Cardiff and Vale University Health Board submission to the Health, Social Care and Sport Committee’s General Scrutiny Inquiry
Contact: Len Richards, Chief Executive
20th June 2019
1. Introduction
Cardiff and Vale UHB welcomes the opportunity to contribute to the Health, Social Care and Sport Committee’s general scrutiny inquiry. This submission provides an overview of the organisation’s strategy, the progress we are making to deliver it, and the next stages on our journey to deliver sustainable health and care services to the populations we serve.
2. Overview
Cardiff and Vale UHB is one of the largest health care organisations in the UK, providing integrated primary, community and hospital services to the local population of Cardiff and Vale which is growing in size rapidly. We also provide specialist services for populations across South Wales and beyond.
We have a directly employed workforce of over 14,000 people and work closely with our partners in local authorities – particularly social care and housing colleagues, independent contractors providing primary care, independent providers delivering community services (such as domiciliary care, residential and nursing home care), and a wide range of third sector organisations. We also have a very active volunteer service with over xxx people supporting us to deliver services that provide the best possible patient experience.
The total cost of providing our services is in circa £1.4bn per year. £1.0bn of our income comes directly through the Welsh Government for our local population, and £0.4bn comes from other health boards and NHS trusts, and Welsh Health Specialist Services Commission for services we provide to the wider populations we serve. We also commission a small amount of activity for our population from neighbouring health boards where it is more convenient for people to receive their care there.
The population in Cardiff and the Vale of Glamorgan is growing rapidly, with Cardiff being one of the fastest growing core cities outside of London. Our plans therefore reflect where we will need to provide additional services (such as primary care provision for the new communities which we are planning in conjunction with the local authorities). We are also working to accelerate our shift to prevention so we can tackle the factors that contribute to the burden of disease (such as smoking and being physically inactive), and take early action where this is needed. Our work with the two Public Services Boards includes a focus on supporting people to have the best start in live, to live well and to age well. Through our wellbeing plans we have a key joint focus on the social determinants of heath such as poverty, education and employment. As an employer of over 14,000 staff, many of whom also live within Cardiff and the Vale, we also have a comprehensive programme of work to support their health and wellbeing.
We also have a significant role to play in training the next generation of clinicians in partnership with our university partners. With Cardiff University, Cardiff Metropolitan University, the University of South Wales and Cardiff and Vale College we train doctors, nurses, therapists and healthcare scientists and health care support workers. We also provide very specialist training on a national and international basis. For example the Welsh Institute for Minimal Access Therapy was the first training centre to be accredited by the Royal College of Surgeons, and jointly with Cardiff University provide a training service to surgeons from across the world. As the transplant centre for South Wales, we participate in a European wide training programme to ensure a pipeline of clinicians for the future.
Our relationships with the Universities is also critical to our ongoing success in the provision of clinical resource. We deliver 38% of the research activity provided in Wales, and are strengthening our joint research work with Cardiff University which will enable us to increase significant the quality and quantity of our research activity so that we can compete with the very best research centres in the UK and across Europe.
In 2015, we published Shaping Our Future Wellbeing, our ten year strategy setting out how we will transform services over the decade to deliver better outcomes for people, particularly reducing the health inequalities that exist across our communities, and ensuring our services are safe and effective. The southern arc of Cardiff represents one of the most deprived areas in Wales. If it were a separate local authority it would have a population of 153,000, and would contain more neighbourhoods in the bottom 10% (most deprived areas) than any other local authority in Wales.
Our strategy also sets out how we are working with our partners to ensure that the first 1000 days in a person’s life gives them the best chance of living well into adulthood, and that we enable people to live well into old age, able to live independently in their own homes, in supportive communities.
We have recognised that the climate we are creating to support service improvement and transformation requires us to work differently with our front line staff, and we are building on our values and behaviours, we are engaging a wide range of staff from across the organisation to shape the next phase of our clinical services plan, and the next major milestones in the delivery of our strategy.
3. Health Board’s integrated medium-term plans (IMTPs) and how these are supporting the delivery of the vision for health and social care set out in ‘A Healthier Wales’ - Abigail Harris, Director of Strategic Planning
Our IMTP is set in the context of our 10 year strategy. The design principles of the strategy, home first, empowering individuals, delivering outcomes that matter to people and avoiding waste, harm and variation are principles which align with A Healthier Wales. In setting the national context A Healthier Wales challenges us to go further in partnership across the public sector and to accelerate the deployment of our strategy.
Our IMTP for 2019 to 2022 has a focus on prevention, bolstering services in the community and supporting the timely access to care regardless of the nature of this care and theorganisationdelivering it. Prevention is working in partnership to co-produce the best possible outcomes, the IMTP contains actions to develop resilient communities, optimise the benefits of interventions and develop wellbeing services in partnership with local authorities and the third sector which empower people to do what they can to improve their own health and wellbeing.
The UHB is adopting an enhanced approach to delivering its preventative role, aligning to its mission statement of ‘Keeping People Well’. This uses elements of both social movement theory and a programme approach to further strengthen preventative action related to patient care, staff health and wellbeing, the working environment and leadership. We also work with Cardiff Council to provide a dedicated No Smoking and Waste Enforcement Officer to challenge smokers on hospital grounds across Cardiff and Vale and issue Fixed Penalty Notices for littering. This is unique to Wales.
We recognise that sustainability for Cardiff and Vale UHB cannot be achieved without sustainability in NHS Wales’s system, social care and communities. Our strategy and this plan recognises the important role we play in delivering specialist services across South Wales, our responsibility for teaching the next generation of clinicians and delivering excellence in clinical research and innovation. We are therefore working through the regional arrangements to develop services with partner health boards across South Wales, in particular we have established a new arrangement with Swansea Bay University Health Board to oversee the development of specialised services in South Wales, and developing a tertiary services plan to confirm how services will be provided into the future.
In addition to integrated prevention services delivered with our partners, a stable primary care service is the critical bedrock of our health care system. We are rolling our primary care mental health and muscular-skeletal services as a value-based service model which aligns with the principles of prudent health care. Our nine primary care clusters are also maturing, with Transformation Funding supporting the develop of cluster and locality (Vale of Glamorgan, Cardiff North and Cardiff South) models of care that, through social prescribing and community development, enable the rich assets available in each community to support people in a more targeted way. Examples such as the community gardening initial in Ely delivering measurable improvements in physical and mental wellbeing.
Shaping Our Future Wellbeing in the Community Programme sets out a plans for a number of community health and wellbeing centres and hubs, linking with local authority services, to enable us to deliver more care and support closer to people’s homes and away from acute hospital sites when this is not needed.
Food insecurity remains a growing problem, with 160 000 children in Wales living in households that are unable to afford the cost of the Governments recommended diet. At the same time a number of benefits and schemes are being under claimed. Alongside the Food and Fun programme (School Holiday Enrichment Programme) which was developed in Cardiff and has now been rolled out across Wales to reduce food poverty, the Cardiff and Vale Public Health Team together with Food Cardiff have developed and delivered a train-the-trainer package and toolkit for front line staff on food schemes.
Our primary care and hospital clinicians are leading a programme of work to improve the pathways through which patients access hospital diagnosis and treatment, or to enable GPS to manage a patient’s care in the community with specialist input from secondary care clinicians. This has enabled us to move a significant amount of our diabetes and cardiology care from hospital to community settings and our Healthpathways™ programme is accelerating this work.
We work closely with Cardiff Council transport team, who host a Consultant in Public Health Medicine from the local public health team one day a week, to tackle the related challenges of air quality, active travel and sedentary behaviour, and climate change. Working across Cardiff PSB, this has resulted in the launch of the Cardiff Healthy Travel Charter, with 14 commitments and three targets over three years by 14 public sector organisations in the City. There is keen Ministerial interest in this work.
We are also supporting the centralization of a number of services to ensure there is service sustainability into the future. We have implemented the regional interventional radiology services for out of hours and will have established the regional vascular service later in the year. These models enable clinicians from across the region to work in the centralized service on a rota. This enables them to maintain their specialist skills and provides a sustainable service model where the right clinicians are available 24/7.
A Healthier Wales sets out a very clear challenge to go faster on rebalancing care away from acute hospital settings. We are completing the development of a new model for rehabilitation and reablement, and will be taking action to reduce un-necessarily long lengths of stay, which can have a huge impact on the deconditioning of an older patient. This will mean that we can reduce the resources require in general hospital services, and building on developments in community care that has been supported by the Intermediate Care Fund and the Transformation Fund. We have established a learning alliance with the Canterbury District Health Board (NZ) which is internationally renowned for having transformed their health and care system over the last decade. The benefits of the alliance are already evident in our system, with measurable improvements in some key areas, such as our unscheduled care system.
4. Finance
Background
The UHB has had a long history of financial challenge and in recent years has made concerted efforts to improve its financial performance and address its deficit. This has led to an improving financial position as shown in the following table.
|
Financial Year |
2016/17 £m |
2017/18 £m |
2018/19 £m |
|
Financial Out-turn Position (surplus)/deficit |
29.243 |
26.853 |
9.872 |
Overview of Financial Performance in 2018/19
For 2018/19 the UHB agreed with Welsh Government, through the formal Targeted Intervention process, that it would not submit an IMTP for approval as it was significantly away from being financially balanced. The Health Board approved an operational plan for 2018/19 which had a projected £19.9m deficit. Whilst no formal mechanism exists for its approval, this position was accepted by Welsh Government and the UHB then received £10m additional annual operating plan funding which reduced the UHBs forecast deficit to £9.9m.
The UHB made good progress in delivering against this plan and the out-turn position is a deficit of £9.872m being £0.028m better than the one year operational plan.
The delivery of this improved financial position was only made possible through the successful delivery of a substantial cost savings programme. The plan for the year was to deliver 4% (£33.8m) cost savings and this was successfully achieved.
Financial Plan 2019/20
For 2019/20 the UHB submitted an IMTP by the end of January 2019 for Welsh Government consideration and this covered the period 2019-20 to 2021-22. This plan has been approved.
The plan aims to deliver a balanced financial position in each of the three years during the period of this plan.
The UHB financial plan for 2019/20 aims to eradicate its carried forward deficit and deliver a year end break even position. This is planned to be achieved by delivering a 3.8% (£31.3m) cost savings target and by minimising discretionary investments.
5. Performance
As at the end of March 2019, the Health Board can demonstrate continuous improvement across a range of key operational performance measures and delivery profiles as set out its IMTP. There also have been some challenges for the Health Board in meeting some measures, particularly in those areas where there have been some exceptional demand increases and capacity constraints.
In terms of the key performance indicators for unscheduled care, the Health Board has made year on year progress in its performance, but, like the rest of Wales and across the UK, A&E targets were not met. 4 hour Emergency Department (ED) transit time cumulative performance for 2018/19 was 86.3%, 2.6% above last year. This was in the context of 3.8% increase in attendances. 12 hour performance also showed an improvement with 99.5% of patients spending less than 12 hours in ED compared to 99.3% last year. Cardiff and Vale has the lowest 12 hour breach volume in Wales. Ambulance handover waits greater than one hour were also 11% lower in 2018/19 compared to the previous year.
Our overall experience of this winter is that we have been more resilient following implementation of our Integrated Winter Plan. This was developed in conjunction with our partners. Whilst winter was not without its challenges and periods of heightened pressure, overall our escalation levels were lower and our system was able to respond to allow us to recover and de-escalate more quickly. Our performance winter on winter improved – with 4 hour performance 3% above last year; 52% fewer 12 hour breaches and 20% fewer patients waiting over one hour for ambulance handover. This year on year improvement is against the wider UK trend.
There was an overall improvement trend for Delayed Transfers of Care with reported performance lower for nine out of the twelve months this year compared to last. The March reported position was 37. The Health Board achieved the Welsh Government reduction targets at the end of March 2019.
In terms of performance against the four Sentinal Stroke National Audit Programme (SSNAP) bundles, we saw improvement in three of the four bundles with the exception of the 12 hour bundle where we have more work to do. Performance against the four areas chosen by Welsh Government within the Quality Improvement Measures (QIMs) was variable and the challenge remains for the Health Board in achieving consistency in delivery.
In terms of the key performance indicators for planned care, the Health Board has continued to make significant progress in eliminating greater than 36 week waits for referral to treatment times. We achieved our IMTP commitment (<=350) with the reported position 327 greater than 36 week breaches. There were 456 fewer patients waiting this year end compared to last, a 58% reduction. This year on year reduction has been part of a four year journey that started with just over 5,600 patients waiting greater than 36 weeks. Since then we have seen a 95% improvement. Our aim in 2019/20 is to treat the remaining complex cases and have no patient waiting greater than 36 weeks.
In terms of diagnostics, the Health Board committed to an IMTP target of zero patients waiting more than 8 weeks for a diagnostic at the end of 2018/19. Cardiff has had the highest number of diagnostic breaches for a number of years – peaking at 6,737 in August 2015. At the end of 2018/19 the Health Board reported 40 > 8 week breaches. Whilst we did not achieve our IMTP target, the reported position represents a 95% improvement with 843 fewer patients waiting this March compared to last. Our aim for 2019/20 is to achieve and then maintain zero breaches.
In terms of therapies, the Health Board achieved its IMTP commitment of a zero breach position as at 31 March 2019. This is the best reported position for the Health Board in nine years. There were 126 fewer patients waiting this March compared to last. Our aim for 2019/20 is to maintain zero breaches.
Performance levels against the 62 day urgent suspect cancer target, whilst showing some improvement in the last few months of 2018/19, is not at the required level. Some exceptional demand increases in the last year, for example 25% in urology and 16% in Gastrointestinal (GI), compounded a number of pre-existing process and capacity constraints. The Health Board, however, remains committed to achieving 95% compliance in 2019/20 – in keeping with its IMTP commitment.
The Health Board achieved the Welsh Government’s follow-up outpatients target of a ’12 month reduction trend’ for follow-up outpatients delayed past their clinically agreed target date. The position at the end of March 2019 was a 22% reduction (28,840 patients) on the previous year. However, we remain a significant outlier in comparison to the rest of Wales. As recently outlined at the Public Accounts Committee, the single biggest constraint for the Health Board has been the recording of and accuracy of its data. The Health Board’s aim for 2019-20 is continuous improvement in line with its Outpatient Follow-Up Improvement strategy.
Cumulative performance for Part 1a of the Mental Health Measure (service users to receive an assessment within 28 days) in 2018/19 was 80.3%, 8.9% above last year but, as a result of a significant increase in referrals, performance was more challenging in the last four months of the year. 10,993 referrals were received by primary mental health services in 2018/19, an increase of 9% from 2017/18. This increase in referrals also impacted on our delivery against Part 1b with 64% of users receiving a therapeutic intervention following assessment within 28 days.
In terms of Primary Care, the current General Medical Services (GMS) contract requires contractors to provide “reasonable” access to their population, which has presented challenges to monitoring access. Leading into the new GMS contract for 2019/20 the expectation is that all practices in Wales will work towards achieving the new access standards announced by WG. In terms of the current position on access there are no practices in Cardiff and Vale with closed lists. Using the latest national survey results (2017-18) for the ease of getting an appointment at a convenient time the position for Cardiff and Vale UHB is:
· 29% very easy (range across Wales 23-37%)
· 30% fairly easy (range 23-37%)
In recognising that a resilient primary care service is the basis for an effective health and care system, we have developed the primary care multidisciplinary model endorsed by the National Primary Care Plan. This is intended to bring capacity to and improve resilience within GMS. The new primary care first point of contact service for Musculoskeletal (MSK) and Mental Health is currently being rolled out, but already more than 100 appointments have been provided across Cardiff & Vale – allowing GP’s to have more time to meet the appropriate level of need.
Other support provided in the community includes:
· The District Nursing service supported 12,932 housebound patients in their own homes during 2018/19.
· The Community Resource Teams in Cardiff and Vale supported 2,231 facilitated discharges from hospitals during 2018/19 over a seven day a week period, working with patients to regain and retain their independence in their own homes.
The Urgent Primary Care/Out of Hours (OOH) service has seen an improvement in performance over the last few years. The average performance (comparing 2017/18 with 2018/19) for urgent triage has increased from 74% to 80%. Emergency home visits average performance has increased from 65% to 75% and emergency face to face appointments from 68% to 75%. In terms of activity there has been an average of around 9,200 contacts per month for 2018/19 (April 18 – end of February 19) compared with 9,700 in the 2017/18 (9,200 in 2016/17). The number of hours covered in OOHs in 2018/19 was almost 44,000 compared to just under 40,000 in 2017/18.
6. Escalation and intervention
We received formal de-escalation of our monitoring arrangements in February 2019 reducing from Targeted Intervention to Enhanced Monitoring. At a Tripartite Group Meeting with Welsh Government, Wales Audit Office and the Healthcare Inspectorate Wales considered that Cardiff and Vale University Health Board had progressed in:
· Performance – We have continued to be amongst the best in Wales in key performance areas and had made significant improvement
· Finance – We have delivered against a Financial Control Target
· Planning – We have made significant progress in our planning arrangements to be able to submit an approvable plan,
Following this we received formal notification of the approval of our IMTP for 2019-22 from the Welsh Government on the 26 March 2019.
This marks significant progress for the organisation and the first time for a number of years we have been able to submit a balanced and approvable IMTP.
We are keen to continue to deliver improved outcomes for our population and remain focussed on performance improvement. We are increasing the use of transparent performance data in the organisation, strengthening our performance monitoring arrangements and ensuring we have clear methodologies and processes in place to monitor the delivery of key projects.
7. Workforce and Integrated Working – Martin Driscoll, Director of Workforce
The Workforce and Organisation Development plan is integrated with the service and finance objectives embedded throughout the IMTP. We also recognise the role we play in supporting a strong workforce for the wider NHS and public sector. We want to have a pipeline of talent for all parts of the system.
Link to the Workforce & OD Plan:
Key issues and challenges:
• Supporting the SOFW Strategic Vision, transformational change, culture and leadership
• Talent Management and Succession; as well as building capability of line managers
• Improving Staff Engagement
• Effective workforce planning - nurse recruitment and hard to fill medical vacancies
• Delivering our Strategic Equality Plan and Implementing the Welsh Language Standards
• Preparing our workforce for Brexit; especially pre-settled and settled status
Transforming Workforce
This stream addresses how we build the capability we need in our workforce and focuses on four themes:
1. Culture and behavioural change - build, buy and borrow.
2. Shape of the workforce and role redesign- optimising roles in Bands 1-4.
3. Cross cutting transformation across the organisation; developing primary care cluster capability and creating roles and competencies that span health and other public sector areas to support regional delivery.
4. Transformation within professional standards e.g., apprenticeships, health care support workers, pharmacy careers, scientific careers.
Efficient Workforce
This stream focuses on delivering our core workforce metrics; delivering pay bill in budget, reducing sickness absence and promoting staff wellbeing.
Sustainable Workforce
This work is focused on ensuring we have the right people in the right roles in the right place at the right time. Project 95% and project switchover focus on nurse recruitment, one of the significant challenges for the organisation and sustaining the eradication of off contract agency usage.
Capable Workforce
Here we are investing in our capability, focusing on talent management and training. Including improving our leadership capability.
Engaged Workforce
We know the link between an engaged workforce and delivery. Improving the wellbeing of our staff and focusing on embedding our vision in values will be core to our success. Taking the learning from our recent staff survey, we will take prioritised action to improve staff experience in key areas.
Risks
We recognise recruitment and retention of our workforce remains one of the core risks to delivering this plan. Our workforce plan sets out some of the ways we will address this challenge, however all elements of the IMTP plan contribute.
Workforce Integration
Some examples of where we are working to support the integration agenda:
Strategic
· Informal meetings with Director of Workforce & OD and Cardiff Council HR Director
· Regional working in NHS Wales, South Central and South East Regions – specifically supporting Paediatrics, Obstetrics, Neonatology, Diagnostics, ENT
· Nationally, the MTC and centralisation of Vascular Surgery
· All Wales Genomics Service
· Alliancing with Canterbury to aid learning and sharing of good practice
Mental Health
· Integrated managers – Health and Social Care
· PC MH service – primary, secondary care (health) and third sector
· CPN pilot triage model – health and police
· Dementia Delivery and Steering Groups – Health, LA, third sector, carers and patients
· Service user involvement – facilitated by CAVAMH for meetings attended in UHB
· Grand Avenue Day Centre – health and LA
PCIC
· Vale Community Resource Service and Cardiff Community Resource Teams – Health, Social Care and Third Sector
· End of Life – Health/Macmillan
· Compassionate Communities, supporting clinical across organisations
· Primary Care Mental Health – primary, secondary care (Health) and third sector
· United Welsh – Well Being for U – Third sector in GP Practices
· Paediatric Out Patients in Community with GPs
· CRTs / LA / Third Sector (age connects and British red cross)
· Mental Health Tier Zero – Mind in the Vale
· Comms Hub – Health / LA / Third Sector
· Nurse Assessors / Independent Sector
· Crisis House – partnership with Gofal
· Dispersed Housing Scheme (Vale) – partnership with Gofal
· Bridge Project – partnership with Salvation Army
· Prison Mental Health Inreach – partnership with Prison services and PCIC
· CAVAMH – partnership working
· Substance Misuse services – partnership with multi-sector APB partners – LA, police, 3rd sector
· IRIS integrated housing scheme (Cardiff) – partnership with Linc Cymru
· Open Doors drop in centre – partnership with service user group (Open Doors)
8. Brexit preparations
We have worked closely with Welsh Government and other partners across health and social care in preparing for EU withdrawal, including for the possibility of a ‘No Deal’ BREXIT. The focus of the preparations has been on ensuring the maintenance of high-quality and safe healthcare.
As is the case for all Health Boards, CVUHB has a nominated Executive Director acting as the Senior Responsible Officer (SRO) overseeing the preparations locally, and contributing to a national group of SROs. Abigail Harris, Executive Director of Strategy & Planning has fulfilled this role, and chaired this group.
CVUHB has actively participated in regional and national planning events to ensure our local plans are as robust as possible, receiving positive feedback from Welsh Government on its planning arrangements.
Since autumn 2018, the CVUHB has had a task and finish group to coordinate business continuity, emergency preparedness and risk management of any potential fallout impacting on staffing, services or supplies. It has maintained a live database of all of the potential risks identified by Clinical and Service Boards in order to determine the potential impact, and where necessary enhance existing business continuity arrangements to support any response.
In line with all other Health Boards, and to deliver the requirements of the NHS Wales Director General; CVUHB held Exercise BREXIT Challenge (22nd February). Its aim was to review and test business continuity preparedness, planning, and organisational resilience in case of disruption to UHB critical services considering potential Brexit-related consequences. The event was facilitated by the Emergency Preparedness Resilience & Response (EPRR) Team, with representation from Executive Directors, Clinical and Service Boards, with positive feedback.
After agreement (16th April) with the European Council to extend Article 50 and UK membership of the EU until 31st October 2019; the UHB Task and Finish Group has been stepped down until September. CVUHB will maintain a state of readiness for the potential of a ‘No Deal’ BREXIT.
9. Conclusion
To conclude Cardiff and Vale has made excellent progress against its Strategy and is on a journey to delivering sustainable health and care services:
· Our IMTP has been approved;
· Our financial position has improved over the last three years from a deficit position in 2016/17 of £29m to a deficit position in 2018/19 of £9m;
· Our health outcomes are amongst the best in Wales, for example smoking prevalence at 16%;
· We have made year on year progress across a range of key operational indicators;
· We have a workforce plan which is integrated into service planning;
· We have been deescalated from Targeted Intervention to Enhanced Monitoring.