance on the quality and safety of services it provides, plans and secures and thereby assures the Board. The Quality and Safety Committee is a statutory committee in all NHS Trusts and Health Boards in Wales, and in WHSSC (Welsh Health Specialised Services Committee). The purpose of the Quality & Safety Committee is to provide evidence-based and timely advice to the Board to assist it in discharging its functions and meeting its responsibilities with regard to the quality and safety of healthcare and to provide assurance to the Board in relation to the Health Board’s arrangements for safeguarding and improving the quality and safety of patient-centred healthcare in accordance with its stated objectives and the requirements and standards determined for the NHS in Wales. Membership of the Quality and Safety Committee To ensure that the Quality and Safety Committee is effective it must have members who are both independent and objective. The role of the committee is to hold the Executives and the organisation’s staff to account and to seek assurance on behalf of the Board, patients, service users and the public. Members must be independent of the organisation, and therefore Executives and other officers cannot be Committee members. However, the Committee requires Executive Directors to be in attendance in order that they can work constructively together to ensure the correct focus on quality and safety. Membership of the Quality and Safety Committee during 2011/12 can be seen in the following table:-


Page 3 of 11

Chair Independent member of the Board Gloria Jones Powell Vice Chair Independent member of the Board Paul Dummer

Members Two other independent members of the

Board, including the Chair of the Audit Committee and the Vice Chair of the Board.

Jo Mussen (tHB Vice Chair) Gareth Jones (Chair of Audit Committee) Jackie Walters Rosemarie Harris

In attendance Medical Director Director of Nursing Director of Therapies and Health Sciences Assistant Director of Nursing Head of Quality & Safety Corporate Governance Manager

The members of the Quality and Safety committee have a broad range of interests and ‘champion’ roles. These can be summarised as:

� Lead Independent Board member for Children � Lead for Older People; Lead for Protection of Vulnerable Adults; Lead for

Mental Health services and Chair of Mental Health Committee; � Lead for the Faculty for Quality Improvement � Chair of Audit Committee � Champion for Cancer � Champion for Veterans Health care

Quality and Safety Committee Structure and Working Arrangements At its meeting in June 2010, the Board approved the establishment of five sub-Committees of the Quality and Safety Committee to assist it in the conduct of its business:- Improving Patient Involvement The purpose of this Committee is to lead and coordinate improvements in the involvement of patients, carers and members of the public in their own care and in evaluating care; and to lead and coordinate improvement in the patients’ experience of health services.

Infection Prevention & Control & Environment of Care Committee The purpose of this Committee is to lead and coordinate improvements in the prevention and control of infection, and the environment of care for patients and the public. Safeguarding Committee The purpose of this Committee is to lead and coordinate improvements in the safeguarding of patients and the public. This committee links together the following committees and areas of Health Board work - Child Protection, Adult Protection,


Page 4 of 11

Domestic Abuse, Care Home inspection, Professional Regulation, Mental Capacity Act and Deprivation of Liberty. Clinical Effectiveness Committee This Committee is responsible for the promotion and monitoring of safe, cost effective and clinically sound treatment offered by the Health Board. The Committee works to improve local clinical effectiveness and patient outcomes through clinical audit and implementation of local and national patient safety initiatives. Risk Management Committee The purpose of this Committee is to ensure that the organisation has robust mechanisms in place for the reporting of clinical and non-clinical risk and overseeing the delivery of the organisation’s Risk Management Strategy. The Quality and Safety Committee has developed links with other Board Committees regarding quality and safety issues, in particular the Audit Committee. A clear demonstration of this is the inclusion of the Chair of the Quality and Safety Committee on membership of the Audit Committee and vice versa. However, it is acknowledged that further work is required to develop robust links for reporting and information sharing amongst all of the Board’s Committees via the ongoing development of Integrated Governance arrangements. Outlined within the Committee’s Terms of Reference, the Head of Internal Audit has unrestricted and confidential access to the Chair of the Committee. The Chair of the Committee has reasonable access to Executive Directors and other relevant senior staff. Quality and Safety Committee Meetings During 2011/12, the Committee established an annual schedule of formal meetings, in-line with its annual work plan and responsibilities to the Board. A schedule of the meetings scheduled during 2011/12 can be seen below:-

� March 2011 � May 2011 � July 2011 (inquorate - meeting postponed) � September 2011(inquorate - meeting held with no decisions made) � November 2011 � January 2012 � March 2012

The Committee was concerned that two meetings within the year were inquorate and this issue was raised with the Board by the Committee Chair. During 2011/12, the Board’s Internal Audit Service undertook a review of the organisation’s corporate governance arrangements. As a consequence, a recommendation was made to the Board to reconsider its Committee Structure and supporting membership. In April 2012, the Board approved a revised Committee Structure and supporting membership, effective of 01 May 2012.


Page 5 of 11

Where meetings were inquorate, escalation arrangements were in place to ensure that any matters of significant concern that could not be brought to the attention of the Committee could be raised with the tHB Chair. Quality and Safety Committee Development & Work Pro gramme Following the publication of the Welsh Assembly Government’s ‘Quality and Safety Committee Handbook’, and in light of the Committee’s requirement to introduce a process of regular and rigorous self-assessment and evaluation of its own operations and performance, the Quality and Safety Committee undertook a self-assessment during February 2011. The outcomes of the Committee’s self-assessment were discussed at a Development Session on 21 February 2011. The outcome of this Session informed development of the Committee’s Workplan for 2011/12. The Work Programme set out a structure through which the Committee could ensure the quality and safety of healthcare through the development of key areas of work, including:-

� the development of a process whereby the Committee could consider, discuss and make comment/recommendations from a quality and safety viewpoint on key strategic documents to the Board;

� the development of a process whereby the Committee could systematically consider the issues of quality and safety of services provided to the Powys population from service providers outside of Powys; and

� a review of sub-Committees to consider whether changes were required to support the fulfilment of the Quality and Safety Committee’s Terms of Reference.

The Committee monitored progress throughout the year in respect of the implementation of its Work Programme 2011/12 and noted that there had been delays in progressing certain actions due to limited capacity to ensure delivery within the timescales agreed. The Committee was assured by officers in attendance that any outstanding actions from the Committee’s Work Programme 2011/12, would be addressed during 2012/13. The Committee also noted that a number of outstanding actions would be addressed via the implementation of an action plan arising from the Board’s review of Corporate Governance, undertaken by Internal Audit. The Quality and Safety Committee Agenda To ensure that the Quality and Safety Committee fulfils its scrutiny and assurance role, without becoming too involved in operational detail, the Committee’s agenda has been consistently aligned to the themes of the Committee’s Workplan and its sub-Committee structure:-

• Leadership for Quality • Clinical Effectiveness • Improving Patient Involvement and Experience • Safeguarding • Infection Prevention and Control & Environment of Care • Risk Management • Organisational Governance and Assurance


Page 6 of 11

The agenda for Committee meetings is set by the Chair in discussion with the three Executive Directors with responsibility for quality and safety (Director of Nursing, Medical Director and the Director of Therapies and Health Sciences) and the organisation’s Corporate Governance Manager (Board Secretary). QUALITY AND SAFETY COMMITTEE ACHIEVEMENTS Patient Focus The Quality and Safety Committee received regular and timely reports from its Improving Patient Involvement and Experience Sub-Committee (IPIE) on their activities throughout 2011/2012. The key areas provided assurance on included the:

• Equality Plan • Carers Measure • Fundamentals of Care • Spiritual Care Standards • Locality Patient Experience Activities • Patient and Public Involvement Contract • Public Engagement

The Quality and Safety Committee were updated on the development of the Equality Plan and in particular the organisations strategic priorities including a focus on service issues relating to people in the protected characteristics such as older people of which patient equality was a key priority, alongside a particular focus on the care of older people. The demographic challenges for Powys on dementia were brought to the attention of the Committee, recognising the work already underway and the significant work going forward in 2012 that required a multiagency approach. Audit results of Fundamentals of Care were shared with the Quality & Safety Committee highlighting areas of good practice and areas for improvement. A corporate action plan was in development for implementation alongside local action plans. The Committee were informed of the process for reporting to Welsh Government and the publication of results. The Quality and Safety Committee were provided information on the Spiritual Care Standards and the communication work being taken forward with the Chaplains to develop improved information systems for patients and staff regarding the services available. Initial information and a progress report on the requirements of the Carers Measure was provided to the Quality and Safety Committee in 2011 and early 2012 respectively, informing them of the requirement on Powys teaching Health Board in leading the development of a joint Carers Strategy with Powys County Council and the other partner organisations. Progress to date was outlined and the priority areas for action highlighted.


Page 7 of 11

Key reports, such as the 5-year strategy ’Together for Health’ and ‘Healthcare Inspectorate Wales 3-Year Work Programme’ were shared with the Committee focusing on the patient experience aspects. The need for Powys teaching Health Board to articulate their approach to patient experience with its partner organisations was emphasised. Regular updates on Localities and Service Directorate patient experience activities were communicated to the Quality and Safety Committee. It was recognised there was a lack of a coordinated system over this work and that a review of how patient experience activities were undertaken was needed to ensure that the good work happening became embedded in day to day practice. It was planned to discuss the balance of coordination and central control of activity in the IPIE Committee in early 2012. The Quality and Safety Committee were kept informed of progress with the Public and Patient Involvement Contract currently in existence. The contract was being renegotiated to concentrate on different ways of engaging patients and the wider public in health issues across Powys. Information on the key concerns from public engagement listening events held was highlighted to the Quality and Safety Committee, the key areas of concern being access to emergency services, services in Aberystwyth and availability of accurate information on which to make comment. Putting Things Right/Redress The Quality and Safety Committee have been kept up-to-date with the implementation of Putting Things Right particularly focusing on communication and awareness raising about the new processes, the development of policies/ guidance and the supporting infrastructure. An action plan supporting implementation was received by the Committee in May 2011 outlining the work to be taken forward Powys-wide. An update on the action plan was received by the Committee in September 2011 updating progress on implementation and this emphasised to the Committee the challenges and the barriers plus what had gone well and what needed to be done differently. The latter reinforced that this was a significant change for the organisation and would take several months to embed. Regular updates on the current position and progress of Serious Incidents reported to Welsh Government have been provided to the Quality and Safety Committee, the most serious reported upwards to the full Board. The Committee were reminded of how the Serious Incident process worked, the timescales for responses, dealing with legacy cases and most importantly the learning from cases and how this was being shared Powys-wide. Older People’s Commissioner: Dignified Care The Older People Commissioner report ‘Dignified Care’ was considered by the Improving Patient Involvement and Experience sub-committee. The important report required a full and thorough response by the teaching Health Board which was developed with the scrutiny of the Quality and Safety Committee Chair, the Older People’s Champion and the Board Chair. The Quality and Safety Committee received the outcome of the Community Health Councils review of care at Brecon


Page 8 of 11

War Memorial hospital. This work, commissioned by the teaching Health Board, provided the independent view of standard of dignity and respect afforded to patients. Transforming Care The Committee received a presentation on the purpose of the Transforming Care work that the teaching Health Board had introduced. The project work across several areas including hospital wards, Community teams, Theatres and Maternity Services. Early indications on outcomes were reported to the Committee. 1000 Lives Plus Programme The 1000 Lives Plus programme has established itself as the leading patient safety initiative in Wales. The programme has three parts; individual subject area improvement initiatives, development of Quality Improvement faculties and the introduction of quality improvement methodology into undergraduate and post graduate clinical training. On a national level Powys is represented on the 1000 Lives National Programme Board and locally, the Health Board participates in nine of the eleven improvement areas. The two areas where there is currently no participation reflect that there is no central pathology laboratory in Powys and that we are not a provider of acute obstetric care. Members of the Committee have received development from experts in safety and quality improvement methodology to support their understanding of the direction of travel in the organisation and of the wider Welsh NHS. The 1000 Lives Plus programme is focussed on producing measurable outcomes, and the committee regularly receives run charts providing data on VTE prevention, falls prevention, transforming care, infection control and surgical measures, mental health and post-stroke care. Powys has been recognised for a number of innovations applicable to a community setting. The clinical leads for the work on preventing catheter associated infections have been invited to present at national conferences and the team responsible for introducing the National Early Warning System have been short-listed for the prestigious NHS AWARDS. Additionally a programme of Patient safety leadership walk rounds has been undertaken during the year. Changes in practice have been made as a result of the walk rounds and the programme has increased levels of staff engagement. All Health Boards in Wales have established a Quality Improvement Faculty, though organisations have been given complete discretion as to the form it takes. Cardiff and the Vale and Aneurin Bevan Health Boards have established a permanent core faculty of 20-30 members of staff to work on specific improvement projects, whilst


Page 9 of 11

the ambition of the Hywel Dda Health Board Quality Improvement Faculty is to become the leading centre of excellence for rural health care. Betsi Cadwaladr and Powys Health Boards have established virtual faculty structures in which staff are invited to collaborate on quality improvement initiatives. The Institute of Rural Health were retained to promote this model to the primary care community within Powys. Feedback however has been that the Health Board is unlikely to engage a GP practice in quality improvement work without offering a financial inducement. Discussions have also been held with the Director of Workforce planning and Organisational development on the introduction of local training in quality improvement methodology. National Clinical Audit and Outcome Reviews Plan 20 12/13 The Plan sets out how participation and the findings from the National Clinical Audit and Clinical Outcome Review (formerly Confidential Enquiries) Programmes, together with a small number of Wales specific audits and other reviews will be used to measure and drive improvement in the quality of Welsh healthcare services over the next 5 years. In total the Plan mandates all Health Boards to participate in 60 named audits if they are applicable to them. Powys tHB will be participating in 10 of these audits, which is a reflection of the range of services offered in the county. Assurance and improving quality and safety The Quality and Safety Committee has a core function of assuring the Board on issues relating to the safety of services and the quality of the care received by patients. The committee utilises a number of ways in which to gain assurance and to identify areas where there are shortcomings and in need of improvement. There are a number of key reports during the year, some provided by auditors from outside of the organisation that outline the performance of the organisation. In addition to external audit reports, the role of the Inspectorate is key. Healthcare Inspectorate Wales (HIW) as part of their planned work programme has undertaken a number of inspections of the services provided in Powys. Each report is considered by the Quality and Safety Committee and specific plans put in place to take forward any recommendations. Throughout the year, the Committee has received presentations from two of the organisation’s localities (North and Women & Childrens) in respect of the quality assurance arrangements in place, including: risk management arrangements; serious incident reporting; Standards for Health Services; Health and Safety issues; and the development of Locality Management Team Meetings and Locality Partnership Forums. This arrangement will continue in the coming year enabling the Committee to receive presentations from other localities (South and Mid). The Committee received a report from the Director of Nursing which outlined the mechanisms in place to ensure that the quality and safety aspects of service provision are considered whilst simultaneously trying to reduce the cost of services. The Committee was also provided with the outcome of impact assessments undertaken on financial savings schemes.


Page 10 of 11

Risk Management The Risk Management Strategy, developed by the Risk Management sub-Committee of the Quality and Safety Committee, which was approved by the Board in February 2011, focuses on five key aims, ensuring:-

1. the development of risk identification and management as an integral part of the organisation’s culture;

2. the development of risk management policies and procedures that are consistently and systematically applied;

3. the identification of responsibilities and accountabilities for risk management at every level of the organisation;

4. that staff are able to both understand and implement their responsibilities for risk identification and management; and

5. that there is a broad spectrum approach to organisational risk identification and management (to include strategic, operational, clinical, and financial).

The Committee received routine updates from the Risk Management sub-Committee with regards to the delivery of the Risk Management Strategy Implementation Plan. The Committee noted a delay in delivering some elements of the Implementation Plan, as a result of organisational restructuring, however noted that the appointment of a Head of Quality & Safety was a significant step forward for the organisation in ensuring that essential milestones were progressed. Advising the Board and citizens The Quality and Safety Committee reported to Board during 2011/12 via the presentation of a Chairs Report, presented at every meeting. In addition the Board considers matters relating to Quality and Safety as a key component of its overall agenda. Further work is required to enable the public and service users to understand the work taking place in relation to quality and safety improvement within the teaching Health Board. The involvement of stakeholders such as the Community Health Councils, the Powys Association of Voluntary Organisations and Powys Carers in the detailed work taking place is key to sharing with their constituent members the improvements being made. The development of a Board Communication and Engagement Framework will be key to making improvements in this area.

Forward Plan There is further work required to enhance governance and assurance within the organisation:-

Assurance Framework The tHB has acknowledged the need to develop and implement its Assurance Framework, aligned to its Annual Plan. The Assurance Framework will identify the Board’s principal risks in meeting its strategic objectives and map out both the key controls in place to manage those risks and also how sufficient assurance against those risks and controls will be gained. The Committee will need to ensure that its Work Programme 2012/13 is developed to ensure that


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the Board receives adequate assurance in respect of quality and safety associated objectives. Risk Management Whilst it is the Audit Committee that has a key role to play in providing the Board with assurance in respect of the effectiveness of the organisation’s system of good governance, risk management and internal control (both clinical and non-clinical) that supports the achievement of the organisation’s objectives, the Quality & Safety Committee will need to establish links with the Audit Committee to be assured that the organisation is managing quality and safety associated risk as effectively as non-clinical risk.

Conclusion

The Quality and Safety Committee’s Annual Report is intended to stand alone as necessary or to be read in conjunction with the teaching Health Boards overall Annual Report. There is some overlap between the two reports. This annual report is not aimed to be a long document, or an itemisation of all the actions taken and outcomes achieved during the year, but to summarise key achievements and challenges of the Quality and Safety Committee. In summary, the Quality and Safety Committee are of the view that the teaching Health Board can demonstrate significant areas of strength in relation to the safety of services and the quality of care provided. The safeguarding functions of the Health Board are of high quality supported by excellent partnership working and highly motivated and competent people, with good policies and systems also in place. The infection prevention and control work undertaken has also been highly effective in the reduction of the spread of infection. The work around improving the patient pathway has resulted in fewer patients than ever before being delayed in their transfer of care through the development of new and extended services. The work within the 1000 Lives Programme provides a platform for further development and is reducing avoidable harm to more patients every day. Gloria Jones Powell Chair, Quality and Safety Committee June 2012

FOR DISCUSSION

Standards for Health Services G&A Module 2011/12


Agenda Item 7.3

BOARD MEETING


STANDARDS FOR HEALTH SERVICES IN WALES 2011/12

GOVERNANCE & ACCOUNTABILITY MODULE

Report of

Director of Therapies & Health Sciences

Paper prepared by


Purpose of Paper

To provide the Board with the organisation’s completed Governance & Accountability Module of the Standards for Health Services in Wales for 2011/12.


The Board is asked to DISCUSS and NOTE the outcome of the Governance & Accountability Module of the Standards for Health Services in Wales for 2011/12.


This paper supports all of the Standards for Health Services in Wales.


The paper fully supports the Board’s Annual Plan 2012/13.


SHSW –Standards for Health Services in Wales HIW – Health Inspectorate Wales

FOR DISCUSSION



Agenda Item 7.3

STANDARDS FOR HEALTH SERVICES IN WALES 2011/12 GOVERNANCE & ACCOUNTABILITY MODULE

Introduction In April 2010, the Minister for Health & Social Services introduced the Doing Well, Doing Better: Standards for Health Services in Wales. The Healthcare Standards for Wales, published in 2005, were updated to ensure that they were fit for purpose to underpin the vision and values and the governance and accountability framework for the new NHS in Wales. The Standards provide the framework to enable organisations to look across the range of their services in an integrated way to ensure that all they are of the highest quality. The Standards set out the requirements of what is expected of all health care services in all settings and are at the centre of the drive for continuous improvement in the quality and experience of services that citizens of Wales are to expect. Organisations and services should use the standards to plan, design, develop and improve services across all health services and in all healthcare settings. Organisations and services should continue to self-assess against the standards at all levels and across all activities as a key source of assurance to enable them to determine what areas are doing well and those that may need to do better and, where necessary, prepare improvement plans to demonstrate progress in achieving the standards. Modular Self-Assessment Process For 2011/12, organisations were required to complete a Governance and Accountability module which would provide a framework for determining how well individual organisations are governed. Guidance issued by HIW outlined that completion of the module would allow the tHB to identify if it:-

was governing well; needed to strengthen its arrangements; and if it had noteworthy practice that it may wish to share.

Issued by HIW in February 2012, the Governance and Accountability module was framed around three key themes:-

Setting the direction Enabling delivery Delivering results, achieving excellence.

As outlined to the Board at its meeting in April 2012, the process undertaken to complete the module in a consistent way included the following steps:-

1. Module completed, including identification of evidence, by relevant officers of the tHB

2. Final document underwent a scrutiny process conducted by Chairs of Board Assurance Committees (Audit, Quality and Safety & Integrated Governance)

3. Document amended and completed in light of feedback received from the scrutiny panel and submitted to Internal Audit

4. Internal Audit Review of completed Module

FOR DISCUSSION



Agenda Item 7.3

5. Conclusion of Internal Audit Review informs the organisation’s Statement of Internal Control.

As a key element of its public assurance role, Healthcare Inspectorate Wales will validate the modular self-assessment and use the results of its overall programme of work carried out during the year to inform its assessment of how well the organisation is performing against the standards. Modular Self-Assessment Outcome Completion of the module concluded that the tHB had assessed its maturity as being at level 3 in each of the module themes – “we are developing plans and processes and can demonstrate progress with some of our key areas for improvement”. The completed self-assessment is attached at Annex A. In completing the self-assessment, a number of improvement actions were identified. It has previously been noted by the Board that the organisation’s Annual Plan 2012/13 will be the vehicle for delivering the organisation’s Standards for Health Services Improvement Plan, underpinned by individual locality and directorate improvement plans. Therefore, an exercise has been undertaken to ensure that the improvement actions identified in completing the self-assessment have been included within the Board’s Annual Plan 2012/13 as an objective. This information is attached at Annex B. Progress against delivery of these objectives will be reported in-line with the performance arrangements set in respect of the Annual Plan 2012/13. An audit of the Standards for Health Services, including the Governance & Accountability Module, was undertaken as part of the approved internal audit plan for 2011/12. This audit reviewed the tHB’s implementation of the Standards and completion of the self assessment (SA). In terms of the Governance and Accountability Module, Internal Audit reported that the tHB should:-

reflect on observations made by HIW in respect of the 2010/11 assessment to inform the process to be used for completion of the module in 2012/13;

secure Board engagement in driving outcome based improvement rather than using the self-assessment as an end-of year exercise; and

demonstrate how the outcome of the module and identified improvement actions are being used to impact on organisational performance/outcomes.

The Executive Lead for the Standards for Health Services (Director of Therapies and Health Sciences) will consider the recommendations made by Internal Audit as a robust process for completing the G&A Module on an annual basis is developed. It is acknowledged that it is necessary to ensure that there is full engagement with the Board in future years.

FOR DISCUSSION



Agenda Item 7.3

Conclusion The tHB has completed the Governance and Accountability Module of the Standards for Health Services in Wales for 2011/12 which has been subsequently reviewed by Internal Audit. The tHB will ensure delivery of the improvement actions identified through delivery of the Board’s Annual Plan 2012/13. Recommendation The Board is asked to DISCUSS and NOTE the outcome of the Governance & Accountability Module of the Standards for Health Services in Wales for 2011/12. Report prepared by: Presented By: Rani Mallison Amanda Smith Corporate Governance Manager Director of Therapies and Health Sciences Background Papers Doing Well, Doing Better, Standards for Health

Services in Wales (2010)

Financial Consequences No direct consequences

Other Resource Implications No direct resource consequences

APRIL 2012

DOING WELL, DOING BETTER: STANDARDS FOR HEALTH SERVICES IN WALES GOVERNANCE & ACCOUNTABILITY MODULE

THE SELF ASSESSMENT

Note: In establishing your level of agreement in relation to each of the statements made, you must be able to demonstrate through your supporting narrative not only what your organisation or business is doing, but how well it is working and the resulting impact on organisation performance. THEME 1 – SETTING THE DIRECTION Desired Outcomes: We place the people who use our services at the heart of our work We make sure our purpose is clear and know to develop and deliver our services to improve overall health and well being We are a value based organisation/business and carry out our work openly, honestly, ethically and with integrity We can demonstrate that:

Strongly disagree……………………………..strongly agree Slightly

Disagree Disagree Neither

agree nor disagree

Agree Strongly agree

Supporting Narrative

We make an effective contribution to the achievement of the strategic vision for health services in Wales

The Chief Executive and Executive Team have participated in the Team Wales, and Team NHS Wales events. The lead Executives meet monthly with their Health Board and Trust colleagues and have delivered specific projects

1



agree nor disagree

Agree Strongly agree Supporting Narrative

through this liaison for NHS Wales. The Chief Executive is the lead CEO for the Medicines Management National Programme other Executive Directors are involved in other national programme workstreams. The Board has established its Corporate Plan and Strategic Workforce & Financial Framework, both of which have been developed in-line with ‘Setting the Direction’ and the Welsh Assembly Government’s 5-year plan.

We have a clear purpose, vision and overall strategic direction that effectively aligns our local needs with the national strategy for health services in Wales

During 2011-12 the tHB revised its Service, Workforce and Financial Framework and published a New Directions, a public statement of its service intentions. The tHB has well established partnership arrangements, i.e. CYPP & LSB, and through these partnership strategies have been developed. Specifically the LSB was able to publish the One Powys Plan during the year, of which the tHB is an active participant. In approving all of these documents, the Board has

2



agree nor disagree


ensured that the strategic direction of the organisation is aligned to the national strategy for health services in Wales. At its meeting in April 2011, the Board approved its Corporate Plan which articulated the organisation’s ambitions and high-level strategic objectives. The Board routinely monitored performance against delivery of the Corporate Plan, via the Integrated Governance Committee.

Our citizens, staff and other stakeholders inform and influence our organisation/business’s purpose, strategic vision and direction

Patient experience of our services and systems of health and social care influence the strategic direction and the priority of certain aspects of work. An example of this is the Patient Story presented to the Board highlighting a year’s delay in the transfer of care of a gentleman. This story influenced the pace with which patient pathway redesign took place. Another example of engagement with the public is that, the tHB has

3



agree nor disagree


undertaken work with clients with HIV to understand the issues and work together to try to improve services. This process of engagement for improvement will be put forward for a Board presentation. The tHB has a well established Maternity Services Liaison Committee which has been cited by external reviewers as innovatible in approach as it is virtual in nature to aid involvement of mothers and meets face to face once per year. Significant public stakeholder events such as those held in support of New Directions, the engagement around South Powys and meetings in North West Powys linked to engagement on services in Hywel Dda have supported the direction of travel in partnership with the local community. Following the appointment of the tHB Chair, a number of meetings were held with partners and stakeholders to

4



agree nor disagree


discuss the strategic direction of the organisation. The Board has established its Stakeholder Reference Group, facilitating engagement with the tHB’s key stakeholders. The work of the Group provides significant input into the organisation’s strategic direction, and its role will be reviewed going forward to strengthen its impact. Moving forward, the tHB has prepared a structured approach to citizen engagement and communication that is comprehensive and consistent across the County through its Engagement Framework due for board approval in April, the development of a communications strategy, and investment in communications capacity. The Board has been developing, in partnership with PAVO, action plan to progress the recommendations in Bridging the Gap, working with the Third Sector, to build additional capacity

5



agree nor disagree


in caring for people with complex conditions and giving us the ability to systematically measure progress in implementing measures to evidence this development. The finalised action plan is due to be presented to the Board in June 2012. The tHB undertook a Staff Culture Survey which, although the response rate was poor, gave a useful perspective in relation to staff views. The Board continues to work in partnership with Powys County Council to deliver joint services, where possible.

We carry out our work instilled with a strong sense of values, supported by clear standards of ethical behaviour

The Board has adopted the NHS Citizen Centred principles and these are included within its Governance Framework, however the organisation has further work to do in developing and implementing codes of behaviour. Positively, the Board receives low levels of complaints, out-weighed by the number of compliments received, and

6



agree nor disagree


this reflects the strong sense of values that the organisation holds in relation to dignity & respect. Professionally qualified staff are expected to adhere to a code of ethical standards laid down by their respective professional bodies. Healthcare Inspectorate Wales recently undertook an external review at Brecon War Memorial Hospital which indicated that the tHB treats people with dignity and respect. The Board ensures that its internal audit plan factors in the need for review of aspects relating to dignity & respect and equality & diversity.

We promote equality and recognise diversity across all our services and activities

Efforts have continued during 2011/12 to raise awareness and to influence policy and decision makers to build in equality impact and diversity thinking and assessment into their processes. The duty in Wales to make a Strategic Equality Plan and Strategic Equality

7



agree nor disagree


objectives has undoubtedly driven this aspect of the work forward. The tHB has undertaken a significant programme of evidence collation and engagement as part of developing the Strategic Equalities Action Plan – which has been developed with input across the tHB and partners. The organisation has well established recruitment processes and HR policies which reflect a strong management of equality & diversity. However, the organisation has further work to do in embedding values of equality & diversity in service delivery and monitoring the impact on patients/users. Professionally qualified staff are expected to adhere to a code of ethical standards laid down by their respective professional bodies.

We apply and embed professional standards and equality requirements in a way

The tHB continues to ensure that all services are developed and delivered to embed professional standards, codes of

8



agree nor disagree


that meets the needs and expectations of patients, service users, citizens and other stakeholders

conduct, NICE guidance and best practice. The Strategic Equality Objectives, most notably the joint objective with the local authority around engagement and plans underway to form a strategic equality steering group will provide invaluable validation and scrutiny. Plans to embed equality thinking into the organisation include a “train the trainer” .initiative. All trainers delivering essential training to staff will design their course content to subtly include consideration of dignity, diversity and human rights. .The first of these “train the trainer” sessions took place in March 2012. The tHB has undertaken further work with clinical leaders regarding professional leadership and standards, particularly on wards and in the Midwifery Service. The tHB has exercised the disciplinary

9



agree nor disagree


process during the year to manage poor professional standards.

10

THEME 1 – SETTING THE DIRECTION Your Overall Assessment In relation to this particular theme, what is your overall assessment of where and how you:

1. Are governing well During 2011-12 the tHB prepared its Service, Workforce and Financial Framework and a supporting Capital plan - Strategic Outline Plan. The Board has also approved its Corporate Plan and a number of supporting documents. The tHB has well established partnership arrangements, i.e. CYPP & LSB, and through these partnership strategies have been developed. In approving all of these documents, the Board has ensured that the strategic direction of the organisation is aligned to the national strategy for health services in Wales. At its meeting in April 2011, the Board approved its Corporate Plan which articulated the organisation’s ambitions and high-level strategic objectives. The Board routinely monitored performance against delivery of the Corporate Plan, via the Integrated Governance Committee. Patient experience of the tHB’s services and systems of health and social care influence the strategic direction and the priority of certain aspects of work. The Board’s relationships with both the Community Health Council and the Voluntary/Third Sector have supported our overall strategic direction through the influence of our plans. The tHB continues to ensure that all services are developed and delivered to embed professional standards, codes of conduct, NICE guidance and best practice. 2. Need to strengthen your arrangements The tHB acknowledges that it has further work to do in fully implementing all of the actions identified within the Board’s key documents, i.e. Corporate Plan, Strategic Workforce & Financial Framework and Strategic Outline Programme. The tHB needs to develop a structured approach to citizen engagement and communication that is comprehensive and consistent across the County. The Board has further work to do in developing and implementing codes of behaviour and embedding values of equality & diversity in service delivery and monitoring the impact on patients/users.

3. Have noteworthy practice which you may wish to share The Board has well established relationships with its partners, particularly the local authority and this can be seen through the development of Integrated Care Pathways and Shared Services.

11

What maturity level have you demonstrated you have reached for this these overall: We are developing plans and processes and can demonstrate progress with some of our key areas for improvement. In relation to this particular theme, what are your priorities for improvement, what action are you going to take (and when) and how will you measure your success? Actions arising from this module will be included within the tHB’s Standards for Health Services Improvement Plan (Annual Plan) and so both documents should be read in unison. Particular actions arising from this theme are as follows:-

• Build capacity and capability within the organisation to ensure delivery of the Board’s Corporate Plan, Strategic Workforce and Financial Framework and Strategic Outline Programme.

• Development of a Communication & Engagement Strategy • Ensure principles of equality & diversity are embedded throughout all areas of the organisation

12

THEME 2 – ENABLING DELIVERY Desired Outcomes: We make sure that everyone involved in delivering health services understands each others contribution, and how together we can deliver a better service We work constructively in partnership with others to improve the quality and safety of services for our patients, services users and the wider community We foster innovation and make the best use of all the resources available to us, including our people, facilities and finances We can demonstrate that:



agree nor disagree



We have the: • Right people • With the right skills • Doing the right things • In the right place • And at the right time

to meet our responsibilities for the provision of safe, high quality care

Although there is a good base upon which the tHB can work, there is a significant forward Workforce Plan to implement to fully manage the changes in service provision ahead. Following changes in leadership and management structures it has become evident that these structures have significantly impacted positively on the delivery of safe, high quality services for patients. An example of this is the focus away from separate commissioner and

13



agree nor disagree


provider units of the tHB into a more integrated approach based on localities. The locality structures enable a single team to focus on the health needs of the entire population in their area. This includes the broad spectrum of primary care, through community and community hospital care to district general hospital care. In relation to specific services, we can be confident that staffing levels are sufficient to meet the needs of the population, particularly in areas where staffing levels are underpinned by a robust staffing methodology (such as Birth rate Plus in midwifery). There are times when recruitment into certain services can be challenging (some of the therapy groups for example) but flexibility of approach is used to ensure patients receive the high quality services through alternative staffing models. There are some challenges regarding

14



agree nor disagree


capacity and capability of middle managers and this has been a focus for development through the introduction of the management seminars, and through development programmes with NLIAH for example. The tHB is gaining greater clarity on how the workforce will need to be developed to deliver the organisation’s strategy.

The different services and parts of our organisations/business work well together, and everyone understands who does what and why

There is a good level of clarity at the Executive and Senior manager level of the organisation, and within direct clinical services this clarity is also good. There is a strong ethos of team meetings at the senior level and Executive and Locality general managers meet as one team ensuring the link between strategic planning and the operational delivery is strong. This is further strengthened by the development of monthly performance management meetings between the Executive team and the Locality Senior Team. This arrangement has supported

15



agree nor disagree


effective communication and problem solving and has strengthened the focus on the key deliverable objectives of the organisation. Significant work has taken place following restructuring, which has delivered positive results. One example of this is the Quality & Safety Unit which was established through the integration of a number of smaller functions. The Unit has a cohesive and clear structure, supported by a who’s who guide in roles and responsibilities.

We properly safeguard all those who work in or access our health services (including those who may accompany patients or services users), paying particular attention to the needs of children and vulnerable adults

There are robust mechanisms in place for the protection of Children, and increasingly effective mechanisms in place for the protection of adults. The organisation has a well established Child Protection Forum and is part of the Powys LSCB (Local Safeguarding Childrens Board). The tHB also leads in some of the areas of development through the sub-groups of the LSCB. The tHB also has in place strong mechanisms for the management of

16



agree nor disagree


LAC and COLA Children. The tHB also has in place an Adult Protection Forum which has been developing and implementing work plans and the recommendations from national inspectoral reports (such as that produced by HIW). Adult protection generally across the UK has not been as well developed as Child protection; however steps have been taken to ensure that adult protection mechanisms can be adopted where applicable from Child protection and the Head of Safeguarding now covers both child and adult protection. In relation to the prevention agenda, the tHB are key stakeholders in the Children and Young peoples Partnership, the focus being on improving the welfare of all children and particularly those who are vulnerable. There has been a significant emphasis on ensuring objectives and business plans are clear and the evaluation of progress is monitored and reported

17



agree nor disagree


through to the Board.

We have the right facilities (equipment and environment) to enable us to consistently deliver safe, high quality services across all the communities we serve

Whilst the level of facilities we have are generally good, there are some areas in particular that are challenging to the new models of health and social care, and plans are both in place and developing further to address these issues. For example, the Integrated Health and Social Care Facility at Builth Wells. This model is the preferred model for rolling out into other parts of Powys as the changing service delivery models are implemented. In relation to the standard of cleanliness and the facilities/equipment available, the implementation of the credits for cleaning system has been helpful in monitoring the standards of cleanliness at ward and department level. Equipment levels and standards are generally high. The tHB has demonstrated has made improvements in respect of the management of Medical Devices,

18



agree nor disagree


supported by a positive Internal Audit Report.

We support the development and delivery of high quality, safe and accessible services through strong, effective financial planning and management

Powys tHB’s financial strategy is clear. Improving the health of the population and reducing health inequalities; providing good quality care within Powys efficiently and effectively; and accessing good quality care outside of Powys only when appropriate. The organisation’s ambition is also clear – to be a highly performing, efficient and effective organisation living within it its means. The financial strategy builds upon the progress made over the past two year in that it’s focus continues to be on:- • Pathway Development and

Management to reduce volume to both English and Welsh providers (system change)

• A programme of repatriation to bring services back in Powys and into Wales (supplier change)

• Maximising operational efficiency of

19



agree nor disagree


preferred providers including Our own local services Primary Care provided services

incl. GMS and prescribed drugs Challenging the price charged by

English and Welsh providers. Developing an efficient platform

of back office functions with NHS Wales and with Powys County Council.

An example of effective financial management shows that we have been able to bring services into the Powys geographical boundary that were previously only accessible to patients through travelling beyond our borders. This improvement has been achieved at reduced cost. A further example of financial management has been our leading performance on influencing GP prescribing behaviour to become the organisation with lowest cost per 1000 PU in Wales.

20



agree nor disagree


We have demonstrated that we have contained costs to 2010/11 levels within an environment of zero percent uplift inflation and growth. We have also demonstrated consistency between our planned and actual performance in that our year end position was broadly in line with our stated aim at the commencement of the year.

Our workforce at all levels in the organisation/business are equipped with the information they need to help them carry out their work effectively, and this information is shared appropriately and securely held

The recent Corporate Health Standard assessment concluded that communications in the organisation were good with some exemplar examples. The staff intranet is a rich resource of information, including policies, news and useful links. This is reinforced by monthly staff briefings, targeted e-mailings etc. The Board acknowledges that there is further work to do in improving access to healthcare records, the management of records and accessing information across multi-agencies. The tHB has commissioned the support

21



agree nor disagree


of an external consultant, supported by NWIS, to undertake a focussed review to aid the implementation of improvements.

We are an innovative organisation/business that takes proper account of the risks (both opportunities and threats) to the achievement of our aims and objectives

Significant work has been undertaken to improve the level of consideration of risk within the organisation relating to our activities. The Board’s Risk Management Strategy outlines the strategic direction for assessing and accepting, transferring or mitigating risk associated with priority activities. This covers the whole spectrum of risk including the strategic planning, Financial, clinical and operational aspects of risk. The Strategy is supported by a recently approved Risk Management Policy which addresses issues of risk appetite. The Corporate risk register holds approx 20 of the highest organisational risks and this has recently been presented to Board. Further updates are expected 6 monthly and Executive Directors will be reviewing those risks in

22



agree nor disagree


between Board consideration. In relation to innovation, the rural nature of the organisation and the significant number of partnerships in care means that innovative solutions to care service provision have had to be found. The development of new roles such as care Transfer Co-ordinators has linked for example Powys services and DGH services for the benefit of patients and for organisational relationships.

We have strong, effective relationships with our workforce, partners, citizens and other stakeholders

The Board has established its Stakeholder Reference Group, facilitating engagement with the tHB’s key stakeholders. The work of the Group will provide significant input into the organisation’s strategic direction. The tHB has recently published an engagement document, New Directions – the purpose of the document is to set out the tHB’s commitment to positive change for the residents of Powys, and also to enable a dialogue on those plans which will inform the tHB’s annual

23



agree nor disagree


service planning process. Moving forward, The tHB needs to develop a structured approach to citizen engagement and communication that is comprehensive and consistent across the County. The Board has established an effective working relationship with the Third Sector. This includes executive involvement with Voluntary Sector Liaison Group with a focus on strengthening this relationship further through the Compact and its associated Codes of Practice with Third Sector. A revised Compact is currently in draft form awaiting wider consultation. The Board has established its Partnership Forum which is the formal partnership mechanism where the Health Board’s Managers and Trade Unions work together to improve health services for the citizens of Powys. It is the forum where key stakeholders will engage with each other to inform

24



agree nor disagree


thinking around national and local priorities on health issues.

Decisions taken throughout our organisation are made by those best placed to do so, are well informed, timely and are effectively communicated

The Board has developed and agreed its Scheme of Delegation ensuring that all Executive Directors have appropriate decision making authority. The Board has established its committee structure and whilst some committees are ‘assurance committees’ there are some with decision making authority, particularly sub-Committees. The Executive Team holds monthly formal meetings where all operational/strategic decision making takes place. It is the responsibility of all Directors to ensure that decisions made are communicated back to respective teams and this is achieved effectively via locality/service team meetings. Decisions of the Board and Executive Team are also communicated throughout the organisation via ‘Key brief’ and the intranet where appropriate.

25



agree nor disagree


It is acknowledged that there is further work to be undertaken in respect of developing a Directorate specific Scheme of Delegation, underpinning the Board’s Scheme of Delegation, in-line with the requirement outlined in the organisation’s Standing Orders. The tHB acknowledges that development of a Communication Strategy will support improvements in this area.

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THEME 2 – ENABLING DELIVERY: Your overall assessment In relation to this particular theme, what is your overall assessment of where and how you:

1. Are governing well Following changes in leadership and management structures it has become evident that these structures have significantly impacted positively on the delivery of safe, high quality services for patients. The locality structures enable a single team to focus on the health needs of the entire population in their area. This includes the broad spectrum of primary care, through community and community hospital care to district general hospital care. In relation to specific services, we can be confident that staffing levels are sufficient to meet the needs of the population, particularly in areas where staffing levels are underpinned by a robust staffing methodology (such as Birth rate Plus in midwifery). Currently there is a good level of clarity at the Executive and Senior manager level of the organisation, and within direct clinical services this clarity is also good. There is a strong ethos of team meetings at the senior level and Executive and Locality general managers meet as one team ensuring the link between strategic planning and the operational delivery is strong. This is further strengthened by the development of monthly performance management meetings between the Executive team and the Locality Senior Team. This arrangement has supported effective communication and problem solving and has strengthened the focus on the key deliverable objectives of the organisation. There are robust mechanisms in place for the protection of Children, and increasingly effective mechanisms in place for the protection of adults. A new Risk Management Strategy has recently been adopted by the Board and outlines the strategic direction for assessing and accepting, transferring or mitigating risk associated with priority activities. This covers the whole spectrum of risk including the strategic planning, Financial, clinical and operational aspects of risk. The Board has developed and agreed its Scheme of Delegation ensuring that all Executive Directors have appropriate decision making authority. The Board has established its committee structure and whilst some committees are ‘assurance committees’ there are some with decision making authority, particularly sub-Committees. The Board has established its Partnership Forum which is the formal partnership mechanism where the Health Board’s Managers and Trade Unions work together to improve health services for the citizens of Powys. It is the forum where key stakeholders will engage with each other to inform thinking around national and local priorities on health issues.

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2. Need to strengthen your arrangements

In terms of Workforce, there is a significant forward Workforce Plan to implement to fully manage the changes in service provision ahead. There are some challenges regarding capacity and capability of middle managers and this has been a focus for development through the introduction of the management seminars, and through development programmes with NLIAH for example. The Board has also made a commitment to ensure improvements in the area delivery of staff annual appraisals. The tHB has to move forward with implementing its Strategic Outline Programme and Capital Programme to support the development of facilities within Powys. The Board acknowledges that there is further work to do in improving access to healthcare records, the management of records and accessing information across multi-agencies. The tHB needs to develop a structured approach to citizen engagement and communication that is comprehensive and consistent across the County. The tHB acknowledges that development of a Communication Strategy will support improvements within service delivery.

3. Have noteworthy practice you may wish to share The focus on the development of sustainable leadership and management teams based locally has developed the platform for a clinically-led primary and community focused organisation. GP/Nurse/Therapist leadership has led to measurable improvements.

What maturity level have you demonstrated you have reached for this theme overall: We are developing plans and processes and can demonstrate progress with some of our key areas for improvement. In relation to this particular theme, what are your priorities for improvement, what action are you going to take (and when) and how will you measure your success? Actions arising from this module will be included within the tHB’s Standards for Health Services Improvement Plan (Annual Plan) and so both documents should be read in unison. Particular actions arising from this theme are as follows:-

Further refinement and delivery of the organisation’s workforce plan Build capacity & capability within the organisation Provide support and resource into improvement of the organisation’s estates, facilities and environments of care, in-line with

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the organisation’s Strategic Outline Programme Development of a Communication & Engagement Strategy Improvement of the organisation’s information governance arrangements, including access to information Implement the organisation’s Risk Management Strategy

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THEME 3 – DELIVERING RESULTS, ACHIEVING EXCELLENCE Desired outcomes: We provide high quality and accessible health services in a manner that ensures equity of access and minimises waste, harm and variation We build on our strengths and take early, decisive action to improve services where we need to We learn from our own and others experience to continuously improve the provision of health services We contribute to the overall improvement of health services in Wales by sharing our learning with others We can demonstrate that:



agree nor disagree



We have a clear understanding of how well we are performing overall, what services are doing well, and what services need improving (including those services that are carried out by others on our behalf) We respond quickly and effectively to address areas of concern, including those relating to individuals’ performance

The Board regularly receives an Integrated Performance report which provides a holistic view of performance. This report highlights those services that are performing well and those services where performance needs to improve. The Report also identifies actions in place to improve those areas of performance where required. The Executive Team holds monthly performance meetings with Locality General Managers/Service Managers to

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discuss all performance related issues, including staff performance. The Board has significant work to do in improving the performance management of staff, ensuring all staff receive an annual performance review.

We operate in accordance with all legal and other requirements placed on us

The Board has developed and agreed its Scheme of Delegation ensuring that all Executive Directors have delegated authority and responsibility for ensuring that all requirements placed upon the tHB are delivered. The Board has established its committee structure and all Committees play a role in providing the Board with assurance that the organisation is compliant with all requirements. Moving forward, the Board will agree its Assurance Framework which will determine all legal and other requirements placed upon the tHB and outline the sources of assurance available to the Board in satisfying itself that all are delivered.

We know what our citizens and others (including our workforce) think of us, and this influences

There is some documented evidence of the citizen perspective of the organisation that has been collated

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what we do and how we do it through some local planning and engagement process, but this is not systematic, or systematically recorded and collated across all engagement functions in the tHB. Significant public stakeholder events such as that held with the South Powys community (5 events) has supported the direction of travel in partnership with the local community. Our relationships with both the Community Health Council and the Voluntary/Third Sector have supported our overall strategic direction through the influence of our plans. The Board has established its Stakeholder Reference Group, facilitating engagement with the tHB’s key stakeholders. The work of the Group will provide significant input into the organisation’s strategic direction. The tHB has structured engagement processes in place for staff including a Partnership Forum, electronic based communication such as Ask the Chief Executive and further work is required on an internal communications strategy,

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to systematically gain record and act on the views of staff.

We measure our performance against “best practice” and other standards set for the services we provide and we use the results to drive improvement in the provision of high quality, safe and accessible services

Performance is generally measured against (AQF) targets set by WAG. We recognise the need to be ambitious and to set high expectations for ourselves and our population. Further work is required to enable a clearer view of those organisations in the upper centile of key performance areas and to plan and implement improvements.

We learn from our own and others experiences, and in turn share our learning with others

There is further work to do in relation to learning. Whilst learning takes place regarding complaints etc in the areas in which the incident or complaint has taken place, a highly effective system for organisational learning is not yet in place. The Risk Management Strategy has however identified that commitment of the Board to investing in organisational learning and the development of robust systems and processes for learning. This work has already started to take place for example in relation to national patient safety Agency reports. NPSA reports are generated where a series or serious incidents from across the country

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results in a learning opportunity for other organisations. There is now a robust process for NPSA alerts in place in the organisation. Furthermore the ‘Signals’ learning system (external) is also to be implemented using the same system developed as NPSA. Management seminars have been developed to ensure that learning among and between middle and senior managers takes place. The programme has been in place for approx 1 year. The tHB has recently developed a Quality Improvement Faculty to support learning amongst clinicians and primary care within Powys. The Faculty is yet to be fully embedded throughout the organisation. Powys tHB continues to actively contribute to the All-Wales 1000 Lives Plus programme, participating in ten workstreams and the workstream leads report to the Clinical Effectiveness Committee, a sub-committee of the Quality and Safety Committee. This reporting mechanism, in addition to use of the Faculty Wiki, enables the spread of learning across the organisation.

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The Board held its Annual Research and Innovation Conference. Poster exhibitions included information about Falls Prevention, Neuro Rehab, Pulmonary Rehab Programme, Orthopaedic Assessment Service, and Repatriation of Podiatric Surgery Service. The presentations included a number of projects that have been short-listed for the NHS Wales Awards, including smoking cessation and the implementation of the early warning system (NEWS). The conference aims to spread learning across health and social care while encouraging more staff to participate in formal research.

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THEME 3 – DELIVERING RESULTS, ACHIEVING EXCELLENCE: Your overall assessment In relation to this particular theme, what is your overall assessment of where and how you:

1. Are governing well The Board regularly receives an Integrated Performance report which provides a holistic view of performance. This report highlights those services that are performing well and those services where performance needs to improve. The Report also identifies actions in place to improve those areas of performance where required. The Board has developed and agreed its Scheme of Delegation ensuring that all Executive Directors have delegated authority and responsibility for ensuring that all requirements placed upon the tHB are delivered. The Board has established its committee structure and all Committees play a role in providing the Board with assurance that the organisation is compliant with all requirements. Our relationships with both the Community Health Council and the Voluntary/Third Sector have supported our overall strategic direction through the influence of our plans. The Board has established its Stakeholder Reference Group, facilitating engagement with the tHB’s key stakeholders. The work of the Group will provide significant input into the organisation’s strategic direction. The tHB has structured engagement processes in place for staff including a Partnership Forum, electronic based communication such as Ask the Chief Executive and further work is required on an internal communications strategy, to systematically gain record and act on the views of staff. 2. Need to strengthen your arrangements The Board has significant work to do in improving the performance management of staff, ensuring all staff receive an annual performance review. The Board will need to develop agree its Assurance Framework which will determine all legal and other requirements placed upon the tHB and outline the sources of assurance available to the Board in satisfying itself that all are delivered. There is further work to do in relation to learning. Whilst learning takes place regarding complaints etc in the areas in which the incident or complaint has taken place, a highly effective system for organisational learning is not yet in place.

What maturity level have you demonstrated you have reached for this them overall: We are developing plans and processes and can demonstrate progress with some of our key areas for improvement.

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In relation to this particular theme, what are your priorities for improvement, what action are you going to take (and when) and how will you measure your success? Actions arising from this module will be included within the tHB’s Standards for Health Services Improvement Plan (Annual Plan)and so both documents should be read in unison. Particular actions arising from this theme are as follows:-

Embed performance management throughout the organisation’s teams Development of a Board Assurance Framework Development of a Communication & Engagement Strategy Improve processes for learning and sharing best practice.

ANNEX B

GOVERNANCE AND ACCOUNTABILITY MODULE 2011/12 IMPROVEMENT ACTIONS

IMPROVEMENT ACTION ANNUAL PLAN 2012/13

AIM OBJECTIVE

Development of a Communication & Engagement Strategy

Ensure active two-way communication with key stakeholders with an interest in Powys tHB Services

Systematic, open, honest and active engagement with Powys residents in service planning and decision making

Implement Annual Action Plan from Communication and Engagement Frameworks, including consultation on delivery plans associated with Together for Health

Ensure principles of Equality & Diversity are embedded throughout all areas of the organisation

Create an organisational culture in which it treats all its service users, staff and partners with dignity and respect at all times

Development of Equality, Diversity and Human Rights action plan to be finalised and implemented

Build capacity and capability within the organisation

Ensuring that the tHB has the capacity and capability to delivery its vision and objectives

• Development of an integrated organisational development strategy to ensure that the organisation’s and structures, systems and processes are fit for purpose to include: • Completion of implementation of

organisational change programme (structures)

• Development/alignment of corporate governance framework

• Identification of capacity and capability of key individuals and assessment of the implications for development strategy

Further refinement and delivery of the organisation’s Workforce Plan

Improve capacity and capability of the organisation and its partners to undertake integrated workforce planning to ensure that the right staff deliver the right care at the right place and time

Development of corporate integrated workforce plan to support service strategy

Improvement of the organisation’s estates, facilities and environments of care, in-line with the Organisation’s Strategic Outline Programme

Improve strategic risk management and compliance with key legislation

Prepare and implement an estates strategy aligned to service requirements, compliance and sustainability

Improvement of the organisation’s Information Governance Arrangements, including access to Information


Develop and implement Information Governance Strategy

Implement the organisation’s Risk Management Strategy


Complete the implementation of the Risk Management Strategy

Embed performance management throughout the organisation’s teams

Ensure the organisation has developed effective integrated information management and ICT systems to support service planning, commissioning and performance management processes

Review arrangements for information management and performance and implement a robust performance management framework

Development of a Board Assurance Framework


Complete the implementation of the Risk Management Strategy

Improve processes for learning and sharing best practice

Improve citizen experience of care through listening and learning

Develop and promote a culture of continuous quality improvement

Develop and implement an annual plan for Improving Patient Experience with local implementation and publish an annual report

Implement action plan to ensure Standards for Health Services are embedded across all services