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Submission to the Health, Social Care and Sport Committee’s general scrutiny inquiry. |
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Contact: |
xxxx Director of Corporate Services & Governance / Board Secretary xxxx |
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Date: |
Written evidence: Tuesday 7 May 2019 Oral evidence session planned for Thursday 23 May 2019 between 9:30am and 11am |
Introduction
Cwm Taf Morgannwg University Health Board welcomes this opportunity to contribute to the Health, Social Care and Sport Committee’s general scrutiny inquiry.
The former Cwm Taf University Health Board, was established in 2009, with responsibility for the provision of services to around 301,000 residents within the local authority boundary areas of Merthyr Tydfil and Rhondda Cynon Taf. Cwm Taf UHB had around 8,100 members of staff working across Primary, Community & Secondary Care. The budget of the Health Board (net of our hosted bodies, Welsh Health Specialised Services Committee and Emergency Ambulance Services Committee) was circa £650 million.
From 1 April 2019, Cwm Taf Morgannwg University Health Board replaced the former organisation, after responsibility for healthcare services in the Bridgend County Borough Council area transferred from Abertawe Bro Morgannwg UHB. The Health Board now serves a population of around 450,000 residents and has around 11,600 staff working across Primary, Community & Secondary Care. We now operate three District General Hospitals, one Health Park and six community hospitals, along with 110 Community Pharmacies, 53 Dental Practices, 55 General Medical Practices and 48 Optometrist Practices. The Cwm Taf Morgannwg UHB has a budget of circa £900 million.
In addition to the originally requested overview of organisational performance, the Committee has also requested a summary of the recent concerns regarding maternity services in the former Cwm Taf University Health Board.
Following changes in the senior clinical management of the maternity service in 2018, it was identified that there was a potential under-reporting of serious untoward incidents in the Health Board’s Maternity Service. This was initially reported to Welsh Government and a number of internal reviews commenced to identify the scale of the problems and to ensure mitigating actions were put in place as quickly as possible.
In October 2018, the Minister for Health and Social Services commissioned an external review of the service from the Royal College of Obstetricians and Gynaecologists & Royal College of Midwives.
The report was published on 30th April 2019 and outlines very serious concerns about the quality of care and the experiences of women and their families in the former Cwm Taf UHB maternity services.
The key concerns identified within the report relate to failings in systems of quality governance with particular attention drawn to issues of:
· Cultures and behaviours
· Lack of staff engagement
· Staffing levels
· Lack of role clarity and inter-professional working
· Assurance regarding data quality and compliance with national standards
· Systems for reporting, investigating and learning from incidents
The report particularly challenges the Board to consider its own systems of governance and assurance in light of the concerns raised. This includes systems for scrutiny of data, regular review of key organisational risks and effective challenge to the Executive Team.
The Board received the report in a special public Board meeting on 30th April and accepted, in full, the findings and recommendations of the review.
This briefing paper aims to provide the headline information and is supplemented by more detailed reports, the links to which are embedded in the narrative.
Key Messages
1. The transfer of the responsibility for commissioning and delivery of services for the Bridgend County Borough Council population transferred from Abertawe Bro Morgannwg University Health Board to Cwm Taf University Health Board on 1st April 2019. This significant change was delivered through a joint Transition Programme which operated during 2018/19.
2. All matters in this paper relating to service and financial performance and, more specifically to maternity services, refer to the former Cwm Taf University Health Board. Looking forward, all planning and delivery arrangements, including the improvements in response to the recent Maternity Services Review will apply across the whole organisational footprint.
3. The former Cwm Taf UHB has a track record of approved IMTPs and delivery against key objectives. Subject to audit, the Health Board reports delivery of all statutory financial targets for 2018/19 and compliance with agreed Referral to Treatment Times (RTT) trajectories.
4. Following local identification of concerns with incident reporting in its maternity service last summer, together with some failings identified in other external audit reports, the escalation status was increased to ‘enhanced monitoring’ in January 2019 on matters relating to quality governance. The Board implemented a number of key measures to improve performance and these have been reported through the public Board. Cwm Taf Board Meeting Papers. However, it is fully recognised that there is significantly more work to be done to ensure that the organisational governance arrangements are sufficiently robust and provide the necessary assurances both internally and for partners and regulators.
5. Cwm Taf Morgannwg University Health Board (the Health Board) received the Welsh Government commissioned report from the Royal College of Obstetrics and Gynaecology and the Royal College of Midwives on 30 April 2019. Cwm Taf Board Papers 30 April 2019 The report identified serious failings in its maternity services at Prince Charles Hospital and the Royal Glamorgan Hospital.
6. Needless to say, the challenges in our maternity service and in particular receiving some of the patient feedback has been a very difficult and sobering experience. The Health Board Chair and Chief Executive have both offered an unreserved apology for the failings in service identified and the Health Board has fully accepted all the findings of the Royal Colleges’ review.
7. Putting things right is now the organisation’s utmost priority. The Health Board takes its responsibilities for delivering high quality, safe care and maintaining good governance arrangements with the utmost seriousness.
8. The Health Board has been working hard to make improvements in maternity care and implementation of some of the recommendations in the report is already underway, including the actions taken following the immediate feedback from the review team in January 2019. However, it recognises that significant work remains to be done and is committed to undertaking all necessary action to deliver the report’s recommendations in full.
9. The decision of the Minister for Health and Social Services to increase its escalation status (‘special measures’ for maternity services in the former Cwm Taf University Health Board area and ‘targeted intervention’ for Cwm Taf Morgannwg University Health Board), provides a strong focus for the organisation so that everyone can be provided with the assurance that all necessary action is being taken, at every level, to deliver improvements.
10. The Health Board also welcomes the expert advice and oversight announced by the Minister for Health and Social Services, and will be working closely with Welsh Government officials to take the required action to put these arrangements in place.
11. With a previous good reputation, an approved Integrated Medium Term Plan (the Plan) and as a new organisation, with the administrative boundary change including Bridgend having come into effect from 1 April, Cwm Taf Morgannwg University Health Board is determined to step-up to the improvement required and deliver on its commitments for the patients, families and staff on behalf of the communities it serves.
Escalation, Intervention and Improvement
12. On 30th April 2019, in response to the Minister for Health and Social Services publishing the reports by the Royal Colleges of Obstetricians & Gynaecologists and Midwives, the Minister announced that the maternity services in the former Cwm Taf University Health Board area were to be placed under ‘special measures’. He also stated that he expects any learning to be applied to the Bridgend locality maternity services.
13. In the same statement, the Minister also announced that the organisation’s overall escalation increased to ‘targeted intervention’. This allows a period for review bodies to look at a range of wider issues including quality governance, serious incident reporting and leadership and organisational governance, and for the Board with its Executive Team, with external support and overview, to put in place the appropriate measures.
14. The Health Board has expressed unanimous determination to deliver the necessary improvements. Some issues will take time so that they can be fully embedded in the organisation’s governance arrangements and therefore we recognise the need to sensitively balance pace with sustainability as we work through the requisite actions. The Board also welcomes the additional oversight arrangements and support that has been made available and is fully committed to working openly and closely with those individuals.
15. Varying degrees of progress have been made in all of the areas identified as part of the January 2019 escalation. This includes Board approval of the measures associated with compliance with the Nurse Staffing Act; agreement of the Ionising Radiation and Medical Exposure Regulations (IRMeR) action plan with HIW and completion of most actions; sign-off, to date, of 25 of the 32 CAPA plans associated with the Human Tissue Authority (HTA) inspection; development of draft quality framework; and progress with development and delivery of a maternity improvement plan. Whilst a considerable amount of work has been undertaken to start to address the identified failings, the Health Board will work with Regulators and with Welsh Government to ensure that progress continues to be made and all necessary assurances given.
16. In November 2018, the Board resolved to establish a Maternity Improvement Board to oversee the development and delivery of an improvement plan in response to the concerns identified. An Independent Chair, external to the Board, was appointed with membership drawn from the service and Health Board management team. Membership also included the Vice Chair of the Board (as Chair of the Quality Safety and Risk Committee) with Welsh Government and Healthcare Inspectorate Wales invited to be in attendance.
17. Specific actions in relation to maternity services include:
· Development of a detailed Maternity Improvement Plan, drawing on the work of the various internal review processes and reports and feedback from staff engagement. This Plan is being reviewed further as a consequence of the external Royal Colleges report, to ensure it fully captures all the recommendations of the external review.
· Assistance secured from the Welsh Government Delivery Support Unit (DSU) to support the multidisciplinary team (MDT) in the process elements of reviewing the SUIs.
· Weekly maternity oversight meetings, attended by Welsh Government officials, were established in addition to the scheduled monthly meetings of the Maternity Improvement Board. The Chief Executive and other senior officers also met periodically with senior officials in Welsh Government to discuss the ongoing reviews and related progress.
18. Wider Improvement Actions include:
· The Health Board has engaged directly with Wales Audit Office (WAO) and asked if we can work with them to be the first organisation to participate in the 2019/2020 thematic review of Quality Governance. We believe that this will help us become early adopters of best practice and accelerate our improvement.
· The Chair and Chief Executive have met with Healthcare Inspectorate Wales (HIW) to discuss progress. The Health Board is keen to work closely with WAO and HIW to align the benefit of both perspectives to help the organisation to quickly strengthen our systems of governance and assurance.
· The Health Board has recognised and fully accepted the need for strengthened assurance in a number of important areas. We are determined to work with Welsh Government officials and others to ensure that we meet the assurance requirements on the quality governance issues raised and very much welcome the further planned assistance that will be provided to the Health Board.
Integrated Medium Term Plan
19. Building on previously approved Integrated Medium Term Plans, our recently approved Plan for 2019-2022 is the first that serves the wider population following the 1st April 2019 Bridgend boundary change. Cwm Taf Morgannwg University Health Board now has responsibility for the commissioning and provision of healthcare for the communities of Merthyr Tydfil, Rhondda Cynon Taf and Bridgend County Borough Councils.
20. Coupled with the strategic direction set out in ‘A Healthier Wales: Our Plan for Health and Social Care’, the next three years provide us with a real opportunity to learn, grow and transform - building on the strengths of both new and existing communities to deliver better health and care for all. The Health Board Plan sets out how we will do that. Where possible, business is described from the perspective of the new organisation, however where this is not possible, as we are early on in the transition and integration, the Plan describes the existing Cwm Taf perspective, the Bridgend perspective and the steps planned to reach an integrated position.
21. Recognising that the short term focus of the Plan is to ensure the smooth and efficient transition of services and staff, we are over the course of this year building on the staff engagement work of recent years to deliver a strategic approach to organisational development that aligns people, strategy and process.
22. Our ambition is to drive even further forward, at pace, our transformation agenda. We are determined that by implementing our Plan and by working closely with our partners we will maximise the resources available to us to ensure that we can continue to deliver safe and effective services to the population of Merthyr Tydfil, Rhondda Cynon Taf and Bridgend. Working together remains important to us and is essential if we are to make our vision a reality.
23. The Health Board objectives will be achieved by working closely in partnership with our staff, partners and local communities; in line with our quality and performance standards; and within a financial envelope which is both value for money and affordable.
24. Over the lifetime of our Plan, we will increase our collaboration with our NHS partner organisations, as well as working more closely with public sector colleagues under both the Social Services and Wellbeing Partnership Board and our revised Public Service Board arrangements. In doing so, we will look to maximise opportunities for workforce modernisation and sustainability afforded by the Well-being of Future Generations Act, Social Services and Well-being Act, Prosperity for All: the National Strategy, A Healthier Wales: our plan for Health and Social Care and the Cardiff City Deal.
Workforce
25. Our workforce is clearly our most significant asset and it is through the commitment, professionalism and dedication of our staff that we are able to deliver high-quality services to our population.
26. During the lifetime of our Plan, the most significant changes directly affecting our workforce are the transition due to the Bridgend boundary change and ensuring the development of a compassionate, learning culture across all of our services.
27. A key focus of our workforce agenda in the short to medium term is to ensure the smooth and efficient transition resulting from the boundary change in April 2019 through a strategic approach to organisational development to enable the new organisation to align people, strategy and processes, and maintain quality and governance of services in doing so. This programme of work will include the implementation of new operational structures which reinforce role responsibilities and accountability for quality and safety as well as performance and financial delivery, underpinned by the development of new organisational values and supporting behaviours.
28. Following the 2018 staff survey, the UHB has embarked on the development of an action plan in partnership with staff side colleagues, developed with the staff at local level. In addition to a range of activity to improve staff engagement and address the outcomes of the survey, a particular focus will be the launch of a Call to Action to eliminate bullying and harassment.
29. Some of our greatest risks to quality of service and service transformation are as a result of workforce fragility and recruitment difficulties in a number of areas across the Health Board. In addition to implementing new and refreshed recruitment campaigns for nursing and midwifery and medical staff, we will have a strong focus on retention and staff engagement.
30. We will also be prioritising workforce modernisation across 2019/20 with investment in knowledge and expertise to drive this agenda forward. To support the modernisation agenda within Cwm Taf Morgannwg, a Workforce Modernisation Board has been established to provide advice and recommendations to the Executive Board and oversee the delivery of the programme of work.
Performance
31. In terms of performance, we have delivered positive performance in a number of key areas in 2018/2019, including in Scheduled Care, Unscheduled Care, Cancer Services, Diagnostic Services and Mental Health Services. The following is a summary of year end achievements, a link to our latest Board report and dashboard is also provided. Cwm Taf Morgannwg UHB Board Papers including latest performance report & dashboard
· Referral to Treatment Times (RTT) – The end of year reported position is that the Health Board successfully delivered 52 and 36 week targets for 2018/19 with zero patients waiting over 36 weeks for treatment.
· Diagnostic Waits– The reported end of year position is 27 patients waiting over 8 weeks, compared to 72 in March 2018. These 29 are in two areas, with 13 waiting for Diagnostic Angiography and 14 waiting for an Endoscopy.
· Unscheduled Care – Performance at a Health Board level for the 4 hour target for end of year i.e. March 2019 was 83.2%. The March performance for the 12 hour target improved to 437 patients (261 at PCH and 176 at RGH) compared to 496 breaches in March 2018.
· Emergency Ambulance Services - March performance for emergency ambulance services against the 15 minute handover target was 90.3%, compared to 90.7% in February. The March performance for emergency ambulance services over one hour was 100%.
· Performance against the Red Ambulance target declined significantly during February to 69.9% from 76% in January. Cwm Taf’s performance was also lower than the All Wales average of 72.4% but remains above the national target of 65%.
· The numbers of patients whose discharge from hospital was delayed improved from 36 in February, to 33 in March.
· Cancer 31 and 62 Day Target - The 31 day target (Non Urgent Suspected Cancers) of 98% was narrowly missed in February with two breaches, both in Urology, resulting in a compliance level of 97.9%. For both patients, the decision to treat was made at the tertiary centre, hence the full wait was at the tertiary centre.
· The 62 day target (USC) compliance was 91% for February, a further improvement on last month’s progress, with breaches in Urology again low at 2, as was the case in January. In total there were seven breaches, with the reasons for non-achievement being delays awaiting diagnostic investigations and delays awaiting surgery, both local and tertiary.
· Mental Health Measure – Part One (Primary Care assessment and treatment), performance was 51.2% against a target of 80%. Part Two (valid care treatment plan completed by end of each month) improved in March to 89% against a target of 90%. Part Three (receipt of an outcome assessment report within 10 days of assessment) was 100%.
· Primary Care CAMHS– The related waiting list has been growing during the last quarter and currently stands at 341, due to an increase in demand. The maximum waiting time has reduced from 30 weeks to 26 weeks. Actions including additional staff resource, have been recruited to respond to the increased demand.
· Specialist CAMHS– Compliance against the four week target was 89%.
32. We have set out in our Plan the profiled performance that we will be aiming for as a Health Board over the next 12 months, as we strive for improvement in our service provision.
33. The Health Board has made very significant strides on development of performance data in recent years and the Integrated Performance Dashboard continues to be developed. In profiling performance for 2019/20, the Health Board has made some ambitious and challenging assumptions in relation to a number of key areas.
34. Our ambition continues to be to have balanced demand and capacity plans where demand is met from internal core capacity, a component of which is provided on a Regional basis. However, manpower constraints in the short to medium term means that a small proportion of outsourcing will still be required to meet the referral to treatment performance targets in 2019/20.
35. The ambition of the Health Board is to sustain its achievements up to March 2019 in the future, whilst taking on the challenge of delivering improvements across the wider organisation from April 2019 onwards.
Finance
36. The Plan outlines the challenges in the coming years faced by all Health Boards in that the core allocation is increasing at a lower rate than growth in expenditure from increasing population need, inflation and cost pressures, which thus requires annual improvements from efficiency and re-design to remain in balance. The Plan provides for the Health Board to meet this challenge and continue its record of finance balance through the 3 year plan period.
37. The level of efficiency and redesign savings required in order to close this gap between funding and demand and so deliver a balanced budget is £12.8m in 2019/20.
This is 1.4% of the controllable budget of circa £900m. The total recurring savings required over three years is £41.8m (4.6%).
38. Key specific local issues the financial plan is aiming to address are:-
· The financial impact of the transfer of Bridgend to Cwm Taf Morgannwg. The Health Board is in the closing stage of the process to assess the element of the underlying ABMU deficit in 2018/19 which relates to Bridgend and will transfer to Cwm Taf Morgannwg, and to agree with Swansea Bay and the Welsh Government how this can be managed in a way which is consistent with the commitment that the Health Board will not be adversely affected by the transfer.
· The delivery and ongoing sustainability of the Health Board’s out of hospital transformation plans.
39. Our broader aim in the Plan is to make the most effective use of all the resources available to the Health Board, as opposed to focusing only on financial savings targets. Whilst the healthcare needs of our local population and the quality and safety of patient care remains our number one priority, the Health Board understands and is committed to radically redesigning both systems and services in order to ensure that the best value is achieved from its resources.
Brexit
40. The Health Board has nominated a Senior Responsible Officer for Brexit which is the Director of Public Health, supported by the Civil Contingencies and Business Continuity Manager.
41. There is representation at the key required national groups and regular updates on progress are provided to the Executive Board and Health Board.
42. A Brexit Risk Assessment and Plan have been drawn up, ensuring that the Health Board has met its obligations with reference to collaborative planning and preparedness. This remains under review as the Brexit process continues.
Conclusion
43. 2018/19 has been a very challenging year for the Health Board. The particular concerns regarding maternity services and wider quality governance arrangements challenge the Board to fundamentally review its processes and working practices to strengthen systems of governance and internal control.
44. Whilst positive progress has been made in the development and delivery of many clinical services, the significant change agenda associated with the boundary change and the quality governance issues identified, has meant that the Board has reflected hard on the way in which it must work differently to provide strong leadership and assurance going forward.
45. In response to the change in escalation status, the additional governance advice provided to the Board will positively support the organisation to improve culture, systems and processes. We will use this opportunity, together with the learning from the 2019 WAO national thematic audit on quality governance and the proposed HIW local governance review, to further strengthen systems of internal control going forward.
46. In addition to strengthened systems of quality governance, it is recognised that further focus on staff and stakeholder engagement will be critical to success.
47. The recruitment of staff continues to be a major challenge. Delivering high quality safe services in this context will require further significant changes to future models of service delivery.
48. The integrated healthcare system in NHS Wales continues to offer the best opportunity to deliver joined-up systems of care. Strong relationships with Local Authority and Third Sector partners, supported by Integrated Care and Transformation Fund resources create the environment to move towards systems of anticipatory care which will improve quality and help manage future demand.
49. Greater engagement with stakeholders, continued development of partnership working, stronger systems of governance and focused leadership will ensure that Cwm Taf Morgannwg UHB delivers the best possible health services for its population.