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Welsh Ambulance Services NHS Trust

Working Together For Success:Annual Delivery Plan 2013-2014

Contents PageIntroduction and Context 2

What are the challenges facing the NHS at a National level 3What are the challenges facing the Welsh Ambulance Service? 4Working Together for Success 2 Years on... 6What do we need to concentrate on in 2013/2014? 11What will our service deliver next year? 12

Our Integrated Business Planning Approach 16 Developing of Integrated Business Planning 16Unscheduled Care: Key Objectives 2012-2013 20Planned Patient Services: Key Objectives 2012-2013 21

Working Together For Success in 2013-2014 22Our Development Objectives for 2012-2013:

1. Improving Clinical Quality and Safety 22 2. Improving Access and Resilience 263. Improving Outcomes and Experience of Care 294. Helping Our Staff to Excel 335. Delivering Value for Money 36

What Further Support is Required to Deliver These Objectives

Service Support Plans 39Supportive Strategies 40

Our Financial Framework for 2013-2014 42The Financial Assumptions for 2013-2014 42

How We Will Monitor ProgressOngoing Risk Management and Assurance 45Monitoring Schedule 46

APPENDICES 47

ForwardDear All

This is now our third Annual Delivery Plan and I am pleased to say a great deal of progress has been made towards delivering the aims we set out in Working Together for Success. I am confident that we are well on the way “to move from being perceived as simply a transport service toa provider of high-quality health care and scheduled transport services’” and want to thank all the staff within the organisation and our health service partners for their commitment and hard work this past year. We have much to celebrate:

We have implemented Phase 1 Clinical Response Model; designed to ensure that the optimum response is dispatched in a timely manner according to need.

We have also finished the first phase of our organisational redesign journey with new teams and leadership roles established and effective relationships being developed

We are responding better to increasing demand than we have ever done before; Answering 40,000 additional calls already this year and attending 5000 additional red incidents within the 8minute performance standard.

We have developed a clinical strategy to further embed clinical leadership, quality and safety in all elements of the service we provide.

There is no doubt that we have faced substantial challenges this year and we do not expect 2013-2014 to be without similar service pressures. We must take further action to ensure that all patients receive the optimum care in the fastest possible time. We will need to manage our increasing demand for emergency services with a reducing amount of resources and, despite the difficult financial constraints experienced across the Health service, we are still committed to transforming our services for the benefit of our staff and patients. We feel that in order to meet the demands we face, we have to continue to work in an integrated way across all departments and operational staff and show renewed focus in the way we go about improving and delivering a high quality service for our patients.

With this in mind we have set the objectives and delivery plan for the organisation this year in a different way. The Trust Board have developed five core priorities for the coming year:

1. Improving Clinical Quality and Safety 2. Improving Access and Resilience3. Improving Outcomes and Experience of Care 4. Helping Our Staff to Excel 5. Delivering Value for Money

We then worked with teams of service leads across directorates, support services and service delivery areas to develop the local actions required, in order to achieve substantial and sustainable improvements in these areas, whilst continuing with the journey set out in Working Together for Success. In order to improve our service during 2013-2014 we will be taking a number of actions to reduce our health associated infections, reduce conveyance to hospital Emergency Department, improve experience of care and clinical pathways, support our staff development through regular team meetings and 1:1 with their managers and finally make sure that every pound the organisation receives is used effectively to ensure the greatest benefit for staff and patients.

We are going to have a busy year, but if we continue to work in teams across the organisation and maintain our progress against these focused delivery plans, I believe we will be in a strong position to achieve and embed clinical excellence for all of our patients. Kind Regards

Elwyn Price-Morris

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Contents PageIntroduction and Context 2

What are the challenges facing the NHS at a National level 3What are the challenges facing the Welsh Ambulance Service? 4Working Together for Success 2 Years on... 6What do we need to concentrate on in 2013/2014? 11What will our service deliver next year? 12

Our Integrated Business Planning Approach 16 Developing of Integrated Business Planning 16Unscheduled Care: Key Objectives 2012-2013 20Planned Patient Services: Key Objectives 2012-2013 21

Working Together For Success in 2013-2014 22Our Development Objectives for 2012-2013:

1. Improving Clinical Quality and Safety 22 2. Improving Access and Resilience 263. Improving Outcomes and Experience of Care 294. Helping Our Staff to Excel 335. Delivering Value for Money 36

What Further Support is Required to Deliver These Objectives

Service Support Plans 39Supportive Strategies 40

Our Financial Framework for 2013-2014 42The Financial Assumptions for 2013-2014 42

How We Will Monitor ProgressOngoing Risk Management and Assurance 45Monitoring Schedule 46

APPENDICES 47

Chief Executive Officer

Introduction and Context2

We published our five-year framework, ‘Working Together for Success’ in December 2010 where we set out a clear goal for the Welsh Ambulance Services Trust in stating that:‘We wish to move from being perceived as simply a transport service toa provider of high-quality health care and scheduled transport services’

To support us in achieving this, each year we develop an Annual Delivery Plan which sets out our priorities for the forthcoming financial year, which moves us closer to where we want to be as an organisation and improves the quality of care we provide in Wales. The Annual Delivery Plan plays a vital role in supporting us to implement the aims we set out in ‘Working Together for Success’ as it provides our staff with a clear sense of priority and action. This allows us to focus on the areas of our work that will make a real difference, and deliver real improvement to the people of Wales.

We published our first Annual Delivery Plan in 2011/2012. This Plan therefore represents the third year of our journey towards our goal. The three Strategic Aims we established at that point remain unchanged:

Strategic Aim 1

To achieve all of the national quality standards of excellence and clinical requirements

Strategic Aim 2

To provide the right service with the right care, in the right place, at the right time with the right skills

Strategic Aim 3

To provide high quality planned patient care services which are highly valued by users

Our strategic aims are being used to drive the improvements across the two main services we provide:

Unscheduled Care: Where we want to... Ensure calls to our services are answered promptly; Safely and effectively assess patient’s clinical and non clinical needs; Quickly provide patients with, or direct them to the right service; Respond quickly to patients with immediately life-threatening conditions; Provide advice, guidance and support regarding healthcare to patients over the phone and via

the internet; Provide more services for patients in their homes or at scene and support them to live

independently in their communities; Develop evidence-based clinical pathways of care in partnership with LHBs;

Planned Patient Care Service: Where we want to... Provide easy to access and easy to use transport booking for both patients and our healthcare

partners; Provide all eligible patients with transport which meets their need and ensure they are picked up

and dropped off at the right time for their appointment; Provide patients who are not eligible for our service with advice and support to access alternative

transport which meet their need; and Ensure all of our patients have a comfortable journey and a positive experience.

Stop patients being transported to or attending an A&E department unnecessarily; Improve the clinical outcomes for patients and their experience when using our services; and Improve the safety of our services.

What are the challenges facing the NHS in Wales?Wales as a Nation: Aiming High

The vision for the health service in Wales is a very compelling one:

‘healthcare that is best suited to Wales but comparable with the best anywhere’ (Bevan Commission, 2010)

The Welsh Government sets out a blueprint for the future in 2011 in ‘Together for Health: A Five Year Vision for the NHS in Wales’. The key challenges and priorities set out are very clear:

i. Improving health as well as responding to sickness: improving the health of the population and changing the culture of a nation

ii. One system for health: to allow health and social care to follow citizens needsiii. Hospitals for the 21st century as part of a well designed, fully integrated network of care :

where hospitals are seen as part of a wide range of services and not the first place that patients need to go.

iv. Aiming at excellence everywhere: reducing harm, waste and variation in everything we do to achieve the best levels of care and patient outcomes possible.

v. Absolute transparency on performance: an open and honest conversation with the public about the quality of the service we provide.

vi. A new partnership with the public: a shared responsibility between the NHS and citizen for improving health and managing sickness.

vii. Making every penny count: ensuring every Welsh pound is spent effectively.

What are the challenges ?

In order to achieve the Welsh Government vision there are a significant number of challenges to overcome. We set these out in our Annual Delivery Plan for 2012/2013, and they remain the key challenges for the coming year, as:

Health Better for Everyone: significant improvements are required in improving the health of the population. This includes giving children a good start in life, reducing the inequality of health of the most and least deprived; reducing the levels of obesity, smoking, alcohol consumption and drug abuse, and increasing people’s quality of life.

Better Access to Services and Patient Experience: further improvements need to be made to improve people’s access to services within primary, community and secondary care settings. A wider range of services which are designed around need, will improve the quality of care and reduce the pressure on secondary care services. The provision of health services, both advice and treatment, on-line and over the telephone will need to be fully exploited if we are to meet the public’s expectations in a modern 24 hours a day, 7 days a week world.

Improving Service Quality, Patient Safety, Outcome and Experience: continued improvement needs to be made in developing and delivering systems which provide care that is evidence based and compares well with the best available. This will significantly improve the safety and outcome for patients, guarantee them the required levels of dignity and respect and make their experience of the service a good one.

Greater Transparency: we will need to provide the public with a greater range of user-friendly information about our services, and how good they are.

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The Health Burden is Growing: the ageing population, high levels of unhealthy living, and the increasing rate and prevalence of chronic conditions in Wales will test the NHS like never before. This will require a concerted effort from all organisations at every point of the system; public health and information, prevention and intervention.

Funding is Limited: the financial outlook for Wales is perhaps the most challenging ever. This will require services to be designed and delivered in a different way, centred around patients and with quality at their heart.

Service Changes within Wales: The need for change is clear as the current system does not achieve the levels of patient safety, experience or outcome that are comparable with the best. The coming years are likely to see a significant change in how services are provided, where they are provided from, and what type of staff provide them.

One system for Wales: the reformed health system in Wales will need to fully integrate to ensure that people are able to access and use services seamlessly. A significant emphasis will also be placed on the NHS to work well with other public services and the voluntary sector to ensure that scarce resources are used as efficiently and effectively as possible.

What priority challenges facing Welsh Ambulance Services Trust: where we will focus our efforts?

Given the national challenges faced by the Welsh Health Service, it is to be expected that the Welsh Ambulance Services Trust, also face a number of significant challenges during 2013/2014, with the most significant set out below. However, these challenges provide the basis for us to think and act differently in finding solutions which provide continuously improving levels of care in a sustainable way.

i. Improving the quality, safety, experience and outcomes of our service: we are committed to improving the services we deliver and this will be our greatest area of focus. The biggest challenge is to achieve this improvement in an accelerated way to allow us to better deal with the increasing need from the public.

ii. Managing the increasing demand for emergency service assistance with a reducing amount of resources: patient needs for our 999 services are increasing at approximately 3 – 4% per year. However, our resources are reducing on an annual basis in real term. We will therefore need to improve the quality of everything we do to reduce and eradicate waste and ensure that we get the service and the outcomes of that service right first time.

iii. Transforming the services we provide to better meet need: providing our services in a different way will clearly test our ambition, skills and resolve. We will need to work closer with the people who use our services and our staff who deliver them to better understand what could be done better at a local level.

iv. Communicating with the public about using the ambulance service in a more informed way: the ambulance service of the future will not need to send ambulances to every call as there will be a range of other services to support people remaining safely within the community. The cultural and behavioural change required from the population of Wales is very significant. This is an area of work that will take a number of years to come to fruition.

v. Supporting delivery of the Local Health Board service improvements: the implications of the service improvements across Wales are wide-ranging and will provide the Trust with a

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very real challenge in terms of effective engagement in the design of new services, their implementation and continued management.

vi. Financial position: the resources available to the Trust in 2013/2014 are extremely constrained. We are not alone in this with the rest of the UK public sector in a similar position. We will therefore need to be very disciplined in addressing issues identified as priorities and be decisive in taking the required actions to achieve the high levels of quality we aspire to within the resources available to us

vii. Developing a clinical culture and supportive environment: we will need to build on the strong foundations we have established over the past two years to cultivate a strong clinical culture and corresponding behaviours within the Trust. We will need to focus on developing a culture which supports effective and professional services and takes every opportunity to learn and improve from everything we do; whether that went as planned or otherwise. This will enable our staff to work within a trusted environment which supports their professional and personal development.

viii. Supporting our clinicians in improving their clinical skills: the provision of ongoing professional development and training is a key enabler in achieving the quality of service and outcomes we desire. The identification of sufficient resources to provide the level of skill acquisition will be extremely challenging given the difficult financial position as will the ability to deliver the necessary education and training without compromising frontline services.

ix. Accessing capital monies to improve our fleet and buildings and Information Communication and Technology: the improvement of our fleet and estates are critical at an immediate, medium and long-term level. However, there is a significant capital funding gap forecast for the next five years. If solutions are not found, the level and pace of service transformation may be reduced and this will impact upon the quality of the service.

x. The continued introduction of the National Ambulance Performance Standards: good progress has been made to date but the next phase of implementation represents a significant challenge for the Trust.

Working Together for Success 2 Years On:The process for delivering our strategic aims

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In order to deliver the vision and goals set out within Working Together for Success we established two main programmes of work in 2011/2012:

Programme 1: Unscheduled CareProgramme 2: Planned Patient Care

The past year has seen a number of improvements made within the healthcare system which has significantly improved the quality of care, safety, experience and outcomes for patients. These include:

i. One system for Wales: Service design The healthcare system in Wales continues to mature since the reforms in 2009. There is evidence of improved partnership between organisation (health, local authority, third sector and emergency services) in addressing the key challenges and providing solutions which are citizen led. The Local Health Boards are also far clearer with regard to the future shape of a number of key services and this will help strengthen partnership working as all organisations work to achieve a range of new and improved services across Wales.

ii. Delivering care in the community setting There is an aim for fewer patients to be admitted to hospital through a reduction in emergency admissions in a number of areas:

16.5% less patients with chronic obstructive pulmonary disorder (COPD) were admitted in 2011/2012 compared with 2010/2011;

14.6% less patients with diabetes were admitted in 2011/2012 when compared with 2010/2011.

There is also an aspiration to reduce the number of patients who are re-admitted to hospital in an emergency .A reduction in the number of with emergency readmissions to hospital in a number of areas:

24.6% less patients with chronic obstructive pulmonary disorder (COPD) were admitted in 2011/2012 compared with 2010/2011

29.6% less patients with diabetes were readmitted as an emergency in 2011/2012 when compared with 2010/2011.

iii. Access to services It is important to ensure more patients have access to dedicated services such as:

Patients suffering a stroke have fast access to thrombolysis service 24 hours a day, seven days a week

Patients should also receive quicker access to emergency services, key to this will be: 65% of Ambulance response times to Category A immediately life-threatening calls

should be within 8minutes or less where possibleiv. Improving the sustainability of services The sustained improvement to the quality of services being delivered has enabled a significant improvement in the reduction of waste and unnecessary variation, and seen an increase in the levels of efficiency and productivity across the NHS. This allowed the NHS to achieve financial balance in the face of an ageing population, an increasing volume and complexity of treatments, a dramatically reduced level of resources and increasing costs of medicines.

7What has been achieved at WAST in 2012-2013?

WAST has been heavily involved in the achievements set out here. Also the last year has seen significant progress made in a number of other areas which include:

What does the evidence tells us about our Unscheduled Care Services performance?Our clinical quality indicator performance is summarised below (up until 30thDecember 2012):

Clinical Quality Indicator Target Performance Performance 2012-

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21 Access: We have delivered Phase 1 Clinical Response Model; designed

to ensure that the optimum response is dispatched in a timely manner according to need.

Quality: We have developed a clinical strategy to further embed clinical leadership, quality and safety in all elements of the service we provide. The aspiration of which is to ensure that there is a focus on clinical excellence embedded in all elements of the patient experience from self-care education through to conveyance home from hospital.

Value for money: We are responding better to increasing demand than we have ever done before; Answering 40,000 additional calls already this year and attending 5000 additional red incidents in 8mins.

Organisational Redesign: The Trust’s design was not appropriately configured to achieve the strategic vision outlined in WTFS to deliver services locally. Work Undertaken - Identified basis of the Trust’s design (provide context and trust people to make decisions locally with partners), the details of the design (e.g. Management structures) developed through involving people, new design reinforced at every opportunity (e.g. selection events)Result – New behaviours and approaches are being developed, structure and processes increasingly aligned with key partners (e.g. LHBs), new ways of working leading to better care

Competency Framework: A changing clinical case mix, which required review of existing competencies & skills

Work Undertaken - Joint partnership approach with staff side colleagues and clinical leads facilitated by NLIAH to develop revised Competency Frameworks for road based and CCC staff linked to the National Competency Framework

Result –Competency Frameworks for road based and CCC workforces that will underpin local integrated plans (within the Trust and with partners)

Alternative Care Pathways Existing care pathways under-utilised nationally due to a ‘disjointed’ and ‘confusing’ referral process, increasing the number of unnecessary conveyances to the Emergency Department

Work Undertaken - A Collaborative service improvement project to design and implement a robust, standardised and clinically safe referral process to Alternative Care Pathways

Result - Implementation of a new referral process in ABMU, over 350 referrals completed since Go Live in September 2012.

2011/12 Year End 2013 to Dec 2012% of patients who received pre-hospital thrombolysis within 60 minutes

70.0% 87.0% 90.9%

% of Acute Coronary Syndrome patients who are documented as receiving appropriate STEMI care

100.0% 26.3% 24.2%

% of stroke patients who are documented as receiving appropriate stroke care bundle

- 55.8% 65.0%

% of older people who have fallen and have suspected fracture of hip / femur who are documented as receiving analgesia

100.0% 78.0% 83.9%

% of older people who have fallen and have suspected fracture of hip / femur admitted to an appropriate hospital within 60 minutes

100.0% 31.6% 23.6%

EMS call abandonment rate (primary line only) 2.5% 5.4% 5.3%% of 999 calls answered within 6 seconds 95.0% 85.7% 83.4%% of 999 calls where pickup time to location verification was within 30 seconds

75.0% 74.7% 73.6%

% chief complaint identified within 30 seconds of location verification

50.0% 36.4% 38.3%

% calls categorised as Category A (Red and Purple) 30.0% 38.6% 39.7%% Telephone Assessment Transfer Rate - 97.9% 97.9%% of calls transferred for clinical telephone assessment which were resolved by nurse

60.0% 59% 49.0%

% response rate to Cat C calls planned clinical telephone assessment within 10 minutes

90.0% 89.4% 86.2%

% of 999 calls where the time from location verification to Allocation was within 30 seconds

65.0% 58.6% 44.9%

% of cardiac arrest calls provided with a defibrillator response within 4 minutes

52.0% 35.6% 31.1%

% of responses to CAT A calls within 8 minutes 70.0% 68.4% 62.7%% CFR contribution to CAT A performance 5.0% 2.9% 3.3%% incidents treated at scene with no transport 20.0% 15% 11.2%% patients referred to alternative provider /pathway 8.0% 4% 4.9%% conveyance rate to A&E department 60.0% 65.6% 65.3%% Patient Handover within 15 minutes 95.0% 62.7% 57.3%

Positive Progress with Clinical Outcomes

Clinical outcomes indicators show that real progress is being made with regards improving the quality of the service and the overall pathways of care followed. Improvements include:

1. Patients suffering suspected stroke now receive the optimum care in the majority of cases. 91% of patients now receive thrombolysis within 60min(target 70%) and compliance with whole bundles of care for stroke have improved by 10% in the past year and 23% in the past 3 years.

2. Correct administration of analgesia has increased by 6% to over 90% in the past 12 months and 84% year to date.

3. We have also seen a 25% increase in the number of patients who have been referred to alternative pathways and care providers. This represents a significantly better outcome for these patients who will now receive care closer to their home in a safer environment than a hospital A&E.

Unfortunately we have observed a reduction in the number of patients receiving appropriate STEMI care and the number of patients suffering suspected cardiac arrest provided with a defibrillator.

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Access Performance

37,795

41,283

46,863

51,791

20,000 25,000 30,000 35,000 40,000 45,000 50,000 55,000

2009/2010

2010/2011

2011/2012

2012/2013

The number of Category A patients

reached <8 minutes has increased over the past

3 years by 13,996(+37%) from 2009/10 to the same mid-year

period in 2012/13

Fig. 1

Despite considerable progress being made with clinical outcomes performance relating to access and timeliness of response has remained relatively static. It is important to note that, despite slight decrease in the percentage response to Red Calls, the total number of calls where a response arrived in 8 minutes or less has actually increased by 5000 attendances as of December alone. (see fig. 1)We have analysed the indicators where improvement was not observed and identified the following contributing factors:

The service has seen a considerable increase in calls over the past 12 months (40,000 Red Category A additional calls year to date, versus last year).

An upwards trend relating to increasing patient acuity and dependency Reducing resources in areas of higher activity both due to financial constrains and increasing

rates of staff sickness Significant barriers to whole systems improvement in the current healthcare system

Taking all things into account we believe that considerable improvement has be made in the past year. We are offering safer, more tailored healthcare services, to more patients than we ever have before. We recognise that there is still considerable room for improvement and we have made sure that one of the core priorities for the coming year is to improve our access and response performance. Many of the development actions detailed in this document are focused on achieving sustainable improvement in these areas.

What the evidence tells us about our Planned Patient Care Services performance?10

The introduction of a new information system in 2010 has enabled the reporting of performance against a suite of national performance indicators. The indicators have been developed in partnership with the Welsh Government, as part of the Griffiths Review.

In the past year we have made a concerted effort to minimise patient waits and manage journeys effectively to minimise travel. We are confident that by the end of the financial year we will be consistently meeting the 70% targets on a monthly basis.

Clinical Quality Indicator

Target 2011/12 Performance

2012-2013 YTD Performance

% of PCS patients arriving within 30 mins of their appointment time

70% 64.7% 66.4%

% of PCS discharge / transfer patients picked up within 60 minutes of ready time

70% 66.4% 67.8%

% of PCS outpatients picked up within 60 minutes of ready time

70% 87.6% 86.7%

We are pleased to report improvement against two of the three PCS specific indicators. Our performance for patients arriving within 30 minutes of their appointment is now nearing our 70% and now almost 87% of outpatients are picked up within 60 minutes of their ready time (against a target of 70%) In order to achieve sustainable improvement in this area of our service, a number of targeted improvement workstreams have begun this year focused on the following:

Direct booking arrangements for follow up as well as first patient hospital appointments Advance warning to clinics and wards of planned arrival/collection times for

patients and notifications when arrival of crews is imminent Improved infection control measures, with alcohol hand jell now available for staff

and patients on all vehicles Online booking is being rolled out on a phased basis across all LHB areas after the

pilot scheme for this technology proved very successful for our patients and LHB partners

Dynamic planning models are being revised and improved to ensure that the optimal use of resources is achieved whilst minimising journey times and maximising patient access to services.

What do we need to concentrate on in 2013/2014?

Fig. 1

In order to accelerate the developments required to achieve the aspirations from Together For Success, the Trust has developed five key priorities for 2013-2014. These give all teams a clear framework to set their local goals and objectives. All the planned activities detailed in this document are organised under these five heading

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What will our service deliver next year?Activity Forecast 2013-2014

Our view is that the pattern of demand is likely to remain consistent in the coming year, but with a broad increase of approximately 3% more emergency calls and patients attended. This represents approximately an additional 5700 red calls and in the region of 8500 additional green calls. With financially limited scope to expand our capacity to meet this demand it is essential that we progress workstreams to ensure more effective demand management and signposting/referral to community based services. As demand continues to rise year on year we will need to use increasingly innovative methods to meet the requirements of patients and the public and reducing the number of patients taken to A+E will be a critical step to supporting the wider health economy.

Fig. 2

13523 14140 13939 14929 14012 13938 14792 14439 1651613600 13342 14557

22468 23949 23005 24405 23686 23053 23992 22991 23481 23571 22867 24470

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

April May June July August September October November December January February March

Forecast Activity for 2013-2014

Forcast Red Calls(previously Cat A) Forecast Green

What Clinical Conditions Will We Most Commonly attend?

Fig. 3

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The largest proportion of activity in the past year was associated with Health Care Professional (HCP) direct referrals to the service. 32% of our workload originated either from GPs, NHSDW or referrals from our own clinicians. The next most common clinical condition was activity relating to falls (22%)

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This figure demonstrates clearly that throughout the year the majority (60% on average) of our workload is accounted for by green calls.

There does not appear to be a trend seasonally to indicate the severity of our calls increases in winter but there are more calls received in general during this period so this one element of the winter pressures experienced.

What model of care will we need to deliver over the coming years?

Unscheduled Care

xi. Following the introduction of the revised National Ambulance Performance Framework in March 2011, and the subsequent work that was undertaken, our unscheduled care service model is very clear. This is illustrated in figure 3 below.

Fig 3 :Unscheduled Care Clinical Mode

The Red 1 and Red 2 (Category A calls) are patients with an immediately life threatening clinical condition who require immediate emergency life support to survive. These calls receive an immediate response with the overall aim of responding to Red 1 (cardiac arrests) within 4 minutes.

The Green 1, 2 and 3 (Category C) calls are patients with a clinical condition which ranges from urgent to low acuity i.e. they are not in immediate danger of losing their life. Patients within this category require urgent or planned care. Importantly, patients within this category require a clinical assessment to determine the care and service most appropriate to their needs. Depending upon their presenting condition, they will typically receive a visit from a paramedic or a clinical telephone assessment from a nurse. Once the clinical assessment is complete the clinician will decide upon the most effective course of action to support the patient in receiving the best possible outcome.

In support of this, we have also introduced multi-disciplinary teams within each of our control centres which consist of GPs, nurses and paramedics. This provides an increased level of clinical decision-making at the point of patient contact and clinical support for our operational staff when they are face-to-face with a patient. All our control rooms have paramedics and nurses working together with our call-takers. These improvements have taken us a considerable step closer to our stated aim of being a mobile clinical service. As of result of these improvements patients will receive more effective clinical assessment and diagnosis, improved response times to immediately life-threatening calls, and care appropriate to their clinical need.

Planned Patient Care Services

The Planned Patient Care Services (PPCS) arm of WAST provides non emergency patient transport (NEPT) to around 1.3million patients each year to outpatient, day unit, day surgery and therapy appointments. Working Together for Success sets out a strategic vision to place patients at the centre of service design and delivery to provide high quality, patient focused care. This direction of travel is focused upon improving access, providing a timely and equitable service that meets the needs of the user.

PPCS are committed to improving patient care and experience and in recent years fundamental service design and delivery improvements have been made. The implementation of a new national operating system (Cleric) was completed in 2009 to incorporate the booking, planning and control functions onto a single software platform. Improving the systems and processes for staff to organise and manage the delivery of NEPT. This has been supported through improved communication technologies with the implementation of a new digital radio system and mobile data terminals fitted to all operational vehicles. This has helped to improve the efficient use of available resources to provide a high quality, patient focused service.

As part of the Trusts clinical response model, suitable unscheduled care calls are conveyed by PPCS into hospital utilising any spare capacity within core planned work. This reduces the demands on unscheduled care, means that PPCS vehicle utilisation is maximised, and improves the timeliness of service for lower acuity unscheduled care patients. The Trust has trained all PPCS staff in the use of an automated external defibrillator (AED) and is in the process of purchasing this equipment for all PPCS vehicles. This will ensure that appropriate equipment will be immediately available should a patient collapse on a WAST PPCS vehicle, as well as allowing PPCS staff to first respond to Red 1 (immediately life threatening e.g. cardiac arrest) calls in their immediate vicinity. Assisting the provision of unscheduled care services, and, most importantly, improving timeliness for the most acutely unwell patients that WAST deal with.

Following the Griffiths review into NEPT, the Trust has been an active member of the NEPT National Programme Board (NPB) that was set up to address the issues identified in the review. We have been fully engaged in the four Griffiths Review pilots to test a number of key initiatives, share best practise and embed sustainable service improvements across Wales:

I. Voluntary Sector Partnership Pilot (Cardiff and Vale LHB). Exploring the feasibility of a third sector provider model for discharge and inter hospital transfer in collaboration with Cardiff and Vale Health Board and St John Cymru Wales.

II. On Line Booking Pilot (Cwm Taf LHB): Providing external Health Board call centre’s with ‘online’ access to Cleric to manage the NEPT bookings process to remove duplication and improve booking detail accuracy.

III. Planning and Control Model Pilot (BCU): This pilot has focused on the implementation of best practice in PPCS control and planning processes to improve the utilisation and efficiency of available resources.

IV. Integrated Transport Model Pilot (Hywel Dda): WAST has been a partner with Hywel Dda Health Board, Local Authorities and third sector providers as part of integrated transport model.

V. In collaboration with the NPB a National Commissioning Framework has been agreed and implemented with all Local Health Boards to provide a consistent platform for the commissioning of services.

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VI. National Eligibility Criteria Review: In collaboration with the NPB & LHB partner’s a revised application process is being developed to ensure that the National Eligibility Criteria is consistently and fairly applied across Wales. Ensuring that eligible patients based upon a medical need have access to NEPT and to appropriately signpost ineligible patients to suitable alternative transport providers.

In conclusion, it has been a very productive year for development of planned patient services with considerable improvements made in relationships with our LHB partners, as well as service performance. The focus for the coming year will be to build on the foundation of best practice pilots from 2012-1013 and further develop services that are locally tailored to deliver the best patient experience within the geographical and resource constraints that face the service. The implementation of virtual booking, enhanced dynamic planning models and revised eligibility criteria will all serve to support our aim to provide timely, high quality and affordable planned patient services.

OUR APPROACH TO REDUCING HARM, WASTE AND VARIATION

Our commitment and approach to reducing waste, harm and variation is now well-established across the Trust. We continue to base it upon the five key pillars of quality: safety, efficiency, effectiveness, timely and patient experience, with all of our improvement plans being driven by one common goal: to improve the quality of service that people receive. The establishment of the Medical Directorate in 2012 has provided a real focal point for the continued drive towards total quality, enabling a systematic, co-ordinated and clinically-led approach to develop within the Trust.We continue to focus on the reducing waste, harm and variation through the national framework that is being developed by Welsh Government and NHS organisations within Wales and across the globe. Our focus in 2013/2014 will continue to be on the delivery of the key national quality initiatives and programmes including the National Programme for Efficiency and Productivity, the National Intelligent Targets programme, the 1000 Lives and 1000 Lives Plus initiatives. Our drive for quality will in 2013/2014 will therefore be focussed around the following areas:

1. Continued improvement of the clinical model and the National Ambulance Performance Standards

2. The Planned Patient Care Modernisation Plan 3. 1000 LIVES and 1000 LIVES PLUS:

I. Stroke collaborativeII. Cardiac collaborative

III. preventing falls in community care 4. Patient engagement and experience5. Public health and health living

This will require transformational change throughout the organisation and across the whole healthcare system.

Our Priority to Address Incidents, Concerns and Health Associated Infections• Focus on embedding best practice for all staff regarding safeguarding vulnerable individuals• Focus on reducing concerns related to attitude and communication in Planned Patient and

Unscheduled Care• Focus on reducing clinical incidents relating to inappropriate use of resource in line with the

Clinical Response Model • Increased incident reporting and further embedding the principles of root cause analysis and

dynamic risk assessment throughout the organisation• Developing additional measures of HAI 2013-2014 performance to include:

• Improved Uniform/Vehicle cleaning audit compliance and performance• Independent Vehicle cleanliness checks

16

15

Developing Integrated Business PlanningFig. 4

Best Practice Planning Model

Local/Directorate delivery Plans

Local/Directorate Risk Registers

Activity Based Capacity Model and

LTFMService

Improvement Revised Clinical

Pathway Plans

Workforce Strategy and Plan

Clinical Strategy and Plan(partial

2013)

Corporate Risk Register

Key

2013-14 ADP onwards2014 ADP onwards

Fleet Strategy and

Plan(2014)

Estates Strategy and Plan(2014)

Operational Development and Delivery

Plans

Capital, Informatics and Clinical Technology

Development plan(2014)

Financial Budgetary and Savings Plan

Fully Integrated

Annual Delivery Plan

Best practice annual planning is achieved by ensuring that those involved understand all the organisational supportive strategies and have mapped out their local risks. This information should then form the basis of local plans which can in turn inform the base case financial model for the organisation. In addition to this, objectives should be set on a bottom up basis, as far as possible, with clear steer from the organisations board regarding the strategic direction of travel.

We have piloted an intermediate approach this year that has allowed for integration of those plans and strategies that are at an appropriate stage of development to align (green in fig. 4 above). Due to the complexity of developing a number of strategies and a long term financial model, these elements will be integrated next year as a part of the planning process for 2014-2015(in red fig. 4).

From next year we will be developing the plan from an activity based capacity model to further ensure the organisational resource is optimally deployed across LHB areas. We will also be developing a long term financial model to support planning in future years.

Recognising the need to embed the principles of integrated planning over a number of years the figure (fig 5.) on the following page outlines how, over the coming years, the organisation will move to a more bottom up approach to monitoring local progress against plans and the subsequent increase in local freedom to set their own objectives. As 2012-2013 has been the pilot year for this approach, organisational strategic priorities were shared with local teams and supportive leads. Plans were developed locally in delivery plan workshops to formulate plans to deliver these objectives.

Annual Delivery Plan 2013-2014 Development ApproachFig. 5

Development of The ADP Process

End Nov ‘12 Produce

Directorate Templates

and Briefing on strategic

priorities

March ‘13 Board Approves

2014-15 ADP Directorate 14-15

Action plans

THIS YEAR2013-14

PlanDelivery

14th Feb ‘13Planning

Manager to Deliver Draft

ADP for Committee

Scrutiny Jan ‘13 Directorate

Planning Workshops with Support teams

Nov ‘12Agree top five

Strategic Priorities and ADP Content

Partially integrated ADP development led by Executive and

Planning Team Top-Down

Planning Manager Track

progress of 2014-15 delivery

Nov ‘14Exec to review

panel outcomes and agree Strategy

Oct ’14Directorate mid-

year progress review

(Peer-peer)2013-14

End Dec ’14Progress

review/LTFR to inform focus areas

2016-17

End Jan ’15Completion

of Directorate and org plans

Feb ‘15Final Draft

ADP

2 YEARS 2015-16

Plan Delivery

Bottom-up, activity modelled ADP development led by operational and

support service leads, guided by Executive strategy setting

Mar ’15Board Approves

2014-15 ADP Directorate15-16 Action plans

Working Together for Success 2011-16

Revised Strategy Development

NEXT YEAR2014-15

Plan Delivery

Track finalised action plans

(Monthly verbal/ Quarterly written

updates)

Dec ‘13Disseminate

Strategic priorities/focus areas 2015-16

Oct ’13Directorate mid-

year progress review

(Exec Panel)2013-14

End Oct ’13Progress

review/LTFR to inform

focus areas 2013-14

End Jan ’14Completion of

Directorate and org plans combined in

ADP

Feb ‘14Final Draft

ADP to Strategy

Committee

Mar ’14Board Approves

2014-15 ADP Directorate15-16 Action plans

Move to fully integrate ADP development and progress tracking

facilitated by Planning Team

17

Our Planning Approach 2013-2014

Fig. 6

Linking Strategy to Local Business ObjectivesWe have worked hard to ensure that the strategic aims set out in Working Together for Success are translated into key actions within an Annual Delivery Plan that is joined up with all local and directorate plans for the coming year. This is illustrated in Fig. 6 above.

This year we have balanced the setting of corporate objectives with the need to recognise what the key local objectives are at an operational and directorate team level. This will enable us to deliver the corporate objectives for the Trust whilst supporting local development priorities. The consequence of this approach is that we will have confidence in our ability to deliver a consistent level of national services and locally tailored approaches to meet the more specific patient, staff and health service partner needs within those teams.

In developing the Annual Delivery Plan for 2013-2014 we have involved Heads of Service, Support Functions and Operational staff to identify the required key actions to deliver the Trusts objectives for the coming year. This has been done in a series of ADP workshops and through discussions to consolidate and rationalise the outputs of the planning workshops; taking into account the resource constraints for next year. A cross section of all staff have been involved in these workshops to ensure that understanding and best practice is shared at all levels and that the five organisational priorities are understood and aligned with local activities.

Business partners from the Medical, Finance, Workforce and Service Improvement departments have been identified to support each team to ensure that a joined up multi-disciplinary approach is taken to developing local plans.

In order to be sure that local plans are deliverable there must be:

1. Clear alignment with both the five year strategy and annual strategic priorities2. Commitment to broader teams working together throughout the year, focused on cooperation

between specialists and operational teams 3. Clarity throughout the organisation regarding the work we will be doing in the coming year,

the interdependencies between plans, timescales and resources required

Delivering Working Together For SuccessStrategic & Business Planning Overview

Strategy

Annual Delivery Plan

Directorate Business Plans

Working Together For Success 2011-2016

2011/12 2012/13 2013/14 2015/162014/15

Strategy, Planning &

Performance

Workforce & OD

Finance & ICT Medical Service

Delivery Corporate

WG Strategy

& Vision

WTFS

Annual Delivery Plans

Annual Directorate Business Plans

Local Delivery

18

4. Comprehensive understanding of local and corporate risks and the required actions to address them

Detailed Annual Delivery Plan2013-14

The following section outlines the identified corporate and operational objectives for the coming year. These articulated in line with the five agreed organisational objectives:

Improving clinical quality and safety Improving access and resilience Improving outcomes and experience of care Helping our staff to excel Delivering value for money

Where appropriate, timescales, measurable outcomes and responsible executive leads have been identified. This will ensure accountability for delivery and way of verifying if the actions have been appropriately designed to achieve our objectives.

It is recognised that these objectives, particularly those relating to patient access, safety and outcomes are intrinsically linked. Many of the planned activities will deliver improvement in a number of areas but it is important that duplication of actions in multiple sections be avoided. For this reason some objectives should be considered in the context of what has already been described in earlier elements of the plan.

19

Unscheduled Care: Objectives for 2013-2014

QU

ALI

TY

& S

AFE

TY

•2% reduction in hospital A+E conveyance-Reduce avoidable hospital conveyance (effective call handling, 0.5% hear and treat; 1% pathways; )

•Avoid 0.5% hospital A+E attendance by providing immediate clinicalintervention for patients, where appropriate within individuals scope of practice,

•60% of patients referred to NHSDW receiving definitive hear and treat

•80% compliance with HAI audit standards. Reduce the risk / frequency of cross-infection and Increase HAI audit compliance

• 5% increase Datix reports •100% identification of and reduction in incidences of harm

•75% compliance against Caldicott-Principles Into Practice (C-PIP) assessment through improved records management

•100% compliance with all safeguarding provisions and protection of vulnerable people(all ages)

•Improved compliance with hospital pre-alerts and introduction of audit

ACC

ESS

& R

ESIL

LIEN

CE

•Appropriate response times for all requests for unscheduled care including : 65% response within 8 mins for Red calls (60% LHB level) (Ambition 70%)and 95% response to Cat C calls within 30 mins

•Improved levels of community resilience via 5% Community First Responder contribution to Cat A Red 1 and 2 calls

•90% response to planned clinical telephone assessment within 10 minutes of allocation

•Reduce Category A responses required by ensuring appropriate call categorisation(80% on retrospective audit)

•Improve access to information (0845 and web) and Enhance support for patients to self-care

•95% Patient handover within 15min

•100% patient handover within 60 min

OU

TCO

MES

& E

XP

ERIE

NCE

•Improve Cardiac arrest survival to discharge rate•Improved rates of Return Of Spontaneous Circulation (ROSC)•Increased identification and appropriate management of fractured hip and femur: 100% given analgesia, and conveyed to hospital within 60 minutes •Full compliance with care bundles for STEMI and stroke•Full Compliance with FAST pathways•Improve identification and management of Sepsis•Patients are treated with dignity and respect and concerns acted upon

•15% reduction in complaints relating to attitude & communication

•High patient satisfaction ratings

STA

FF E

XCE

L •Workforce clinical skills and operational competencies mapped: every team has an integrated service, workforce and financial plan identifying how skills deficits/surpluses will be met

•90% compliance with statutory and mandatory training

•100% PDPs completed with 6 months of joining WAST/Quarterly Review

•Sickness absence level of no greater than 5.62% and 100% return to work interviews for all periods of sickness

•Focus on team based working evidenced through regular team meetings and discussion of objectives

•50% completed staff survey •To consistently reward and celebrate success

•Reduced grievances processed through formal protocol

•100% Compliance with Equality and Diversity processes=Reduced Complaints

•Increase Welsh Language capacity and awareness within the organisation

VALU

E FO

R M

ON

EY

•Achieve financial balance

•Deliver risk assessed savings programme (Current savings circa £15milllion)

•£Zero operational budget deficit through delivery of required quality of care / service within expenditure available

•Reduce overall unit cost of local service delivery year on year, taking into account activity variation

•All teams to plan and deliver an agreed service improvement activity

•Secure contracts and minimise income variation going forward

•Use every £ of resource effectively and efficiently

Fig. 6

Planned Patient Care: Key Objectives for 2013-2014

The key to successful improvement in unscheduled care will be maintaining a careful balance between patient safety, outcomes and experience, measured against equitable access and value for money.

The core drivers for improvement in unscheduled care, for each of the five strategic objectives are detailed in this diagram.

It is also important that these drivers are defined in terms of measurable outcomes. For instance, the reduction in avoidable conveyance will be measured not only as a net reduction of 2% but also as an increase in hear and treat, treat on scene and referral to alternative pathways.

QU

ALI

TY

& S

AFE

TY •80% compliance with

HAI audit standards. Reduce the risk / frequency of cross-infection and Increase HAI audit compliance

•5% increase Datix reports

•100% identification of and reduction in incidences of harm

•75% compliance against Caldicott-Principles Into Practice (C-PIP) assessment through improved records management

•100% compliance with all safeguarding provisions and protection of vulnerable people(all ages)

AC

CE

SS &

RE

SILL

IEN

CE •100% Confirmed

Eligible patients accessing servicesacross Wales

•90% of patients to arrive at the treatment centre within 30 minutes of their appointment time

•70% of PCS discharge / transfer patients picked up within 60 minutes of ready time

•70% of PCS outpatients picked up within 60 minutes of ready time

•Improve access to information (0845 and web) and Enhance support for patients to self-care O

UT

CO

ME

S &

EX

PE

RIE

NC

E •High quality vehicle environment •Initiation of regular patient survey and completion by 1% service users •Minimised average journey times•15%Reduction in complaints relating to attitude & communication•High patient satisfaction ratings •Patients are treated with dignity and respect and concerns acted upon

STA

FF E

XC

EL •Workforce clinical skills and

operational competencies mapped: every team has an integrated service, workforce and financial plan identifying how skills deficits/surpluses will be met

•90% compliance with statutory and mandatory training

•100% PDPs completed with 6 months of joining WAST/Quarterly Review

•Sickness absence level of no greater than 5.62% and 100% return to work interviews for all periods of sickness

•Focus on team based working evidenced through regular team meetings and discussion of objectives

•50% completed staff survey •To consistently reward and celebrate success

•Reduced grievances processed through formal protocol

•100% Compliance with Equality and Diversity processes=Reduced Complaints

•Increase Welsh Language capacity and awareness within the organisation

VALU

E FO

R M

ON

EY

•Achieve financial balance

•Deliver risk assessed savings programme (Current savings circa £15milllion)

•£Zero operational budget deficit through delivery of required quality of care / service within expenditure available

•Reduce overall unit cost of local service delivery year on year, taking into account activity variation

•All teams to plan and deliver an agreed service improvement activity

•Secure contracts and minimise income variation going forward

•Use every £ of resource effectively and efficiently

Fig. 7

Whilst the overarching objectives for planned improvement for planned patient care services are the same as those prescribed for unscheduled care, there are some very distinct areas that we will be focusing our attention on during 2013-2014. Including:

Providing the best quality vehicle environment

Ensuring equitable access for eligible patients

Ensuring journey times are minimised within our available resource

Ensuring patients are collected and taken home in a timely manner

Ensuring that variation from local LHB contracts is minimised and agreed performance levels delivered

Improving Clinical Quality and Safety The primary motivation for this objective is to ensure that patients receive the best possible quality safe care in a setting that is conducive to the best possible health outcomes. It is increasingly clear that this is not necessarily a hospital emergency department.We will be focussing on:

Reducing Health Associated infections (HAI) through effective vehicle cleaning and hand washing.

Ensuring that pathways of care are the best possible for our patients Ensuring our patient records are captured accurately and protected according to straight

forward information governance processes Developing appropriate clinical and non-clinical training packages for all patient facing

staff. Developing the specifications for the best possible systems for clinical records and

communication technologyFig.12

Patient Safety

Clinical Leadership

Quality

Right Service

Right Care

Right Place

Right Time

Right Skills

During 2013-2014 we will aim to increase our HAI audit compliance, reduce conveyance to hospital A+E by 2%, increase our clinical incident reporting, and ensure that hospital pre-alerts are communicated in an effective and timely manner. We will also be focusing on applying consistent standards of leadership, quality and safety across the wider range of services we offer including Health Courier Services and Community First Responders

22

Cardiff and Vale Police Control Pilot and Alcohol ServiceThe Cardiff and Vale operational teams have developed a number of new models of delivery focused on improving safety and quality. These include:

Placing paramedics in police control to provide support to control staff or police officers who arrive first on scene where someone is in need of medical attention; One excellent example of the value of this when a police operator took a call that involved a baby turning blue and in a potential fatal position. The paramedic took over the call and directed immediate actions before getting an ambulance on scene straight away. The baby survived.

Similarly, the Alcohol Treatment Service in Cardiff, having now seen in excess of 400 patients, is another valuable example of how WAST can work in partnership to support accessible services that offer appropriate immediate clinical intervention/supervision to patients who do not necessarily require hospitalisation. This service also offers a valuable patient education package to reduce occurrences of alcohol related incidents and illness.

Proposed Clinical Model The foundation of this object for the coming year will be the revised clinical strategy (Fig.12). Through adopting an approach that places clinical leadership, patient safety and quality at the heart of all our processes and procedures we will ensure that the Right Service and Care is delivered at the Right Place, at the Right Time by appropriately skilled practitioners. This model will continue to be developed and rolled out across operational teams over the coming year. The first step of which will be to properly embed the Clinical Team Leaders in their new roles.

1. Improving Clinical Quality and Safety

23

19

19

7, 20

6,7,8

6,7,8

7,8

7,8

13

19 20, 21

7,8,21

2% reduction in hospital conveyance

Roll out piloted JRCAL, evidence based pathways for resolved Hypoglaecaemia, Falls, and Epilepsy on a phased basis to all LHB areas

April–December 2013 6,7,8 Director of Strategy, Planning

and Performance Strategy

Work with Cardiac Network and LHBs to implement protocols and pathways for direct admission to PPCI labs/units

April-March 2014 6, 7, 8 Medical Director Medical and Clinical

Based upon each LHB provision of Stroke services, set-up a direct “fast track” admission pathways for ambulance crews to access

April-May 2013 7, 8 Director of Service Delivery Medical and Clinical

Agree and implement Direct Admissions protocols with (Stroke, NOF, PCI, Maternity):

Director of Strategy, Planning and Performance Service Delivery/Strategy

BCU Pilot April-July 2013 7,8,21 Director of Strategy, Planning and Performance Service Delivery/Strategy

Other LHB Areas July 2013-2014 7,8,21 Director of Strategy, Planning and Performance Service Delivery/Strategy

Audit of skills gap identified by the implementation of the clinical competency framework 2013-2014 24, 25 Workforce Director Medical/Workforce/Service

delivery

Develop a costed implementation plan to address any skill gaps Oct-14 24 Workforce Director Finance/Medical

Optimise the utilisation of senior clinicians through clear referral guidelines and signposting in control

July 2013-March 2014 6,7,8,24 Director of Service Delivery Strategy/ Service Delivery

Provide additional clinical leadership and support to paramedics to ensure they work to their full scope of practice

2013-2014 1,24 Medical Director Medical

Implementation of ORH recomendations relating to clinical leadership in control rooms April 2013-2014 7,8 Director of Strategy, Planning

and Performance Service Delivery/Strategy

Develop register to record frequent callers to the service who have needs identified which are not classed as requirimg urgent healthcare

April-August 2013 3 Director of Service Delivery Strategy

Establish multidisciplinary approach to more appropriately direct frequent users who do not require urgent healthcare to the most appropriate service.

August-October 2013 3 Director of Service Delivery Strategy

Train staff to gain access to self-service reports within the data warehouse

April-October 2013 19, 20 Director of Service Delivery Strategy

Development of Mental Health Pathways to ensure safe, high quality care and admissions avoidance

2013-2014 phased by LHB 8 Director of Strategy, Planning

and Performance Strategy/Service Delivery

Objectives Key Actions: SupportLeadStandards For Health

Timescales

Working Together for Success in 2013-2014Our Development Objectives for the Coming Year



23

19

19

7, 20

6,7,8

6,7,8

7,8

7,8

13

19 20, 21

7,8,21

60% of patients referred to NHSDW receiving definitive

hear and treat

Re-establish the range of clinical codes that are appropriate for nurse triage

April-August 2013 19 Nursing Director Strategy

Review and effectively align capacity with demand in NHSDW

August-October 2013 8 Director of Service Delivery Strategy

Undertake root cause analysis to understand the reasons for call return and develop improvement recommendations

October-December 2013 8 Nursing Director Strategy

Implement recommendations of the ORH report regarding clinical leadership in control

April-December 2013 8, 19 Medical Director Service Delivery

Review feasibility of introducing CAS-CAD interface April-June 2013 8,19 Nursing Director ICT

Consider development of technical interface between NHSD and MIS 2013-2014 19 Director of Finance and ICT Service delivery/ICT

Fully comply with all safeguarding

provisions and protection of

vulnerable people (all ages)

Deliver enhanced guidance, training and referral pathways for safeguarding vulnerable patients to all Service Delivery staff

August 2013 onwards 11 Director of Service Delivery Medical and Clinical/Service

Delivery

Audit the effectiveness of Safeguarding Policies and Procedures in operational compliance 2013-2014 11 Nursing Director Medical/ Clinical

Ensure that HOS and all operational staff fully understand their roles and responsibilities and implement clear lines of accountability for Safeguarding

2013-2014 1,13 Director of Service Delivery Service Delivery/ Clinical/ Medical

Complete Safeguarding work plan in line with timescales contained within it. 2013-2014 11 Nursing Director Medical /Clinical

Increase HAI audit compliance

(independent vehicle inspection findings,

Staff D+V and Incidents reported)

Produce Infection Prevention and Control action plan April-June 2013 13 Nursing Director Medical / Clinical

Restrict cleaning products to IPC approved range 2013-2014 13 Nursing Director Medical / Clinical

Improve monitoring and management of Infection control (Vehicle and Uniform)audit 2013-2014 13 Director of Service Delivery Service Delivery

Reduce the risk / frequency of cross-

infection

Develop and implement organisational campaign to highlight appropriate Hand Washing process

June-December 2013 13

Communications Nursing Director

Identification of Infection control leads within each locality and compliance with HIW action plan and audit requirements for infection control

April-March 2014 13 Director of Service Delivery Medical/Clinical


Timescales



23

19

19

7, 20

6,7,8

6,7,8

7,8

7,8

13

19 20, 21

7,8,21

5% increase Datix reports

100% identification of and reduction in

incidences of harm

Strengthen DATIX functionality(saving mid-way) and access to improve accurate collection of recorded incidents. May-July 2013 23 Corporate Secretary Corporate/ Service Delivery

Establish register , monitor and disseminate, via locality managers and CTLs, intelligence regarding older people who have fallen at an LHB level

2013-2014 6,7,8 Medical Director Med/HoS

Focus on feeding back trends/report generated by clinical risk team to all operational staff 2013-2014 23 Corporate Secretary Service Delivery

Ensure robust leadership and governance is in place for HCS service by addressing areas of risk identified in the service review

April-May 2013 1, 17 Director of Strategy, Planning and Performance Strategy

Implement all Wales WAST policies and procedures for HCS April- July 1 Director of Strategy, Planning and Performance Strategy

75% compliance against Caldicott-

Principles Into Practice (C-PIP) assessment through improved

records management

Baseline audit of clinical records management and dissemination of recommendations

September-December 2013 20, 21 Director of Service Delivery Medical and Clinical

Receive and understand recommendations of the information commissioners office report on Information Governance

May-13 20,21 Director of Strategy, Planning and Performance Medical and Clinical

Implementation of recommendations of above Dec-13 20,21 Director of Strategy, Planning and Performance All Directors

Avoid 0.5% hospital A+E attendance by

providing immediate clinical intervention for patients, where appropriate within individuals scope of

practice

Introduce self audit tool to enable individuals to assess own clinical practice April 2013-2014 20,21

Director of Service Delivery Medical and Clinical

Align clinical competency framework to ensure appropriate skill sets are in place to deliver immediate interventions April 2013-2014 20,21


Set up standardised CPD programme to enable the development of these competenmcies April-May 2013 20,21


All staff to be provided with regular CPD and statutory training that is appropriately focused on clinical skills development 2013-14 6,8,10


Assess performance against standards of clinical practice relating to falls assessment/referral and address performance issues

August-October 2013 20,21 Medical Director Medical and Clinical

To support patients and families managing end-of –life with dignity and respect; develop approach and implement systems to measure and improve pathways for these patients

May-December 2013 6,8,10 Medical Director Medical/Clinical


Timescales


Improving Access and Resilience

Within the very constrained financial environment we have described we will need to make extraordinary efforts to respond to the rising demand for our service, within the resource that we currently have. By improving access and resilience we will aim to build a more flexible adaptable service that meets the needs of the Welsh public. For both unscheduled and planned services this will mean developing smarter pathways and ensuring that the staff and vehicles we have are multi-purpose where possible. We will also continue to offer information and support to patients through the “Choose Well Campaign

We will also need to make sure the fleet and staff we have are deployed in the right way at the right time in line with the clinical response model. In order to do this we will make sure that the deployment points for these staff are in the right place and that status plan management reflects real-time demand on a day to day basis rather that filling rotas according to a static plan throughout the year. Making better use of the Community First Responders we already have will also be important, not only because this will allow more patients to receive immediate care quicker, but also because this will help them to feel more valued as a regularly utilised resource.

Finally we will be revisiting our planned services routes & schedules with our LHB partners and rolling out revised eligibility criteria to ensure that those who need to access the service can on an equitable basis. This will enable us to offer a more timely service to patients and make better use of the vehicles and staff we have.

What Will Improved and Access and Resilience will deliver?By improving our Access and Organisational Resilience we our planning on seeing a number of improvements, including:

Responding to 65% of Red (previously Category A) calls within 8 minutes and work towards a cumulative all Wales performance of 70%

100% of Eligible patients will be able to access Planned Services; and 90% will arrive at their appointment within 30min of their allotted time

More patients will be given advice over the phone, treated on scene or referred to alternative pathways to reduce clinically unnecessary conveyance to emergency departments across Wales.

26

Pathways Pilot in Abertawe Bro MorganwwgThe Service Development Team has worked closely with WAST Operational colleagues within the ABMU Localities, and LHB partners, to improve the processes for accessing Care Pathways. The aim of this work was to make it more robust and easier for front line Paramedics to access Pathways for their patients.

If a paramedic is treating a patient who is suitable for referral (for Falls, resolved Hypo or Epilepsy) they can now make a referral via a single Co-ordination Point, which is available 24/7.

Since go live in September 2012, a total of 519 patients have been referred to Community Based Teams, meaning that ABMU’s ‘Referrals to Alternative Provider’ rate has increased by 30 %

2. Improving Access and Resilience

23

19

19

7, 20

6,7,8

6,7,8

7,8

7,8

13

19 20, 21

7,8,21

Category A Performance of 65% nationally (60% LHB level) within 8 minsand 95%response to

Category C calls within 30min

Implement the outputs of the 2012-2013 Rota review April-December 2014

8 Director of Service Delivery

Implement reviewed meal break policy and implement learning from “Flip-Flop” BCU pilot

July 2013 onwards

8, 25 Director of Service Delivery Service Delivery

Working in partnership with LHB teams to develop appropriate deliverable service model for unscheduled care services 2013-2014 8

Director of Strategy, Planning and Performance Strategy

Develop new workforce model to support the revised clinical model/strategy(e.g. aligned with revised rosters/working patterns

August-December 2013

8 Director of Service Delivery Workforce/ Service Delivery

Explore, and implement in partnership with LHBs, an enhanced portfolio of acute low acuity services offered outside of a hospital setting eg minor injuries units

April-December 2013

6,7,8,18Director of Strategy, Planning


Implement recommendations of ORH report in Control April-December 2013

8 Director of Service Delivery

Identify obstacles to reaching appropriate response times and demand management for Red calls; identify mitigating strategies around balancing capacity for 0845/999calls

June-December 2013

8, 19 Medical Director Medical/Clinical

Update status plan management in line with independent recommendations and ensure optimum flexible use is made of the range of Trust resource available (including PCS/HCS)

2013-2014 8 Director of Service Delivery Service Delivery

Take a leading partnership role in development of the South Wales Programme Trauma Pathway 2013-2014 1,7,8 Medical Director Strategy/Medical

Development and implementation strengthened operational oncall arrangements.

August-December 2013

7,8 Director of Service Delivery Service Delivery

Refresh and implement phase 1 of the new clinical response model

April-December 2013

6,7,8,18 Medical Director Strategy

5% Community First Responder

contribution to Cat A Red 1 and 2 calls

Evaluate the results of the South Wales Fire and Rescue CFR pilot scheme and implement learning on a national scale

July 2013-January 2014

7, 16 Director of Service Delivery Service Delivery

Improved call categorisation to inform optimum response to calls

Under the auspices of the “Choose Well” programme further develop patient education and access to alternative care provides through current directory of services and supportive patient information content.

July-October 2013

3 Nursing Director Medical/Clinical

Implement the recommendations of the ORH report relating to Control 2013-2014 8, 19 Director of Service Delivery Service Delivery


Timescales


2. Improving Access and Resilience Planned Services

100% Confirmed Eligible patients accessing

services

Pilot and roll out revised eligibility criteria for PCS in order to optimise appropriate access to services and ensure efficient use is made of existing resources.

April-December 2013

8Director of Service Delivery

Strategy

Roll out online booking approach piloted in Powys to all other LHB areas

July 2013-March 2014

8, 5Director of Service Delivery

Strategy

Introduce more robust planning arrangements to match supply and demand for PCS April 2014 8

Director of Service DeliveryStrategy

Develop an information base to enable analysis of eligible patients gaining access to services May-13 8

Director of Service DeliveryStrategy

90% of patients to arrive at the treatment centre

within 30 minutes of their appointment time

Improve operational management of PCS functions through roster review and centralised planning function

May-December 2013

8Director of Service Delivery

Service Delivery

Implementation of booking reminder system for PCS patients April 2014 18Director of Service Delivery

Strategy/Service Delivery

Pilot May-Sept 2013 18Director of Service Delivery


Roll out Jan- Dec 2014 18Director of Service Delivery



Timescales


Improving Outcomes and Experience of Care One of the core elements of Working Together for Success is the importance of ensuring that patients’ experience of care and outcomes are best we can provide. This will involve taking a more holistic view of the entire patient journey not just the limited element we currently play a part in. The Clinical Model(Fig. 13), based in a foundation of clinical leadership and education that we will be adopting going forward is set out to achieve this. With everything from patients education on self care through to outcomes of care.

Fig. 13

We want to ensure that all of our patients experience the best quality of care that is delivered in a way that prioritises patient choice and dignity in care. In order to achieve this we will be doing a number of things over the coming year including:

Revising our current information collection on patient outcomes, focusing on partnership working with LHB colleagues to better understand outcomes

Ensuring compliance with and audit of Stroke, Sepsis, Falls and Cardiac arrest pathways Giving patients more opportunities to feedback on their experiences and acting on what we

learn to ensure continuous quality improvement culture Focus on enhancing Welsh language capacity within the organisation, meeting the diverse

needs of the Welsh population, through proactive recruitment, development and retention of bilingual staff.

ClinicalContact CoordinationCentre

Response

Self Care

&Information

Home

ZoneSelf Care

Pathway

HospitalH

O

U

T

C

O

M

E

Safety

9991110845PlannedScheduled(GP Urgents)

Choose Well

Health Prevention

Health Protection

Self Care

Clinical LeadershipClinic

al Supervision

PUBLIC HEALTH

Q U A L I T Y

Clinical Model

29

Paramedic Pathfinder ModelThe experience of implementing this model of clinical decision making in England was, on the whole, extremely positive. It utilises a clinically safe algorithm to help operational staff to make decisions about what the best pathway is for a range of patients. This presents a highly beneficial opportunity to the trust, so we will be focusing on the following actions to develop this model in Wales going forward:

Quantify the cost, technology, training and resource implications to establish the feasibility of implementing this model in 2013-2014

Understand the degree of alignment with existing pathways work across the organisation and minimise disruption to these developments

Explore existing sub-acute and urgent care facilities available to service the sick patients who would not require conveyance to an emergency department but do require urgent care of some form under the Pathfinder model. These may need to be in place prior to commencing a pilot of the model

3. Improving Outcomes and Experience of Care

23

19

19

7, 20

6,7,8

6,7,8

7,8

7,8

13

19 20, 21

7,8,21

Full compliance with care bundles for STEMI

Develop and introduce audit tool for CTLs to monitor STEMI pathway compliance to measure local and individual performance

April-May 2013 6,7,8 Director of Service Delivery Medical and Clinical

Improved rates of ROSC (metric TBA)

Develop and introduce audit tool for CTLs to monitor ROSC compliance to measure local and individual performance


Identify root causes of inadequate compliance in ROSC pathway and identify actions to address these issues May-July 2013 6,7,9 Medical Director Service Delivery

Establish in, collaboration with LHBs, a data recording/reporting system to be able to provide reports on outcomes of cardiac arrest survival to discharge

April-October 2013 8,19,20 Medical Director Medical and Clinical

Adopt and implement up to date JRCALC/UK ResusCouncil Guidelines for ROSC

April-August 2013 7,8 Medical Director Medical and Clinical

Cardiac Arrest Survival Improvement Plan to be developed and implemented

April-August 2013 6,7,23 Director of Service Delivery Medical and Clinical/ Service

Delivery

Additional Clinical Support Officers to be funded by British Heart Foundation in post May 2013-2014 5 Medical Director Medical /Clinical

Increased identification and appropriate management of

fractured hip and femur: 100% given

analgesia, and conveyed to hospital

within 60 minutes

Develop and introduce audit tool for CTLs to monitor falls pathway compliance to measure local and individual performance

April-May 2013 6,7,8 Medical Director Medical and Clinical


Timescales



Compliance with Sepsis pathways

To improve the identification and management of sepsis through the MEWS /Sepsis screening tool in line with 1000lives+:

- - Medical Director Medical/Clinical/Service Delivery

Develop and Test screening tools April-May 2013 7,22Medical Director Medical/Clinical/Service Delivery

Roll out to all LHB Areas May-August 2013 7,22Director of Service Delivery Medical/Clinical/Service Delivery

Full Compliance with Stroke (including FAST)

pathways

Identify root causes of inadequate compliance in STEMIpathway and identify actions to address these issues May-July 2013 6,7,9 Medical Director Service Delivery

Develop and introduce audit tool for CTLs to monitor Stroke pathway compliance to measure local and individual performance


Identify root causes of inadequate compliance in Stroke pathway and identify actions to address these issues May-July 2013 6,7,9 Medical Director Service Delivery

Develop and introduce audit tool for CTLs to monitor FAST pathway compliance to measure local and individual performance

April-May 2013 6,7,8 Director of Strategy, Planning and Performance Medical and Clinical

Identify root causes of inadequate compliance in FAST pathway and identify actions to address these issues May-July 2013 6,7,9 Medical Director Service Delivery

High patient satisfaction ratings

Design and implement system to routinely collect and act upon patient satisfaction ratings

April-October 2013 5,23 Nursing Director Patient Experience Team


Timescales



Improved rates of ROSC (metric TBA)

Place AEDs on PCS ambulances April 2013-2014 16Medical Director

Medical /Clinical

Initiation of regular patient survey and completion by 1%

service users

Introduce suggestion cards in PCS vehicles and undertake snapshot patient satisfaction surveys

April-December 2013 5

Director of Service Delivery

Service Delivery

High patient satisfaction ratings

Develop PCS patient forum and respond/develop actions to address feedback

July-December 2013 5,24 Nursing Director Patient Experience Team

Undertake local review to ensure that PCS vehicles reflect Health Board SLA requirements and address any issues identified

August-December 2013 8, 23

Director of Service DeliveryService Delivery

Minimised average journey time

Develop information and reporting system to measure current average journey time and identify opportunities to improve this

2012-14 8, 23 Director of Strategy, Planning and Performance Service Delivery

Further review of local planned routes and service specifications for PCS in partnership with LHBs 2013-2014 6,8 Director of Service Delivery Service Delivery


Timescales


Helping Our Staff to Excel In order to deliver the trusts aspirations in 2013-2014 The key to the Trust successfully delivering WTFS are:

• Supporting individuals and teams to make decisions as close to issues as possible (within agreed priorities/constraints), recognizing that “power is where decisions are made”

• Enabling relationships to be built with and between colleagues and partners; engaging behaviors are a key requirement for all staff

• Enabling colleagues to make decisions through engaging with partners/stakeholders is fundamental and underpinning to the Trust’s success.

Sustainable workforce In order to achieve a sustainable workforce the organisation will need to supply of appropriately competent staff to deliver service needs. We will aim to improve productivity and efficiency by conducting rota reviews and revising meal break policies to ensure our staff have access to regular breaks in the right environments. We will also help our staff to excel by renewing our focus on health and wellbeing whilst supporting our staff to prevent illness and return to work through a new occupational health facility.

Engagement It is important that all our staff feel engaged and involved in the organisational and strategic developments underway. We aim to improve staff engagement in a number of ways, including:

• Effective partnership working through the partnership forum and by ensuring staff side representation in all core decision making groups

• Shared understanding and ownership of required workforce change through the adoption of an open and transparent approach to describing the challenges and solutions identified for the organisation

• Clear communication processes with all staff, partners and stakeholders including the development of organisational team brief, regular team meetings and the trust intranet

Effective Leadership We have identified the need to further enhance our leadership model. We will do this by embedding a coaching-style at all levels; introducing teams based working with a view to delivering high quality outcomes and enhancing ownership of personal development needs. We are committed to ensuring that all members of the trusts’ workforce all have:

A Personal Development plan in place that is regularly discussed and review Regular 1:1 with their manager and monthly team meetings Access to development opportunities and talent identified

Within this focus, effective organisational development across the Trust aims to ensure that structures, processes and systems join up to enable improved performance through people.

33

Developing the Clinical Competency FrameworkThe development of the competency framework is an example of our commitment to the principles outlined above, because: It was developed in partnership with workforce and staff-side representatives from the outset. It focuses on ensuring that all staff are consistently able to excel in their roles; It will enable us to map the requirements for a sustainable, fit for purpose workforce and support

the development of a workforce and organisational development plan to deliver this And outlines the skills and competencies that all levels should exhibit in order to progress

beyond their current positions in the future

4. Helping Our Staff to Excel

23

19

19

7, 20

6,7,8

6,7,8

7,8

7,8

13

19 20, 21

7,8,21

100% PDPs completed with 6 months of joining

WAST + evidence of Quarterly review

Ensure all staff have protected time to complete PDPs and regularly review their progress 2013-2014 26 Chief Executive Workforce/Service Delivery

Develop a standardised approach to CPD that promotes flexibility in line with individual requirements

August-December 2013 26 Medical Director Medical/ Workforce/ Service

Delivery

Develop a standardised approach to CPD that encourages sharing of specialist knowledge with colleagues through presentation of audit findings

August-December 2013 26 Medical Director Medical/ Workforce/ Service

Delivery

Support the development of clinical supervision networks and ensure sufficient capacity aligned with competency framework and CTL scope of practice/protected time

2013-14 1,8,26 Medical Director Workforce/ service delivery

Focus on team based working evidenced

through regular team meetings and discussion

of local and strategic objectives

Develop a ‘Team Brief’ process to improve communication with staff - through team meetings, intranet, MDT screens

April-May 2012 18, 19 Chief Executive Corporate

Fully embed the Aston Team based working methodologies and put in place local clinical and operational leadership structures with the capacity to support this approach

April-May 2013 18 Director of Service Delivery Workforce/ Service Delivery

Introduce workforce information stands accross our stations and buildings to deliver staff communications

October 2013-2014 18, 19 Corporate Secretary Corporate

Hold two CTL conferences to share challenges and best practice 2013-14 6,18 Medical Director Medical /Clinical

Develop and roll Coaching Champions across all directorates April-Sept 2013 25,26 Workforce Director Workforce

Increase staff survey completion to 50%

Ensure protected time for staff to complete staff survey and the implementation of agreed actions resulting from feedback received

April-September 2013 5 Workforce Director Service Delivery

Continued raising of awareness of the importance of completing staff survey 2013-2014 5 Workforce Director All Directorates

Increase the long term sickness cases resolved

Monitor compliance with timely and consistent Case Management reviews are conducted across the organisation

2013-14 25 Director of Service Delivery Workforce

Ensure staff are adequately resourced in the field ,and equipped with the appropriate skills to safely discharge their duties, by developing an organisational workforce plan that utilises the agreed competency framework to map our current capacity against our required skill set and capacity.

April-October 2013 16 Director of Service Delivery Workforce/ Medical Clinical


Timescales


4. Helping Our Staff to Excel

23

19

19

7, 20

6,7,8

6,7,8

7,8

7,8

13

19 20, 21

7,8,21

Increase Welsh Language capacity and awareness within the

organisation

Continued implementation of trust Welsh language scheme; ensuring optimised access to language training, identification of areas that require additional welsh speaking resource and proactively recruiting welsh speakers.

2013-2014 18,25 Workforce Director Workforce/ Service Delivery

Reduced grievances processed through

formal protocol

Identify opportunities to apply flexible working and leave availability within constraints of local service requirements

2013-14 25 Director of Service Delivery Service Delivery

Investigate the main cause and pattern of staff grievances

April-October 2013 25 Workforce Director All Directorates

Identify actions to address common grievances October 2013-2014 25 Workforce Director All Directorates

Sickness absence level of no greater than 5.62%

Provide CTLs and locality managers with robust local intelligence regarding sickness trends and durations at an individual/team level

2013-14 24 Workforce Director Workforce

Staff wellness campaign to highlight trust services and encourage healthy choices

August 2013-2014

3 Corporate Secretary Corporate

Full roll out of revised occupational health and staff wellbeing services

June-December 2013

3 Workforce Director Workforce

Provide training to all trust managers in supporting staff wellbeing and professional sickness management

August –December 2013

3 Workforce Director Workforce-Training

Develop the Workforce information system to support evidence based and implementation of ESR 2013-14 18,19 Workforce Director ICT

100% Compliance with Equality and Diversity

processes=Reduced Complaints

EIA Process-monitor the degree to which the principles are embedded in service wide behaviors 2013-14 2 Director of Service Delivery Workforce

To consistently reward and celebrate success

Implement the communications strategy elements aimed at enhancing staff moral through recognition and reward

2013-14 25 Chief Executive Corporate/ Workforce

Develop and hold Annual staff awards Ceremony April-August 2013 25 Chief Executive Corporate

Develop and implement staff suggestion scheme April-May 2013 5,25 Corporate Secretary Corporate

Develop a mechanism for sharing operational good news stories 2013-14 5,25 Corporate Secretary Corporate/ Service delivery


Timescales


Delivering Value for Money As with any public sector organisation, delivering an increasing range and amount of services in the way we have detailed in this plan, is extremely difficult within the financial limitations we have previously describe. For this reason we have to make every effort to demonstrate Value for Money in the use of the funding we do receive. There are a number of opportunities available to use in the coming year to make better use of the resources we have and to invest in schemes that will generate substantial efficiency and effectiveness gains in the medium and long term.

These include:

Local measures to reduce fuel consumption and costs , as well as a focus on reducing energy waste through estates workstreams

Optimised stock management and control to ensure stockpilling is minimised and national approach is taken to ensure consistant adherance to procurement guidlines.

Ensuring that the senior clinicians we employ are properly utilised through appropriate case allocation and other value add activities such as education and leadership

Enabling managers throughout the organisation to manage their budgets effectively through accurate, user friendly, regular reports and supportive education regarding effective financial management.

If these workstreams, and the other developments featured on the previous pages, are successful we will aim to see every £1 of resource used effective and efficiently, minimised variation on contract income, an increased portfolio of revenue generating activities and the organisation remaining with allocated budget for the full financial year. We will ensure that the demands placed on the service are met through the existing financial envelope and will achieve this by reducing the overall unit costs of each of the services we provide.

36

5. Delivering Value for Money

23

19

19

7, 20

6,7,8

6,7,8

7,8

7,8

13

19 20, 21

7,8,21

Achievement of financial balance

Provide good, timely and accurate financial information to enable Service Delivery management to operate effectively and deliver objectives.

2013-14 1, 18 Director of Finance and ICT Finance and ICT

HCS to review Health Board charges to maximise income and investigate external training opportunities

April-August 2013 1, 26 Director of Strategy, Planning


Increased focus on supporting locality managers in developing additional budgetary management skills and increasing the awareness of more junior operational staff of the national and local resource/budgetary constraints

2013-14 1,26 Director of Service Delivery Service Delivery/ Finance

Optimise the utilisation of senior clinicians through clear referral guidelines and signposting in control

July 2013-March 2014 6,7,8,24 Director of Service Delivery Strategy/ Service Delivery

All teams to plan and deliver an agreed

service improvement activity

Revise processes for developing policies and procedures , with the aim of reducing travel and move to increasing models of digital communication to reduce corporate costs

April-August 2013 1, 6 Corporate Secretary Corporate

Devise and implement strategies to increase fuel efficiency across all LHB areas and reduce spend by 2% 2013-14 12 Director of Service Delivery Service Delivery

Implement Working Differently Working Together 2013-14 24,25 Workforce Director Workforce

Reduce spend on clinical consumables through assessment of current usage/contract 2013-14 15, 16 Medical Director Finance & ICT/ Service

Delivery

Reduce IPC and cleaning product spend 2013-14 11,16 Director of Service Delivery Service Delivery

Reduce Medical Gas expenditure through new Gas contract

April-December 2013 16 Medical Director Service Delivery

£Zero operational budget deficit through

delivery of required quality of care / service

within expenditure availabl

Introduce improvements to locality stores & equipment and effective Asset Management: supported by stock control and rationalised ordering protocols. Scope feasibility of “Just in Time” procurement model

October 2013-2014 15,16 Director of Finance and ICT Finance and ICT


Timescales


5. Delivering Value for Money

Reduce overall unit cost of local service delivery year on year, taking into

account activity variation

Provide an estate that is fit for purpose and economically provided. Focused on: 2013-14 12, 22 Director of Strategy, Planning

and PerformanceService Delivery/ Estates/

Strategy

Local Energy saving measures April-December 2013 12 Director of Strategy, Planning

and PerformanceService Delivery/ Estates/

Strategy

ISO14001 Compliance 2013-14 12,16,22 Director of Strategy, Planning and Performance

Service Delivery/ Estates/ Strategy


Timescales


Value for money workstreams still under developmentWe are still in the process of developing robust activities to deliver this objective during 2013-2014. They will focus on (not exclusively): Procurement expenditure reduction Minimised back office costs Optimum utilisation of resources Non-pay expenditure reduction/ maintenance- including fuel cost minimisation Pay costs and in particular the balance of overtime costs Income generation opportunities including Health Courier Services Contract management

Support to Deliver 2013-2014 Objectives

Core Workstreams Unscheduled Care

Commitment to Equality and Diversity.

Commitment to responsible use of resource and minimising Environmental Impacts

Commitment to working with our partners and stakeholders to deliver the best health outcomes for the people of Wales

Supp

ortiv

e Co

rpor

ate F

uncti

ons


2. Improving Access and Resilience

3. Improving outcomes and experience of care

4. Helping our staff to excel

5. Delivering value for money

StrategicPriorities

•Workforce Strategy :

Embed team based working

Agree and implement rota and meal break policies

Deliver Occupational health and staff support workstream

Establish workforce capacity/ competency gap

Update ESR/ and develop a trust-wide workforce plan

Workforce

•ICT Strategy:Trust Website/ Intranet redesignImplement Virtual Control ModelUnified communicationsImplement integrated telephony systemProvide CFRs with communication Devices•InformaticsDeliver an action plan to ensure compliant Information Governance throughout the organisationDevelop and implement CAD Roll out data warehouse and single platform systems

Finance

•Implement Clinical Strategy, focused on: Completion of

HIW Action plan

Conduct feasibility assessment to implement Paramedic Pathfinder

Conduct an audit of the effectiveness of Safeguarding Policies in operational compliance

Improve monitoring and management of Infection control

Increase nurse led assessment

Clinical Model

•Review of Estates Strategy.

Deliver: Wrexham

ARC Cardiff ARC

FBC Reduction in

high risk maintenance backlog

Implement ISO14001 compliance

Local Energy saving measures

Estates

•Revise and implement fleet strategy, focussed on: Implement

agreed recommendations of fleet review

Procure required fleet

Undertake local review to ensure PCS vehicles reflect Health Board SLA requirements

Develop maintenance plan for medical devices

Fleet and Equipment

•Fully aligned budget setting based on:

Development of LTFM

Support savings scheme identification

Introduce procurement and stock control measures

Provide increased support to locality managers in budget monitoring

ICT and Informatics

•Corporate Strategy:Improve DATIX functionality (Staff feedback)Revise processes for developing policies

Communications Strategy:Develop a ‘Team Brief’ to improve internal communicationDevelop and hold annual staff awardsDevelop and implement staff suggestion scheme

Corporate

39

All directorates have aligned their strategies to support the delivery of the agreed organisational objectives for 2013-2014, whilst remaining on track to deliver the aspirations of working together for success.

Examples include:

1. Improving Clinical Quality and Safety through improved monitoring and management of local Infection Control measures

2. Improving Access and resilience by developing a virtual control and unified communications

3. Improving Outcomes and Experience of Care through the procurement of a sustainable fit for purpose fleet of vehicles.

4. Helping Our Staff to Excel by providing occupational health and wellbeing services, whist ensuring they are kept informed of developments through regular team briefs.

5. Delivering Value for Money through the development of a long term financial model and supporting locality managers with budgetary management.

Alignment of the ADP with other Trust StrategiesThe ADP is developed in parallel with the trust Fleet, Informatics, ICT and Estates strategies, among other existing plans. The developments outlined in the ADP are critically independent with the delivery of these strategies, which are widely available for review.

Fleet StrategyIt is recognised that the Fleet Strategy, albeit less than 12-months since its approval, will require an update in the near future. As evaluation work is being conducted into areas like the use of alternative types of vehicles and the alignment of fleet with the clinical response model, workforce plan and the Clinical Strategy, the profile of vehicle procurement may well change again. It is however crucial for WAST to be able to demonstrate, with robust evidence, best practice and value for money in its fleet procurement programme.

Estates Strategy

The trust aims to ensure that the estate that we occupy offers the best possible environment for staff and the most effective and efficient network of resource centres and maintenance facilities. Whilst the core principles of the Estates Strategy remain as planned a number of external factors have affected our progress towards delivering new facilities. We have also learned a number of important lessons from the development of both HART and Dobshill facilities that we will apply in the course next year. Although subject to securing confirmed capital finding and appropriate locations in the coming year our strategic efforts will be focused on:

• ARC & Fire Station Wrexham full business case approval and proceed to build

• ARC Cardiff Outline Business Case, securing site and commence planning process

Minor capital works, and ensuring our existing estate is fit for purpose and safe for our staff to inhabit, will also be a major priorities over the coming year; Asbestos condition monitoring, remediation and removal works, along with legionellosis testing & cleansing are essential to providing safe habitable facilities for all staff. We will also be focusing on:

• Fire Safety Management

• General improvement works and enhanced energy efficiency measures across the estate

• Achieving and maintaining ISO 140001 Environmental Accreditation

Finally we will be aiming to identify opportunities for income generation whilst ensuring that all facilities within the trust have appropriate building cleaning in place.

ICT and Informatics Strategy

All of the planned workstreams for next year remain aligned with the ICT and Informatics strategies. These workstreams are focused on:

Patients and Citizens• Better direct patients and the public to the information or care they need or to getting to their

appointment on time; • Give the public access to the information they need to know in the right way, at the right time

and in the right place, whether that’s at home or on the move; • Provide contact with care providers, such as telephone consultations and e-booking

appointments;

40

41

• Use commonplace ways to communicate such as SMS and voicemail as reminders to help patients keep their appointments;

• Better connect the public and patients to us by providing a wider range of services via the internet or remotely;

• Improve how we coordinate patient care with health care providers and other associated services by improving communication, sharing and integration of patient information so that patients only have to describe their problem or give information once.

Staff and Partners• Give staff appropriate access to modern systems, tools and high-quality, up-to-date, relevant

information so that evidence-based clinical and care decisions can be made effectively; • Use technology to inform staff of progress, changes and alerts wherever they are in the most

appropriate way to them as individuals; • Give power to staff to gain knowledge with self-service access to relevant, timely and accurate

information about themselves, their area and the Trust; • Offer staff choice about how they access IT services and how we communicate with them; • Involve staff to play a part in improving the operation of the systems they use; • Work with staff to develop information literacy skills via e-learning so that staff are confident

and effective in their use of information and technology; • Enrich our sense of belonging to our professional communities and with each other by using

social media tools and other current systems.

42

Our Financial Framework 2013-2014The Financial Assumptions for 2013-2014-Financial outlook 2013-2014 The final revenue allocations are unconfirmed at this stage, but we believe that one of three outcomes are likely at this stage:

• The least likely is an uplift in the organisational budget in the region of 3% in line with forcast increases in activity

• The Best case is a “Flat cash” outcome (i.e. no uplift for inflation and cost pressures)

• The Worst Case is a “Flat cash minus 5% (i.e. net reduction in funding)

Budget setting methodology In order to set budgets for the coming year, the initial directorate budget control totals as per 2012-2013 recurrent base are utilised i.e. planned 2013-2014 budget not to exceed 2012-2013 net budget.

Then each directorate has being asked to identify equivalent cash releasing efficiency savings equal to offset its own identified cost pressures as a minimum. In addition to this the following assumptions are being applied:

• The impact/options for a potential 5% budget reduction has been modelled in Directorate ADPs

• Budgets have been set at an 2013-2014 price base including pay drift due to incremental awards among other cost pressures

• A Zero Based Budgeting approach was then taken to cost base

• With regards capital charges, the funding assumed is as per 2013-2014 forecast

Estimated Cost pressures include: As previously highlighted there are a number of substantial cost pressures forecast for next year; further compounding the strain placed on the organisation by a likely “flat cash” allocation in the face of rising demand for services. These include(not exclusively):

• Pay awards £1.2m (1.1%)

• Incremental Drift £0.7m (0.6%)

• Pensions auto enrolment resulting in additional corporate contributions to individual pensions £0.4m (0.4%)

• Non pay inflation £0.8m (2.8%)

The overall impact of this is estimated to be 2.3% increase in costs to the organisation overall. The funding gap identified as a result of non-achievement of previous year’s cash releasing savings will compound financial challenge for 2013-2014. Capital The final 2013-2014 Capital allocations currently not confirmed, however conservative estimates are that Discretionary Capital is anticipated to be circa £3.058m. With this in mind, Directorate ADP assumptions requiring capital support will be subject to bid prioritisation whilst resource is sought

Other Financial Risks Identified:43

A number of key risks have also been identified within the plan. These are very similar to those that have been managed during 2012-2013 and include:

a critical financial risk of failure to achieve planned efficiency savings or failure to achieve Ambulance response performance targets, without exceeding budgeted operational funding levels;

Failure of the wider health economy to achieve the 15 minute national patient handover target. If the handovers remain at current levels this would impose an additional unfunded full year cost pressure on the Trust in excess of approximately £3m;

Increases in activity will increase the cost of the Trust of approximately £60 per patient for variable costs and additional cost in order for the Trust to continue to meet its performance standards;

Fuel prices remain volatile and appear to be on an upward trend. Each 1p increase in the cost per litre will increase fuel expenditure by £40k based on current consumption levels;

any reduction in income from WHSSC will result in further savings being required in order to achieve a breakeven plan;

any changes in statutory requirements (e.g. in infection control) will cause an additional cost pressure for the Trust; and

Emergency vehicle maintenance is not always controllable and the majority of the EMS fleet is currently over 4 years old. Therefore there is a risk that emergency vehicle maintenance expenditure will need to be greater than the budget for reasons outside the Trust’s control.

How Will We Monitor Progress?

Ongoing Integrated Risk Management and AssuranceThe proposed approach across Wales is that organisations should utilise a Board Assurance Dashboard (appendix 4) that ensures that there is a “golden thread” that links all organisational plans and priorities, risk, delivery and measurement into an overall system of assurance.

The components of the Assurance System can be summarised as follows:

Plans and priorities

Organisational priorities are currently set out in 3/5 year strategic plans and are translated into specific aims and objectives as part of the annual planning process. These plans are rooted in the Citizen Centred planning principles for Wales and encompass Welsh Government and local priorities for improvement and change. There may be a need to consider the format of local plans to ensure that they are supportive of this proposed system of assurance.

RiskAgainst each strategic objective, there will be a need to assess the risk of achievement prospectively as a fundamental part of the planning process. This should be undertaken in a structured way and in accordance with the organisations risk assessment procedures.

This will in essence form the corporate risk register at the beginning of the year and will be updated regularly to reflect the periodic review of risk registers as set out in local policies. There will need to be a reconciliation against the existing corporate risk register to ensure that these are all appropriately captured. Any new risks identified during the year will be assigned against the relevant objective. The Audit Committee will wish to assure itself that any new risks or significant escalation of risk, were reasonably unforeseen at the start of the year.

DeliveryAnnual plans will already include actions and processes to ensure delivery of the agreed priorities and to mitigate risk. This is another way of describing “controls and safeguards” but in a way that the organisation will more widely understand. Again, depending on the current style of Annual Plans, there may need to be a consideration of re-formatting to ensure that these are captured and summarised in a way that supports a translation into the overall Board Assurance Dashboard.

MeasureThis can be simply described as “How do we know” and will be a combination of quantitative and qualitative information. Whilst historically, the routine performance reports against Welsh Government targets have been seen as “outside” the assurance framework, this proposal reflects that these are fundamentally part of this process and the “Performance dashboard” should ideally be integrated into this overall system of assurance.

45

Approach to Monitoring Plan Delivery and RiskThe core elements of effective integrated planning include robust identification of local and corporate risks, robust data regarding service demand, clear alignment with strategic priorities and the detailed financial constraints that the organisation is operating in. For this reason an optimum process for planning business developments for the coming year starts with the identification of local risks and the subsequent identification of development actions that address these risks.

The resultant formal and informal review process for the delivery plans should take the form that ensures that progress is monitored and risks dynamically assessed on ongoing basis. This should be managed without the requirement for excessive documentation or micromanagement of operational plan delivery. Therefore this should be conducted according to the following structure:

Monthly exception reports from nominated local plan leads, on progress with delivery of plans, obstacles to delivery, resource, capacity and general service risks. This is coordinated and documented by the local Planning Team. Local risk registers will also be reviewed and updated at this point, with any substantial additions or changes escalated to the corporate register. The head of planning will then provide a summary verbal update to Bi-Monthly Strategy, Planning and Performance Committee.

Quarterly progress reports to board regarding any substantial variances from planned actions will be produced to provide regular assurance as to the likelihood of delivering against development and performance objectives. This will include a populated copy of the assurance dashboard detailed below.

Mid-Year and End of Year formal performance reviews will require local directorate leads to produce evidence of their performance, delivery against plan and dynamic risk management. A summary of these reviews, and any actions or emerging priorities for the following year, will be produced for review by the Board. Any feedback will then be shared with leads to ensure that any required changes in approach or priorities advocated by the board are acted upon promptly.

46

Appendix

1. Summary Workstreams and Timelines 46

2. Financial Plan 2013-2014 x

3. Capital Plan 2013-2014

x

4. Assurance Dashboard Template 50

5. Draft Directorate Business Plans

x

6. Draft Health Board Area Plans X

7. Workforce supportive Information X

These documents are illustrative and subject to change over the coming year in order to ensure a flexible approach that is responsive to local and national health service changes

47

Appendix 1- Insert Summary Gant Chart Under Development

46

Appendix 2- Financial plan47

48

Appendix 3- Capital Plan49

Appendix 4- Proposed DashboardStrategic Objective 1 – To improve the health and well-being of the local population and those that use our services

Plans / Priorities Risks Risk Rating

Delivery Measures Assessment RAG Further Assurance

requirement

Board / Committee

meetingPlan

Now

Reduction in avoidable harm from diabetes by 20% against the 2012-2013 baseline by 2015

Population trends on obesity continue to rise

25 25 Multi-partner group established with detailed delivery plan to be agreed by December 2013

Numbers diagnosed in primary care

1% increase from 2012 baseline

Progress reports on agreement of delivery plan to be produced setting out detailed programme management arrangements

Integrated planning and performance

Reduction in inpatient days

0 % change over previous year and 0 % change in previous month

Reduction in avoidable amputations

0 % change over previous year and 0% change in previous month

Health Board is able to demonstrate to the population that it is a public health practicing organisation

Platinum Corporate Health Standard not attained

12 12 Multi-disciplinary Corporate Health Standard Group Established. Actions monitored through formal programme management mechanism

Assessment against Standard 3 – Health promotion, protection and improvement

2011/12 assessment of 4

Progress report to be provided to January 2013 Committee

Workforce Committee

Achievement of corporate health standard

Assessment date is March 2013

Director of Public Health Annual Report

Good progress including reduction in staff obesity and implementation of No smoking policy

For illustrative purposes only

50

Appendix 5- Directorate Business Plans (TBC)Example Plan- Directorate X

Executive Sponsor: Tim JonesDelivery lead Clare DonaldsonMain stakeholders:• PATIENTS

Status against plan

Additional Resource requirements• 2 – 3 FTEs over 12 months

Performance Metrics

Interdependencies to other plans• Clinical Skills Enrichment• Navigation systems•Cost improvement x

Risks to delivery of Plan• Pathway redesign support for stroke pathway• IT mapping exercise for new routes•

Key service risks• Staff resistance to change• Jglo8• H8yo;8

A1 STEMI Care bundles

APR 13 MAY 13’ JUN13’ ’JUL 13 AUG13 SEP 13

A2A3 A4

’

Local ObjectivesA1 To improve the proportion of patients with a acute ST-elevation myocardial infarction (STEMI) who receive an appropriate care bundleA2 Increase the number of patients being referred to appropriate care pathways to at least 8%

A3

ETCETC

SHS Area

Local MEASUREs (where applicable) EXPECTED CHANGE

Number of Cat C care ferred to self-careNumber of website hitsNumber of patients conveyed to hospital

IncreaseIncreaseDecrease

1.2

1.4

1.3

Score

16

12

6

’OCT 13 NOV 13 DEC 13 ’ FEB 14 MAR 14 ’

Quality

Pathways

Workforce

JAN 14

Under Development

51

Appendix 6- Heads of Service Business Plans Example Plan- Directorate X

Executive Sponsor: Tim JonesDelivery lead Clare DonaldsonMain stakeholders:• PATIENTS

Status against plan

Additional Resource requirements• 2 – 3 FTEs over 12 months

Performance Metrics

Interdependencies to other plans• Clinical Skills Enrichment• Navigation systems•Cost improvement x

Risks to delivery of Plan• Pathway redesign support for stroke pathway• IT mapping exercise for new routes•

Key service risks• Staff resistance to change• Jglo8• H8yo;8

A1 STEMI Care bundles

APR 13 MAY 13’ JUN13’ ’JUL 13 AUG13 SEP 13

A2A3 A4

’

Local ObjectivesA1 To improve the proportion of patients with a acute ST-elevation myocardial infarction (STEMI) who receive an appropriate care bundleA2 Increase the number of patients being referred to appropriate care pathways to at least 8%

A3

ETCETC

SHS Area

Local MEASUREs (where applicable) EXPECTED CHANGE

Number of Cat C care ferred to self-careNumber of website hitsNumber of patients conveyed to hospital

IncreaseIncreaseDecrease

1.2

1.4

1.3

Score

16

12

6

’OCT 13 NOV 13 DEC 13 ’ FEB 14 MAR 14 ’

Quality

Pathways

Workforce

JAN 14

Under Development

Appendix 7- Supplementary Workforce GuidanceOutcome Suggested inputs Output/KPI

Strong and trusting two way relationships between managers/team leaders and each of their individual members of staffEvery member of staff has a clear understanding of their team and Trust goals and culture (e.g. Staff Charter)

Managers/team leaders to arrange to meet each of their staff regularly and focus on the relationshipsIndividuals given as much autonomy as possible in relation to what they should be doing and how they should be doing itEffective use of support (e.g. Employee Wellbeing service)

Every member of staff has a recorded PADREvery member of staff has a Personal Development PlanImproved productivity

Every individual within the Trust knows which team they belong to and owns their team’s purposeEvery team uses the staff survey to identify actions they need to do undertake

Team based working development for each teamStaff survey data

Every team has an agreed purpose statementEvery individual identifies with their teamIncreased engagement

Each team understands what levels of competence (skills, knowledge & behaviour) are required to deliver WTFS and has developed a plan as to how it will get there including reviewing the rotas and other ways of working

The competency frameworks (road based workforce and CCC)Discussions with partner organisationsto ascertain competency levelsReview of rotas to ensure that staffing levels & competence meet local demand needs

Job descriptions, KSF outlines, scopes of practice created/ amended to meet local needsIncreased matching of people and equipment to meet local demands: increased “performance”; reduced overtime; increased ability to provide dedicated learning time; dedicated team time etc

Outcome Suggested inputs Output/KPI

Every member of staff is competent against their KSF outline evidenced through an annual review/assessment

Reviewing of KSF outlinesAccess learning to meet individual requirements/ needs: - Feedback/coaching- Mandatory training- CPD sessions- Workshops

Every employee has a KSF review/assessment against their KSF outline (to include full compliance against mandatory training requirements)

Managers and staff use electronic systems to record all activity (e.g. PADR, attendance, training)

Ensure manager/employee self-service and OLM utilised

Workforce information recorded for all staff

€¦ · web viewpatients suffering suspected stroke now receive the optimum care in the majority...

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