Cardiff and Vale University Health Board Annual Report 2015 16

Cardiff and Vale University Health Board Annual Report 2015 16

GOFALU AM BOBL, CADW POBL YN IACH CARING FOR PEOPLE, KEEPING PEOPLE WELL

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C ARDI F F AN D VALE UNIVERSITY HEALTH BOARD ANNUAL REPORT 2015-16

C ARDI F F AN D VALE U N I VERSI T Y H EALT H BOARD AN N U AL REPORT 2015- 16

About us

Accessibility

Contents

At Cardiff and Vale University Health Board our aim is to care for people and keep people well.

If you would like this document in any other language or format please contact The Communications and Engagement Department on 029 20 746381 or [email protected]

Joint Foreword from the Chair and Chief Executive

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About us

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The Annual Report will outline the work of Cardiff and Vale University Health Board (CAV UHB), highlight some of our key achievements and demonstrate how we are listening to the views and needs of our population, implementing many of these as part of our ambitious 10 year strategy: “Shaping our Future Wellbeing Strategy”. Our priorities, key objectives and plans are set out in our Integrated Medium Term Plan (IMTP), and the Annual Quality Statement provides us with an overview of what we are doing well and how we are listening to our public, patients and staff in order to achieve the strategy.

Email: [email protected] Website: www.cardiffandvaleuhb.wales.nhs.uk

Shaping our Future Wellbeing

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Partnerships and working with others

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Performance

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Proud to work at CAV

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Sustainable Development

76

Accountability Report 2015-2016

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Finance Director’s commentary

101

Summary financial statements

103

Audit Opinion 2015-2016

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Twitter: @CV_UHB Facebook: www.facebook.com/cardiffandvaleuhb

Ways to get involved

Annual Quality Statement Audit Opinion

Let’s Talk

Integrated Medium Term Plan

Via the website

Director of Public Health Annual Report

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Contact us

Finally we produce an Annual Governance statement which sets out: Shaping our Future Wellbeing Strategy

Our Population’s health

A full PDF version is available on our website.

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Joint Foreword from the Chair and Chief Executive We are pleased to bring you the Annual Report for 2015-2016. This is a retrospective look at the previous 12 months and is also an opportunity to share with you our priorities for the year ahead. As one of the largest Health Boards in the UK we have a growing reputation for delivering outcomes that matter to people, and we have a strong and steadily improving track-record in performance and how we deliver services to our local communities. Last year we set ourselves some ambitious targets and this year is no exception. With one of the fastest growing populations and an increasingly elderly population across Cardiff and the Vale of Glamorgan, it is vital that we are ensuring we get the best quality of services, continue to use innovation and to ensure that we continue to provide the most cutting edge clinical equipment and facilities available. As a University Health Board we work with our partners across the two Local Authorities, Universities and academia, charitable and third sector and businesses. By working together in the Public Services Partnership Boards, Health Enterprise Alliance Regional Transformation (HEART) and Clinical Innovation Partnership we ensure that we continue to push the boundaries of health and wellbeing and we are proud to illustrate some of these in this report. In 2015/16 we ended the financial year with a small surplus of £68,000. As a UHB we have been determined to meet our statutory duty and improve on our position from previous years. There was slippage on some capital programmes which will be delivered in 2016/17 and we recognise that we still have a long way to go.

While this has set the foundations of our financial performance we are not complacent, and recognise the challenges ahead in a difficult economic climate that adversely affects the health of some of the most socially deprived people in Wales. Our vision is Caring for People, Keeping People Well which underpins the 10 Year Strategy, Shaping our Future Wellbeing. This strategy aims to treat people as close to home as possible and reduce health inequalities across Cardiff and the Vale of Glamorgan. This year we have not yet received approval of our Integrated Medium Plan (IMTP), and as a result we recognise how vital it will be to keep focused on our key activities and delivery. As the report is published, Welsh Government has increased our escalation to targeted intervention. We will continue to work positively with Welsh Government to ensure that our plan is approved and in place by March 2017. As a UHB our community focus and preventative agenda is vital, and with public health promotion we will continue to improve the health and wellbeing of all our citizens and to make “ home first” wherever possible the option of choice. The principles of empowering patients by providing them with the information and the ability to enable them to take more personal responsibility is a cornerstone of our strategy. Repeatedly our patients tell us that they receive excellent treatment at Cardiff and Vale. This is due to our staff, and the service/care that they receive from us. We are proud to have a skilled and professional clinical and non-clinical workforce from across the globe, all of whom contribute to the positive patient experience and the high levels of patient satisfaction. However we accept that we don’t always get it right and when we do it is important that we listen to and act upon the concerns raised, no matter how small.

Our staff have not only provided us with this bedrock of reputation but have developed some of the most cutting edge clinical innovation, advancing medicine, health and wellbeing by years. Some of these innovations, such as the Clot Retrieval Service, Robot Prostatectomy and Pectus Surgery are highlighted within this report. While it is important to reflect and learn from the previous year, we want to also share with you some of our future ambitions for 2016/17. This builds on the good progress we made in 2015/16, improving our performance on treating stroke, reducing referral to treatment times, reducing cancer waits, improving emergency care, reducing hospital acquired infections and improving mental health. As a Health Board we are consistently seeking to improve outcomes that matter to patients and we are one of the Health Boards seeking to be identified as the site of the Major Trauma Unit for Wales.

The mechanism we have developed to deliver these achievements and our 10 Year Strategy, Shaping our Future Wellbeing is our BIG Priorities: • BIG 1 - Re-organising the way we use our medical inpatient beds at the University Hospital of Wales (UHW) and the University Hospital Llandough (UHL). • BIG 2 - Developing the Perfect Locality. • BIG 3 - Eliminating unwarranted Clinical Variation. As a provider of NHS services we are ever mindful that it is public money and we want to continue to provide the best quality care at the best value for our patients. We are proud of the work of all staff who work at CAV, and who we know also try to ensure that patients remain at the heart of everything that they do. We will continue to meet and listen to our citizens and seek your views on services that matter to you. Thank you to all our staff, patients, stakeholders and our hundreds of volunteers for contributing in making CAV UHB a great place to work and continuing to provide excellent health and wellbeing services to our communities.

Maria Battle Cadeirydd Chair

Adam Cairns Prif Weithedwr Chief Executive

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Chapter 1 About Us

Our structure

Cardiff and Vale University Health Board is one of the largest NHS organisations in Europe. Founded in 2009, it provides a range of health and wellbeing services to its population. We spend around £1.4 billion every year on providing our communities with the full range of health and wellbeing services including: • Primary and community based services: GP practices, Dentists, Pharmacy and Optometry and a host of community led therapy services via community health teams. • Acute services through our two main University Hospitals and Children’s Hospital: providing a broad range of medical and surgical treatments and interventions. • Public Health: we support the communities of Cardiff and Vale with a range of public health and preventative health advice and guidance.

We have an annual budget of around £1.4 billion, the vast majority of which is spent on staffing costs, equipment, treatments and drugs. As with most NHS organisations we have a challenging financial position and currently have a Cost Improvement Plan (CIP) target or savings to make of around 3%. As a publicly funded body we are ever mindful of the need to be publicly accountable and ensure that we obtain the best value healthcare services for our population without compromising on quality. The challenge of an ageing as well as rising population is placing a considerable strain on these resources and as a UHB we have to become more innovative in the ways in which we can meet these challenging demands and provide services within our financial envelope.

We have a workforce of around 14,500 staff who consistently deliver high quality services to all of our patients. Our organisation is structured and designed into eight Clinical Boards which cover the four areas above and much more. The eight Clinical Boards were created in June 2013 and have been successful in providing strong leadership in clinical areas and have

Cardiff and Vale University Health Board Public Health Corporate Services Children and Women Clinical Board

• Tertiary centre: we also serve a wider population across Wales and often the UK with specialist treatment and complex services such as neuro-surgery and cardiac services.

Public Health Improving the health of our population and reducing inequalities. Providing preventative health care information and advice including access to health and well-being services.

Primary, Community and Intermediate Care Offering first line health services at GP surgeries, dentists, optomtetrists and a range of therapy and community based services accessible as close to home as possible.

resulted in the acceleration of operational decision-making, greatly enhancing the outcomes for patients in their care. The Boards are held to account via the Executive Directors and a process of scrutiny is ensured through monthly performance boards and a robust authorisation process. More detail can be found on the Clinical Boards below:

Clinical Diagnostics and Therapeutics Clinical Board

Dental Clinical Board

Medicine Clinical Board

Mental Health Clinical Board

Specialist Services Clinical Board

Surgery Clinical Board

Primary, Community and Intermediate Care Clinical Board

Acute and Tertiary Care Providing unscheduled or emergency care. Elective care and specialist services to a wider population across Wales, including diagnostics and therapeutic services.

General Medical Services

Corporate Services Providing the support services required to run an integrated health system across Cardiff and Wales ensuring patient safety, governance, quality assurance, performance and excellent delivery of all services.

General Dental Services

Community Pharmacy Services

Our corporate and planning services are an integral part of the overall structure and smooth running of the UHB and include: • • • • • • •

Strategy and Planning Finance and Performance Human Resources Estates and Facilities Information and Technical Services Communications and Engagement Corporate Governance

Optometry Services

North West Clusters

South East Cardiff Clusters

Vale Clusters

The progress and scrutiny of the Corporate Services directorates are through a combination of governance, executive director and senior management accountability and progress mapped against key projects within their areas of expertise.

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Our Board The Board of Cardiff and Vale University Health Board consists of 21 members including the Chair, Vice Chair and Chief Executive. We have nine Independent Members, all of whom are appointed by the Cabinet Secretary for Health, Social Services and Sport and several Associate Members.

Our Governance arrangements

The Board is the corporate engine of the UHB and is also responsible for governance, scrutiny and public accountability. Openness and transparency are key to the Board’s operating, and public meetings are held every six weeks. All of the agenda and Board papers are published on the CAV UHB website.

The Board is supported by a Board Secretary who provides advice on corporate governance and ensures that our statutory and corporate standards are in place and up to date.

Full details of the Board Members’ roles and responsibilities, their committees and attendance at those committees is included here with the table of members and their committees.

Maria Battle

The Board has robust governance arrangements in place to ensure probity, strategic and delivery plans are in place, risks are mitigated and assured, and we have the appropriate controls in place to govern corporate and clinical situations.

Cadeirydd Chair

Marcus Longley Is-Cadeirydd Vice Chair

Details of the Annual Governance Statement for 2015/16 can be found here alongside our Corporate Risk Assurance Framework (CRAF).

Information Governance and retaining patient confidentiality Protecting the confidentiality of the information of patients is essential, and there are strict controls in place to govern how we store, record and share data. Ensuring that data is only shared appropriately and standards are retained is the responsibility of the Caldicott Guardian. This role is currently undertaken by the Medical Director, and more information on data security and any breaches is contained within the Annual Governance Statement.

Stuart Egan

Eileen Brandreth

Aelodau Annibynnol Technoleg Gwybodaeth Gyfrifiadurol Independent Member Information Computer Technology

Ivar Grey

Aelodau Annibynol Undeb Llafur Independent Member Trade Union

Aelodau Annibynnol Cyllid Independent Member Finance

Margaret McLaughlin

Prof Elizabeth Treasure

Aelodau Annibynnol Trydydd Sector Independent Member Third Sector

Aelodau Annibynnol Prifysgol Independent Member University

Vacant

Vacant

Swydd wag - Aelodau Annibynnol Awdurdod Lleol Swydd wag - Aelodau Annibynnol Cymuned Independent Member Local Authority Independent Member Community

Vacant

Swydd wag - Aelodau Annibynnol Cyfalaf ac Ystadau Independent Member Capital and Estates

Martyn Waygood

Aelodau Annibynnol Cyfreithiol Independent Member Legal

Adam Cairns Prif Weithedwr Chief Executive

Alice Casey

Gweithredol I’r Prif Swyddog Gweithredu Chief Operating Officer

Raj Chana

Cyfarwyddwr Gweithredol Gweithlu a Datblygu Sefydliadol Executive Director of Workforce and Organisational Development

Sharon Hopkins

Cyfarwyddwr Gweithredol Iechyd y Cyhoedd Executive Director of Public Health

Dr Graham Shortland

Cyfarwyddwr Meddygol Gweithredol Executive Medical Director

Peter Welsh

Cyfarwyddwr Llywodraeth Corfforaethol Director of Corporate Governance

Bob Chadwick

Cyfarwyddwr Cyllid Gweithredol Executive Director of Finance

Abigail Harris

Cyfarwyddwr Gweithredol Cynllunio Strategol Executive Director of Strategic Planning

Fiona Jenkins

Cyfarwyddwr Therapiau a Gwyddor Iechyd Gweithredol Executive Director of Therapies and Health Sciences

Ruth Walker

Brif Nyrs/Cyfarwyddwr Nyrsio Gweithredol Chief Nurse/ Executive Nurse Director

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Our Clinical Structure Medicine Clinical Board

Case Study - Rehabilitation Centre Volunteers

Staff - 1,555

£

Budget - £98.8m (Annual budget for 2015-16 was £102m due to funding for Hepatitis C, NICE/High Cost drugs and Cystic Fibrosis drugs)

The Medicine Clinical Board covers a challenging portfolio of work which includes unscheduled care and the acute medical wards of Stroke. Our teams work together to provide a frontline service for patients who enter our hospital environment and embed the health board’s ethos of caring for people, keeping people well. The Medicine Clinical Board is separated by directorates: unscheduled care, the Emergency Unit, Barry Minor Injuries Unit, Stroke, Cystic Fibrosis, Endoscopy, Clinical Gerontology. The Stroke Rehabilitation Centre (SRC) at University Hospital Llandough recruited 16 student volunteers to assist as it developed its services to include seven day rehabilitation. The 45 bed consultant led unit has a multidisciplinary team to offer on-going management and rehabilitation to patients who have had strokes. The SRC reviewed its resources to enable its patients to receive seven day rehabilitation while they are on the unit. This includes the appointment of new rehabilitation assistants as well as the time of student volunteers to help support activity on the ward. The volunteers work in partnership with staff to assist and organise activity sessions for patients at the SRC. Activities include arts and crafts and quizzes, with some activities organised around individual needs. A key role as a volunteer is befriending, where volunteers can support patients at their bedside by simply reading or speaking to them. Key Achievements: • Developed community based diabetes services. • Improved access to retinopathy (access to prevention, screening and treatment). • Established nursing float to allow ‘specialling’ of patients with dementia. • Delivered memory clinics within Referral To Treatment (RTT) targets.

• Developed two year plan to meet Joint Advisory Group (JAG) requirements in Endoscopy ensuring compliance with diagnostics and surveillance. • Extended Frail Older Persons Assessment Liaison (FOPAL) service.

David Cox is currently studying Speech and Language Therapy at Cardiff Metropolitan University. After receiving an email from the School of Health Sciences looking for volunteers David jumped at the chance to get involved. He said “I’m interested in Stroke as an area, as it is not only related to my studies but is also realistically somewhere I could end up working. I wanted to get real life experience and a feel for what it would be like working in this kind of environment. “I’ve really enjoyed the experience so far. It’s been interesting and I have met a lot of people and am learning what life is like for people after they have suffered a stroke. This is something I hadn’t had previous experience of before. “A typical day can vary. We can be involved in group activities to help with patients’ rehabilitation and their speech and language. “I really enjoy speaking with patients to talk about their interests, keep them active and lift their spirits. “I would highly recommend volunteering to any students as it has been a really rewarding experience.”

Laura Lopez-Bueno is also studying Speech and Language Therapy and saw volunteering as a good opportunity to learn from others. She said “The offer of volunteering at the Stroke Rehabilitation Centre really appealed to me. Not only can I interact with service users but I also get to meet and learn from students from other disciplines. “A lot of my experience so far has been in paediatric areas and I wanted more insight into the adult field, so this opportunity was perfect for me. I can now enhance my skills and experience around adult care. “At university the focus is on placements and, as worthwhile as these are, volunteering gives me more flexibility to get real life experience and observe a lot more, as you are not being graded as part of your course. “I feel that you can help just by being here. It is such a great opportunity to meet the team and I think it’s such an invaluable experience for any student to undertake.”

Abi Ford is studying Podiatry and was particularly interested in getting involved with stroke services. She said “Stroke really interests me as it’s something that affects a lot of people and there are many different consequences to it. “Through volunteering I am involved in various activity groups on the unit including art groups, pamper session and film clubs. This enables me to not only spend time with patients but to get to know them. It’s nice to be able to make a small difference to their day. “Volunteering is great as you’re in a position to help others, and it is such a good opportunity to learn new things and discover what other professionals do.”

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Primary, Community and Intermediate Care (PCIC) Clinical Board

£

Staff - 804

Key Achievements:

Budget - £280m

PCIC also commission services from the third and independent sectors as well as managing the Primary Care contractors. PCIC provide a broad range of services mainly primary and community based, but including the specialist palliative care team. The range of services can be seen via the map below.

Cardiff North Cluster

Cardiff West Cluster

Lisvane

Pentyrch

Western Vale Cluster

Whitchurch & Tongwynlais

Pontprennau & Old St Mellons Rhiwbina

Llanishen

Pentwyn Cyncoed Creigiau

Morganstown

Llanrumney

Cardiff East Cluster

Heath

Radyr Llandaff North

Gabalfa

Penylan

St Fagans Fairwater

Rumney

Cathays

Llandaff

Plasnewydd

Peterston-super-Ely

Riverside

CC

Canton Ely

Cardiff South East Cluster

Adamsdown Splott

Caerau Llandow

Trowbridge

Cowbridge Grangetown

St Bride’s Major

Butetown

City & Cardiff South Cluster

Wenvoe

Penarth Rhoose St Athan

Barry

Central Vale Cluster

Cardiff South West Cluster

• Commenced the construction of the Dinas Powys Medical Centre to provide state of the art premises providing primary and community services.

• Developed a single point of access (communications hub) model in the Vale for community health and adult social care enquiries to capture, process, triage, and signpost service users, ensuring better access and information at the initial point of contact.

• More ambulatory blood pressure monitoring (ABPM) is taking place in primary care via the Welsh Government (WG) investment.

• Reviewed the Cardiff and Vale GP Out Of Hours (OOH) service model and gained investment to support the team to increase clinical capacity/skill mix and improve access for acutely unwell patients. Along with increased GPs, this has included the introduction of Advanced Nurse Practitioners seeing patients face to face, Nurse Triage, and the planned addition of a prescribing Pharmacist. • Reduced harm and waste while improving quality in Medicines Management. We have had the greatest reduction in overall antibiotic (and high risk C. Diff antibiotic) usage in Wales over the past 12 months.

Dinas Powys

Llantwit Major

• Community Resource Teams moved to work on a seven day a week basis in order to respond to vulnerable patients on the weekend and bank holidays.

• Commissioned smoking cessation from Community Pharmacies in our most deprived communities.

Eastern Vale Cluster

Western Vale Cluster GP practice population size: 27,407 No. GP practices: 3 No. Dental practices: 7 No. Optometrists: 7 No. Pharmacies: 6

Central Vale Cluster GP practice population size: 62,356 No. GP practices: 8 No. Dental practices: 9 No. Optometrists: 7 No. Pharmacies: 14

Eastern Vale Cluster GP practice population size: 36,444 No. GP practices: 5 No. Dental practices: 6 No. Optometrists: 5 No. Pharmacies: 9

Vale of Glamorgan Locality Total Practice Population: 126,207 Total CRT referrals: 2,316 Total District Nursing Referrals: 6,646 Total DN Contacts: 98,976 CRT Average Case load: 400

Cardiff East Cluster GP practice population size: 54,867 No. GP practices: 5 No. Dental practices: 7 No. Optometrists: 4 No. Pharmacies: 10

Cardiff North Cluster GP practice population size: 106,597 No. GP practices: 11 No. Dental practices: 16 No. Optometrists: 13 No. Pharmacies: 19

Cardiff West Cluster GP practice population size: 52,715 No. GP practices: 8 No. Dental practices: 8 No. Optometrists: 8 No. Pharmacies: 18

Cardiff North West Locality Total Practice Population: 226,012 Total CRT referrals: 1,853 Total District Nursing Referrals: 9,165 Total DN Contacts: 106,934 CRT Average Case load: 509

Cardiff South East Cluster GP practice population size: 62,812 No. GP practices: 8 No. Dental practices: 5 No. Optometrists: 6 No. Pharmacies: 16

Cardiff South West Cluster GP practice population size: 66,700 No. GP practices: 11 No. Dental practices: 10 No. Optometrists: 8 No. Pharmacies: 5

City & Cardiff South Cluster GP practice population size: 38,865 No. GP practices: 7 No. Dental practices: 9 No. Optometrists: 9 No. Pharmacies: 10

Cardiff South East Locality Total Practice Population: 156,544 Total CRT referrals: 1,717 Total District Nursing Referrals: 7,642 Total DN Contacts: 102,368 CRT Average Case load: 375

• The Acute Response Team anticoagulation monitoring service reduces the need for hospitailisation prior to elective surgery and allows speedy hospital discharge for stabilisation of warfarin. The first annual review of this service shows that an average of 13 hospital bed days were saved per patient with an average of 833 contacts per month. • Established a ‘new’ student branch surgery on the Cardiff University Campus.

• GP Clinical Lead working with practices to agree the use of teledermatology as the preferred referral method. This will allow a more rapid response and free up face to face consultations with dermatologists for the patients most in need. • Established a Community Diabetes Model, providing consultant support and education to GPs with consultants in diabetes attached to named GPs for community clinics, case notes review and advice by email, allowing GPs access to senior decision making in a timely manner and avoiding unnecessary referrals to hospital outpatient clinics. • Strengthened our clinical leadership with GPs, Dental, and Optometry now supported with Lead GPs (Community Directors), a Dental Advisor and Optometry Advisor. • Established a dedicated nurse led Continence Service, to both enhance the service and allow District Nursing to continue its vital work, focus on embedding the new District Nursing leadership model and maximise access for patients. • Implementation of the new framework for Continuing Healthcare (CHC) with increased numbers of complex patients being supported to be cared for at home via CHC budget and District Nursing service. • Appointed two Macmillan GP Facilitator posts (via funding secured from Macmillan) to provide training, advice and support to General Practice on issues relating to End of Life care and cancer.

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Cluster Development - planning and provision of care locally • North Cardiff recruited Cluster Primary Care Nurses for Older People, linked to Cardiff Community Resource Teams (CRT) providing additional support to GPs in managing patients identified at high risk of admission.

The increase in the CRT resource is in line with the health board’s strategy ‘Shaping our future wellbeing’ which has a focus on ‘Home First’, to 'enable people to maintain or recover their health in or as close to home as possible.'

• Eastern Vale has appointed a Cluster Integrated Care Doctor linked to Vale CRS to provide additional support to GPs to manage patients identified at high risk of admission.

The CRTs work closely with the Emergency Unit, GPs, patients, families and carers to arrange for care packages to be implemented in the home reducing the need for hospital admissions in the first place, preventing any unnecessary hospital admissions and enabling discharges at the weekend.

• City and South East are recruiting a community based Diabetes Specialist Nurse working at a Cluster level to support patients locally, providing enhanced information, advice and sign-posting, promoting self-care, in a cluster with high diabetes prevalence. • Each locality has clusters who have recruited cluster based pharmacists /Prescribing Advisors in practices to reduce harm and waste from polypharmacy and provide additional specialist support to patients with complex medication regimes.

Case Study - Community Resource Teams (CRT) Three CRTs operating across Cardiff and the Vale have adopted a seven day working pattern to include weekends and bank holidays. During 2015, the CRTs saw over 2,000 patients in a primary care setting which prevented unnecessary hospital stays and admissions. The extra resource has meant 245 additional patients have been supported by the CRTs at weekends and bank holidays during the first six months of the expansion. This relieves pressures on hospital beds and enables patients to receive care in their home environment.

The extra resource aims to free up GPs’ time where the team will work with patients before they get to a stage where they are admitted to hospital. The improved access for patients will also lead to improved communication for GPs, district nurses and other health board colleagues in dealing with patient care.

The teams work with a variety of patients over 18 years of age who require care and support at home and may have conditions such as fractures, Stroke, Parkinson’s Disease, MS, road traffic accidents or a life limiting condition. They work with patients in their own homes and identify individual goals to help patients regain their independence and rely less on family, carers and the care sector.

The Multidisciplinary Team consists of health staff from Cardiff and Vale UHB including Physiotherapists, Occupational Therapists, Dieticians, Speech & Language Therapists, Nurses and Consultants, local authority staff from Cardiff Council and Vale of Glamorgan Council including Occupational Therapists, Registered Managers, Homecare Managers, home care staff and voluntary sector.

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Mental Health Clinical Board Staff - 1,250

£

Budget - 67 million

The Mental Health Clinical Board covers community and in-patient settings and is designed with the service user in mind, with a focus on recovery and rehabilitation. The Clinical Board works in collaboration with local authority colleagues, our charity and third sector agencies to co-create services, and the majority are now provided closer to home, supporting people within the local community. Our staff and service users have a long-term vision for increasing community care and shared care models. We have community teams, primary mental health services and inpatient services, as well as managing specialist services such as Addictions, Low Secure and Younger Onset Dementia care. We cover adult mental health services and older persons’ mental health services and work hard to break down the stigma of mental health, which affects 1 in 4 people in the UK.

Hafan y Coed In March 2016 Hafan y Coed, the new purpose built Adult Mental Health Unit opened. The new facility is the first of its kind in Wales providing a modern, therapeutic and stimulating environment to adults experiencing a mental health illness. Hafan y Coed, which means Haven of Trees, was developed by Cardiff and Vale University Health Board in partnership with service users and staff, to provide an inpatient environment which expresses openness, safety, caring and recovery. The Welsh Government invested £88 million into the new unit to provide modern, state of the art facilities for people experiencing mental health illnesses. The unit was designed to promote dignity and respect for service users and includes individual bedrooms with ensuite facilities and individual courtyards and garden areas on each ward so service users can enjoy fresh air as part of their rehabilitation. Additional facilities throughout the unit include access to single sex sitting rooms, quiet areas for service users and visitor rooms. There will also be access to therapeutic spaces including multi-use rooms, garden areas, gym facilities and a small outdoor sports pitch to enhance recovery for service users during their stay. Rehabilitation and recovery will be the focus at the new Adult Mental Health Unit which is based at University Hospital Llandough (UHL). The theme of nature was decided by service users and over 40 pieces of artwork were specially commissioned for the new environment. Artwork was designed and created by service users and local artists enabling the nature theme to run throughout the décor.

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Case Study – Better Tomorrows, Will Ford (Service User) ‘We grow better tomorrows when we plant good seeds today’. Ten years ago I would not have been able to contribute these ten words to the Hafan y Coed art project. Ten years ago depression and agoraphobic tendencies were affecting me so badly that I found it hard to believe I had any choices in life at all. I barely ever spoke to anyone, avoided going outside and had been living alone for years. The literal and emotional isolation I experienced as a result meant the last thing on my mind was any hope for a better tomorrow. Fast Forward from June 2005 to June 2015 and the difference would appear to be miraculous. In June 2015 I published my second e-book, won a poetry competition and a film I helped to devise, film, direct and actually appeared in was featured at a short film event as part of the Glastonbury Festival. I sometimes host and organise open mic poetry events, other spoken word performers ask me for tips so often than I am in the process of planning a book of advice to others wishing to share their work and am through to the semi-final of a competition for performers called Last Mic Standing.

But there was no sudden miracle recovery from permanently shy and anxious to being able to find myself through creativity and words as I have. It may be a cliché to say that change for the better can only be approached one day at a time but like many clichés, it is completely true. Recovery (in whatever context) is not a journey with a definitive end, but an ongoing approach to life, a path created partly by the choices we make, the assistance we are willing to seek or accept, and the way we interpret the things that happen to us, the way we perceive ourselves and how that affects how we think people perceive us. Many people who have gone through terrible experiences become convinced that the world is a terrible place, where only terrible things happen. An unhappy past creates an unhappy present, and for many this creates only the expectation of an unhappy future. Things went wrong in the past and the disappointment this causes leads people to expect nothing to go right, to expect nothing good. It is not easy to believe after a long time of things going wrong that there is anything we can do to change the way we feel or the way life is going. It is easy to say but not easy to believe that what we choose today creates the person we will be tomorrow.


But everything we experience, do, think or tell ourselves is a seed that gets planted within ourselves that is fed by what we say, do or think next. As hard as life can get, and it sometimes gets unbelievably hard, there is always something we can do, there is always something we can tell ourselves that (even if we don’t truly believe it at the time) will plant a seed within us that can lead to better tomorrows. Ten years ago I would not have believed an idea so simple could sum up the way I now choose to approach life. I had to live those ten years in order to be able to see that it was what was happening. Had I not wished to express myself freely I would never have written anything down. I would not have had the sense of release that creativity gave me. I would not have sought avenues to explore that creativity. I would not have become a Service User Representative via Sefyll. I would not have been part of the Arts Project for the new Adult Mental Health Unit. I would not be writing these words.

It may be helpful to consider the ten words at the beginning of this piece as words that reach out far beyond mental health issues. In any way, any job, any relationship, any project, any personal goal, any leisure activity, any attempt to move forward in any situation or move on from any circumstances you could possibly name, we grow better tomorrows when we plant good seeds today.

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Surgery Clinical Board Staff - 1,800

£

Clinical Directorate Budget - £120m

The Surgery Clinical Board has five directorates which provide a significant number of emergency and elective services to Cardiff and Vale residents which include Trauma and Orthopaedics, General Surgery, Urology, Ear Nose and Throat, (ENT), Maxillo-Facial Surgery and Ophthalmology. In addition to direct service provision for the local community of Cardiff and the Vale, the Surgery Clinical Board provides a significant number of services beyond the local population at both the University Hospital of Wales (UHW) and University Hospital Llandough (UHL). Clinical Directorate

Trauma and Orthopaedics

General Surgery and Wound Healing

Specialty General trauma Pelvic trauma Spinal trauma Elective orthopaedics Specialist foot & ankle surgery Specialist hand surgery Specialist hip surgery Hip arthroscopy Specialist knee surgery Specialist shoulder surgery Paediatric surgery Spinal surgery Adult scoliosis surgery Paediatric scoliosis surgery Breast surgery Elective vascular surgery Emergency vascular surgery Endocrine surgery Colorectal surgery Sacral nerve stimulation Benign pancreatic surgery Upper GI surgery Liver surgery Emergency general surgery Wound Healing Emergency urology surgery Urology cancer surgery Continence services Diagnostic urology Non-cancer surgery

Population Coverage Cardiff and Vale South Wales South Wales South East Wales South East Wales South East Wales South East Wales South Wales South East Wales South East Wales South East Wales South Wales South East Wales South East Wales Cardiff and Vale Cardiff and Vale South East Wales All Wales South Wales South Wales South East Wales South East Wales South Wales Cardiff and Vale Cardiff and Vale South East Wales Cardiff and Vale Cardiff and Vale Cardiff and Vale

Head and Neck Services

Urology

Specialty Maxillo-facial surgery Ortho-ignathic surgery Complex oral cancer surgery Adult ENT surgery Paediatric ENT surgery Audiological medicine Adult Cochlear surgery Paediatric Cochlear surgery General ophthalmology services Emergency urology surgery Urology cancer surgery Continence services Diagnostic urology Non-cancer surgery Pain Services

Anaesthesia

Resuscitation Perioperative Services

Preassessment

Theatres

Sterile Services

Population Coverage South East Wales South East Wales South East Wales Cardiff and Vale South East Wales Cardiff and Vale South East Wales South Wale Cardiff and Vale Cardiff and Vale South East Wales Cardiff and Vale Cardiff and Vale Cardiff and Vale Acute Pain Service Chronic Pain Services Outpatients Daycases Pre-assessment Anaesthesia Services to other Trusts Resuscitation Education and training Daycase Inpatient One stop clinics CPEX testing Main theatres Short Stay Surgery Day Surgery HSDU UHL HSDU UHW Scope decontamination facilities

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Budget and Patients/Service Users and how we meet their needs The table below summarises the scale of the services provided in 2015/16 Specialty

Outpatients

Daycases

Inpatients

Trauma & orthopaedics

90915

5043

7268

General Surgery

32877

3844

7797

Urology

21277

1114

2167

120,447

4922

3996

16125

554

12

281,641

15,477

21,240

Head and Neck services including ophthalmology and audiology Surgical support services Total

Available resources in the division Specialty

WTE

Budget (£’s)

Trauma & orthopaedics

413.53

18,631,302

General Surgery/Urology

432.93

20,079,898

Head and Neck services

178.78

13,410,187

Surgical support services

842.72

60,540,698

1,867.96

112,662.085

Total

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Audiology

Key Achievements: • Several of the specialties in surgery now have ERAS (enhanced recovery after surgery) as the normal standard of care delivered to patients which enables them to recovery more quickly from surgery and so reduce the risk associated with longer hospital stays. • There has been a huge amount of work carried out in the Clinical Board in order to improve processes to reduce the variation in treatment of thromboprophylaxis in the surgical setting. The outcomes of the work have made a significant improvement to patient care and safety. • Introduction of urological robotic surgery has transformed the delivery of prostate cancer services in South Wales by bringing teams together from different health boards to deliver a high volume centre for complex urological surgery, which is also a NICE recommendation. Overall there are better outcomes for patients and the current data has been presented in local and national audit meetings such as the Welsh Urological Society. • Trauma and Orthopaedics have developed pathway improvement with other services such as social work, therapies and community teams to improve the care frail, older patients receive. Frail, older patients do not cope with change, let alone admission to hospital with all the complexities that entails. Attention has been given to simplifying the ward routine and environment to resemble something that the patients can understand.


• A bespoke Dementia training package for the Clinical Board has been developed by the Practice Educators in conjunction with a Psychiatric Liaison Nurse for the Older Person. This training package was presented at the recent UHB Nursing awards by the Practice Development Nurses and won runner up in the category for education and learning and other Clinical Boards have enquired about using the training package. Plans going forward are to continue the above work with Ward B6 to pilot coloured zimmer frames, and the roll out of yellow painted toilet doors which have already been introduced on Ward B2 to encourage recognition. Other initiatives include encouraging patients to utilise the day rooms for luncheon clubs and similar events. • As of 11 August 2016 the Clinical Board had gone 370 days without an MRSA reported infection.

Traditionally hearing loss, Tinnitus and balance conditions have been initially referred to Ear, Nose and Throat (ENT) or Audio Vestibular Medicine (AVM). However, the majority of these referrals will inevitably result in assessments and subsequent treatment by Audiology. In line with the principles of Prudent Healthcare and the ENT implementation plan, all referrals are now triaged for conditions relating to Tinnitus, hearing and balance at point of entry into the health board directly to Audiology, and only patients with red flag conditions and those needing medical input are then referred back to ENT/AVM. Referral rates back to ENT/AVM are low at only 7% for hearing and Tinnitus. The majority of these are for Magnetic Resonance Imaging (MRI) investigation (there is a future plan for advanced practitioners to reduce this burden), and 22% for balance. However, the patient will already have had a full medical history taken together with all investigations being completed, enabling one appointment only with ENT/AVM for a management plan. This pathway redesign has reduced the need for patient appointments by 78%. We achieved a significant reduction in the referral to treatment time, Tinnitus reduced by 22 weeks, hearing aid fittings reduced by 13 weeks and balance assessment by 10 weeks. More than 3500 patients will be treated on this new pathway each year. As the redesign of these three pathways has been successful, we plan to create three primary care sites which will, together with the University of Wales clinic, deliver services solely by advanced primary care Audiologists, removing 17000 patients off site, delivering services closer to

patients’ homes, addressing their needs with ease of parking, short distances to walk from car park to clinic, quiet calm environments, and the feeling of uninterrupted quality time with their clinician. This will also reduce the Did Not Attend (DNA) rates, the use of ambulances and the need for home visits. The long-term vision for all patients with hearing loss, Tinnitus and balance is to self-refer to advanced practitioners with the added benefit of releasing valuable time for General Practitioners (GPs).

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Specialist Services Clinical Board Staff - 1,550

£

Budget - £125m

The Specialist Services Clinical Board is made up of seven clinical directorates with associated clinical services and sub-specialties. The Clinical Board comprises a number of highly specialised areas serving both the South East region and wider all Wales population. The services also generally provide secondary care services to the local Cardiff and Vale of Glamorgan population. For certain specialities, services are provided on a South Wales and all Wales basis. The services provided by the Clinical Board are predominantly Welsh Health Specialised Services Committee (WHSSC) commissioned and provide for the wider regional and Welsh population. Services are currently structured through the seven directorates outlined below: • Cardiothoracic Services • Critical Care

There is a dedicated outpatient and diagnostic department based on the B1-C1 Link corridor at UHW, a dedicated 12 bedded Cardiac Day Case Unit, three fully commissioned Cardiac Catheter Laboratories, four inpatient wards (including an eight bedded Critical Care Unit (CCU) and 14 bedded Cardiac Intensive Care Unit (ICU), and three Cardiothoracic Theatres within the General Theatre suite. 2. The Critical Care Directorate provides adult critical care services at both UHW and UHL. The main unit is based on A3 and B3 at UHW and has flexible Level 3 and Level 2 capacity for 31 patients. The UHL unit has flexible capacity for six patients. Critical Care demand fluctuates significantly, and whilst the majority of patients are admitted through the secondary and tertiary emergency streams, there is an element of pre-booked highly complex elective surgery on both sites that requires Critical Care support. There is now a dedicated Post Anaesthetic Care Unit on the UHW site which cares for up to 6 postoperative elective surgical patients.

• Haematology & Clinical Immunology • Medical Genetics • Nephrology & Transplant • Neurosciences • Artificial Limb & Appliance Service (ALAS) 1. The Cardiothoracic Services Directorate is based primarily in UHW (with additional secondary care outpatient and diagnostic services in UHL) and provides outpatient, specialist diagnostic, day case and inpatient services to both the local Cardiff and the Vale Glamorgan and also the wider South East Wales populations.

3. The Haematology and Clinical Immunology Directorate is based primarily in UHW (with a supporting Haematology Day Unit in UHL) and provides outpatient, day treatment and inpatient services to both the local Cardiff and Vale, and also the wider South East Wales populations. The Haematology service is the only Level 4 centre in Wales. Clinical Immunology services are predominantly outpatient and lab based at UHW, with the majority of treatments delivered through patient home treatment services. There are also close links with paediatric services for both specialties.


There is a dedicated Haematology Day Unit, and a highly specialised ward (both general Haematology and the Bone Marrow Transplant Unit) on Ward B4 Haematology based at UHW. In April 2015, Specialist Services took over the management of the Teenage Cancer Trust Unit which provides inpatient treatment for up to eight patients. 4. The Medical Genetics Directorate provides an all Wales Clinical Genetics service to all 7 LHBs. The service is outpatient and lab based with a small but highly specialised workforce of consultants and genetic counsellors. The directorate also manages the FH (Familial Hypercholesterolemia) all Wales service. 5. The Nephrology and Transplant Services Directorate is based at UHW and provides outpatient, specialist diagnostic, dialysis and inpatient services to both the local Cardiff and Vale, and also the wider South East Wales populations. There is a dedicated outpatient department based in the Tertiary Tower T1 at UHW, and 2 inpatient wards: General Nephrology (ward B5) and the Cardiff Transplant Unit in the Tertiary Tower (T5). The Directorate is also responsible for the management of the multiple dialysis units across the southeast region, and are jointly contracted by NHS Blood and Transplant (NHSBT) with Birmingham Foundation Trust to provide the NORS (National Organ Retrieval Service) for Wales and South West England. 6. The Neurosciences Services Directorate is based primarily at UHW and provides outpatient, specialist diagnostic, day treatment and inpatient services to both the local Cardiff and Vale, and also the wider South East Wales populations. The Neurology Service is based on Ward C4 (with 8 dedicated inpatient beds, a 6 bedded day treatment unit and a 2 bedded telemetry unit).

The Neurosurgery service consists of 3 wards; C4, B4 and the 18 bedded high care ward in the Tertiary Tower (T4). The regional Neuro-rehabilitation and Spinal Injuries services are currently based in Rookwood Hospital with outpatient and inpatient (as well as specialist therapy) services. 7. The Artificial Limb and Appliance Centre is based on the Rookwood Hospital site with a depot at Treforest. ALAC provides outpatient, specialist diagnostic/assessment, prosthetic and wheelchair services to both the local Cardiff and Vale, and also the wider South East Wales populations.

Key Achievements: • Opened a four-bedded research unit on C4 to support Neurosciences research and development, and clinical trials. • Implemented Phase 1 of the new Adult Congenital Heart Disease service. • Transferred the Teenage Cancer Unit from Children and Women’s Clinical Board to Specialist Services. • Achieved all Referral to Treatment (RTT) targets for the ALAS service for the first time from November 2015. • Successfully recruited to a number of key senior leadership posts. • Opened a Post Anaesthetic Care Unit (650 admissions, reduction in mortality and length of stay for elective surgical patients and no cancellations as a result of lack of critical care beds). • Delivered a position of 0 x 36 week waits in all Directorates within the Clinical Board with the exception of Neurosurgery (66). • Delivered 807 Cardiac Surgery FCEs (compared with 709 FCEs in 2014/15).

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Case Study – Bed free Surgical Ward The new Post Anaesthetic Care Unit (PACU) at University Hospital of Wales has all but eliminated planned operations being cancelled due to a lack of Critical Care beds. It has also led to a reduction in hospital stays and complications, cut costs and won the backing of patients. The unit helps to protect planned surgery from unexpected surges in emergency demand. Staff introduced a ‘bed free’ approach where patients are taken to theatre for their operation and recover in the PACU on their ward bed. It means that there is always a space for them to return to the ward when safe to do so and ensures the highly skilled specialist staff on the unit are treating those most in need. Gareth Scholey, Consultant in Intensive Care at Cardiff and Vale University Health Board, said: “This has been a real patient centred approach and has been extremely successful, exceeding all expectations. “Patient satisfaction in the unit is extremely high. Feedback is overwhelmingly positive and clinical outcomes are excellent.” In the previous year 81 operations had to be cancelled due to the lack of Critical Care beds. The introduction of the PACU has meant only two operations were cancelled – neither occasion related to lack of beds. Cancelling planned operations has been a major problem for the NHS across the UK. Increasing levels of emergency surgery and delays in moving patients out of intensive care and into ward areas and other factors have put increasing pressure on the service. The team at UHW looked at the problem and put in a place a ‘patient centred’ approach, separating elective, or planned surgery, and emergency surgery. They also put strict criteria on who could access the service but also introduced a bed free strategy. Gareth explained: “Patients go to theatre on their ward bed and are nursed in PACU. This leaves a virtual space on the surgical ward in which no other patients can be placed, something that had been a real problem in the past.

“Now when patients are ready to leave PACU and return to the ward they can do so immediately, reducing delays and making the best use of resources.

“We have seen double the number of patients we expected. The evidence shows that PACU care shortens length of stay and patients have fewer complications. Our data also shows that patients are getting good post-operative care.”

The PACU approach has also eliminated the need for post-operative one to one care on the surgical wards meaning better use of nursing time and a reduction in nursing costs.

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Children and Women Clinical Board Staff - 1,700

£

Budget - £88m

The Children and Women Clinical Board delivers care across the whole patient pathway and has responsibility for tertiary specialist services, local secondary services and universal and targeted services. These support health, wellbeing, education, development and public health amongst the population of children, young people, parents, families, women and their partners. This includes national and local partnership family focused initiatives and safeguarding priorities. The table below captures the essential services within the Directorates. It is worth noting that some services are provided for the whole of Wales, and this is of particular relevance when considering the strategic importance of Child Health services and the


future configuration of services for the Noah’s Ark Children’s Hospital for Wales (NACHFW). Similarly when considering service change, WHSSC remains a commissioner of our services on behalf of other LHBs in Wales. There are also services provided on behalf of or in conjunction with local authority partners.

Directorate

Specialty

Population coverage/ special groups

Provided from:

Community Child Health

Community Paediatrics

Cardiff and Vale

UHL, St David’s, Health Centre’s and Clinics

(500 staff)

Paediatric Palliative Medicine

South Wales

UHW, Ty Hafan

Looked After Children’s Service

Cardiff and Vale

Lansdowne Hospital

Key Achievements:

Paediatric Audiology

Cardiff and Vale

• Midwifery Team have had a number of posters and presentations accepted at both national and international conferences.


Child Psychology

Cardiff and Vale

UHW, UHL, St David’s, Special Schools, Community

Health Visiting and School Nursing

Cardiff and Vale

Community and Schools

Children’s Community Nursing Team

Cardiff and Vale

UHL and Community

Flying Start

Cardiff and Vale

Community

Families First Consortia, Early Years and Healthy Lifestyles

Cardiff

Community

Childhood Immunisations

Cardiff and Vale

Schools

Children’s Therapy Services

Cardiff and Vale


Children’s Continence Services

Cardiff and Vale


Neurodevelopment Service

Cardiff and Vale

UHL, and St David’s,

Primary Mental Health

Cardiff and Vale

St David’s, Health Centre’s and Clinics

Cardiff and Vale

Community

• Work has started on the Ronald MacDonald House “home away from home” with 30 rooms expected to finish late 2017. • Healthy Eating Day in NACHFW supported by local school children. • Two midwives have been appointed to be NICE reviewers of the high risk Intrapartum guidance and Fetal monitoring guidance which is a huge accolade for midwifery and particularly for Cardiff.

Directorate

Specialty

Population coverage/ special groups

Provided from:

Acute Child Health

Paediatric Surgery

Mid & South Wales

UHW

Paediatric Critical Care

Mid & South Wales

Paediatric Cardiology

Mid & South Wales

Portage Services

Neonatology

Mid & South Wales

General Paediatrics

Cardiff and Vale

Specialist Nurses for: YOT, Substance Misuse and Integrated Family Support

Paediatric Infectious Diseases

South Wales

Paediatric Hepatology

South Wales

Paediatric Respiratory Medicine (Including CF)

South Wales

Paediatric Neurology

South Wales

Paediatric Endocrinology

South Wales

Paediatric Diabetes

South Wales

Paediatric Gastroenterology

South Wales

Paediatric Oncology

South Wales

Paediatric Nephrology

South Wales

Paediatric Metabolic

South Wales

Childrens Therapy Services including Hydrotherapy

Cardiff and Vale

Play Specialist Services

Cardiff and Vale

Paediatric Neuro-rehabilitation

Mid & South Wales

Paediatric Pain control / Palliative Care

Mid & South Wales

(700 staff)

Obstetrics & Gynaecology Gynaecology Obstetrics (500 staff) Fetal Medicine

Community multiagency team based Cardiff and Vale

UHW

Cardiff and Vale

UHW

Mid & South Wales

UHW

Gynaecology Oncology

Mid & South Wales

UHL

Colposcopy

Cardiff and Vale

UHW

Urogynaecology

Cardiff and Vale

UHW

Sexual Assault and Referral Centre

Mid & South Wales

CRI

Midwifery

Cardiff and Vale

UHW, UHL

Endometriosis

Mid & South Wales

UHW

Pregnancy Advisory Service (PAS)

Cardiff and Vale

UHW

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Case Study – Breastfeeding support to new mums Suzan Watkins is a Maternity Support Worker who works within the Maternity Department at the University Hospital of Wales. Suzan goes above and beyond giving breastfeeding support to new mums. She supports parent education and embraces new challenges such as newborn spot screening. She is a credit to the service, and the Directorate has received so many thank-you letters from women she's provided care to that they're too numerous to mention. Suzan was won the Unison Branch Award for education and training.


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Clinical Diagnostics and Therapeutics Clinical Board Staff - 1,965

£

Budget - £114.5m

Staff are supported by the Clinical Board, professional leads and directorate management teams to implement measures to ensure high quality, safe and dignified care and to support continuous service improvement. The Clinical Board welcomes feedback from patients and service users in a number of ways eg informal, two minutes of your time, national surveys, concerns and compliments, Datix reports. This feedback is collected, captured, reported, acted upon and monitored and then shared throughout the Clinical Board to allow for shared learning. There have been a number of stakeholder engagement events in the Clinical Board, for example a successful joint patient focus group with RNIB Cymru, and Laboratory Medicine stakeholders’ feedback and open day. RNIB Cymru is actively involved in the design of a pilot care environment within the Clinical Board (Radiology reception) with the intention of attaining Visibly Better Cymru accreditation. The Clinical Board developed a ‘Patient Experience and Engagement Framework’ to further develop this work under the heading of ‘Hear My Voice’.


Key Achievements: • ISO 15189 accreditation in Cellular Pathology, Biochemistry and Laboratory Genetics. • Improved Stroke metrics, shorter waiting times for diagnostics, reduced turnaround time in pathology and improved pharmacy processes. • Fully automated booking system for outpatients, including patient reminders to improve booking and patient experience.

HEAR MY

VOICE

Case Study - Radiology Department: New Clot Retrieval Technique Patients who suffer mobility and speech problems after a devastating stroke are making a full recovery thanks to a revolutionary new form of treatment. The clot retrieval service, based within the UHB is the only one of its kind in Wales and has shown to greatly improve outcomes when compared with other techniques. It involves surgically removing a clot which is preventing an artery from supplying blood to the brain – an ‘intricate and complicated’ process according to experts, and has been proven to allow patients to make a full recovery.

One patient to benefit from the treatment is Osman Marks, from Ely, Cardiff, who suffered a stroke while lifting weights in the gym. Mr Marks procedure was carried out by Dr Sujit Nair, Consultant Neuroradiologist. The 39-year-old said he owes his life to Dr Nair and Dr Shetty from the Stroke Team who work closely with the Ambulance Service, Emergency Unit and Anaesthetic and Radiology staff, who have allowed him to continue his love of fitness and mixed martial arts. The dad of one, who had been experiencing stress and pains down his neck before the stroke, said he suffered two transient ischaemic attacks (TIA) – or “mini strokes” – within a couple of hours of one another. Within just 24 hours of undergoing the clot retrieval technique, which Osman opted to stay awake for, he had gained almost full mobility. “I cannot thank them enough,” said the IT consultant. “Within a month I was running five miles and getting back to my one-to-one boxing sessions.”

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Dental Clinical Board Staff - 386

£

Key Achievements:

Budget - £17.1m

The Dental Clinical Board encompasses the University Dental Hospital, Community Dental Service and Designed to Smile. The Dental Hospital treats around 100,000 patients per year and, as a teaching hospital, has strong links with the School of Dentistry. It provides dental care for patients who are screened as suitable for treatment by undergraduate dental students. The School of Dentistry is the only one of its type in Wales and provides unique and important leadership in dental research, teaching and patient care. The Community Dental Service (CDS) provides primary care dental services to children and patients with special requirements including the elderly and disabled. It also acts as a safety net service for patients who are unable to access NHS dental treatment. In addition, the CDS provides a wide range of preventative care through the national Designed to Smile programme, which targets children under the age of 11 in areas of high need.

• The School of Dentistry ranked the best in the UK for Dentistry in the 2016 Guardian University Guide out of 119 UK Universities and ranked 1st in The Times Good University Guide 2016. • £2.2m investment from Cardiff University to enable the refurbishment of the School’s 2nd floor Phantom Head suite. • Maintained a high level of Green (RAG score) on the Tier 1 targets across all domains. • Implemented the WHC 2015-001 Improving Oral Health for Older People Living in Care Homes – team appointed and delivering oral health education to care home staff. • Completed the five year Clinical Trial in conjunction with Cardiff University in November 2015. This was the first study of its kind which looked at the effects of fluoride varnish versus fissure sealants. • Formalised agreement with Renishaw PLC regarding Cadcam 3D technology. • Innovation through technology – agreed funding to roll out digital radiology system within Community Dental Services. • Set up text message reminder system and voice recognition dictation within the University Dental Hospital (UDH). • Reduced patient letter turnaround times from dictation to sign off to two weeks. • Appointed three Specialist Trainees in Special Care Dentistry.

Case Study – Designed to Smile Programme The Community Dental Service was recognised for their achievements in delivering the Designed to Smile programme by the National Institute for Health and Care Excellence (NICE) Forum 2016. The NICE Forum addresses the challenges being faced by the healthcare sector and the ways in which NICE and other key partner organisations can provide practical support, guidance and tools for high quality, integrated care. In association with the Patient Safety Congress, this is the largest gathering in the UK for those concerned with delivering high quality care across the health system. Designed to Smile is Wales’ National Oral Health Promotion programme targeted at children living in deprived areas. The Designed to Smile programme is making a massive difference to the lives of children in Wales. The latest figures show that dental decay has reduced by 12% in five-year-olds since 2008 and there has been an overall reduction in the average number of teeth affected when children have tooth decay. NICE have confirmed that Designed to Smile is one of 20 highly commended examples of shared learning.

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Cardiff and Vale Health Charity Cardiff and Vale Health Charity (RCN 1056544), is the official charity supporting all the wards and departments of Cardiff and Vale University Health Board. Through our spending in 2015-16 the Health Charity has supported multiple UHB strategies, including the Volunteering Framework and the Staff Health and Wellbeing Action Plan from the Health and Wellbeing Advisory Group. The Health Charity has continued to provide the CAV Free Wifi network, which is quickly becoming an essential service for patients and carers spending time in hospital. In addition, Health Charity donors, The Moondance Foundation enabled the purchase of six new AutoPulse machines (mechanical CPR) for use by wards and the Resuscitation Service. The value of this equipment for the very sickest patients was illustrated by presentations from Leading Improvements in Patient Safety, a UHBwide programme that increases the capacity and capability of our staff to make improvements to clinical practice. We are delighted that our donors can provide such practical support in the implementation of this programme. Our general purpose ‘Make It Better Fund’ continues to grow, due to the generosity of staff who join our internal Staff Lottery. The Make It Better / Staff Lottery Panel now considers bids from any staff member to a maximum value of £20,000. Some of the projects funded in 2015-16 are outlined below: The Serenity Mural decorates a large wall in the new Psychiatric Intensive Care Unit secure garden, part of Hafan y Coed (‘Haven of Trees’). Bryce Davies, a local artist, worked using the themes of trees, animals and water, to create a piece that speaks to patients and staff of hope and positivity.

The sensory system funded by Make It Better for the Paediatric Emergency Unit has had excellent impact. Nursing staff report easier cannulating and bleeding of generally calmer children, who have even sung along to their favourite songs whilst having painful burns dressed. The system has helped relieve a great deal of stress for children, carers and staff alike. Noori Jane Devlin volunteers once a week in the five Mental Health Services for Older People (MHSOP) wards, playing a portable electronic keyboard purchased by the Make It Better Fund. The hour begins with quiet, reflective improvisation, followed by a piece of music that the patients, many of whom have advanced dementia or severe mental illness, will be familiar with. Music helps many of the patients to unlock emotion and release tension, but it also helps to bring people together on the ward, as people can talk through the quiet playing. Noori says, ‘I think the music helps visitors to feel and see that their loved ones are being cared for aside from the basics like medical help and food.’

Cardiff & Vale

HealthCharity ElusenIechyd Caerdydd a’r Fro

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Noah’s Ark Children’s Hospital for Wales The Children’s Hospital celebrated its one year anniversary in May 2015 and this purpose built facility continues to impress. During the past year, we have: • Opened Latchmosphere, an interactive children’s radiology department. • Opened the Leon Montanari room, an area to support parents when explaining cardiac conditions to families. • Celebrated Christmas with celebrities, patrons and local businesses, including Gareth Bale, the Cardiff Devils, Cardiff City FC, Cardiff Blues, the Welsh Guards, the Aladdin cast and the Shrek cast. • Started work on the garden. An outside area is instrumental in a child’s recovery. It will include a therapy zone to deliver therapy to children who are long term inpatients. • Started work on building a new Ronald MacDonald parents’ accommodation.

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Chapter 2 Our population’s health Cardiff and Vale has one of the fastest growing and aging populations in Wales and the UK. Between 2014 - 2034 it is projected that Cardiff alone will have a population increase of 26%* (footnote- source Cardiff Liveable City report). Added to a population that is living longer, with increased complex needs, this is placing a significant challenge on health services across both Cardiff and Vale of Glamorgan.

As a UHB we are committed to reducing these gaps in health inequalities and are, through a range of health promotions and services, seeking to reduce health inequalities through behavioural change and increasing the accessibility of advice and services closer to people’s homes and relevant to their own health needs.

Tobacco

Immunisations

We aim to reduce the number of people using tobacco in Cardiff and Vale.

We aim to increase the immunisation uptake in Cardiff and Vale.

Key Achievements:

Key Achievements:

• The number of adults smoking in Cardiff and the Vale has dropped from 20% to 18%. The Welsh average is currently 20%.

• Uptake of seasonal flu vaccine among pregnant women in Cardiff and the Vale was 87.9% compared to an average of 75.6% in Wales.

The demographics are changing rapidly too. It is projected that there will be more people aged over 65, more school age children and more working age people between the ages of 30-50. The city region in particular has a long history of being open and inclusive, and is the most ethnically diverse local authority in Wales with just over 15% of its population originating from black and minority ethnic groups. A combination of economic factors and healthy lifestyle choices means that Cardiff and Vale has some of the highest health inequalities in Wales, and life expectancy differences between the most socially deprived and the most affluent can mean as much as 22 years. This gap is caused by a range of complex factors, such as unhealthy behaviours which increases the risk of disease, particularly in terms of obesity, alcohol consumption, smoking and low levels of healthy eating and physical activity. There are significant “wider determinants” of health such as housing, household income and levels of education and access to health and healthcare services that contribute to inequality in health.

• Launch of the Tobacco 20 campaign to engage staff in the Leadership Challenge to reduce the number of smokers on UHB grounds in line with the Smoke Free Policy.

• Uptake of seasonal flu vaccine among over 65s in Cardiff and the Vale was 68.9% compared to an average of 66.6% in Wales. • Uptake of seasonal flu vaccine among under 65s in Cardiff and the Vale was 48.3% compared to an average of 46.8% in Wales.

In response to this, we have developed key priorities for public health, tobacco, obesity, immunisations, alcohol and falls prevention.

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Alcohol

Falls Prevention

Obesity

We aim to reduce the number of people drinking over the recommended levels in Cardiff and Vale.

We aim to reduce the number of older people experiencing falls in Cardiff and Vale.

We aim to reduce the number of people who are overweight and obese in Cardiff and Vale by improving diet and nutrition and increasing levels of physical activity. Key Achievements:

Key Achievements:

Key Achievements:

• Within its remit as a Responsible Authority on alcohol licensing, we work in close partnership with South Wales Police, Cardiff Council, Vale of Glamorgan Council, licensed premises and other Responsible Authorities to ensure that the night-time economies of Cardiff and the Vale are safe environments for members of the public and visitors to enjoy.

• We funded local fitness professionals to undertake ‘Otago’ training, a strength and balance technique to prevent and reduce falls.

• We advise licensed premises on safer sales of alcohol consumption (eg by minimising harm of alcohol consumption through drinks promotions). We regularly contribute ‘conditions’ to licenses to ensure that premises operate as safely as possible. To date, the UHB has successfully worked in partnership with South Wales Police to ensure that numerous large scale premises operate as safely and responsibly as possibly. Additionally, the UHB has provided evidence and representations at several license hearings. • The number of adults in Cardiff and Vale who reported drinking above alcohol guidelines at least once in the last week has fallen from 44% to 42%. • The number of adults in Cardiff and Vale who reported binge drinking at least once in the last week has fallen from 26% to 24%.

• There are currently 11 Otago classes running in various locations across Cardiff, with further classes planned for the Vale. • We produced an educational video featuring testimonials from participants in the class, who described the significant improvement to their health and lifestyles as a result of the technique. The video has been shared with partners and GPs to increase membership of the classes. In addition, we have trained 397 people in Making Every Contact Count, to help them make positive interventions in everyday conversation in regard to smoking, diet, alcohol, exercise and immunisation.

• The Specialist Weight Management Service was launched at University Hospital Llandough. The service is designed to improve long-term health and is for people with a body mass index (BMI) of 40 or above (35 and over for people with additional health problems). It provides tailored support from a nurse, consultant and dietitian as well as an occupational therapist, physiotherapist and psychologist. • Cardiff and the Vale has the lowest rate of child obesity in Wales. According to the Child Measurement Programme 2014/15, only 20.9% of children aged four and five are overweight or obese compared to the Welsh average of 26.2%. • The number of adults in Cardiff and the Vale who reported doing zero physical activity in the past week has fallen from 35% to 34%. • Food Cardiff (a partnership between Cardiff and Vale University Health Board, Public Health Wales, City of Cardiff Council and Cardiff University) piloted its Food and Fun initiative in five schools across Cardiff during summer 2015. The programme was created to address growing concerns around child hunger, social isolation and a decline in academic skills during the school holiday. The programme delivered nutritious meals, sports activities and food education to children in socially deprived areas of the city.

• The programme has won several awards: PS100 Health and Nutrition Award at the Cost Sector Catering Awards 2016, Public Health England Award for contributions to public health at the Advancing Healthcare Awards 2016, Social Impact and Diversity Award at the Footprint Awards 2016. • Food and Fun was so successful that four other local authorities across Wales have adopted the model this year.

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Case Studies

Case Studies

Obesity

Diabetes

When the Specialist Weight Management Service was launched by Health Minister Mark Drakeford, it was hailed as an important new weight-loss intervention. It was designed for people with a BMI of 40+, providing a multi-disciplinary approach to help them lose weight and change their eating habits for life.

Speaking to the Cardiff and Vale Public Health team to warn others of the dangers, she said: “I can do normal things like going away on holiday, but my diabetes comes first. It is always at the forefront of my mind and I check my glucose levels four or five times a day.”

David’s ambition is to lose weight so he can improve his mobility. This would enable him to walk around the local shops, take the dog for a walk and, ultimately, be fit and mobile enough to play with his grandchildren. He added, “I don’t go out any more and I’d love that to change. I’d like to be eating better, forever.”

Geraldine visits professional lead podiatrist Scott Cawley every three weeks to ensure her feet are not at risk of further infection.

Sian Jones, from Barry, was referred to the service after her gastric band had to be removed due to complications. She said: “My struggle with weight has been life-long. I had a gastric band fitted in Bristol which worked fantastically well at first and I lost 8st, but it slipped and caused me all sorts of problems.

Geraldine Pittman, from Cardiff, was diagnosed with Type 1 diabetes in her twenties. She was unaware of the long-term dangers and didn’t take the right steps to look after herself.

“I could barely drink water and I became anaemic, so I had no choice but to get it removed. Since being referred to this new service I have been really encouraged by it. The attitude of staff is really empathetic and they really want to understand.

Geraldine, 54, said: “These days there are excellent classes that teach you how to look after yourself if you have diabetes, but back then it was different. There wasn’t education around lifestyle choices like there is now.”

“Obesity is a complex issue which needs complex treatments.” David Smith, 59, from Grangetown, was one of many patients referred onto the service. He had tried to lose weight in the past, with little success, and was not eligible for bariatric surgery due to ill health. He said, “I found it impossible to do on my own. I need that support from the team. They point you in directions that you don’t see yourself.”

If not managed properly through healthy eating, exercise and checking blood glucose levels, diabetes can cause problems with circulation and sensation in the feet. In some cases, this can result in foot ulcers and infections. In 2000, Geraldine had an ulcer in her foot which became infected with MRSA. She was at risk of losing her leg but luckily only needed surgery to repair a bone in her toe. Geraldine has learned to look after herself thanks to the help and support she gets from Scott Cawley, her podiatrist at UHW. She now eats a healthy diet – with the odd treat – and sees her doctor at the first sign of any foot injury. Her new lifestyle means she can enjoy her life.

Scott said: “Geraldine’s experiences show why it’s important for people to take control of their diabetes before it takes control of them. As healthcare professionals, it’s important we transfer this knowledge so that people can make healthier lifestyle choices, reducing their risk of complications. As Geraldine has shown, it’s never too late to change.” Our community disease profile is also changing: the number of people with chronic illnesses or conditions across Cardiff and the Vale of Glamorgan is steadily increasing. The age profile of our population and the increased awareness and diagnosis of long-term conditions such as dementia, heart disease, lung cancer and diabetes is commensurate with an aging population living longer. As a UHB we are continuing to increase our knowledge around these conditions and reduce the causes of death, and are currently involved in mapping out a population needs assessment, required as part of the Social Services and Wellbeing Act 2014 (Wales). The public needs assessment will provide us with more information about the health needs of our population, and enable us to design our services and inform the work of all public services and the third sector. This work is well underway and will deliver its first iteration in 2016/17. The information or further collation of “community assets” will enable us to define our strategic approach and how we deliver services best suited to the needs of our population.

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Chapter 3 Our Strategy - Shaping our Future Wellbeing As an organisation we are constantly seeking to improve the ways in which we work with patients, carers, and those who are seldom heard in the community or have little contact with health services. In September 2015 the health board approved an ambitious ten-year strategy, Shaping our Future Wellbeing, which has been developed using the principles of Prudent Healthcare, is clinically led and also co-produced with our partners and the community. We are proud that the strategy has been developed with patients and for patients. Shaping our Future Wellbeing conveys our vision, which is to, Care for people and keep them well, to continuously improve the health and wellbeing of our population now and in the future. It is based upon a number of design principles, all of which are aligned with the Principles of Prudent Healthcare introduced by the Welsh Government. It focuses on: • • • •

Empowering the person. Home First. Delivering outcomes that matter to people. Avoiding unwarranted variation and reduce harm and waste.

We are now two years into the strategy, and have previously focused on a number of key areas and made significant progress in those, including reducing the number of people waiting for cancer treatments, reducing the time you wait to be treated, referral time, improving our interventions on Stroke, improving on the waiting times for receiving diagnostic services such as MRI scans and x-rays and reducing the delayed transfers of care for patients.

Integrated Medium Term Plan (IMTP) The Integrated Medium Term Plan (IMTP) supports how we plan to deliver the Strategy, Shaping our Future Wellbeing over a three year cycle. The IMTP is assured every year as part of this three year cycle by Welsh Government, and falls under the statutory NHS Framework. The way in which we plan, design and deliver our services is outlined in the IMTP and we work with a range of partners to support us. New legislation is changing the way in which we deliver our services. The Social Services and Wellbeing Act (2014) and the Wellbeing of Future Generations Act (2015) will place a greater emphasis on co-production, prevention and earlier intervention all of which are key aims of our strategy. As we write this Annual Report, we have yet to seek assurance from Welsh Government on the three year IMTP for 2016-17 to 2018-19 but we will continue to work with Welsh Government to achieve this by March 2017. Our IMTP is a publicly available document and can be viewed here.

BIG – Bold Improvement Goals – our priorities for 2016/17 We recognise that in achieving the 10 year plan we need to be able to develop programmes of work that we can design, deliver and evaluate. In March 2016 we developed three priority areas towards delivering the strategy and as outlined in the IMTP. We identified that these were Bold Improvement Goals or BIG, 1, 2 and 3. This has three specific goals or Priorities. BIG 1 - is focused on assessing the mix of patients we currently have on our medical wards to see if we could treat them more effectively in a different clinical setting. We believe we can and a significant piece of work is currently underway to achieve this. BIG 2 - is focused on community services and how we deliver these. We have already started a conversation, and this is the next stage of listening to our patients, staff and partners to ensure that we keep delivering high quality, sustainable services as close to people’s home as possible and to create the perfect locality for them. BIG 3 - will focus on a small number of specific health pathways or how you receive your treatment. We will be identifying ways in which we can reduce waste, harm and clinical variation in order to not only make us more efficient but provide the patients with a far better experience or outcome.

Values into Action Values into Action is the health board’s programme to better understand what behaviours can help embed our values into our everyday working lives. It is about translating our values into the tangible behaviours we want to see from each other, and to inspire us to keep improving our patient and staff experience. ‘Our Values into Action’ underpins the three BIG priorities that link to our strategy – Shaping our Future Wellbeing. It’s about achieving consistency of behaviours that work for patients, colleagues and healthcare partners.

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Chapter 4 Our partnerships and working with others Public Service Boards and the Acts As a university teaching hospital, we pride ourselves on being a centre of excellence for learning and development in medicine, research and clinical innovation. We have strong links with our academic and research partners, Wales Deanery, Cardiff University, University of South Wales and Cardiff Metropolitan University. Cardiff has a strong and enviable reputation as a School of Medicine and we are proud that many of the students remain in Cardiff and continue to help us deliver not only the basics of health services but of cutting edge clinical innovations, some of which can be found in this report. The health board currently trains the largest number of allied health professionals, healthcare scientists and nurses of any health board in Wales. We also work closely with the two Local Authorities, City of Cardiff and Vale of Glamorgan, across a number of strategic Public Service Boards and Public Health, and there is a far greater emphasis on collaborative working and coproduction across other public sector organisations and the third sector.

2015/16 has been a significant year in Wales, with the enacting of the Well-being of Future Generations (Wales) Act 2015 and the Social Services and Wellbeing (Wales) Act 2014. These world leading pieces of legislation, coupled with continued implementation of Prudent Healthcare and the launch of the UHB’s Institute of Health Improvement (IHI) inspired Shaping Our Future Wellbeing Strategy and provided key context for the refresh of Cardiff and Vale UHB’s Integrated Medium Term Plan 2016/17-18/19. Our partnership strategies, What Matters and The Vale of Glamorgan Community Strategy, have shaped our approach and are reflected in all that we do.

Well-being of Future Generations (Wales) Act 2015 The Well-being of Future Generations (Wales) Act 2015 places a well-being duty on public bodies to do things in pursuit of the economic, social, environmental and cultural well-being of Wales, in a way that accords with the principle of sustainable development. It requires public bodies to report on such action, including setting and publishing well-being objectives that are designed to maximise its contribution to achieving each of the national well-being goals.

Health Enterprise Alliance for Regional Transformation (HEART) Building on Shaping Our Future Wellbeing, the UHB has worked in partnership with Cardiff University, the City of Cardiff Council and the Vale of Glamorgan Council (the partners) to develop an overarching strategic blueprint. The blueprint builds upon the existing engagement work to develop organisational strategies and priorities and is underpinned by the principles of Prudent Healthcare and legislative developments, including the Well-being of Future Generations (Wales) Act 2015. The partners have acknowledged that this is a pivotal moment for the region. Cardiff is the fastest growing city in the UK with an increasing population aged over 65 and under the age of 4. There are significant health inequalities in our region and services are not sufficiently flexible to respond to these challenges. Further, significant investment is required in estates and technology in the coming years. Transformational change is required to deliver the quality of care that our citizens expect. HEART is aimed at addressing these core challenges through collaborative working, building upon each of the partners’ strengths and better aligning our resources. It creates an ambitious vision for innovation, integration and citizen focused health and wellbeing. These opportunities and the ambition can be summarised in an agreed mission statement outlining the partners intention to “generate a globally significant revolution in health and wellbeing, building on all of our strengths and aligning our resources to find new, replicable and sustainable ways to help Cardiff and Vale citizens lead fulfilling, healthy lives.”

In order to realise this mission, the partners have agreed nine strategic objectives in three key areas. These objectives form the basis of the “Cardiff and Vale system model”. In summary, we will focus upon: Citizen led services through strengthened community networks, technology enabled support and co-ordinating our support and response to our population based upon intensity of need. Working together more effectively to make the best use of assets, workforce and other resources. Driving innovation to accelerate the process from idea to implementable solution, attracting new sources of funding and providing swifter access to research for our population. A governance mechanism and proposal for programme management support is being developed to progress the plans. The HEART Programme Board will be established to provide overall leadership, accountability and stakeholder engagement, supported by a Steering Group responsible for delivering the programme of work. Initial areas of focus will be on joint master planning, collaborative asset management and integrating health and social care.

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Chapter 4 Innovation: creating and developing ideas for health and wellbeing in the future Cardiff and Vale University Health Board (UHB) has a strong international reputation for developing innovative clinical research and treatment that directly benefits our patients. The Medicentre for innovation is located on the University Hospital of Wales (UHW) site and encourages fledgling start-ups for innovation to thrive. Over the years we have continued to strengthen our ties with Cardiff University and have formalised many of the partnerships with academia and business to ensure that our ideas become a reality more quickly and that they have a strong chance of reaching the market and benefiting our patients. Professor Adam Cairns is the health lead on innovation in Wales and has established the Clinical Innovation Partnership with Cardiff University, formalising the ambitions and work of both organisations. The UHB is driving the innovation agenda with partners and has established a multi-disciplinary team (MDT) focused on taking ideas to development. 2016/2017 is its inaugural year and the Clinical Innovation Partnership will focus on dementia care where Cardiff University has a strong track record in leading research into dementia studies through the MRC Centre for Neuropsychiatric Genetics and Genomics. Dementia continues to remain one of the key aims of our 10 year strategy – Shaping our Future Wellbeing. We believe that through research, innovation and embracing advances in technology and through bio-sciences and life sciences, we will continue to drive improvements in patient outcomes and help us deliver a more sustainable health service for citizens and patients today and in the future.

UK’s first Pectus Carinatum surgery The University Hospital of Wales (UHW) performed the UK’s first invasive procedure to correct pectus carinatum, more commonly known as a “pigeon chest”, to correct chest deformities. The surgery involves a minimally invasive procedure to correct where the ribs appear to be pushed out. A specially designed brace was used by surgeons in a state of the art facility, the only one of its kind in Wales, which has an observation gallery and a live link to the teaching facility held in the Welsh Institute for Minimal Access Therapy (WIMAT) training facility in Cardiff Medicentre. Prof Mustafa Yuksel, a consultant cardiothoracic surgeon from Istanbul in Turkey, designed the brace and has carried out over 150 similar operations in his home country. He was invited by Margaret Kornasewska, Consultant Thoracic Surgeon at UHW and Cardiff University’s (WIMAT) to bring his expertise to Wales for this Specialist Surgical Event by WIMAT, which is a Postgraduate Surgical Training department within the Wales Deanery, and which in collaboration with UHW organises specialist training and brings innovation in surgery to Wales.

Wales’ first robotic treatment for prostate cancer

Community midwifery team go mobile with new devices

Over 350 patients in Wales have benefited from the introduction of the first surgical robotic procedure treating prostate cancer. The pioneering procedure was supported by £2.5 million from Welsh Government and offers a regional service benefiting patients across South and West Wales. The procedure is conducted by surgeons from Abertawe Bro Morgannwg, Aneurin Bevan, Cwm Taf and our own Cardiff and Vale UHB surgeons.

Using the latest in digital and information technology, the Community Midwifery team has moved to mobile working. Last year we rolled out new mobile devices to help save time, reduce duplication and provide a better level of service to expectant mothers.

The Da Vinci Robot Prostatectomy is a procedure which involves precise keyhole surgery to remove the prostate using robotic techniques. This method of treatment for prostate cancer has major benefits over traditional surgical treatment with less post-operative pain, reduced blood loss, reduced length of stay, quicker recovery and better overall outcomes for patients. The robotic surgery is already vastly improving the lives of patients and is now the preferred treatment for the removal of the prostate following the diagnosis of clinically localised prostate cancer. As part of the development of the new service, surgery was moved to the Short Stay Surgical Unit at UHW in keeping with the aim of enhanced recovery for patients, who now only need an overnight stay for their procedure compared to up to three days with open surgery, with overall fewer complications.

Previously when visiting a patient in the community, a midwife would hand write notes on paper which wasted time and required duplication of effort, with someone having to input this information back in the office. This led to discrepancies and inaccurate data collection, delays in inputting the information and low compliance with reporting figures for the national maternity indicators to Welsh Government. The solution developed within CAV UHB, with the assistance of the information technology department, provided an innovative solution to improve the operational capability and patient experience. All 85 mobile devices have now been rolled out to the community, enabling pregnant women to directly book maternity services onto the electronic maternity information system at their GP surgery or in a community setting. Data recorded through these devices is more accurate with better information reporting as part of data collection for Welsh Government Performance Indicators. Environmentally less paper is used and it is a far more accessible and secure system for storing patient data and information. The team recently presented this project at the Maternity, Midwifery and Baby conference in Birmingham as an example of best practice and innovation.

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Chapter 5 Our Performance Putting things right There are times when people do not have a positive experience of our services and we welcome people sharing their concerns in order for us to investigate and identify where improvements could be made. We remain committed to ensuring that all our patients receive high quality and dignified care, therefore it is disappointing to hear of occasions when this has not been the case. Occasionally, some of these concerns become of interest to the media, and whilst we try to be as open and honest as we can, because of issues of patient confidentiality this often makes it difficult for us to respond in a public forum. We hope this annual report offers reassurance to our current and future patients, relatives and carers. We encourage patients, families and carers to raise concerns at the time so that where possible we can resolve issues in a timely and effective manner. We encourage staff to be accessible to patients and carers, to listen to their experiences and to locally resolve the concerns where possible. Many of the wards hold protected, regular sessions for patients and families to discuss concerns with the ward manager. We have placed 300 posters around the Health Board in English and Welsh advising people how to raise their concerns with staff. Contact details for the Community Health Council and contact details for the concerns team are displayed on the posters.


Chapter 5 Our Performance Cardiff and Vale Community Health Council We work closely with Cardiff and Vale Community Health Council (CHC), an independent statutory organisation that acts as a voice for patients and the public. It is also an NHS watchdog for all aspects of health care. We work together to discuss the delivery and development of the services we provide. We also welcome reports from the CHC and are grateful for their on-going advice, challenge and support. For more information, please contact: Community Health Council Offices Third Floor Park House, Greyfriars Road Cardiff CF10 3AF Telephone: 02920 377407

Principles of Remedy

Emergency Preparedness

The Health Board has fully embraced the regulations which guide the handling and response to concerns (complaints and incidents) launched by Welsh Government in April 2011. In addition, the UHB’s approach to dealing with concerns very much reflects the ‘Principles of Remedy’ published by the Public Services Ombudsman for Wales.

NHS organisations are required to undertake emergency planning and associated activities within the context of the Civil Contingencies Act 2004 (CCA).

http://www.ombudsmanwales.org.uk/~/media/Files/Documents_en/Princ iples_for_Remedy.ashx. These six principles underpin the way we manage our concerns process, with a focus on: • Getting things right • Being customer focused • Being open and accountable • Acting fairly and proportionately • Putting things right • Seeking continuous improvement. Since the Welsh Government regulations came into force, we, like many other NHS organisations in Wales, have seen a significant increase in the volume of complaints about services provided by us. There has been an increase in the total number of concerns (formal and informal) since the Putting Things Right regulations were introduced in 2011. http://www.cardiffandvaleuhb.wales.nhs.uk/sitespl us/documents/1143/Annual%20Quality%20Statm ent%202016.pdf

Robust Major Incident plans are in place to ensure that we are prepared to respond to incidents in line with the CCA and related guidance from the Cabinet Office, UK Resilience and Welsh Government. The plans are subject to regular review to make sure they are up-to-date and that they reflect lessons learned from any incidents, as well as any structural changes within the organisation. The health board collaborates with the South Wales Local Resilience Forum and partner agencies to develop plans, deliver training and exercises to staff, and to inform the development of response plans.

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Performance Management Framework The UHB’s performance management framework is underpinned by the NHS Wales Outcomes Framework 2015/16. This is made up of the following areas: Staying healthy People in Wales are well informed and supported to manage their own health. Safe care People in Wales are protected from harm and protect themselves from known harm. Effective care People in Wales receive the right care and support as locally as possible and are enabled to contribute to making that care successful.

Using outcome measures mandated by Welsh Government (WG), performance in 59 areas across the seven domains is scrutinised under the following headings: • Improving our patients’ experience of care. • Improving the health and wellbeing and reducing inequality of care for our population. • Making effective use of our staff and resources.


Hand Hygiene

Stroke – Sustained Compliance Against Four Stroke Bundles

The All Wales Care indicator for hand hygiene requires all ward areas to monitor whether all staff disciplines working in patient areas have adequately decontaminated their hands, in accordance with the WHO 5 moments of hand hygiene. The health board’s overall compliance score across 2015/16 steadily improved over the period, reaching 94% in March 2016.

The expectation on the UHB is to demonstrate continuous improvement with the objective of achieving the SSNAP UK average (SSNAP is the audit tool used throughout the UK to record detailed data on stroke patients treated in hospitals) by the end of March 2016. The Welsh Government has chosen four areas within the Quality Improvement Measures (QIM) to focus on for all-Wales benchmarking purposes:

Performance for the period covered by this report across a range of these measures is explored below.

Improving Our Patients’ Experience of Care

WG benchmarking standard

Target 61.8%

Healthcare Acquired Infections

4 Hour QIM

Direct Admission to Acute Stroke Unit within 4hrs

The current targets have been set for achievement by March 2017. The UHB is already achieving the C. difficile target though this will need to be maintained. Progressive plans exist for Staph. aureus Bacteraemia.

12 Hour QIM

CT Scan within 12 hours

Dignified care People in Wales have timely access to services based on clinical need and are actively involved in decisions about their care.

24 Hour QIM

Assessed by a Stroke Nurse within 24 hours

89.1%

72 Hour QIM

Formal Swallow Assessment within 72 hours

84.9%

Individual care People in Wales are treated as individuals with their own needs and responsibilities.

C. difficile – Welsh Government target 28 cases per 100,000 population

Our staff and resources People in Wales can find information about how their NHS is resourced. Assurance that the UHB is achieving the requisite standards is provided primarily via the Board’s performance report. This is considered in the open section of Board meetings and available for public scrutiny on the UHB website.

• Rate (April 2016) 25.24 / 100,000 population Staph. aureus Bacteraemia – Welsh Government target 20 cases per 100,000 population • Rate total Staph. aureus (April 2016) 27.77 / 100,000 population

91%

The table below shows the UHB’s performance against all of the QIMs (NB operated in shadow form April to September 2015): Stroke Care performance Indicators

Target

Apr-15 May-15 Jun-15

Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

1. Within 4 Hours care KPI

95%

37.5%

31.0%

30.4%

33.3%

38.0%

27.7%

47.1%

54.5%

38.6%

41.2%

28.8%

34.8%

1a - Direct Admission to Acute Stroke Unit

95%

38.3%

35.7%

37.8%

35.7%

44.0%

29.8%

49.0%

59.5%

41.9%

48.0%

37.3%

35.6%

1b - Swallow Screening

95%

48.8%

55.3%

66.7%

61.7%

60.9%

62.8%

57.5%

68.4%

56.8%

49.0%

61.8%

65.9%

2. Within 12 Hours Care KPI

95%

93.8%

97.6% 100.0% 98.2%

98.0%

93.6% 100.0% 97.7%

95.5%

96.1%

98.3% 100.0%

2a - CT Scan

95%

93.8%

97.6% 100.0% 98.2%

98.0%

93.6% 100.0% 97.7%

95.5%

96.1%

98.3% 100.0%

3. Within 24 Hours care KPI

95%

43.8%

54.8%

67.4%

63.2%

60.0%

53.2%

66.7%

68.2%

68.2%

49.0%

28.8%

56.5%

3a - Assessed by a Stroke Consultant

95%

62.5%

66.7%

73.9%

70.2%

66.0%

59.6%

72.5%

75.0%

77.3%

60.8%

33.9%

63.0%

3b - Assessed by a Stroke Nurse

95%

81.3%

97.6%

93.5%

96.5%

92.0%

91.5%

94.1%

95.5%

95.5%

92.2%

91.5%

93.5%

3c - Assessed by One of OT, PT, SALT

95%

79.2%

81.0%

87.0%

87.7%

86.0%

85.1%

86.3%

77.3%

86.4%

76.5%

69.5%

78.3%

4. Within 72 hours Care KPI

95%

47.9%

61.9%

84.8%

87.7%

82.0%

80.9%

72.5%

81.8%

77.3%

76.5%

79.7%

67.4%

4a - Formal Swallow Assessment

95%

5.6%

18.2%

54.5%

80.0%

64.7%

75.0%

50.0%

76.2%

78.6%

61.1%

75.0%

60.0%

4b - OT Assessment

95%

77.3%

81.1%

97.5%

94.3%

81.4% 100.0% 97.7%

94.7%

84.6%

93.5%

98.2%

85.7%

4c - Physiotherapy Assessment

95%

93.2% 100.0% 100.0% 98.0%

95.2%

97.4%

97.9%

97.5%

95.1%

95.7%

98.2%

97.4%

4d - SALT Communications Assessment

95%

5.0%

72.2%

68.2%

56.5%

76.0%

80.0%

50.0%

54.2%

47.6%

7.1%

57.1%

88.9%

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The UHB monitors its cleanliness using the all Wales “Credits 4 cleaning” system, deployed across all sites. Areas and departments are categorised as being very high risk, high risk, significant risk or low risk based on the potential consequences to patient outcomes. Cleanliness audits are undertaken weekly, with the 4 week average being used to determine for each clinical area, and for the UHB as a whole, whether the acceptable level of cleanliness has been achieved.

UHB performance against the cleaning standards for areas assessed to be of the highest risk September 2014 and March 2016.

96% 94% 92% 90% 86% 84% 82% 80%

Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

USC Very High Actual Very High Target Non USC 31 Day Actual High Target Significant Actual Significant Target

At the end of March 2016, there were 1598 patients on an elective referral to treatment time pathway waiting in excess of 36 weeks against our planned improvement milestone of 1692. The UHB has demonstrated continuous improvement throughout the year in reducing the numbers of patients waiting in excess of 36 weeks (a 33% in year improvement), with the position now being the lowest level since April 2012.

In October 2015 there was a change in the ambulance triage model, reducing the number of patients triaged as having an immediate or life threatening condition. This led to a significant improvement in the proportion of patients with a potentially immediate or life threatening condition in Cardiff and the Vale, who the Ambulance Service responded to within 8 minutes. In the first 6 months of the year, 58.9% of calls assessed as immediate were responded to within 8 minutes, with the average for the second half of the year being 74.3%.

100% 90%

2000

80% 70%

1500

60% 50% 40%

1000

30% 20%

500

10% 0%

0 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 Apr-16 May-16

Arriving within 8 mins Arriving > 8 mins % Compliance

Proportion of Ambulance transfers taking place within 15 and 60 minutes (Targets 95% and 100%) 100%

Referral to Treatment Time: No. of Open Pathways > 36 weeks 6000 5000

The Welsh Government has set a target that 95% of most patients referred for consultant led elective care should be treated within 26 weeks from date of receipt of referral, with the remaining 5% seen within 36 weeks.

Ambulance l C Calls ll & R Response R Rate t within ithi 8 minutes i t ffor patients ti t with ith Immediate or Life Threatening Conditions 2500

98%

Performance in March 2016 was 94.7% in the very high risk areas, 94.4% in the high risk areas and 91.3% in the significant risk areas.

Elective Access - Waiting Times/Cancelled Procedures

Emergency Unit (EU) & Ambulance Access Performance

100%

% Compliance

Cleaning Standards


4000 3000 2000 1000 0 Apr

2013-14

May

Jun (Q1)

2014-15

Jul

Aug

Sep (Q2)

Oct

2015-16 Actual

Nov

Dec (Q3)

Jan

Feb

Q4 Profile Target

Mar (Q4)

90%

The proportion of patients whose transfer of care from the Welsh Ambulance Service to the UHB’s care was within 15 minutes and 60 minutes demonstrated an improvement on the previous year for the first 9 months of the year, but then deteriorated markedly in the final quarter as a consequence of demand being 5-8% higher than the previous year and the 5 year average. Performance over the year ranged from a peak of 76% and 92% respectively in the summer months, to 37% and 77% in March 2016.

80% 70% 60% 50% 40% 30% 20% 10% 0%

Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

%4hrs 2015/16

84%

87%

87%

86%

81%

81%

81%

78%

81%

76%

74%

74%

60

61



Mental Health

2015/16 was very much a case of building the foundations for the future whilst seeking to maintain and / or improve upon the minimum service standards laid out in the Mental Health Measure, namely:

Part 2: Target - Mental Health Service Users should have a valid Community Treatment Plan completed at the end of each month. The Welsh Government’s minimum standard of 90% was met in every month of 2015/16.

95.0% 90.0% % Compliance

85.0% 80.0% 75.0% 70.0% 65.0% Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15 Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

USC 62 Day Actual

89.0% 90.1% 84.0% 84.5% 81.3% 80.0% 81.8% 81.9% 76.9% 71.8% 64.4% 83.1% 64.1% 69.7% 62.7% 61.1% 70.9% 74.0% 74.2% 79.0%

62 Day Target

95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0% 95.0%

Non USC 31 Day Actual

98.2% 96.9% 98.2% 96.0% 98.0% 89.9% 96.0% 96.4% 96.3% 97.1% 96.3% 95.2% 93.2% 97.3% 94.1% 96.0% 97.9% 97.5% 100.0% 95.0%

31 Day Target

98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0% 98.0%

Part 4: Provision of an advocacy service for patients was achieved on all occasions. Urgent Suspected Cancer

Performance in Delivering the Mental Health Measures 1,200

Non-Urgent Suspected Cancer

Number of patients treated

Number treated within 62 days

% treated within 62 days



% treated within 31 days

Head and neck

55

41

74.5%

41

52

96.3%

Upper Gastrointestinal

59

35

59.3%

35

76

98.7%

Lower Gastrointestinal

81

47

58.0%

47

116

96.7%

Lung

84

73

86.9%

73

180

96.8%

Sarcoma

7

3

42.9%

3

8

100.0%

167

107

64.1%

107

46

100.0%

1

1

100.0%

1

38

100.0%

Breast

150

130

86.7%

130

153

96.2%

Gynaecological

44

43

97.7%

43

50

96.2%

Urological

209

122

58.4%

122

122

87.8%

Haematological

42

30

71.4%

30

96

99.0%

Acute Leukaemia

0

0

0

33

100.0%

100.0%

90.0%

1,000 80.0%

70.0%

800 60.0%

600

50.0%

40.0%

Skin Brain/CNS

400 30.0%

20.0% 200 10.0%

0

0.0%

Feb-15

Mar-15 Apr-15 May-15 Jun-15

Jul-15

Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16

653

868

749

674

781

745

708

877

887

989

776

806

950

893

Part 1a

100.0%

98.7%

65.5%

77.2%

86.2%

76.6%

79.8%

72.9%

85.8%

81.8%

75.3%

47.8%

88.9%

82.2%

Part 1b

97.2%

95.8%

97.5%

99.3%

96.8%

98.2%

98.2%

98.3%

97.0%

98.2%

93.3%

96.1%

97.1%

94.3%

Part 2 Compliance

90.1%

89.3%

90.7%

92.2%

90.8%

91.3%

90.9%

90.1%

90.6%

91.1%

90.2%

90.0%

90.7%

90.4%

6.3%

7.7%

5.6%

56.3%

71.4%

75.0%

85.7%

83.3%

71.4%

90.9%

93.3%

88.9%

Referrals

Part 3 Compliance

Part 1: Service users of primary mental health services should receive an assessment within 28 days and receive therapeutic intervention following assessment within a further 28 days. The standard of 80% for the first assessment was met over the course of the year, although the resilience of the service to cope with supply and demand shocks was tested at times, with performance fluctuating greatly. At the end of the year, the health board had got back to a position where 82% of patients were assessed within 28 days, and 94% of those requiring a therapeutic intervention received it within a further 28 days.

100.0%

60.0%

% Compliance

In Child and Adolescent Mental Health Services the UHB has agreed a new specification for secondary care services with Cwm Taf Health Board who provide our services. This incorporates the CAPA model (Choice and Partnership Approach). After procurement and transfer arrangements have been completed, primary mental health services will be provided locally from within Cardiff and Vale.

Compliance with the cancer standards for USC and Non USC Pathways.

Through a developing programme of pathway transformation and capacity investment, these challenges were addressed, and the UHB ended the year with a reduced level of backlog and delivering an improving trajectory of performance.

Part 3: Former users assessed under part 3 of the Mental Health measure should receive a report detailing an outcome of their assessment within 10 days of the assessment. This was a new measure introduced in June 2015, against which the UHB has been making steady improvement from 6% in quarter 2, rising to 91% in quarter 4. The expected level is 100%.

Monthly Referrals to LPMHSS

The UHB has made significant progress over the course of the year in improving the effectiveness, accessibility and resilience of its mental health services. Demand for the adult and older people’s mental health services has continued to grow, rising linearly from an average of approximately 650 per month in 14/15 to over 830 in 15/16, with the latter 6 months of 2015/16 seeing the average volume rise to just under 900 referrals per month.

Children’s cancer

3

3

100.0%

3

26

100.0%

Other

19

16

84.2%

16

31

100.0%

UHB Total

921

651

70.%

651

1027

96.3%

Cancer 71% of cancer patients who were referred by their GP as urgent with suspected cancer commenced treatment within 62 days of their referral over the course of 2015/16, against a minimum expected standard of 95 %. 96.3% of patients who were not on an “urgent suspected cancer” pathway commenced treatment within 31 days of the requirement for treatment being agreed with them. This is relative to the minimum expected standard of 98%. Over the course of the year, the UHB encountered a number of significant challenges in the management of the high volume tumour site pathways, namely skin, urological and gastrointestinal.

Delayed Transfers Of Care An average of 79 beds per day in 2015/16 were occupied by patients whose transfer of care had been delayed, which represents a 4.8% improvement on 2014/15. In the first 9 months of 2015/16 the UHB, in conjunction with the Vale of Glamorgan and Cardiff Councils, had achieved a steady reduction in the number of patients whose care was delayed. However, with the closure of a number of domiciliary providers at the start of the 2016 calendar year, the position again deteriorated, with the March 2016 census recording 107 patients as having their care delayed, 8% above the annual average.

Number of patients in a hospital bed whose transfer of care was delayed, and the daily average number of beds lost as a result of these delays. 180 160 140 120 100 80 60 40 20 0 Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

Yearly avg

Avg daily beds - 14/15

52

73

67

74

91

81

86

93

69

100

122

95

83

Avg daily beds - 15/16

95

100

81

71

83

84

80

61

55

74

85

76

79

# DTOCs 14/15

69

82

83

112

94

100

109

96

95

150

155

133

106.5

# DTOCs 14/15

124

117

109

98

97

101

97

75

70

82

105

107

99

62

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Chapter 6 Proud to work at CAV Awards National award for surgeon

Families First fly national kite mark

Mr Owen Hughes, a consultant urological surgeon, was presented with the BMA Cymru Wales/ BMJ Clinical Teacher of the Year Award for 2015.

The Families First Dietetic Team successfully completed and passed the Children and Young People’s Participation Standards for Wales assessment, gaining them a prestigious kite mark.

The award recognises a clinical teacher in Wales who has excelled in their work supporting doctors in training and medical students in Wales.

Team triumph at The BMJ Awards 2015 Dr Barney Hawthorne and his team at University Hospital of Wales were named Gastroenterology Team of the Year at the British Medical Journal Awards.

Nurses shine at RCN Awards Three Cardiff and Vale UHB nurses won specialist awards at the fourth Annual RCN in Wales Nurse of the Year Awards held at City Hall, Cardiff. Executive Nurse Director Ruth Walker said: “I want to offer congratulations to three shining stars who were recognised for their accomplishments at the Awards. Emily Carne, Deborah Davies and Emily Brace were honoured for their outstanding achievements in their respective clinical areas. Each one has been instrumental in driving change to achieve the best outcomes for our patients.”

NHS Wales Award win The Health Board was recognised for its work with Aneurin Bevan University Health Board and Velindre NHS Trust to develop a dedicated service for patients with cancer-associated thrombosis, and won the Promoting Clinical Research and Application Award (supported by BMA Cymru Wales). The service has been developed in partnership for patients with cancer-associated thrombosis and is helping to improve care, safety and wellbeing.

Deputy Director of Finance, Chris Lewis won National Award Chris Lewis, Deputy Director of Finance, was crowned winner of the Deputy Finance Director of the Year at the Healthcare Financial Management Association Awards in central London.

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Chapter 6 Proud to work at CAV Awards National award for Nutrition and Dietetic Team The Nutrition and Dietetic Team had an appetite for success with another prestigious award win. The team won the Dr Schär Institute Gastroenterology Project Award 2015 for their submission specifically aimed at improving the nutritional care of gastroenterology patients.

Videographer receives award for outstanding contribution towards Teddy’s Story Carl Rogers, Videographer in the Media Resources Centre at the University Hospital of Wales, was commended with a Staff Recognition Award from his Clinical Board for his compassionate film about Teddy’s Story. Teddy’s story is a remarkable and moving story about how Teddy Houlston became the world's youngest organ donor at 100 minutes old. The story made national and international headline news.

Team wins top radiography award The Nuclear Medicine and Molecular Imaging team has won a top radiography award. Team won, The Society of Radiographers Wales Region Team of the Year 2015, which was presented during a ceremony at the Houses of Parliament in November.

Health Board scores number 50 in Stonewall Top 100 Employers The Health Board celebrated reaching number 50 in the Stonewall Top 100 employers list.

The Radiography Team of the Year Annual Awards, organised by the Society of Radiographers, recognises the hard work and dedication of radiography teams across the country.

Dental school ranks in the top set Cardiff University School of Dentistry has been ranked in the top set by the Guardian and the Times in the Good University Guides. The School celebrated bring ranked 1st in the Guardian University Guide 2016 and the Times Good University Guide 2016, making it one of the best places to study dentistry in the UK.

Stonewall Cymru Ally of the Year Award for Keithley Equality Manager, Keithley Wilkinson received, Stonewall Cymru’s Ally of the Year. Keithley was presented with this prestigious award at the Stonewall Cymru annual Workplace Equality Index Awards 2016 in January at the Senedd and hosted by the Presiding Officer, Dame Rosemary Butler AM.

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Chapter 6 Proud to work at CAV

Chapter 6 Proud to work at CAV

Awards

Awards

RCP Excellence in Patient Care Awards

Celebrating our Stars!!

Dr Orhan Uzun, Consultant Paediatric Cardiologist at the University Hospital of Wales, won the RCP Excellence in Patient Care Awards for the Consultant or SAS doctor award category.

The health board holds an annual awards ceremony to recognise and celebrate our staff. Last year, more than 500 people packed into the City Hall to witness 33 awards across 13 categories.

Health Visitors achieve Baby Friendly Accreditation A dedicated team of health visitors achieved a prestigious accreditation following an initiative to promote and support breastfeeding and strengthen mother, baby and family relationships. The Flying Start team achieved the Baby Friendly Accreditation after a four year process to implement Baby Friendly Standards.

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Welsh Language


The UHB workforce profile identifies that approximately 76% of the workforce is female. This is not representative of the local community where a little more than half the population is female. The numbers of female and male directors, managers and employees as at 31st March 2016 is shown opposite:

% WTE staff by payband.

The organisation’s Welsh Language Scheme will be replaced in 2016/17 to reflect the requirements of the new Welsh Language Standards. The Welsh Language Commissioner will expect the UHB to comply with these standards, which cover all aspects of healthcare and public services provided.

Consultant Other medical Band 9 Band 8D Band 8C Band 8B Band 8A Band 7 Band 6 Band 5 Band 4 Band 3

The Commissioner will also expect the organisation to increase the opportunities for staff to use the language internally. These Standards have largely kept the original requirements of the Scheme but have strengthened them further, for example:

Total

Director

10

12

22

Manager

45

12

57

Employee

10965

3516

14481

Total

11020

3540

14560

Band 1 -25%

-20%

-15%

-10%

-5%

0%

5%

10%

15%

20%

25%

A Productive, Efficient and High Performing Workforce Ethnicity 81% White

• providing appointments and consultations in their chosen language, and • bilingual information for patients and service users.

Age Profile

Male

Band 2

• offering the choice of language of English or Welsh for patients.

The Standards are expected to be introduced to the organisation in 2016/2017 and we are awaiting confirmation from the Welsh Language Commissioner of the range of standards we are required to comply with. A 30-day consultation period will follow this notification for the UHB to provide feedback on them. The Standards will help the organisation in the long term to improve the quality of services for patients/service users who prefer to speak Welsh.

Female

6%

Asian or Asian British

1%

Black or Black British

1%

Chinese or any other ethnic group

2%

Mixed

0%

Other specified

9%

Undefined or not stated

The information included in the table below provides data against the UHB’s core workforce key performance indicators (KPIs). Performance against these KPIs is monitored on a monthly basis through the UHB Executive Performance Management meetings with Clinical Boards and also at the Health Service Management Board (HSMB).

All Clinical Boards and Corporate Directorates scrutinise their vacancy and turnover rates at departmental level to implement local recruitment and retention strategies. A key cross-cutting theme has been a focus on registered nurses at Band 5 level. At the end of March 2016, the UHB had a nurse vacancy rate at Band 5 of 9.97% (189 vacancies), up by 0.33% from March 2015. Turnover increased in the same period by 2.25% to 11.20%. There has been a net increase of 26 wte more in post and 10 wte more vacancies than a year ago.

Gender and Contract Type

UHB Workforce Key Performance Indicators 38% Female Full-Time 38% Female Part-Time 20% Male Full-Time 4%

Male Part-Time

Staff in Post by Staff Group

Comparison with Previous Month

2015-16 target

2014-15 Outturn

YTD (March 2016)

Monthly Actual (Mar 2016)

1. Vacancy Rate (WTE)

4.72%

4.96%

4.13%

 0.11%

5.00%

2. Turnover Rate (WTE)

8.53%

8.12%

8.12%

 0.50%

7.0% - 9.0%

3. Sickness Absence Rate

5.71%

5.09%

4.85%

 0.05%

5.00%

4. PADR Rate

55.57%

560.16%

60.16%

 1.39%

85.00%

Key Performance Indicator

16%

14%

12%

12.92%

Unqualified Nursing

4.83%

?????

7.49%

Additional Clinical Services

15.51%

Administrative and Clerical

6.39%

Allied Health Professionals

8.56%

Estates and Ancillary

3.75%

Healthcare Scientists

10.35%

Medical and Dental

30.03%

Nursing and Midwifery Registered

0.18%

Students

10%

8%

6%

4%

2%

0% Under 21

21-25

26-30

31-35

36-40

41-45

46-50

51-55

56-60

61-65

66-70

Over 70

Although this is an improvement, there is still a risk that without a strong nurse establishment in place the UHB faces a constant challenge of meeting service capacity needs and providing the level of quality and safe care required. The Workforce and OD team, Clinical Board Nurses and Operations

team have been working together to form a ‘Nurse Workforce Sustainability Plan’ which includes short, medium and long term actions to ensure the nurse workforce needed in the future is available, sustainable and adaptable.

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In January 2015, the Workforce and OD function initiated ‘bulk’ one-stop shop recruitment days to boost the levels of recruitment activity needed by the UHB. Following these four bulk recruitment events, Clinical Boards have been using this leaner hiring methodology locally, holding specialist nurses events to boost recruitment offers made to nurses. In addition, Clinical Boards have been recruiting nurses from Europe, with more than 100 offers of employment having been made, and 68 of these offers have been accepted. 42 staff have commenced employment since December with a further 8 starting on 25 April 2016. Further recruitment in Europe and the Philippines is anticipated for 2016/17. During 2015 the Heads of Workforce and OD undertook an analysis across the Clinical Boards of the other recruitment challenges and hard to fill roles. A number of strategies were developed to improve the short, medium and long term recruitment availability of Speech Therapists, Sonographers, Radiologists, Cardiac Scrub Nurses, Paediatric Anaesthetists, Recovery Practitioners, Anaesthetics Clinical Fellows, Perfusonists, GP Sessions in Out of Hours, Sexual Health Medical Staff, Community Directors, Qualified Mechanical and Electrical Tradesmen, Consultants and Middle Grade Doctors in Emergency Medicine and a number of other sub-speciality posts. A further action plan is under development identifying specific and bespoke actions and initiatives into 2016/17. In 2015/16 we made the following significant changes to our education commissioning numbers:


• Increase in several advanced practice courses requested; eg Neonatal Nurses, EU and Mental Health Occupational Therapy. • New commissioned places include Respiratory Physiology, Bioinfomatics, Genomics and Genetics. Work is underway to better understand the commissioning requirements for new entrants in the Independent Sector and Nursing Homes.

the agile method sickness reduction plan in January 2015 by returning staff to work, and keeping staff at work well and engaged. Four Clinical Boards and Planning met the sickness targets set by the UHB to be achieved by March 2016, and a further three Clinical Boards got to within 0.50% of reaching their targets.

Sickness Absence Data 2015/16 and 2014/15

The UHB considers reducing sickness absence as the number one workforce priority and has set sickness targets as follows: Year 1 2015/16 = 5% (0.75% reduction Year 2 2016/17 = 4.5% (0.5.% reduction) Year 3 2017/18 = 4% (0.5% reduction)

2015-2016 Number

2014-2015 Number

Days lost (long term)

158352.80

169856.30

Days lost (short term)

69926.10

80830.63

We are committed to creating an environment where Health and Wellbeing is promoted to all staff, both within the workplace and outside of it. During 2015/16 the programme of health and wellbeing work has been led by the Director of Workforce and OD, with a Maximising Attendance Group to enable members of staff to get back to work and keep our staff healthy and well by:

Total days lost

228278.90

250686.93

Total staff years

12248.65

12040.76

Average working days lost

11.63

13.02

Total staff employed in period (headcount)

13947

13735

4499

3832

• Empowering managers to consistently manage absence using an approach which supports employees to return to work / stay healthy as well.

Percentage staff with no sick leave

36.79%

34.27%

• Ensuring sufficient support is in place for staff (including taking personal responsibility), and • therefore enabling achievement of a sickness absence reduction from 5.75% to 5%.

• General Nursing numbers increased from 120 to 200. • B.Sc. (Hons) Healthcare Science - Biomedical Science - Blood, Infection, Cellular and Genetics increased by 100% from 3 to 6 places.

The March 12-month cumulative figure of 5.09% is the best performance position for the UHB for five years and two months (since January 2011), and was 0.90% above the year-end target of 5.00%. There has now been a month-on-month reduction for 14 months in a row. The result is a £1.6 million direct cost reduction since the commencement of

Iechyd a Lles Health and Well-being

Total staff employed in period with no absence (headcount)

The organisation recognises the importance of annual appraisals for all staff and has measures in place to monitor Personal Appraisal Development Review (PADR) compliance levels on a weekly basis. The UHB has a target of 85% and, as can be seen above, compliance as at 31 March 2016 is 60.16 %. Since 2011 the UHB PADR rates have steadily increased from 6% to around 55-60%. Medical appraisal has a different reporting cycle and compliance has improved significantly now it is aligned to the Revalidation process and timescales, with a compliance rate of 77.58% being reported at the end of March 2016. Monthly appraisal training sessions take place.

UHB Sickness Performance Against Target. 6.50% 6.00% 5.50% 5.00% 4.50% 4.00% Apr

May

Jun

Jul

Aug

Sep

Oct

Nov

Dec

Jan

Feb

Mar

5.0% Target

4.96% 4.52% 4.57% 4.74% 4.83% 4.99% 5.35% 5.21% 5.42% 5.44% 5.12% 4.83%

2014-15 Actual

5.67% 5.23% 5.26% 5.44% 5.54% 5.70% 6.06% 5.92% 6.13% 6.14% 5.83% 5.53%

2015-16 Actual

5.21% 4.98% 5.09% 5.15% 4.95% 4.91% 5.20% 5.21% 5.19% 5.21% 5.12% 4.85%

5.0% Target

2014-15 Actual

5.0% Target

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Engaging Leaders and Culture Change

Improving levels of employee engagement is proven to have an impact on performance and outcomes, including: mortality rate; health and wellbeing; absenteeism; patient satisfaction; quality of services; and financial management (NHS Employers, 2013). To support this, the results of the 2013 National Staff Survey, the November 2013 Engagement Pulse Survey, and the UHB Local Survey in 2015 are being used to develop the focus of Clinical Boards and the nature of the actions they prioritise. The Local Staff Survey undertaken in August 2015 saw a significant increase in response rate since 2013 (22% in 2015 compared with 8% in 2013) and the survey focused specifically on engagement. Across all aspects of engagement there was a marked improvement from an overall score of 51% in 2013 to 60% in 2015. During 2015/16 we placed great emphasis on further developing a set of UHB Values with staff that would help positively influence behaviours. The Francis and Andrews Reports highlighted the impact of negative culture on organisational performance and patient outcomes, and we recognise the impact the same culture can have on staff morale and engagement within the UHB. To further embed UHB values, many Clinical Boards are now introducing discussions on organisational values into their selection processes, and also PADRs with staff. UHB job descriptions also now incorporate detail of the UHB values and we have incorporated the values into the questions we ask at Consultant Panel Interviews.


Flexible & Sustainable Future Workforce

The UHB has produced Management Guidance to support the embedding of UHB Values and Behaviours into everyday practice. In our recent 2015 Local Staff Survey we asked an additional question to establish views about values and behaviours. Findings indicate increasing awareness of values. During 2016/17 we will be further developing this work as we engage with staff to describe the behaviours that we would expect to see if we were living our values, and to integrate this into ways of working across the UHB. The UHB two day Coaching for Performance Programme was re-launched in November 2015 and will be running every 2-4 months in 2016. Day 1 of the programme is a key element of the the UHB’s ‘Being a Leader’ and Senior Leadership programmes. This training helps managers to develop a coaching style of leadership culture and management and empowers them to use coaching skills in their everyday work. The UHB Workplace Mediation Service is provided by the Learning Education and Development (LED) Department and provides confidential, impartial support to two or more people in dispute to attempt to reach an agreement. The UHB is committed to mediation as a culture and way of dealing with conflict and dignity at work issues which helps individuals and teams in dispute explore and understand their differences so they can find their own solution. Mediators are Cardiff and Vale UHB employees who are trained and accredited through ACAS and act as internal mediators in addition to their day jobs.

During 2014, the UHB achieved the Platinum Corporate Health Standard which is the highest level of the Standard, and recognises the organisation’s sustainable development and corporate social responsibility work, in addition to continued efforts to improve the health and wellbeing of our employees. This Award runs until 2017 and the Health and Wellbeing Group continue to monitor against the standard achieved. As part of the 6 criteria within the standard, the Health Board presented a case study on its ‘Work Ready’ programme, which enables people from disadvantaged groups to develop the skills and knowledge required in support worker roles. The Work Ready Programme provides students with unpaid placements of 16 hours per week in either a clerical or clinical setting for a period of 24 weeks. The UHB has had five intakes for both branches of the programme, and saw 52 individuals start a placement during 2015/16. On completion of the programme, students are provided with a basic reference and are given the opportunity to apply for work through the UHB Temporary Staffing Office

Opportunity steps to employment

Interested in caring for people or administration? We will gladly interview you!

Cardiff and Vale UHB In partnership with A4E.

Successful completion job opportunities. Facilitor and mentor support. 6 month course, 25 hours per week, comprehensive induction package.

Future Workforce Transformation is necessary to underpin the achievement of the ten year vision for the UHB and within the emerging clinical services strategy “Shaping our Future Wellbeing”. The longer term Workforce Transformation Plan is set within the context of the UHB Strategic and Financial Framework and a number of strategic drivers, including Shaping our Future Wellbeing, Mental Health Services Review, Setting the Direction & Service Transformation, Together for Health, South Wales Programme, Working Differently – Working Together.

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Equality, Diversity and Human Rights The UHB has continued to make good progress in addressing the equality, diversity and human rights agenda. In 2015/16 the UHB maintained and enhanced its previous good work and continued to celebrate its successes, but has also met some new challenges, not least gaining a better understanding of how to adopt and undertake a more positive action approach to our work around disability and employment. The UHB understands and accepts that it has a responsibility to all of us to lead the way in creating an inclusive workforce that is representative of the patients we serve. The UHB has a specific Equality, Diversity and Human Rights Policy which applies to all staff and was adopted after an extensive consultation. The aim of this policy is to support the elimination of all forms of unjustifiable discrimination from UHB functions and policies, and the creation of an environment where diversity is valued. The Policy sets out the organisation’s commitment to promoting equality, diversity and human rights in relation to employment, service delivery, goods and service suppliers, contractors and partner agencies. The UHB aims to ensure that no individual or group receives less favourable treatment either directly or indirectly. Last year, as part of our work on positive action we developed a working relationship with Quest, a specialist supported placement employment organisation which enables people with learning disabilities to enter the world of work. They provide assessment and support for people to identify their skills and training needs, source a work placement, provide jobsearch skills and, if paid work is secured, provide retention support once in work.


Freedom to Speak Up

? ?

Wales for Africa The health board works in partnership with the Welsh Government to support the ‘Wales for Africa’ initiative, launched in 2006. This year, the health board held an Art Exhibition titled ‘Wales for Africa’.

FREEDOM TO SPEAK UP SAFELY

?

?

?

?

g ian ch ject my Pro a y un db o te N ea the Cr om fr

This year the health board will strengthen the support it offers to colleagues who may wish to raise a concern. Freedom to Speak Up Safely will bring together a number of systems and processes for staff to raise concerns. A new helpline will be available supported by an online hub of resources. This will include video testimonies of colleagues, staff representatives and others discussing the benefits of speaking up.

Oriel yr Aelwyd : The HeARTh Gallery was proud to host the exhibition, which showcased the work of several organisations from Wales that are dedicated to improving health and medicine, education, infrastructure, conservation, recycling and trade in several African countries.

Five different organisations were represented: Mothers of Africa and the Go-Zambia project, Life for African Mothers, Educational Awards in Sierra Leone, Penarth and District Lesotho Trust, the Welsh Government’s International Learning Opportunities Programme with the Health Board, and an independent artist. Through their work initiatives of sharing skills, establishing positive collaborative working relationships with local communities and supporting education and health, these charities in Wales are helping to build strong communities in Africa.

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Chapter 7 Sustainable Development Sustainable Development

Governance

Environmental Management Systems

The estate is valued at £594.81million and covers a land area of 87.273 hectares. As part of the Estate Strategy, significant developments are planned for the future, with further phases for the Children’s Hospital and other major developments on the UHW site. Estate rationalisation is currently on-going.

The Sustainable Development Governance structure at Cardiff and Vale University Health Board includes:

The health board achieved the Environmental Management Standard ISO14001, which is incorporated across all sites. Objectives and targets are established as part of this.

The Government Financial Reporting Manual (FReM) requires eligible entities under the Greening Government, which are not exempted by de minimis limit or other exemption, to produce a sustainability report for inclusion within the Management Commentary. This is in accordance with Sustainability Reporting in the Public Sector guidance, issued by HM Treasury. For 2015/16, public bodies in Wales that report under the FReM and meet the FReM de-minimis are required to produce a FReM sustainability report. A report has been prepared by the health board to meet this requirement and summarises our performances, projects, challenges and achievements during 2015/16.

• The Assistant Director of Capital, Estates & Facilities who is the Lead Director for Environmental Management/Sustainable Development (SD) matters. • The Capital Planning Estates and Operational Services department’s Health and Safety meetings, which report to the Health and Safety Operational Group. This is chaired by the Assistant Director of Planning who reports to the Director of Planning. • The Environmental Management Steering Group, chaired by the Assistant Director of Planning, which includes representatives from energy, waste, transport and Cardiff University. The group reports to the Capital Planning Estates and Operational Services department’s Health and Safety meetings. • The Energy Management Group, a local forum of Capital Planning Estates and Operational Services which meets every three months, focusing on specific operational energy management issues. Systems and methods used to collect data for reporting include: • CarDio – developed by and reported to NHSSSP. • Waste Management KPI report. • Estate Condition and Performance Report (this includes energy, transport and waste). • The Capital Planning Estates and Operational Services’ monthly Health and Safety report. • The Quarterly Energy Management Steering Group reports.

The health board received this accreditation in 2003 across all sites. This system has been maintained and we continue to be accredited via bi-annual audits undertaken by business standards company BSI. In 2015, the standard was revised and the health board is currently updating the internal management system ahead of this transition, while recording and integrating additional energy management documentation. In addition, the entire system was reviewed and the procedure format updated and audited by BSI. A new and revised Environmental Policy was approved by the Board during October 2015. Some benefits of ISO14001: • Ensures that a robust Environmental Management system is implemented. • Promotes and develops a program of effective environmental management, including the reduction of environmental impact and resource usage. • Identifies relevant environmental legislation for compliance. • Improves relationship with local community (people are reassured that we are managing our environment correctly). • Creates a greater environmental awareness and ownership. • Engages staff and encourages appropriate and sustainable behaviours. • Demonstrates that we are effectively managing environmental issues. • Ensures continual environmental improvement.

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Chapter 7 Summary of Performance Environmental Greenhouse Gas Emissions 2013-14

2014-15

2015-16

Greenhouse Gas Emissions

25090

23727

30,027

Gross Emissions Scope 1 (direct)

24,951

23568

29,865

Gross Emissions Scope 2

139.23

158.94

15.91*

Greenhouse Gas Emissions

Non-Financial Indicators (1,000 tC02e)

146.8*

Gross Emissions Scope 3

Related Energy Consumption (million KWh)

Electricity: Non-renewable

24

35

20

Electricity: Renewable

0

0

0.029**

Gas

122

115

137

LPG

0

0

0

Other

0

0

0

7.5

7.5

8.2

Expenditure on Energy Financial Indicators (£million)

Expenditure on official business travel (note figures do not include subsistence)

Please note that Scopes 2 and 3 were originally reported together (highlighted above). In order to achieve consistency throughout NHS Wales, Scopes 2 and 3 are now being reported individually as seen above in * and **. Greenhouse gas emissions incorporate procurement and energy across the health board; oil consumption has to be included in the total. The figure here is based on usage and not deliveries, as there remains an unused quantity which would distort the figures.

3.1

2.23

2.2

The emissions figures 2015/16 for scopes 1, 2 and 3 are estimated. This is based around the lack of confidence with the BGB data. Also, the travel data needed for the CarDio Toolkit around carbon generation from business travel cannot not be determined, as the specific details around personal vehicles is not known. The Automated Metering Programme is being developed to capture up-to-date, accurate consumption data, based around all fiscal meters. Once complete, all data gathered will be put into the newly acquired database, which will generate consumption and cost data. This will then be used to compare against the BGB/current supplier performance statements.

Figures are calculated using the CarDio Toolkit, developed by the Stockholm Institute for the NHS in Wales. The above figures from 2015/16 do not include energy purchases associated with the Dalkia CEM contract at University Hospital Llandough (UHL), as these are not included in the CarDio Toolkit calculations. The Dalkia arrangement is based around the management of the CHP technology at UHL. Dalkia have ownership of the gas meter that feeds the supply to the scheme, therefore any consumption is not directly associated with the health board.

• Annual steam system survey and corrective action.

Based on the estimated data, along with the Noah’s Ark Children’s Hospital for Wales (179 beds) and Hafan y Coed at UHL (135 beds), whose figures will not be realised till March 2017, overall consumption has increased by 26.55%.

• Purchase of Energy and Water Management Database.

We are still performing within the bands of ‘Good Practice’ based on the KPI of GJ/100m3 for both gas and electricity consumption. The KPI is based on the benchmarking approach taken from the Energy Consumption Guide for hospitals, published by The Department of the Environment, Transport and the Regions as part of their best practice programme. The figures gained for expenditure on official business travel were based on data from payroll (business miles claimed) and Allstar (fuel card provider). These figures do not include subsistence for the last two years. *** The figures for the solar PV generation at Hafan y Coed have been estimated. Readings were taken in July 2016 and the figures are based on a pro rata basis, with a start date of 11/09/15. A number of energy saving measures have now been identified/reviewed during 2015/16. Key projects include: • Boiler Burner Management (proof of concept). Now Proven.

• A full review, adjustment and optimisation of heating and cooling temperatures. • Provision of high-efficiency packaged steam boiler plant at Rookwood Hospital. • Insulation schemes in plant-rooms and ducts. • UHW utility Automated Meter Reading programme. • UHW sub-metering programme (pending).

• We participated in the forecast sale of carbon allowances resulting in a cost avoidance of circa £20k. We previously engaged with the Carbon Energy Fund regarding the feasibility, design and implementation of large scale energy-savings schemes. The health board has changed its approach as a result of the Re:fit Cymru programme, established by the Welsh Assembly Government during 2016. Whilst the dynamics may have changed, the scope to review energy schemes will remain, which will include: • New combined heat and power facility at UHL including all associated plant upgrades. • LED lighting programme at UHW and UHL. • Photovoltaic installation for UHW/UHL to generate electricity through solar energy. • Investment in Building Management systems at UHW and UHL. • Fuel Cell Technology.

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Waste We recognise the importance of effective waste management and have worked hard over the last three years to ensure full compliance with the Hazardous Waste Regulations and duty of care legislation. From September 2015 to February 2016, 525 internal waste audits were undertaken. 10,136 samples were taken to assess compliance with the Hazardous Waste Regulations 2005 (Amended 2009) and Safe Management of Healthcare waste (WHTM 07-01). Overall compliance was 98%. The volume of domestic residual waste at landfill has decreased significantly to zero following commencement of a new contract in April 2015, which sees all domestic waste collected on behalf of the health board disposed of at an alternative facility using Energy from Waste (EfW) technology. The cost of waste disposal from our premises has remained stable partially due to improved operational practice; however there has been a slight increase in disposal weight by 4%. Introducing a baler for cardboard has generated an income of over £15k. Cardboard bio boxes have also been introduced at a number of clinical areas for non-sharp waste contaminated with medication. This replaces the use of sharps boxes, which had a detrimental environmental impact through incineration of plastics.


Waste Of the 896 tonnes of waste disposed by Alternative Heat Treatment, approximately 90% (806 tonnes) is used as a sustainable fuel source. New staff members are trained in waste management, focusing on waste minimisation and compliance with the legal requirements of waste segregation. Reducing the availability of general waste bins within office environments has increased recycling.

Non-Financial Indicators (tonnes)

2013-14

2014-15

2015-16

Total Waste

3,985

4212

4406

Landfill

1424

1376

0

Reused/Recycled

597

929

533

Composted

62

144

136

Non infectious offensive waste

692

672

655

0

0

1431

Alternative Heat Treatment

873

878

896

Incinerated without energy recovery

371

355

362

Total Disposal Cost

1.156

1.163

1.123

Landfill

0.142

0.217

0

Reused/Recycled

0.095

0.011

0.094

0.1876**

0.0048

0.008

0.192

0.0199

0.0135

0

0

0.017

Alternative Heat Treatment

0.425

0.418

0.437

Incinerated without energy recovery

0.282

0.289

0.281

Incinerated with energy recovery

A target of 25% recycling has been set as part of the ISO14001 standards. Currently we are achieving 59%, representing a year on year improvement. Including the 806 tonnes of Alternative Heat Treatment used as a refuse derived fuel (RDF) would increase this to 77%. Financial Indicators (£million)

Composted Non infectious offensive waste Incinerated with energy recovery

Use of Resources Reducing water usage is a challenge, especially as healthcare requires large volumes for washing, cleaning, catering and consumption. Water safety compliance also affects usage, as a regular flushing regime is required for low usage outlets.

While we saw an increase in consumption of 10.56% (from Hafan y Coed and Noah’s Ark Children’s Hospital for Wales), we also saw an overall decrease in the unit cost from £2.65 - £2.38 per m3. 2013-14

2014-15

2015-16

Supplied

582,658

23727

30,027

Per bed

582.66

23568

29,865

1.43

1.514

1.502

Finite Resource consumption

Non-Financial Indicators (m3)

Financial Indicators (£million)

Water Consumption (Total Estate)

Water Supply costs (Total Estate)

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Sustainable Travel The health board has a Sustainable Travel Action Plan for each hospital site, as required by Welsh Government. The action plans address the following key areas: Travel planning – each year, staff Travel to Work and Patient/Visitor Travel surveys are undertaken. These are used to monitor progress against action plans and inform future plans. The survey results reveal a general trend of moving away from single occupancy car use and into more sustainable forms of transport and travel. Car sharing – The health board has an online carshare facility, hosted by Liftshare, open to all staff. Car sharing is promoted regularly over the intranet and by on-site promotional events. There are currently 114 members recorded on Liftshare and we know that staff also car-share informally. Public Transport – The health board liaises regularly with councils (Cardiff and Vale) and transport operators to review and improve services regarding frequency, timings and access. During 2014-15, New Adventure Travel (NAT) expanded the 303/304 service to UHL to include a day service in addition to the evening and weekend services. Both Cardiff Bus and NAT have extended their services to UHL during 2015-16 Cycling – Over recent years, using both Cardiff Council Sustainable Travel City and Sewta grants, the health board has improved facilities for cyclists at each main hospital site. We have also operated a cycle to work scheme since August 2012 to encourage staff to engage in active travel. To date, almost 850 orders have been processed, saving employees £146, 362.

Walking – The health board has developed active travel maps for safe cycling/walking routes to and from its main sites. In addition, a lunchtime walking club has been established at UHL. We also actively encourage staff to participate in national events such as Cymru Travel Challenge, to change transport and travel behaviours.

One exciting new development is the provision of an Aroma coffee franchise in the new Children’s Hospital serving a range of beverages, refreshments and light meals. The outlet provides a new dimension to the existing range of food and drink provision within the health board. Dependent on the success of the franchise, additional outlets will be considered and progressed.

Social

The relationship with the Community Payback/Probation service established in 2014/15 is still active.

Development at Hafan y Coed is now complete. It was designed to include low and zero carbon technology to reduce environmental impact, which was achieved through the installation of a 72kW solar PV array. The project succeeded in minimising the environmental effects of biodiversity, noise, dust and pollution. We are committed to developing flexible working methods to help staff maintain a work/life balance and to also help with the recruitment and retention of staff. The health board has two Teddy Bear Nurseries to provide childcare at UHW and UHL. We also provide contacts for alternative childcare within the local area, including childminders and/or holiday playschemes. The health board has banned smoking on its sites (except where appropriate facilities are provided for patients) and provides smoking cessation support to those wishing to quit. Healthy eating is encouraged and supported through information and healthy option choices. The series of themed menus in the Heathfields restaurant at UHW continues; the restaurant is currently under renovation.

The scheme provides resources for on-site projects, while the health board provides funding, materials and equipment. The partnership is set to continue into 2016/2017 to satisfy the following projects: • Continued painting of the glass tunnel link and Dovecote House at UHW. • Litter and cigarette clean-up on a weekly basis at main UHL entrances. Other schemes will be delivered as and when they are identified. Our accommodation strategy also impacts on environment and sustainability. The current strategy aims to ensure that departments are located on the most appropriate sites and in appropriate buildings. Different working methods are promoted to effectively use the space and resources, while improving sustainability. These include: • Hot-desking. • Shared spaces and meeting rooms. • Open-plan offices. Services have been moved from Whitchurch Hospital and Dinas Powys and been redistributed throughout the health board.

Economic With a workforce of 14,589, the health board is one of the largest employers in the Cardiff and Vale area. Procurement is now handled centrally by the Shared Services team. However they adhere to the Sustainable Procurement Action Plan which aims to make all procurement in the NHS more sustainable. Goods are purchased locally where possible and local companies are used for services such as plumbing, consultancy and building. Other economic initiatives maintained since 2014/15 include the arts group, with the remit of encouraging and supporting local artists. The UHL site has an art gallery, promoting culture and the arts.

Staff Engagement There is a growing strategy towards staff engagement. Currently there is a programme of awareness delivered through the Learning, Education and Development team. Presentations are delivered on two platforms: corporate inductions for new staff and during mandatory training sessions - ‘Mandatory May’ at UHW and ‘Mandatory Movember’ at UHL. There are a number of environment-themed stands at UHW, based around awareness events including World Environment Day, Cycle to Work Week and Is your Home Winter Ready. Events are planned for the remainder of 2016 and for 2017. Work is currently undergoing to revamp the Environmental Issues pages on the internet. This platform will hold all relevant information to help and support staff at home and at work. Through regular site visits and audits, engagement programmes will be delivered to help support those teams where needed.

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Contents

Accountability Report 2015-16

1.

Corporate Governance Report and Director’s Report

86

2.

Remuneration and staff report 2015-2016

87

2.1

Salary and pension entitlements of senior managers 2015-2016

89

2.2

Changes to Board membership in 2015-2016

89

2.3

Remuneration Relationship

89

2.4

Pension benefits

91

2.4.1 Cash equivalent transfer values

92

2.4.2 Real increase CETV

92

2.5

Reporting of other compensation schemes – exit packages

93

2.6

Tax assurance for off-payroll appointees

94

2.7

Consultancy expenditure

95

3.

Parliamentary accountability and audit report

96

3.1

Fees and charges

96

3.2

Managing public money

96

3.3

Material remote contingent liabilities

96

3.4

Expenditure regularity

96

4.

Financial targets

97

4.1

Long term, expenditure plans 2011-2016

97

5.

Other Mandatory Disclosures

100

86

87



Chapter 7 1. Corporate Governance Report and Directors Report

Chapter 7 2. Remuneration and Staff Report 2015-2016

Governance Statement for 2015-2016. There is a cross reference to the Annual Governance Statement in respect of the following information:

The pay and Terms and Conditions of Employment for the executive team and senior managers have been, and will be determined by, the UHB’s Remuneration and Terms of Service Committee, within the framework set by Welsh Government. The Remuneration and Terms of Service Committee also considered and approved applications relating to the Voluntary Release Scheme. The UHB’s Remunerations Committee members are all Independent Members of the Board and the committee is chaired by the UHB’s chairperson.

• The composition of the UHB and Governance structures. Pages 4-8. • Details of the UHB’s membership to include Independent Members (IM) and Executive Directors. Page 24. • Major activities of the UHB during the year. Pages 6-7.

The Remuneration Report is required to contain information about senior managers’ remuneration. The senior management team consists of the Chief Executive, executive directors and non-executive directors. Full details of senior managers’ remunerations are given in the tables below:

• Audit Committee membership. Page 24. • Information on personal data related incidents. Page 22. • Equality and diversity. Page 22.

Salaries of Senior Managers

Information in respect of published sickness data is captured within the Annual Report and a summary is shown in the table below: Name and title

2015-2016 Number

2014-2015 Number

31-Mar-2016

Other Salary Remuneration (bands of bands of £5,000) £5,000)

Bonus Payments (bands of £5,000)

Benefits in kind (Rounded to the nearest £00)

£000

£000

£000

£000

Days lost (long term)

158352.80

169856.30

Days lost (short term)

69926.10

80830.63

Pension Benefits (Rounded to the nearest £000)

Total (bands of £5,000)

£000

£000

Officer Members

Total days lost Total staff years Average working days lost

228278.90

250686.93

12248.65

12040.76

11.63

13.02

Adam Cairns, Chief Executive

200-205

0

0

0

7

205-210

Alice Casey, Chief Operating Officer

145-150

0

0

0

0

145-150

Abigail Harris, Executive Director of Planning

145-150

125-130

0

0

0

20

Bob Chadwick, Executive Director of Finance (1)

50-55

0

0

0

8

55-60

Christopher Lewis, Acting Executive Director of Finance (2)

90-95

0

0

0

153

245-250

Dr Sharon Hopkins, Executive Director of Public Health Fiona Jenkins, Executive Director of Therapies & Health Science

Total staff employed in period (headcount) Total staff employed in period with no absence (headcount) Percentage staff with no sick leave

13947 4499

13735 3832

135-140

0

0

0

43

180-185

95-100

0

0

0

3

100-105

Dr Graham Shortland, Executive Medical Director

160-165

0

45-50

0

116

325-330

Ruth Walker, Executive Director of Nursing

130-135

0

0

0

80

210-215

95-100

0

0

0

0

95-100

Other Directors

36.79%

34.27%

Peter Welsh, Board Secretary Independent Members (IM) Maria Battle, Chair

65-70

0

0

6

0

70-75

Marcus Longley, Vice Chair

55-60

0

0

0

0

55-60

Ivar Grey, IM - Finance

15-20

0

0

2

0

15-20

Eileen Brandreth, IM - Information Communication & Technology

15-20

0

0

0

0

15-20

Professor Elizabeth Treasure, IM - University Margaret McLaughlin, IM - Third (Voluntary) Sector

0

0

0

0

0

0

15-20

0

0

0

0

15-20

Councillor Christopher Elmore, IM - Local Government (3)

10-15

0

0

0

0

10-15

Martyn Waygood, IM - Legal

15-20

0

0

20

0

15-20

Saleem Kidwai, IM - Community

15-20

0

0

0

0

15-20

Brendan Sadka, IM - Estates

15-20

0

0

1

0

15-20

0

20-25

0

0

0

20-25

Stuart Egan, IM - Trade Union Associate Members Paula Martyn, Chair, Stakeholder Reference Group

0

0

0

0

0

0

Rosemarie Whittle, Chair, Health Professionals' Forum (4)

0

25-30

0

0

0

25-30

Sian Walker, Associate Member - Local Authority (5)

0

0

0

0

0

0

The pension benefit is not an amount which has been paid to an individual by the LHB during the year, it is a calculation which uses information from the pension benefit table. These figures can be influenced by many factors e.g. changes in a persons salary, whether or not they choose to make additional contributions to the pension scheme from their pay and other valuation factors affecting the pension scheme as a whole.

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Chapter 7 Salaries of Senior Managers

Name and title

31-Mar-2015

2.1 Salary and pension entitlements of senior managers 2015-2016

Other Salary Remuneration (bands of bands of £5,000) £5,000)

Bonus Payments (bands of £5,000)

Benefits in kind (Rounded to the nearest £00)

£000

£000

£000

£000

£000

£000

200-205

0

0

9

0

200-205

Pension Benefits (Rounded to the nearest £000)

Total (bands of £5,000)

Cardiff and Vale University Local Health Board Officer Members Adam Cairns, Chief Executive Tracy Myhill, Executive Director of Workforce & Organisational Development / Deputy Chief Executive Alice Casey, Chief Operating Officer

65-70

0

0

0

3

70-75

145-150

0

0

0

0

145-150


125-130

0

0

1

69

190-195

Charlotte Moar, Executive Director of Finance

160-165

0

0

0

86

250-255

45-50

0

0

0

0

45-50

Christopher Lewis, Acting Executive Director of Finance Dr Sharon Hopkins, Executive Director of Public Health Fiona Jenkins, Executive Director of Therapies & Health Science

110-115

0

0

0

0

115-120

95-100

0

0

5

0

100-105

Dr Graham Shortland, Executive Medical Director

160-165

0

35-40

0

0

195-200

Ruth Walker, Executive Director of Nursing

125-130

0

0

0

0

125-130

We wish to bring to your attention that the column for bonus payments contains amounts paid to consultants under the National Clinical Excellence and Distinction Award Scheme. Clinical Excellence and Distinction Awards are awarded at a National level by the Advisory Committee on Clinical Excellence Awards (ACCEA) which is an independent, advisory Non-Departmental Public Body (NDPB) and succeeded the Advisory Committee on Distinction Awards (ACDA). The awards are given to recognise and reward the exceptional contribution of NHS consultants, over and above that normally expected in a job, to the values and goals of the NHS and to patient care. All Clinical Excellence Awards and Distinction Awards are funded separately to the UHB by Welsh Government. Neither Stuart Egan nor Rosemarie Whittle are remunerated as Members of the Board, however they are employees of the UHB. Their salary costs are shown in the other remuneration column. The Board Secretary is a member of the NHS Wales Lease Car Salary Benefit Scheme, which is open to all UHB employees. An element of an employee’s salary is ‘swapped’ for the use of a new car. In the Remuneration Table for 2015/16 the amount of £4,450 swapped for the use of the car has been included in the salary column.

2.2 Changes to Board Membership in 2015-2016 Other Directors Peter Welsh, Board Secretary Alison Gerrard, Board Secretary

45-50

0

0

1

0

45-50

140-145

0

0

0

0

140-145

65-70

0

0

5

0

70-75

Independent Members (IM) Maria Battle, Chair Marcus Longley, Vice Chair

55-60

0

0

0

0

55-60

Ivar Grey, IM - Finance

15-20

0

0

2

0

15-20

Eileen Brandreth, IM - Information Communication & Technology

15-20

0

0

0

0

15-20

0

0

0

0

0

0

Professor Elizabeth Treasure, IM - University Margaret McLaughlin, IM - Third (Voluntary) Sector

15-20

0

0

0

0

15-20

Councillor Christopher Elmore, IM - Local Government

15-20

0

0

0

0

15-20

Martyn Waygood, IM - Legal

15-20

0

0

20

0

15-20

Saleem Kidwai, IM - Community

15-20

0

0

0

0

15-20

Brendan Sadka, IM - Estates

15-20

0

0

0

0

15-20

0

20-25

0

0

0

20-25

0

0

0

0

0

0

Stuart Egan, IM - Trade Union Associate Members John Harrison, Chair, Stakeholder Reference Group Paula Martyn, Chair, Stakeholder Reference Group

0

0

0

0

0

0

Rosemarie Whittle, Chair, Health Professionals' Forum

0

55-60

0

1

0

55-60

Sian Walker, Associate Member - Local Authority

0

0

0

0

0

0

1. Robert Chadwick – Commenced 9 December 2015. 2. Christopher Lewis – Commenced 17 November 2014 and ended 8 December 2015. 3. Christopher Elmore – Board role suspended from 30 March 2015 as he was standing for a parliamentary seat in the General Election. He did not win a seat in Parliament and resumed his Board role from 8 May 2015. 4. Rosemarie Whittle – Commenced 6 September 2011 and ended 30 September 2015. 5. Sian Walker – Commenced 25 March 2014 and ended 30 September 2015.

2.3 Remuneration Relationship

Band of highest paid director’s total remuneration £000 Median total remuneration £000 Ratio

2015-2016

2014-2015

210-215

200-205

28

28

7.56

7.18

Reporting bodies are required to disclose the relationship between the remuneration of the highest paid director in their organisation and the median remuneration of the organisation’s workforce. The banded remuneration of the highest paid director in the UHB in the financial year 2015-2016 was £210,000 £215,000 (2014-2015, £200,000 - £205,000). This was 7.56 times (2014-2015, 7.18) the median remuneration of the workforce, which was £28,094 (2014-2015, £28,186). In 2015-2016 the highest paid director was the Medical Director; in 2014-2015 the highest paid director was the Chief Executive.

90

91



Chapter 7 Band of Chief Executive remuneration Median total remuneration £ Ratio Band of highest paid director’s remuneration Median total remuneration £ Ratio

2015-2016

2014-2015

200-205

200-205

28,094

28,186

7.21

7.18

210-215

200-205

28,094

28,186

7.56

7.18

In 2015-2016, 2 (2014-2015, 7) employees received remuneration in excess of the highest paid director. Remuneration for these staff ranged from £215,000 to £225,000 (2014-2015, £205,000 to £225,000). All these employees are Medical Consultants; remuneration for the highest paid staff includes payments for additional sessions worked, and varies from month to month. Total remuneration includes salary and non-consolidated performance related pay. It does not include severance payments, employer pension contributions and the cash equivalent transfer value of pensions. The guidance also suggests that this information should include benefits in kind. The UHB does not have the relevant information available to comply with this requirement. In addition, please note that overtime payments are included where applicable in the calculation of both elements of the relationship. During 2015-2016 the Medical Director had been awarded a Silver Clinical Excellence award which is a higher level than the Bronze Clinical Excellence award he held in 2014-2015. These awards are not made by the UHB but are awarded at a national level by the Advisory Committee on Clinical Excellence Awards (ACCEA) which is an independent, advisory Non-Departmental Public Body (NDPB) and succeeded the Advisory Committee on Distinction Awards (ACDA). The awards are given to recognise and reward the exceptional contribution of NHS consultants, over and above that normally expected in a job role, to the values and goals of the NHS and to patient care. All Clinical Excellence Awards and Distinction Awards are funded separately to the UHB by the Welsh Government. The Clinical Excellence Award is the major contributor to the increase of the ratio between the median remuneration of the workforce and the highest paid director. The absolute decrease in the median total remuneration is reflective of a slight change to the overall composition of the workforce.

2.4 Pension benefits

Name and title

Real increase Real increase in pension in pension lump sum at at pension age (bands pension age (bands of of £2,500) £2,500) £000 £000

Lump sum at Cash Total accrued pension age Equivalent pension at pension age related to accrued Transfer pension at Value at at 31/03/16 31/03/2016 31 March (bands of (bands of £5,000) 2016 £5,000) £000 £000 £000

Cash Real increase Equivalent (decrease) Transfer in Cash Value at Equivalent 31 March Transfer 2015 Value £000 £000

Adam Cairns - Chief Executive

0-2.5

2.5-5

80-85

240-245

1,562

1,504

40


0-2.5

(2.5)-0

30-35

85-90

480

454

20

Bob Chadwick - Executive Director of Finance (From 09/12/2015)

0-2.5

0-2.5

70-75

220-225

1,658

1,596

13

Christopher Lewis - Acting Executive Director of Finance (From 17/11/2014 to 08/12/2015)

5-7.5

17.5-20

45-50

130-135

806

617

125

Dr Sharon Hopkins - Executive Director of Public Health

2.5-5

7.5-10

35-40

105-110

739

669

62

Fiona Jenkins, Executive Director of Therapies & Health Science

0-2.5

0-2.5

40-45

130-135

922

886

26

Dr Graham Shortland - Executive Medical Director

5-7.5

17.5-20

90-95

275-280

1,941

1,771

149

Ruth Walker - Executive Director of Nursing

2.5-5

12.5-15

45-50

145-150

895

798

87

Peter Welsh, Board Secretary

(2.5)-0

(5)-(2.5)

40-45

125-130

970

976

(18)

Employer’s contribution to stakeholder pension £000

As Non-Officer Members do not receive pensionable remuneration, there will be no entries in respect of pensions for Non-Officer Members. The UHB is also contributing to the National Employment Savings Trust (NEST) pension scheme in respect of Alice Casey, Chief Operating Officer. The UHB was unable to obtain pension benefit information from NEST in time for publication, however as the UHB has only paid £366 Employers Pension Contributions to this scheme in 2015-2016, it does not expect the pension benefit would have been material.

92

93



Chapter 7

Chapter 7

2.4.1 Cash equivalent transfer values

2.5 Reporting of other compensation schemes – exit packages:

Cash Equivalent Transfer Value (CETV) is the actuarially assessed capital value of the pension scheme benefits accrued by a member at a particular point in time. The benefits valued are the member’s accrued benefits and any contingent spouse’s pension payable from the scheme. A CETV is a payment made by a pension scheme or arrangements to secure pension benefits in another pension scheme or arrangement when the member leaves a scheme and chooses to transfer the benefits accrued in their former scheme. The pension figures shown relate to the benefits that the individual has accrued as a consequence of their total membership of the pension scheme, not just their service in a senior capacity to which disclosure applies. The CETV figures and the other pension details include the value of any pension benefits in another scheme or arrangement which the individual has transferred to the NHS pension scheme. They also include any additional pension benefit accrued to the member as a result of their purchasing additional years of pension service in the scheme at their own cost. CETVs are calculated within the guidelines and framework prescribed by the Institute and Faculty of Actuaries.

2.4.2 Real increase in CETV This reflects the increase in CETV effectively funded by the employer. It takes account of the increase in accrued pension due to inflation, contributions paid by the employee (including the value of any benefits transferred from another scheme or arrangement) and uses common market valuation factors for the start and end of the period.

2015-16

Exit packages cost band (including any special payment element)

less than £10,000 £10,000 to £25,000 £25,000 to £50,000 £50,000 to £100,000 £100,000 to £150,000 £150,000 to £200,000 more than £200,000 Total

Exit packages cost band (including any special payment element) less than £10,000 £10,000 to £25,000 £25,000 to £50,000 £50,000 to £100,000 £100,000 to £150,000 £150,000 to £200,000 more than £200,000 Total

2015-16

2015-16

2015-16

2014-15

Total number of exit packages Whole numbers only

Number of compulsory redundancies Whole numbers only

Number of other departures Whole numbers only

Total number of exit packages Whole numbers only

Number of departures where special payments have been made Whole numbers only

0 1 0 0 0 0 0 1

3 7 3 2 0 0 0 15

3 8 3 2 0 0 0 16

3 7 3 2 0 0 0 15

5 24 18 7 2 0 1 57

2015-16

2015-16

2015-16

2014-15

Cost of compulsory redundancies £'s

Cost of other departures £'s

Total cost of exit packages £'s

2015-16 Cost of special element included in exit packages £'s

Total cost of exit packages £'s

0 17,946 0 0 0 0 0 17,946

21,973 133,950 98,563 136,966 0 0 0 391,452

21,973 151,896 98,563 136,966 0 0 0 409,398

21,973 133,950 98,563 136,966 0 0 0 391,452

45,987 414,488 613,079 495,059 261,811 0 214,836 2,045,260

94

95



Chapter 7

Chapter 7

Redundancy costs have been paid in accordance with the NHS redundancy provisions. Other departure costs have been paid in accordance with the provisions of the NHS Voluntary Early Release Scheme (VERS). Exit costs in this note are accounted for in full in the year of departure on a cash basis in this note as specified in EPN 380 Annex 13C. Where the UHB has agreed early retirements, the additional costs are met by the UHB and not by the NHS pension scheme. Ill health retirement costs are met by the NHS pension scheme and are not included in the table.

For all new off-payroll engagements or those that reached six months in duration between 1 April 2015 and 31 March 2016, for more than £220 per day and that last longer than six months. Employees engaged via other Public Sector bodies

Other engagements

No. of new engagements, or those that reached six months in duration between 1 April 2015 and 31 March 2016.

0

8

No. of the above which include contractual clauses giving the right to request assurance in relation to income tax and national insurance obligations.

0

7

Of which:

0

8

2.6 Tax assurance for off-payroll appointees

No. for whom assurance has been received.

0

1

For all off-payroll engagements as of 31 March 2016, for more than £220 per day and that last longer than six months.

No. for whom assurance has not been received.

0

7

No. that have been terminated as a result of assurance not being received.

0

0

This disclosure reports the number and value of exit packages taken by staff leaving in the year. Note: The expense associated with these departures may have been recognised in part or in full in a previous period. All 15 special payments are severance payments. The highest payment was £68,483, the lowest payment was £6,303 and the median payment was for £22,236. Two exit packages were above the UHB’s contractual limits. As per Welsh Government guidelines, approval was sought and received from the Director General for Health and Social Services.

Employees engaged via other Public Sector bodies

Other engagements

47

17

No. that have existed for less than one year at the time of reporting.

0

8

No. that have existed for between one and two years at the time of reporting.

1

9

No. that have existed for between two and three years at the time of reporting.

3

0

No. that have existed for between three and four years at the time of reporting.

3

0

No. that have existed for four or more years at the time of reporting.

40

0

No. of existing engagements as of 31 March 2016 Of which:

No. for whom assurance has been requested.

While the UHB does not have the contractual right to request the appropriate assurance from other public sector bodies, it has been agreed by the Welsh Government that this assurance can be obtained via written confirmation from the Director of Finance of the public body who is invoicing us for the staff concerned. This has been requested for all staff meeting the disclosure criteria in 2015-2016. In respect of staff engaged from outside the Public Sector, the UHB will be following up all instances where no response has been received. Should this remain outstanding, the UHB will take appropriate professional advice as to its next steps in relation to this. For any off payroll engagements of board members and/or senior officials with significant financial responsibility between 1 April 2015 and 31 March 2016. Employees engaged via other Public Sector bodies

Other engagements

No. of off payroll engagements of Board members, and/or, senior officials with significant financial responsibility, during the financial year.

0

0

No. of individuals that have been deemed “board members, and/or senior officials with significant financial responsibility”, during the financial year.

0

0

Please note that the UHB considers its Board members are the only officials who have significant financial responsibility within the Health Board.

2.7 Consultancy expenditure As disclosed in Note 3.3 of its annual accounts the UHB spent £2.285m on consultancy services during 20152016. The vast majority of this was spending on the review and redesign of UHB services with the ultimate aim of improving clinical outcomes.

96

97



Chapter 7 3. Parliamentary Acountability and Audit Report

Chapter 7 4. Financial Targets

3.1 Fees and charges

4.1 Long Term, Expenditure Plans 2011-2016

The UHB incurred costs amounting to £0.411m for the provision of the statutory audit by the Wales Audit Office. In addition £0.007m was paid to them to verify the expenditure incurred against grants made to the UHB by Local Authorities.

Performance against the revenue resource limit: 2011/12 £’000

2012/13 £’000

2013/14 £’000

2014/15 £’000

2015/16 £’000

3.2 Managing public money

Net operating costs for the year

778,891

825,267

817,810

835,855

853,594

In line with other Welsh NHS bodies, the UHB has developed standing financial instructions which enforce the principles outlined in HM Treasury on Managing Public Money. As a result the UHB should have complied with the cost allocation and charging requirements of this guidance and the UHB has not been made aware of any instances where this has not been done.

Less general ophthalmic services expenditure and other non-cash limited expenditure.

(18,779)

(20,014)

(20,750)

(21,957)

(24,547)

Less revenue consequences of bringing PFI schemes onto SoFP

(1,028)

(1,028)

(1,028)

(1,028)

(1,028)

Total operating expenses

759,084

804,225

796,032

812,870

828,019

Revenue resource allocation

759,135

804,291

776,855

791,506

828,087

51

66

(19,177)

(21,364)

68

3.3 Material remote contingent liabilities The UHB has been informed by its legal advisors that £8.494m of claims for clinical negligence against it had been assessed as having a remote chance of succeeding. If the claims were to succeed against us, £8.454m of this figure would be recoverable from the Welsh Risk Pool. Hence the net liability to the UHB regarding these is £0.040m

3.4 Expenditure regularity As a result of pressures on public spending, the UHB has had to meet considerable new cost pressures and increase in demand for high quality patient services, within a period of restricted growth in funding. This has resulted in the need to deliver significant cost and efficiency savings to offset unfunded cost pressures to work towards achieving its financial duty, which is break even over a three year period. The UHB will be required to continue to identify efficiency and cost reduction measures in order to militate against future cost and service pressures.

Under / (over) spend against allocation

From 1 April 2014 section 175 of the National Health Service Wales Act places two financial duties on Health Boards: • To ensure that its expenditure does not exceed the aggregate of the funding allotted to it over a period of 3 financial years. • To prepare a plan in accordance with planning directions issued by the Welsh Ministers, to secure compliance with the first duty above while improving the health of the people to whom it is responsible and the provision of health care to such people and for that plan to be submitted to and approved by the Welsh Ministers. The first assessment of performance against the three year statutory duty will take place at the end 2016-2017. In 2014-2015 and 2015-2016, the UHB submitted to and got approval for its Integrated Medium Term Plans (IMTP) for the periods 2014-2015 to 2016-2017 and 2015-2016 to 2017-2018 by the Welsh Ministers. The UHB is therefore considered to have met its statutory duty for these financial years. In years prior to 2014-2015 the UHB’s statutory financial duty was to ensure that its expenditure did not exceed the funding allotted to it on an annual basis. The Revenue Resource Limit shown above for 2011-2012 included £12m brokerage received in November 2011. Under the terms of the brokerage agreement the UHB’s Revenue Resource Limit was subsequently reduced by £6m in both 2012-2013 and 2013-2014.

98

99



Chapter 7

Chapter 7

Performance against the capital resource limit:

As disclosed in the performance against break even duty table above, the UHB is permitted to remove certain elements of expenditure (which it incurs but over which it doesn’t have managerial control) when comparing its expenditure to its annual revenue resource limit. For the purposes of a meaningful comparison of income and cost, this has been treated as notional income in the above. Hence the expenditure figures shown below are shown gross (with no expenditure removed).

Gross capital expenditure Add: Losses on disposal of donated assets Less NBV of property, plant and equipment and intangible assets disposed

2011/12 £’000

2012/13 £’000

2013/14 £’000

2014/15 £’000

2015/16 £’000

58,251

52,398

66,662

92,690

41,935

(7)

1

0

(7)

3

(452)

(1,679)

(6,740)

(960)

(33)

0

0

0

0

0

(442)

(3,558)

(190)

(7,805)

(938)

How the UHB has utilised its revenue funding:

2015-2016 Annual Expenditure £1,223m

Less capital grants received Less donations received Charge against Capital Resource Allocation Capital Resource Allocation (Over)/underspend against Capital Resource Allocation

57,350 57,404 54

47,162 47,228 66

59,732 59,851 89

83,925 84,004 79

40,967 41,027 60

Nursing Staff £203m


Medical & Dental Staff £131m


Other Staff Costs £200m


Drug Costs £80m

Drug Costs £71m

Primary Healthcare £229m


Continuing Healthcare Costs £44m


Healthcare from Other Providers £188m


Other Hospital & Community Expenditure £148m



2015-2016 Annual Income £1,223m



2014-2015 Annual Income £1,182m Nursing Staff £199m


Training & Education £46m




Welsh Health Specialist Services Committee £191m




Other LHB's £68m

Other LHB's £67m

Drug Costs £68m

Drug Costs £62m

Welsh Government Allocations £837m




All Other Income £81m








2011-2012 Annual Expenditure £1,150m 2012-2013 Annual Income £1,182m

2013-2014 Annual Income £1,162m

Nursing Staff £194m Training & Education £51m






Other LHB's £68m

Other LHB's £67m

Drug Costs £61m






Continuing Healthcare Costs £36m Healthcare from Other Providers £192m Other Hospital & Community Expenditure £148m

2011-2012 Annual Income £1,150m Training & Education £76m Welsh Health Specialist Services Committee £169m Other LHB's £68m Welsh Government Allocations £771m All Other Income £66m

100

101



Chapter 7 5. Other Mandatory Disclosures

Chapter 7 Finance Director’s Commentary

A number of required disclosures are detailed in the Annual Governance Statement. Others are shown below:

The summary financial performance statements for the UHB for the year 2015/16 are presented on the pages following this commentary.

a. Public Interest Declaration Each Director has stated in writing that there is no relevant audit information of which the NHS body’s auditors are unaware. They have taken all the steps that they ought to have taken, as a director, in order to make them aware of any relevant audit information and to establish that the NHS body’s auditors are aware of that information. All Board members and Senior Managers within the Health Board (including Clinical Board Directors) have declared any interests in companies which may result in a conflict with their managerial responsibilities. No material interests have been declared during 2015-16. b. Disclosure Statements As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer obligations contained within the Scheme regulations are complied with. This includes ensuring that deductions from salary, employer’s contributions and payments in to the Scheme are in accordance with the Scheme rules, and that member Pension Scheme records are accurately updated in accordance with the timescales detailed in the Regulations. c. Carbon Reduction Strategy The Health Board has a Carbon Reduction Strategy. The organisation is undertaking risk assessments and carbon reduction delivery plans are being developed in accordance with emergency preparedness and civil contingency requirements as based on UK Climate Impact Programme (UKCIP) 2009 weather projections to ensure that the organisation’s obligation under the Climate Change Act and the Adaptation reporting requirements are fulfilled as detailed in the Welsh Government statutory guidance documents ‘Preparing for a changing climate Part 1 and 2.

The NHS Finance (Wales) Act 2014 changed the statutory financial duties which the UHB had operated under in years prior to 2014/15. Details of the changes are included within the Summary Financial Statements. The UHB’s in year Financial Performance was as follows: UHB Performance against its Revenue Resource Allocation In line with the rest of NHS Wales, the UHB faced another year of significant financial challenge in 2015/16. The UHB approved its three year Integrated Medium Term Plan (IMTP) for submission to the Welsh Government at its 31st March 2015 Board meeting. The extensive budget planning work to support the 2015/16 Financial Plan identified a £42.0m savings requirement in order to achieve a break even position in 2015/16. This comprised the following: • £22.0m underlying deficit • £(17.6)m allocation uplift • £37.6m inflationary, service and cost pressures In order to mitigate these pressures the UHB aimed to deliver a £28.8m savings plan in 2015/16, being 3.5% of net relevant expenditure. This left a planned deficit of £13.2m. This plan was submitted to the Welsh Government on 1st April 2015 and the UHB received written confirmation of its subsequent approval by the Minister for Health and Social Care on August 6th 2016. The Health Board has worked closely with the Welsh Government all year in order to address this financial shortfall which has steadily reduced due to further costs reduction measures being put in place and additional allocations being made by Welsh Government. These actions enabled the UHB to achieve a yearend outturn financial position of a £0.068m surplus against its Revenue Resource Limit. UHB Performance against its Capital Resource Allocation The UHB effectively managed its considerable capital programme during the year to deliver a small surplus of £0.060m against its Capital Resource Allocation of £41.935m. Performance against Better Payments Practice Code The UHB achieved a 93.0% compliance rate in respect of the Confederation of British Industry’s Better Payments Practice Code, which requires the UHB to pay 95% of its non NHS invoices within 30 days of their receipt.

102

103


Chapter 7 Looking Forward The UHB produced a three year IMTP, a final version of which was submitted to Welsh Government in July 2016 for consideration. Welsh Government however were not in a position to approve this plan and have subsequently requested submission of a one year operational plan which the UHB duly completed and provided to Welsh Government in September 2016. This plan has been discussed with Welsh Government and subject to any further revisions requested, is awaiting formal approval. This operational plan contains the Financial Plan for 2016/17. The Financial Plan sets out the resources available to support the delivery against key performance and service improvements outlined in the operational plan. The context for the UHB is a very challenging financial year. The UHB has to make significant savings to mitigate against the pressures of an underlying deficit, significant cost pressures and service change investments above allocation increase levels. Whilst the operational plan has yet to be agreed, the UHB aims to make a minimum of further £26m of financial savings which is equivalent to 3% of the relevant budgets. Despite this ambitious savings plan, the UHB does not however, currently have a Financial Plan that manages to deliver a breakeven position in 2016/17 (or delivery of a break even position for the current period which is 2014/15 to 2016/17). This will be subject to further consideration at Board level and the options to secure financial sustainability will need to be discussed further with Welsh Government. The financial statements for 2015/16 shown here are only summaries and might not contain sufficient information for a full understanding of the UHB’s financial position and performance. Further information is contained in the full financial statements 2015/16 for the UHB which are published alongside this annual report. The Auditor General for Wales report on these annual accounts was unqualified and he further issued a report alongside the opinion to explain the UHB’s performance against its statutory financial duties. This report included an auditor’s statement on the consistency of the Explanatory Foreword and the Annual Governance Statement and this was also not qualified. The full financial statements can be found on the UHB’s website. Alternatively, please do not hesitate to contact me if you would like a copy of the full set of the annual accounts or if you have any queries about them.

Robert Chadwick Executive Director of Finance Cardiff and Vale University Health Board Headquarters University Hospital of Wales Heath Park Cardiff CF14 4XW Tel 029 20 743297 Email: [email protected]


Chapter 7 Summary Financial Statement The National Health Service Finance (Wales) Act 2014 came into effect from 1 April 2014. The Act amended the financial duties of Local Health Boards under section 175 of the National Health Service (Wales) Act 2006. From 1 April 2014 section 175 of the National Health Service (Wales) Act places two financial duties on Local Health Boards: • A duty under section 175 (1) to secure that its expenditure does not exceed the aggregate of the funding allotted to it over a period of 3 financial years. • A duty under section 175 (2A) to prepare a plan in accordance with planning directions issued by the Welsh Ministers, to secure compliance with the duty under section 175 (1) while improving the health of the people for whom it is responsible, and the provision of health care to such people, and for that plan to be submitted to and approved by the Welsh Ministers. The first assessment of performance against the 3 year statutory duty under section 175 (1) will take place at the end of 2016/17, being the first 3 year period of assessment.

Revenue Resource Performance 2015-16 £'000 Net operating costs for the year

853,594

Less general ophthalmic services expenditure and other non-cash limited expenditure

(24,547)

Less revenue consequences of bringing PFI schemes onto SoFP

(1,028)

Total operating expenses

828,019

Revenue Resource Allocation

828,087

Under /(over) spend against Allocation

The Health Board did not receive any repayable brokerage in either 2015/16 or 2014/15. The Health Board received £10.5 million repayable cash support in 2014/15, which was repaid in 2015/16. Later in 2015/16, the UHB applied for and received further repayable cash support of £10.5m. Repayment will be in accordance with the integrated Medium Term Plan for 2016/17 to 2018/19.

68

104

105



Chapter 7 Capital Resource Performance

Public Sector Payment Policy - Measure of Compliance 2015-16 £'000

The LHB is required to keep within its Capital Resource Limit : Gross capital expenditure

41,935

Add: Losses on disposal of donated assets

3

Less NBV of property, plant and equipment and intangible assets disposed

(33)

Less capital grants received

0

Less donations received

The figures for 2015-16 exclude both the number and value of non-NHS bills paid to primary care services and contractor services. The comparators for 2014-15 have been restated to reflect this treatment.

(938)

Charge against Capital Resource Allocation

40,967

Capital Resource Allocation

41,027

(Over) / Underspend against Capital Resource Allocation

60

Duty to prepare a 3 year plan The NHS Wales Planning Framework for the period 2015-16 to 2017-18 issued to LHBs placed a requirement upon them to prepare and submit Integrated Medium Term Plans to the Welsh Government. The LHB submitted an Integrated Medium Term Plan for the period 2015-16 to 2017-18 in accordance with NHS Wales Planning Framework.

The Minister for Health and Social Services approval status

Prompt payment code - measure of compliance The Welsh Government requires that Health Boards pay all their trade creditors in accordance with the CBI prompt payment code and Government Accounting rules. The Welsh Government has set as part of the Health Board financial targets a requirement of 95% of the number of non-NHS creditors within 30 days of delivery.

2015-16 to 2017-18

2014-15 to 2016-17

Approved

Approved

The LHB has therefore met its statutory financial duty under section 175 (2A) of the National Health Service (Wales) Act 2006.

NHS Total bills paid Total bills paid within target Percentage of bills paid within target

2015-16 Number 14,912 11,627 78.0%

2015-16 £000 210,308 194,230 92.4%

2014-15 Number 5,329 3,665 68.8%

2014-15 £000 191,904 178,399 93.0%

Non-NHS Total bills paid Total bills paid within target Percentage of bills paid within target

244,279 227,109 93.0%

355,592 321,702 90.5%

Restated 233,470 206,598 88.5%

Restated 369,684 334,651 90.5%

Total Total bills paid Total bills paid within target Percentage of bills paid within target

259,191 238,736 92.1%

565,900 515,932 91.2%

Restated 238,799 210,263 88.1%

Restated 561,588 513,050 91.4%

As per Welsh Government Technical Update note dated 18th February 2015. NHS Supply Chain from 1st October 2015 has been classified and treated as an NHS Body for part year. Consequently this has seen an increase in NHS number within target rising from 65% to 78%. There has been no material change to the other targets. During 2015/16 the UHB suffered some cash flow difficulties which impacted on our ability to pay invoices within the target referred to above. During March the Welsh Government provided the UHB with repayable cash assistance of £10.5m. While this assistance enabled the UHB to meet many of its payment commitments, the timing of the assistance meant that it didn’t impact greatly on our performance against this target. However, the fact that it allowed us to settle a number of invoices which were already older than 30 days should impact positively on our 2016/17 performance.

The Late Payment of Commercial Debts (Interest) Act 1998

Amounts included within finance costs (note 10) from claims made under this legislation Compensation paid to cover debt recovery costs under this legislation Total

2015-16 £ 769.79

2014-15 £ 0

0

0

769.79

0

106

107



Statement of Comprehensive Net Expenditure

Statement of Financial Position as at 31 March 2016

For the year ended 31 March 2016 31 March

31 March

2015-16

2014-15

2016

2015

£'000

£'000

£'000

£'000

Expenditure on Primary Healthcare Services

229,428

219,500

Non-current assets

Expenditure on healthcare from other providers

232,472

221,236

Property, plant and equipment

632,013

592,851

Expenditure on Hospital and Community Health Services

761,113

763,050

Intangible assets

1,658

1,398

1,223,013

1,203,786

Trade and other receivables

7,860

17,974

Less: Miscellaneous Income

369,246

367,314

Other financial assets

0

0

LHB net operating costs before interest and other gains and losses

853,767

836,472

Total non-current assets

641,531

612,223

0

0

(20)

(608)

15,109

15,315

(153)

(9)

114,185

117,039

853,594

835,855

0

0

2,695

562

131,989

132,916

1,593

2,200

Total current assets

133,582

135,116

Total assets

775,113

747,339

151,422

127,084

0

0

76,190

87,535

Investment Income Other (Gains) / Losses Finance costs Net operating costs for the financial year

Current assets Inventories Trade and other receivables Other financial assets Cash and cash equivalents Non-current assets classified as "Held for Sale"

Other Comprehensive Net Expenditure 2015-16

2014-15

£'000

£'000

7,088

12,162

Net gain / (loss) on revaluation of intangibles

0

0

Provisions

Net gain / (loss) on revaluation of available for sale financial assets

0

0

Total current liabilities

227,612

214,619

(Gain) / loss on other reserves

0

0

Net current assets/ (liabilities)

(94,030)

(79,503)

Impairment and reversals

0

0

Non-current liabilities

Release of Reserves to Statement of Comprehensive Net Expenditure

0

0

Trade and other payables

10,960

11,823

7,088

12,162

0

0

Provisions

10,191

19,904

Total non-current liabilities

21,151

31,727

526,350

500,993

General Fund

416,459

396,438

Revaluation reserve

109,891

104,555

Total taxpayers' equity

526,350

500,993

Net gain / (loss) on revaluation of property, plant and equipment

Other comprehensive net expenditure for the year Total comprehensive net expenditure for the year

846,506

823,693

Current liabilities Trade and other payables Other financial liabilities

Other financial liabilities

Total assets employed Financed by : Taxpayers' equity

108

109



Statement of Changes in Taxpayers' Equity

Statement of Cash flows for year ended 31 March 2016

For the year ended 31 March 2016 General

Revaluation

Total

Fund

Reserve

Reserves

£000s

£000s

£000s

Changes in taxpayers' equity for 2015-16 Balance at 1 April 2015 Net operating cost for the year

104,555

(853,594)

500,993 (853,594)

2014-15

£'000

£'000

(853,594)

(835,855)

39,702

(12,640)

4,273

71,639

(16,407)

(18,160)

(826,026)

(795,016)

(42,541)

(78,262)

53

1,568

(679)

(728)

Cash Flows from operating activities Net operating cost for the financial year Movements in Working Capital

396,438

2015-16

Other cash flow adjustments Provisions utilised

Net gain/(loss) on revaluation of property, plant and equipment

0

7,088

7,088

Net gain/(loss) on revaluation of intangible assets

0

0

0

Net gain/(loss) on revaluation of financial assets

0

0

0

Cash Flows from investing activities

Net gain/(loss) on revaluation of assets held for sale

0

0

0

Purchase of property, plant and equipment

Impairments and reversals

0

0

0

Proceeds from disposal of property, plant and equipment

Movements in other reserves

0

0

0

Purchase of intangible assets

1,752

(1,752)

0

Proceeds from disposal of intangible assets

0

0

0

0

0

Payment for other financial assets

0

0

0

0

Proceeds from disposal of other financial assets

0

0

5,336

(846,506)

Payment for other assets

0

0

871,863

Proceeds from disposal of other assets

0

0

526,350

Net cash inflow/(outflow) from investing activities

(43,167)

(77,422)

(869,193)

(872,438)

871,863

872,845

Capital receipts surrendered

0

0

Capital grants received

0

0

(537)

(607)

0

0

871,326

872,238

2,133

(200)

562

762

2,695

562

Transfers between reserves Release of reserves to SoCNE Transfers to/from LHBs Total recognised income and expense for 2015-16

(851,842)

Net Welsh Government funding

871,863

Balance at 31 March 2016

416,459

109,891

Net cash outflow from operating activities

Net cash inflow/(outflow) before financing Cash flows from financing activities Welsh Government funding (including capital)

Capital element of payments in respect of finance leases and on-SoFP Cash transferred (to)/ from other NHS bodies Net financing Net increase/(decrease) in cash and cash equivalents Cash and cash equivalents (and bank overdrafts) at 1 April 2015 Cash and cash equivalents (and bank overdrafts) at 31 March 2016

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Setting the scene

Audit Opinion 2015-16

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1. Scope of responsibility

2. The Health Board’s governance/assurance framework

The Board is accountable for Governance, Risk Management and Internal Control. As Accountable Officer and Chief Executive of the Board, I have responsibility for maintaining appropriate governance structures and procedures as well as a sound system of internal control that supports the achievements of the organisation’s policies, aims and objectives, whilst safeguarding the public funds and this organisation’s assets for which I am personally responsible. These duties are carried out in accordance with the responsibilities assigned by the Accountable Officer of NHS Wales.

The Health Board has been constituted to comply with the Local Health Board (Constitution, Membership and Procedures) (Wales) Regulations 2009. It comprises of the Chair, Vice Chair, Chief Executive, nine Independent Members and seven Executive Directors. There are also three Associate Members.

Cardiff and Vale University Health Board was established in October 2009 and is one of the largest NHS organisations in the UK. We have responsibility for the health of around 472,400 people living in Cardiff and the Vale of Glamorgan, the provision of local primary care services (GP practices, dentists, optometrists and community pharmacists) and the running of hospitals, health centres and community health teams. Together, these provide a full range of health services for our local residents and those from further afield in Wales who use our specialist services. We are also a teaching Health Board with close links to Cardiff University which has a high profile teaching, research and development role within the UK and abroad, and enjoy strong links with other educational establishments. Together, we are training the next generation of clinical professionals. The Health Board has responsibility for every part of the local health system and has defined its mission as:

“Caring for people, keeping people well” This Annual Governance Statement details the arrangements in place for discharging the Chief Executive’s responsibilities to manage and control the Health Board’s resources during the financial year 2015/2016. This responsibility is monitored and managed through a robust Corporate Risk and Assurance Framework (CRAF).

The Board functions as a corporate decision-making body with Executive Directors and Independent Members being equal members sharing corporate responsibility by the Board. The Board is supported by the Board Secretary who provides advice on Corporate Governance.

The principal role of the Board is to exercise effective leadership, direction and control, including:

 Setting the overall strategic direction of the Health Board within Welsh Government policies and priorities.

 Establishing and maintaining high levels of corporate governance and accountability including risk management and internal control.  Ensuring delivery of the Health Board’s aims and objectives through effective challenge and scrutiny of performance across all areas of responsibility.  Ensuring delivery of high quality and safe patient care.

 Building capacity and capability within the workforce to build on the values of the Health Board and creating a strong culture of learning and development.

 Enacting effective financial stewardship by ensuring the Health Board is administered prudently and economically with resources applied appropriately and efficiently.  Instigating effective communication between Health Board and its community to ensure its services are planned and responsive to identified needs.  Appointing, appraising and remunerating Executives.

The Board has approved Standing Orders for the regulation of proceedings and business. They are designed to translate the statutory requirements set out in the Local Health Board (Constitution, Membership and Procedures) (Wales) Regulations 2009 into day to day operating practice. Together with the adoption of a scheme of matters reserved for the Board, a detailed scheme of delegation to officers and earned autonomy framework and Standing Financial Instructions, they provide the regulatory framework for the business conduct of the Health Board and define “its ways of working”. The Standing Orders and Standing Financial Instructions were updated and approved by the Board in March 2014. Further amendments were approved by the Audit Committee in April and the Board in May 2015, reflecting the establishment of the All-Wales Ambulance Services Committee and the Shared Services Committee. These documents are supported by a suite of corporate policies and, together with the Values and Standards of Behaviour Framework, make up the Health Board’s Governance Framework. In January 2015 a review of these arrangements commenced to support the further development of the UHB’s 10 year Strategy ‘Shaping our Future Wellbeing’.

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2.1 The Board and its committees


The following table sets out the dates of Board and committee meetings held during 2015/2016 Board/Committee

The Board provides leadership and direction to the organisation and has a key role in ensuring governance arrangements are in place. The Board has an open culture with its meetings held in public – meeting papers are available on the Health Board’s website. Together, Board Members share corporate responsibility for all decisions and play a key role in monitoring performance against objectives and plans. In addition to responsibilities and accountabilities set out in terms and conditions of appointment, Board members also fulfil a number of Champion roles where they act as ambassadors for these matters. These are summarised in Appendix 1. The Board is supported by a number of committees, each chaired by an independent member. All committees are constituted to comply with The Welsh Government Good Practice Guide – Effective Board Committees. The committees, which meet in public, provide regular reports to the Board that contribute to its assessment of assurance and provide scrutiny against the delivery of objectives. The Board receives a full copy of the minutes which detail the business, activities, attendance and main issues dealt with by the committee. Copies of the papers and minutes are available from the Board Secretary and also the Board’s website. A summary of the committees’ responsibilities and Terms of Reference are also on the Cardiff and Vale University Health Board’s website. The Board agreed work plans for each of the committees in early 2015. All committees reviewed their Terms of Reference during 2015/16 and prepared a Work Plan for 2016/17 to support the Board’s business for this period. Critical to this assurance is the work of the Audit Committee – its Annual Report provides a summary of matters considered during the year and is available in full on the following link. http://www.cardiffandvaleuhb.wales.nhs.uk/audit-committee The Annual Quality Statement for 2015/16 will be published in September 2016 and will include a summary of the work undertaken during the year by Quality, Safety and Experience Committee. Committees also work together on behalf of the Board to ensure that work is planned cohesively and focussed on matters of greatest risk that would prevent us from meeting our mission and objectives. To ensure consistency and links between committees, the Health Board has Governance Co-ordinating Group, chaired by the Chair of the Health Board.

Dates of Meetings in 2015/2016

Board

Audit

05.05.15

14.04.15

24.09.15

26.11.15

28.01.16

26.05.15 02.06.15 workshop

22.09.15

08.12.15

23.06.15

29.09.15

22.12.15

Charitable Funds

Health and Safety

02.06.15 special 07.07.15 board

28.07.15

28.04.15

Mental Health Act Monitoring

19.05.15

People, Planning and Performance Committee

12.05.15

Quality, Safety and Experience

21.04.15

Remunerationand Terms of Service

07.04.15 20.05.15

06.10.15

21.07.15

06.08.15

08.09.15

03.11.15

15.09.15

10.11.15

10.09.15 & 30.09.15

09.02.16

08.03.16

26.01.16

02.02.16

19.01.16

15.03.16

15.12.15

23.02.16

03.11.15 16.12.15

03.02.16

01.09.15 20.10.15

16.06.15

31.03.16

All meetings were quorate except for the Charitable Funds meeting on 08.03.16 and the Quality, Safety and Experience meeting on 01.09.15. All decisions at those meetings were ratified at the subsequent Charitable Funds Committee meeting and the Quality, Safety and Experience meeting. In addition escalation arrangements are in place to ensure that any matters of significant concern that could not be brought to the attention of the quorate committee could be raised with the Health Board Chair. In support of the Board, the UHB is also required to have three Advisory Groups. These are: • Stakeholder Reference Group • Local Partnership Forum • Healthcare Professionals’ Forum The three advisory groups have all met during the year and minutes are available on the Health Board’s website. They have provided a valuable sounding board in developing our Integrated Medium Term plan and service change proposals across South Wales. Key business and risk matters considered by the Health Board and its committees during 2015/2016 included: • Overseeing the implementation of the 2014-2017, three year Integrated Medium Term Plan (IMTP) and actively involved in the development of the 2015-2018 three year plan submitted to Welsh Government on 1 April 2015; • Receiving update on the South Wales collaborative e.g. neonatal services.

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• Receiving regular reports on Patient Experience and feedback ensuring that where concerns are raised, these are escalated to the Board and, where necessary, result in the Board proactively activating agreed multiagency procedures in co-operation with partners. • Routinely considering the Board’s performance in relation to key national and local targets and agreeing mitigating actions in response to improve performance where appropriate. This included actions to address cancer target performance, stroke services, cardiac surgery, ophthalmology and unscheduled care.


During 2015/16, key aspects of Board business and issues delegated to the Audit Committee for consideration and advice, including action taken included: • Agreement of the Internal and External Audit Plans for the year. • Receiving Internal and External Audit Reports and subsequently monitoring progress against Audit Action Plans. • Agreeing the annual counter fraud plan and monitoring counter fraud activities.

• Approval and sign off of the Annual Accounts for the Health Board.

• Regular review of the register of gifts and hospitality.

• Regular monitoring of Welsh Government performance targets and agreed actions to improve performance where appropriate.

• Sign off the Health Board Annual Accounts, as delegated by the Board.

• Financial performance monitored at each Board meeting.

• Monitoring overall risk management process by reviewing the UHB Risk Register at each meeting.

• Outcome of the Wales Audit Office Structured Assessment. • Routinely receiving reports on Service and Capital Performance and Assurance. • Receipt and consideration of the Wales Audit Office Annual Audit Letter. • Fundamentals of Care Audit and monitoring of Action Plan.

• Monitoring of Governance Arrangements across the organisation, included hosted bodies.

Appendix 1 sets out details of Board and committee membership, meetings attended during the tenure of the individual in 2015/2016 and any Champion Roles performed. All decisions made by the Board and committees are included on an Action Log and at each of the meetings progress is monitored. These Action Logs are also published on the Health Board Internet.

• Receiving updates on the Action Plan in response to the Emergency Services Independent Review Update. • Agreeing our priorities for quality improvement aligned to our Quality Strategy. • Receiving positive feedback from the Ministerial unannounced spot check visits to our hospitals; the unannounced HIW inspection visits and our own Independent Board Member visits. • ‘Putting Things Right’ and introduced revised local arrangements to speed up the engagement and response to concerns. • Receiving a range of Annual Clinical Reports.

2.2 Organisational management As Chief Executive and Accountable Officer, I have personal responsibility for the overall organisation, management and staffing of the UHB. I am required to assure myself, and therefore the Board, that the UHB executive level management arrangements are fit for purpose to provide effective leadership and have accountability for professional standards. During the year, the following changes were made to the Board membership.

• Routinely receiving assurance reports from the committees of the Board, Stakeholder Reference Group, Healthcare Professionals Forum and Local Partnership Forum.

Executive Positions

Start Date*

Finish Date

• Receiving regular update on the Health Board Corporate Risk and Assurance Framework.

Christopher Lewis, Acting Director of Finance

17th November 2014

8th December 2015

Robert Chadwick, Director of Finance

9th December 2015

• Annual Review of Standing Orders and Standing Financial Instructions. • Board and committee Work plans for 2015-16 and Review of Board Committee Terms of Reference.

Independent Members

• Dementia three year Plan – End of Year 1 Report. • Delayed Transfers of Care.

Saleem Kidwai

1st April 2012

31st March 2016

• Winter Plan Review and preparation for 2015/16.

Brendan Sadka

1st April 2013

31st March 2016

• Results of Patient Satisfaction Survey.

Christopher Elmore Note: Stood down temporarily between 30th March and 7th May 2015 as standing for Parliament.

Re-joined 8th May 2015

31st March 2016

Rose Whittle, Associate Independent Member – Chair of Health Professional Forum Post

11th February 2014

30th September 2015

Sian Walker – Associate Independent Member, Local Authority

25th March 2014

30th September 2015

• Shaping Our Future Wellbeing Strategy 2015-2025. • Staff survey results 2015. • Annual Health and Care Monitoring audit 2015. • Child and Adolescent Mental Health Services (CAMHS) • Prudent Healthcare. The above key issues were also debated at the appropriate Committees and key issues identified to the Board when the minutes of the Committees were received. This endorses the strong link between the Committees and the Board annual work plans.

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Supporting the Chief Operating Officer, new Clinical Boards were established in June 2013 and continue to develop. The purpose of creating the Clinical Boards is to: • Liberate the people whose roles are to care for and keep well those we serve. Create a mechanism for integrating what we do around those we serve. • Fuel staff management. • Power up clinical leadership and engagement. • Drive more localised decision making. • Create manageable sized chunks of our organisation. Provide the basis of good accountability. • Ensure we have strong and effective leadership and management. • Drive better use of resources, and greater collaboration to make this happen. Drive pathway improvement and collaborative working.

3. Purpose of system of internal control The system of internal control is based on an on-going process designed to identify the risk profile of the UHB. This includes an assessment and prioritisation of those risks which have the potential to impact on the achievement of our policies, aims and objectives, the evaluation of the likelihood of those risks being realised, the impact should they be realised, and the action required to manage them efficiently, effectively and economically. The system of internal control has been in place for the year ended 31 March 2016 and up to the date of approval of the annual report and accounts. The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risks; it can therefore only provide reasonable and not absolute assurances of effectiveness.

4. Capacity to handle risk The Corporate Risk Assurance Framework (CRAF) has been further developed since being introduced in early 2014. In August 2015 the Board participated in an Audit Committee sponsored workshop which allowed members to focus on the extreme risks facing the Health Board. This discussion included the Board’s ‘Risk Appetite’ and acceptance of certain risks and their management and mitigation. This led to a further refining and refocusing on the principal risks that threaten the achievement of goals, the system and controls in place to ensure those risks are managed and how the Board knows whether it is successful or not. This enables the Board to develop action plans to address any matters of concern. In addition to the Board workshop, a further workshop/training session was held in November 2015 for assistant directors and corporate senior leads. The Board regularly receives a report on the CRAF and the relevant extracts monitored by respective committees to provide further assurances. In addition the Stakeholder Reference Group (representing a range of public stakeholders) were briefed throughout the year on the management and mitigation of the highest risks. The Board’s appetite for risk is reflected in the Integrated Medium Term Plan which sets out the Board’s priorities and focus for the next three years. During the year any new high risks would be particularly brought to the attention of the committees and the Board.


The Board has a Risk Management Policy and supporting Risk Assessment Procedure that explains to staff its approach to risk management. Each Clinical Board and Corporate Department has responsibility for maintaining a comprehensive risk register with the lead Executive Director responsible for highlighting and assessing the most significant risks for inclusion in the Corporate Risk and Assurance Framework. Risk Assessments are undertaken based on a 5 x 5 scoring matrix i.e. the impact of the risk multiplied by the likelihood of it happening. The UHB regularly publishes its updated Corporate Risk Assurance Framework including an assessment of strategic risks and how these are being managed. The most recently published CRAF can be found via the following link: http://www.cardiffandvaleuhb.wales.nhs.uk/risk-register

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The following table is an extract from that framework of the highest strategic risks (scoring 20 or more) facing the UHB in March 2016: Principal Risks

Risk Score

COMMISSIONING – Failure to embed a commissioning approach to ensure services are based on evidence and population need.

20

OPERATIONAL AND CLINICAL EXCELLENCE – Failure to recognise deteriorating patients resulting in avoidable harm.

20

Summary of Controls


Principal Risks RESOURCES - Plan, resource and implement safe and adequate estate.

Risk Score 25

UHB Strategic Capital Planning Programme 2014/15-2018/19 received by Board - Sept 14 Major and discretionary Capital programmes, estates inspections and audits. Capital prioritisation process.

Commissioning Framework and priorities

Maintenance requests and prioritisation. Development of robust Business Cases to secure capital investment from WG to support service change programmes inc. CRI, Making a Difference etc. Major Capital Group chaired by Chief Executive in response to facilities for paediatric assessment in the community not meeting the Quality Standards. In Paediatric Audiology clinics are being provided in UHW. Weekly clinics established for those "not able to test" in the community.

ALERT training. Implementation of Critical Care Outreach Team (CCOT) in Surgery and Specialist Services at UHW. Implementation of National Early Warning System (NEWS)/RAILS tools and training. Introduce staff working in Community Hospitals to NEWS training when they attend Intermediate Life Support (ILS) Training. Learning from mortality review meetings.

20

RESOURCES - Meet statutory compliance in respect of estates maintenance.

25

Estates and statutory compliance. Audit process. Prioritisation of maintenance requests.

All Resus/Cardiac Arrests are electronically recorded.

Establishment of dedicated compliance team.

Record of all high NEWS scores.

External audit of statutory compliance

Weekly review of Serious Incidents at meeting between Executive Nurse Director, Medical Director and Chief Operating Officer. OPERATIONAL AND CLINICAL EXCELLENCE Insufficient critical care capacity and workforce to meet need.

Summary of Controls

Occupational therapists and Physiotherapists working together to improve services for Long Term Ventilated Patients.

RESOURCES - Risks to neonates and high risk mothers as a result of providing on-going care to neonates in a clinically unsuitable environment.

25

Contingency for escalation agreed with Executive Team, Neonatal Network and both Directorates. 1. Maternity Escalation Protocols in place. 2. Joint interface meetings with Maternity & Neonatal services set up to maintain close liaison.

Recruited to most critical care nursing vacancies but retention of staff is a concern. Nursing establishment reviewed on an annual basis.

3. Database to record maternal and in-utero transfers in place along with risk assessments.

Post Anaesthetic Care Unit opened Jan 2015 to support elective surgery.

4. Neonatal Network supporting better working across Welsh Network. 5. Four bedded area made available in Delivery Suite and staffed to receive emergency Neonatal admissions for stabilisation and transfer only.

Rules in place re block booking of temporary staffing to cover shifts. Escalation policy in place.

6. Temporary staffing put in place to support separation of "clean" and "dirty" NICU.

Psychology interventions in place to support staff and the CC recruitment and retention plan e.g. staff 1-1 service. Skills training for staff (communication & conflict resolution, resilience sessions) and staff wellbeing group (culture, value, Organisational Health Reviews).

7. Daily SI meetings chaired by END. 8. Liaison with WAST /CHANTs at the earliest possible opportunity. 9. Create new admissions area in ward T1 which will allow the existing NICU to run down and commence the refurbishment work on the new capital build.

Local Delivery Plan for the Critically ill signed off by HSMB. Active involvement in newly established Theatres & Critical Care Planning Group (first meeting 8.03.16).

10. Welsh Government has approved funding for Phases 1A and 1B. 11. Unit open and accepting neonates up to 16 cots.

OPERATIONAL AND CLINICAL EXCELLENCE Bone Marrow Transplantation – unacceptable waiting times leading to potential relapse or death.

25

Written control documents in place. MDT discussion prior to patient being placed on list. Internal meetings and discussions to monitor waiting list Issue escalated to Clinical Board and Quality and Safety meetings. CNS input. Regular contact with Finance Directorate and WHSSC re: funding for services - business case (Phase 1 & 2) has been submitted and approved. Regular forecasts submitted.

RESOURCES - Vehicle congestion and traffic management on the UHW site leading to:-

20

Temporary traffic flow management and traffic lights to assist with vehicle flows at the busiest times.

a) patients missing appointments/staff arriving late leading to service disruption

Indigo police manage the traffic on site and security staff are also occasionally utilised to manage traffic flows.

b) Emergency service vehicles unable to flow freely on the site

The UHB has a Sustainable Travel Policy and Procedures to encourage site users to utilise alternative transport arrangements.

c) Potential contact with pedestrians and/or cyclists

The site has various cross-hatched road markings and yellow lines to keep traffic moving and to resist blocking key areas.

d) Contact/collision with other vehicles

Independent traffic survey completed.

e) Increased environmental impact (new risk added March 2016)

Regular SLA meetings set up with WHSSC. JACIE report received. Apheresis Nurse Specialist post in place. Number of beds available for transplant patients increased by 2, but this has led to number of general haematology beds reducing by 2. Pilot of Mobile Chemotherapy Unit underway.

RESOURCES - Deliver financial balance and savings programmes

25

Budgets and savings targets delegated to budget holders. Clinical Board Financial and savings plans peer reviewed and tested by senior finance team and Finance Director. Monthly monitoring on financial performance and savings plans. Focus of attention at HSMB, Management Executive meeting and the Big Room. Performance Management Framework / Clinical Board regular meetings.

OPERATIONAL AND CLINICAL EXCELLENCE Identify clinical failures and patterns from information and data sources.

20

Clinical Governance arrangements. Mortality Reviews. Electronic reporting of incidents and near misses implemented during 2015.

SBAR reports produced on key operational pressures for review by Management Executive. External support procured from GE Finnamore to drive forward transformational change with efficiency and cash releasing benefits.

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Principal Risks RESOURCES - Plan, fund and maintain effective & resilient IM&T systems.

Risk Score 20

Summary of Controls IM&T implementation programme. IM&T Sub-committee established to oversee progress. Health and Care Standard 3.4 - Information Governance and Communications Technology.

RESOURCES - Laboratory Information Management System (LIMS) - Risk of clinical governance and information governance concerns as LIMS goes live into additional laboratory areas due to the level of robustness of the system.

20

Collaboration with NWIS to develop solutions to national system issues. NWIS Project Management Arrangements. Staff training arrangements. Each laboratory has contingency procedures to ensure urgent or emergency results are communicated by telephone. 20

• There have been a number of announced and unannounced Dignity and Essential Care (DECI Inspections/Healthcare Inspectorate Wales (HIW)) visits throughout the year. These have provided the UHB with independent assurance in relation to the quality of care across the UHB. Immediate assurance issues were identified in some inspections in both acute services and in primary care contractor services. Immediate actions have been taken where required and improvement plans have been developed to address other findings following the inspections.

Internally developed risk management strategies.

Disaster recovery plan in place.

GOVERNANCE - Comply with relevant, up to date and accessible policies, procedures and other control documents


Policy on Policies and other written control documents revised in July 2014 to make process much simpler. New format approved for all other documents in September 2014. Staff training and awareness. Intranet and internet access arrangements. Re-enforced with all Clinical Boards the need to have arrangements in place to respond to Royal College and other documents. Proforma sent to them all for them to complete or advise of alternative format. Information regarding review of database presented to Lead Executive for their advice and oversight regarding their ongoing review and maintenance.

Underpinning the high level strategic risks, are more specific operational risks where additional focus is required. As demonstrated above actions are being taken to manage all of these risks but it is acknowledged some of them do present a significant challenge to the UHB. There have been a number of high profile clinical matters during 2015/16 which have also required significant and focussed attention as follows: • During 2015, the UHB established a multi-agency group to manage a patient safety concern relating to the practice of a dental practitioner, employed by a dental practice within Cardiff and the Vale of Glamorgan area. In October, the UHB undertook a Patient Notification Exercise (PNE) to inform patients (past and present) that the practice of a named dentist from Cardiff and Vale had fallen below acceptable standards for infection, prevention and control. The UHB has also commissioned an external review, the Terms of Reference of which have been jointly agreed with Public Health Wales and Healthcare Inspectorate Wales. We await this report. • The Neonatal Unit (NNU) at the University Hospital of Wales experienced a number of closures due to infection, prevention and control outbreaks during 2015. In August and November, the NNU closed due to Acinetobacter baumanii outbreaks. On both occasions a multi-disciplinary and multi-agency group was established to manage the incident and to ensure that all possible measures were put in place to re-open the NNU, minimise risks to mothers and to babies and also to minimise the risk of re-occurrence. A fully re-furbished interim Neonatal Unit has been developed in a new location and a seven million pound capital investment has been secured from Welsh Government to develop a new, permanent Neonatal Unit at University Hospital Wales. This was discussed at the Quality, Safety and Experience Committee Meeting (oral 15 December 2015 minute UHB 15/210) and Board Meeting (24 September 2015 minute UHB 15/210). The UHB is currently in the process of commissioning an external review to a) review the process that was followed during the incident and b) to determine whether the UHB has put in place every reasonable measure to prevent a re-occurrence.

• A series of unannounced Trusted to Care visits to Older Persons Mental Health services were carried out by Board members and senior nursing staff during December 2015 and January 2016. Overall the inspections revealed areas of noteworthy practice as well as areas for improvement. There were no areas identified requiring immediate assurances from the Clinical Board. The findings were reported to the February 2016, Quality, Safety and Experience Committee The Community Health Council has also carried out a series of unannounced and announced visits to several of our mental health departments across the UHB during 2015 and confirmed to us that ‘while there were some areas identified for improvement, there were no significant, systemic issues identified as were found in North Wales’. • The UHB also commissioned an independent review of the Emergency Unit after staff raised concerns about the pressure and challenges being faced on a daily basis. The report was published in June 2015. A Steering Group, chaired by the Chief Operating Officer was established to oversee implementation of the recommendations. Report against progress is reported through the Quality, Safety and Experience Committee. • Healthcare Inspectorate Wales published a Homicide Review in March 2015. Although the UHB had limited involvement with the perpetrator, it has contributed to a detailed multi-agency action plan to address the findings. The Quality, Safety and Experience Committee received reports and continue to receive progress updates in relation to these matters. These will be detailed in the Annual Quality Statement that will be published in September 2016.

5. The Control Framework An essential feature of our control framework is ensuring there is a robust system for measuring and reporting on the quality of our services. This will be described in the Annual Quality Statement to be published in September 2016 and will also be linked to our Annual Report for 2015/16. During 2015/16 the Health Board has undertaken a considerable amount of work to implement and embed the revised Health and Care Standards Framework. This has provided us with an opportunity to refresh and revise our approach to self-assessment and we have moved towards alignment with the internal processes for the development and monitoring of the Integrated Medium Term Plan. A pilot self-assessment has been undertaken during March 2016 and a full self-assessment will take place in May/June 2016. More detail on the Standards can be found on the following link: http://www.wales.nhs.uk/governance-emanual/how-the-health-and-care-standards-arest

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Key improvement themes for 2016/17 include: Internal Audit review of the Health and Care Standards The level of assurance given as to the effectiveness of the system of internal control in place to manage the risks associated with Standards for Health and Care Standards is Reasonable Assurance. During the current transition year the Health Board has made good initial progress towards the effective implementation of the new Health and Care Standards together with the piloting of an appropriate assessment process. However, given that the formal timetable pertaining to the 2015/16 Health and Care Standards assessment extended into the early part of 2016/17 the current Audit review was unable to ascertain or provide comment or assurance relating to the review, approval and sign-off by Executive and Independent Member Leads and that of the UHB Quality and Safety Committee. There is, however, documented intention that this will take place in addition to the introduction of a ‘definition based’ assessment scoring outcome to replace the piloted RAG rating when looking at the remaining 17 Standards, as used with the legacy Healthcare Standards for Wales. Therefore, an additional internal audit review will be undertaken in the summer of 2016/17 to ensure that these outstanding elements are implemented accordingly, thereby providing additional assurance as to the newly introduced 2015/16 Health and Care Standards.

5.1 Shaping our Future Wellbeing Strategy • Implementation and monitoring of BIG (Bold Improvement Goals), focussed work on the development of: 1) Re-stratification of Medical Beds- to ensure we align wards to patient need. 2) Perfect Locality – to develop a specification for a single perfect locality for commissioning from 2017/18. 3) Value Based Outcomes - to dramatically improve outcomes and at the same time eliminate non-value adding or unnecessary activities, processes and costs. • Progression of detailed Values & Behaviours work to improve patient experience and staff engagement in order to improve patient care quality and safety.

5.2 Patient Experience • Implementation of concerns performance management mechanisms for Clinical Board’s Performance Reviews to drive improvements in their management.

As part of the annual self-assessment process, the Board has completed the Governance and Accountability assessment module and has: • • • •

Openly assessed its performance using the maturity matrix. Responded to any feedback provided by Healthcare Inspectorate Wales. Reviewed performance against actions identified in the 2014/15 self-assessment. Plans in place to achieve the improvement actions as part of our Integrated Medium Term Plan.

The process has been subject to independent internal assurance by the organisation’s Head of Internal Audit. As referenced in the Head of Internal Audit Opinion and Annual Report, Audit and Assurance have reviewed the completed module and concluded that the completion and assessment was appropriate. Governance and accountability

We do not yet have a clear, agreed understanding of where we are (or how we are doing) and what/where we need to improve.

We are aware of the improvements that need to be made and have prioritised them, but are not yet able to demonstrate meaningful action.

We are developing plans and processes and can demonstrate progress with some of our key area for improvement.

□ 

Setting the direction Enabling delivery

□ 

Delivering results achieving excellence

□ 

Overall Maturity level

□ 

□

2014/15 Assessment

We have well developed plans and processes and can demonstrate sustainable improvement throughout the organisation/ business.



2015/16 Assessment

We can demonstrate sustained good practice and innovation that is shared throughout the organisation/ Business and which others can learn from.

• Increased visibility of the Patient Experience Team across UHB sites through the Information and Support Centres to encourage visitors, patients and carers to provide feedback utilising different methods. • Implementation of Freedom to Speak Communications Plan to ensure that the new process is communicated effectively to staff and the public are aware of the work to improve their trust and confidence in the UHB.

5.3 Clinical Innovation • Establishment of the Clinical Innovation Hub at the UHW as the Clinical Innovation Centre for Cardiff and Vale. • Alignment of the Faculty of Quality Improvement to the Clinical Innovation Programme. In addition, the Health Board is in the process of completing a self-assessment against the Health and Care Standard on ‘Governance, Leadership and Accountability’ for presentation to the Quality, Safety and Experience Committee in September 2016.

6. Corporate Governance Code The Health Board has undertaken an assessment against the main principles of the UK Corporate Governance Code as they relate to an NHS public sector organisation in Wales. The Board is in full compliance with the code with the following non-material exceptions: Section 3.10 – 3.11 – Board appointments are typically made for a period of three-four years. These are Ministerial appointments which the Board itself is unable to influence apart from the personal encouragement of asking people from diverse backgrounds to apply. On a positive note the Board currently has a gender ratio of 10:13 males to females thereby exceeding Government targets; Section 4.1 – The Board does not have a dedicated secretariat function. Secretariat support is however provided from an experienced, skilled officer reporting to the Board Secretary.

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7. Ministerial Directions

8. Other elements of Control Framework

A list of Ministerial Directions issued by the Welsh Government during 2015-16 are available at:http://gov.wales/legislation/subordinate/nonsi/nhswales/2015/?lang=en. The Health Board can confirm that all of these Directions have been fully considered and where appropriate implemented.

A formal system is in place that tracks regulatory and inspection reports against statutory requirements and all such reports are made available to the appropriate Board committee. The overarching tracking report is monitored by the Audit Committee twice a year and also the Healthcare System Management Board, the senior operational management group.

The Ministerial Directions of significant importance to the UHB are: • Directions to the Local Health Boards as to the Statement of Financial Entitlements (Amendment) (No5) Directions 2015. (2015 No.30, 2015 No.14, 2015 No.7) • Directions to Local Health Boards as to the Personal Dental Services Statement of Financial Entitlements (Amendment) 2015 (2015 No.24) • Directions to Local Health Boards as to the General Dental Services Statement of Financial Entitlements (Amendment) 2015 (2015 No.23) • Directions to Local Health Boards as to the Statement of Financial Entitlements (Amendment) (No.4) 2015 (2015 No.20) • The Primary Medical Services (directed Enhanced Services) (Wales) (Amendments) Directions 2015 (20105 No.19) • The National Health Service (Cross-Border Healthcare) (Telemedicine) (Wales) Directions 2015 (No.17) • NHS Blood and Transplant (Gwaed a thrawsblaniadau’r GIG) (Wales) (amendment) (No.2) Directions 2015 • The National Health Service (General Medical Services – Premises Costs) (Wales) Directions 2015 (2015 No.9) • The Pharmaceutical Services (Advanced and Enhanced Services) (Wales) (Amendments) Directions 2015

Control measures are in place to ensure that all the organisation’s obligations under equality, diversity and human rights legislation are complied with. As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer obligations contained within the Scheme regulations are complied with. This includes ensuring that deductions from salary, employer’s contributions and payments into the Scheme are in accordance with the Scheme rules, and that member pension scheme records are accurately updated in accordance with the timescales detailed in the Regulations. The organisation has undertaken risk assessments that are in place in accordance with emergency preparedness and civil contingency requirements. The organisation has undertaken risk assessments and Carbon Reduction Delivery Plans are in place in accordance with emergency preparedness and civil contingency requirements as based on UKCIP 2009 weather projections. This will ensure that the organisation’s obligation under the Climate Change Act and the Adaptation Reporting Requirements are complied with. The Health Board actively engages with the 1000 lives Plus Programme, and the Board promotes use of methodologies for improvement, and is aware of improvements made and barriers to extend. The Board received two days of Patient Safety training in September 2014. No material weaknesses or matters of non-compliance have been identified for these elements of the Health Board’s control framework.

9. Three year integrated medium term plan A range of Health Circulars (WHCs) were published by Welsh Government during 2015-2016 and are centrally logged within the Health Board with a lead Executive Director being assigned to oversee implementation of any required action. Where appropriate, the Board or one of its committees is also sighted on the content of the WHC.

Further to the National Health Service Finance (Wales) Act 2014 becoming law in Wales from 27 January 2014, new duties with regards to operational planning and finance were placed upon the Local Health Boards. These duties are: • A duty under section 175 (1) to ensure that its expenditure does not exceed the aggregate of funding allotted to it over a period of three years, and • A duty under section 175 (2A) to prepare and obtain approval from the Welsh Ministers for a plan which achieves the first duty above, while also improving the health of the people for whom the UHB is responsible and improving the healthcare provided to them. The first assessment of performance against the three year statutory duty will take place at the end of 2016/17. The Board has undertaken a significant amount of work and continues to ensure the organisation maintains progress to develop its three year Integrated Medium Term Plan. The Health Board agreed to submit its 2015/16-2017/18 plan to Welsh Government on 31 March 2015 despite it not being financially balanced. The Board noted this did not meet their statutory responsibility but continued to work with the Welsh Government towards achieving financial sustainability. Following further discussions with Welsh Government, the Health Board’s final plan obtained Ministerial approval in August 2015.

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A copy of the full 2015/16-17/18 Plan is available on the Health Board’s website via the following link: www.cardiffandvaleuhb.wales.nhs.uk/sitesplus/documents/1143/CVUHB%20IMTP%20201516%20final%20draft%20010415%20with%20appendix.pdf A copy of the summary 2015/16 – 17/18 Plan is available on the Health board’s website via the following link: www.cardiffandvaleuhb.wales.nhs.uk/sitesplus/documents/1143/imtp%20summary%202015%20%202018.pdf The 2015/16 – 17/18 Plan entitled ‘Progressing Our Future’, set out to continue to address the challenges of the stark health inequalities in our ageing population, the difficulties with patient flow out of hospital following an unplanned admission, staff shortages in some difficult to recruit to roles and our risks in relation to our estate, and medical and IT equipment. The improvements delivered in 2014/15 were built on in 2015/16 through the publishing of our 10 year strategy ‘Shaping Our Future Wellbeing’ and the continued strengthening of our planning, performance and analytical capacity and capability. This has driven the desire to adopt a ‘home first’ principle in all that we do and has seen progress in delivering our 2015/16 Plan in the following areas: • Our GP clusters have really developed over the year, and our primary care developments are supporting the shift in the balance of care away from hospitals. More people with a long term condition are being managed in the community (diabetes, INR and heart failure represent examples of transformation in the way we deliver care); our Community Resource Teams are now working seven days a week, helping to support timely discharges from acute hospital care, and preventing unnecessary admissions; we are providing more targeted health improvement interventions to increase immunisation and screening rates, and to improve healthy lifestyle behaviours, focusing on particular at risk communities. • We have delivered the agreed plan for referral to treatment times, with a significant reduction in the number of people waiting over 52 and 36 weeks for treatment. This has been achieved by tackling the backlog of patients waiting, and putting in sustainable measures where demand outstrips capacity on an ongoing basis. • We have improved our emergency care pathways resulting in the more timely delivery of unplanned (emergency) care – with key performance indicators showing the improvements made. • We have introduced a number of actions to improve infection prevention and control, and whilst we did not achieve all of the national targets, considerable improvements have been sustained. • We have recruited locally, nationally and globally to reduce our nursing vacancies and have reduce our sickness levels to a 4 ½ year low. • We have delivered a number of significant capital development milestones including the Children’s Hospital for Wales and the Adult Mental Health Unit at UHL. • Despite the ongoing financial challenges and service pressures, we have delivered our financial plan. Delivery against the Plan for 2015/2016 was monitored throughout the year through the respective Committees and the Board and in general terms progress was made against the key issues. In line with the rest of NHS Wales, 2015/16 presented the UHB with another year of considerable financial challenge. Despite the planned delivery of 3.5% savings and considerable cost avoidance schemes the UHB submitted a plan to Welsh Government with a forecast deficit of £13.2m for 2015/16. The Health Board has worked closely with Welsh Government all year in order to address this shortfall. Additional allocations have been made by Welsh Government and the reported year end outturn financial position is a surplus of £0.068m. The Health Board recognises that the delivery of this is supported by significant non recurrent allocations from Welsh Government and that further ongoing work and discussion with Welsh Government is required to achieve financial sustainability.


The first assessment of performance against the three year statutory duty will take place at the end of 2016/17. Despite delivering a balanced position in 2015/16, given the fact that the UHB ended 2014/15 with a £21.364m deficit, the delivery of a break even position by 31st March 2017 will be extremely challenging and difficult to achieve. The UHB has produced a draft three year IMTP, which has been considered by the Board and was submitted to Welsh Government at the end of January 2016. This draft plan emphasises the application of our Future Wellbeing strategic principles: • • • •

Empower the Person Home First Outcomes that matter to people Avoid Harm Waste and Variation

The draft plan has been discussed with Welsh Government and is currently being refined. The UHB intends to revise its draft plan and when this is complete it will be submitted to Welsh Government for formal consideration. The context for the UHB is a very challenging three years. The UHB has to make significant savings to mitigate against the pressures of an underlying deficit, significant cost pressures and service change investments above allocation increase levels. Whilst the plan has yet to be finalised, over the three year period starting 2016/17 the UHB aims to make a minimum financial saving which is equivalent to 9% of the relevant budgets. Despite this ambitious savings plan, the UHB does not however, currently have a Financial Plan that manages to deliver a breakeven position over the three year period 2016/17 to 2018/19 (or delivery of a breakeven position for the current period which is 2014/15 to 2016/17). This will be subject to further consideration at Board level and the options to secure financial sustainability will need to be discussed further with Welsh Government.

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10. Review of effectiveness

11. Internal Audit

As Accountable Officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review of the system of internal control is informed by the outcome of Board and Committee scrutiny, the internal auditors, the Executive Directors within the organisation who have responsibility for the development and maintenance of the internal control framework, and comments made by external auditors in their letter and other reports.

Internal audit provide me and the Board through the Audit Committee with a flow of assurance on the system of internal control. I have commissioned a programme of audit work which has been delivered in accordance with public sector internal audit standards by the NHS Wales Shared Services Partnership.

Internal Sources

External Sources

Performance management reports.

Population Health Information.

Service change management reports.

Wales Audit Office.

Workforce information and surveys.

Welsh Risk Pool Assessment reports.

Benchmarking.

Healthcare Inspectorate Wales reports.

Internal and clinical audit reports.

Community Health Councils visits.

Board and committee reports.

Feedback from healthcare and third sector partners.

Local counter fraud work.

Royal College & Deanery visits.

Standards for health assessments board.

Regulatory, licensing and inspection bodies.

Executive and Independent Member WalkRounds.

External benchmarking and statistics.

Results of internal investigations and serious incident reports.

Accreditation Schemes.

Concerns and compliments. Whistleblowing and safety valve. Infection control reports. Information governance toolkit self-assessment.

National audits. Peer reviews. Feedback from service users. Local networks (e.g. cancer networks). Welsh government reports and feedback.

Patient experience surveys and reports. Compliance against legislation (e.g. Mental Health Act/Health & Safety, Data Protection).

The scope of this work is agreed with the Audit Committee and is focussed on significant risk areas and local improvement priorities. The overall opinion by the Head of Internal Audit (see below) on governance, risk management and control is a function of this risk based audit programme and contributes to the picture of assurance available to the Board in reviewing effectiveness and supporting our drive for continuous improvement. The Head of Internal Audit’s opinion is arrived at having considered whether or not the arrangements in place to secure governance, risk management and internal control are suitably designed and applied effectively in the following with assurance domains: • • • • • • • •

Corporate Governance, Risk Management and Regulatory Compliance Strategic Planning, Performance Management and Reporting Financial Governance and Management Clinical Governance, Quality and Safety Information Governance and Security Operational Service and Functional Management Workforce Management Capital and Estates Management

12. Head of Internal Audit Opinion The scope of this audit opinion is confined to those areas examined in the risk based audit plan which, has been agreed with senior management and approved by the Audit Committee. The Head of Internal Audit assessment should be interpreted in this context when reviewing the effectiveness of the system of internal control and be seen as an internal driver for continuous improvement. The Head of Internal Audit opinion on the overall adequacy and effectiveness of the organisation’s framework of governance, risk management, and control is set out below.

Reasonable Assurance The effectiveness of the system of Internal Control has been undertaken by the committees of the Board in respect of assurances received. This was also supported by the Corporate Risk Assurance Framework with high risk being closely monitored by the respective committee. A particular focus during the year has been to improve the performance information provided to the Board so that the Board can be assured on the accuracy and reliability of the information as well as ensuring it is focusing on the most important matters. In particular weaknesses had been identified in the length of time it was taking to code patients and outcomes. This might have caused delay, for example, in identifying areas of unexpected high death rates. This matter has received focussed attention with the Board receiving regular reports. I am now satisfied that the mortality information presented to the Board reflects an accurate position.

-

Yellow

+

The Board can take reasonable assurance that arrangements to secure governance, risk management and internal control, within those areas under review, are suitably designed and applied effectively. Some matters require management attention in control design or compliance with low to moderate impact on residual risk exposure until resolved.

In reaching this audit opinion, it has been concluded that each of the eight assurance domains, including the three primary domains (Corporate Governance and Risk, Clinical Governance, Quality and Safety and Financial Governance), have been allocated reasonable assurance. In total, 42 audit reviews were completed during the year, and it was pleasing to note that the number of reports receiving Limited Assurance had reduced from the previous year to six Limited Assurance and two No Assurance during 2015/16. Management action plans have been developed to address the issue raised and progress is regularly monitored. It should also be noted that the Blood Management report which received Limited Assurance during the year was subsequently followed up and it was identified that good progress had been made in addressing many of the previously reported weaknesses and a revised assurance rating of Reasonable was then assigned.

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The following reviews received Limited Assurance: Review Title

Objective and Action Taken

Blood Management

The overall objective was to ensure that the organisation has put in place systems and procedures that ensure that there is an adequate supply of safe, good quality blood products to treat users of their services. Agreed action was implemented during 2015/16 and this review was subsequently followed up and a revised rating of Reasonable Assurance was given in March 2016.

Medical Locums

The purpose of the review is to establish if the use of medical locums is appropriate and authorised and that the quality of care provided is appropriate. Agreed action included reviewing and updating the procedure and service level agreement, in addition to providing more detail regarding reasons for usage.

Deprivation of Liberty Safeguards (DoLS)

Theatre Stock

Business Continuity Follow Up

Management of staff Leavers – (draft report)

The purpose of the review was to establish if adequate procedures are in place within the Health Board to ensure that DoLS are consistently complied with and authorisations are obtained for all relevant UHB patients. The scope of the current review was limited to establishing the level of compliance with procedures and did not include any clinical review of the DoLS assessments.

13. Wales Audit Office The Audit Committee agreed the Wales Audit Office (WAO) Annual Plan for 2015/2016 which set out specific areas to be covered in relation to both the audit of the financial statements and performance management audit assignments. The Committee reviewed the progress on both national and local work at each meeting. The following performance reports were/will be presented to the relevant Board Committee who agreed the Health Board’s plan to address any issues raised.

Date Issued

Date Considered By/To be Considered by Committee

Combined Follow-Up Review of Informatics and Communications Technology Audits

February 2015

June 2015

Information Governance Sub-Committee to People, Planning and Performance Committee

A Comparative Picture of Orthopaedic Services

February 2015

July 2015

People, Planning and Performance Committee

June 2015

January 2016

People, Planning and Performance Committee Quality, Safety and Experience Committee

Title of Review

Agreed actions included enhancing the level of training, disseminating guidance, maintaining documentation and improving compliance with timescales.

Medicines Management

The purpose of the review was to provide assurance to the Audit Committee that appropriate amounts of stock (including consignment) were held securely, with stock movements appropriately authorised and tracked. Agreed action included implementing an improved stock control system, reviewing and resetting required stock levels, updating the stock policy and improving consignment agreements.

Follow-Up Review of Hospital Cleaning

September 2015

October 2015

Management of Follow-Up Outpatient Appointments

October 2015

November 2015

Follow up review to assess progress with the implementation of agreed actions following the previous Limited Assurance Report. Agreed action included formalising continuity arrangements within clinical boards and ensuring adequate resource is in place for business continuity.

Diagnostic Review of ICT Capacity and Resources

November 2015

March 2016

Operating Theatres

January 2016

July 2016

Structured Assessment

January 2016

February 2016

The purpose of the review is to ensure that management are clear on their responsibilities to ensure leavers are properly recorded and removed from all UHB systems and processes. Management action is currently being agreed. It should be noted that this report is still at draft stage.

The following reviews received No Assurance: Review Title

Objective and Action Taken

Estates Department – Timesheets and Rotas

The overall objective of the review was to ensure that the UHB has appropriate structures in place to adequately manage rotas and time recording within the Estates Department. Agreed action included improving the authorisation process and consistency of timesheets, review current work rotas and improve the retention of documentation.

Llanishen Stores (draft report)


The purpose of the review is to provide assurance to the Audit Committee that an appropriate amount of stock is held securely, with stock movements appropriately authorised and tracked and that patients receive a timely service. Management action is currently being agreed. It should be noted that this report is still at draft stage.

Assurance Committee

People, Planning and Performance Committee IMT sub-Committee to People, Planning and Performance People, Planning and Performance Committee Board

The actions are recorded in a tracking report and the Audit Committee monitors progress in addressing them. A summary of the WAO Structured Assessment for 2015 of the Health Board’s governance arrangements is included within the Annual Audit Report published in January 2016. This concluded: Arrangements which support good governance and the efficient, effective and economical use of resources continue to evolve, but further improvement is needed particularly in relation to managing estate risks and achieving financial balance: 1. The Health Board has an approved Integrated Medium Term Plan (IMTP), but operational pressures and a failure to identify and deliver the required cost reductions mean that it is currently forecasting a deficit of £23.2 million, compared to a planned deficit of £13.2 million at the end of 2015-16. 2. The Board has set a clear vision and promotes an open and transparent culture through generally robust governance arrangements, but further improvements, including the continuing need to strengthen organisational capacity, are necessary. 3. The Health Board has set an ambitious change agenda, demonstrates strong community engagement and partnership working and has made positive progress in relation to workforce planning, but there remain significant risks around estates.

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A delivery plan has been developed to respond to the detailed recommendations set out in the Annual Audit Report and progress will be monitored through the Audit Committee during 2016/17.

14. Equality and Diversity Control measures are in place to ensure that all the organisation’s obligations under equality, diversity and human rights legislation are complied with. The control measures include: • Health Board Equality Monitoring Annual Report. • Equality reports to Quality, Safety and Experience Committee on the Health Board’s objectives and actions. • Reports to the Equality and Human Rights Commissions’ enquiries. • Reports to the Centre for Equality and Human Rights enquiries. • Report to the Welsh Government Equalities team. • Provision of evidence to the Health Care Standards Audit, specifically Standard 2. • Equality Impact Assessments.

15. Disclosure Statements • The UHB records reported information governance incidents both through the Patient Safety e-DATIX system and the central Information Governance processes. Both work closely together to ensure consistency and accuracy of reporting. The Caldicott Guardian and through Information Governance sub-Group, monitor these incidents closely and provide an assurance function for the Board. • The UHB did not report any serious incidents in respect of data breaches to the Information Commissioner’s Office (ICO) in 2015/2016. There were a number of cases that were reported in previous years that remained under the scrutiny by the ICO in 2015. All cases were closed down in September 2015. No fines were enforced. In order to effect continuous improvement through learning and audit the UHB invited the ICO to audit its Data Protection Act arrangements in May 2016.


16. Conclusion As Accountable Officer, based on the assurance process outlined above, I have reviewed the relevant evidence and assurances in respect of internal control. I can confirm that the Board and its Executive Directors are alert to their accountabilities in respect of internal control and the Board has had in place during the year a system of providing assurance aligned to corporate objectives to assist with identification and management of risk. My review confirms that in general the UHB has a sound system of internal control however, there are some areas where improvements are required as described within the report, particularly in relation to Internal Audit reports where Limited or No Assurance has been received. During 2015/2016 through our Corporate Risk and Assurance Framework, we have proactively identified areas requiring improvement and requested Internal Audit to undertake detailed assessments in order to manage and mitigate associated risks. A number of reports issued by audit concur with our view and have consequently provided the UHB with clear recommendations to ensure that focussed and urgent management actions are in place to address identified shortcomings. These actions are then monitored through the Board and its committees to ensure appropriate assurances can be provided. The first assessment of performance against the three year statutory duty will take place at the end of 2016/17. Despite delivering a balanced position in 2015/16, given the fact that the UHB ended 2014/15 with a £21.364m deficit, the delivery of a three year break even position by 31st March 2017 will be extremely challenging and difficult to achieve. We are working very closely with Welsh Government in respect of addressing this and other outstanding issues in order for our IMTP for 2016-19 to be approved. Robust performance management arrangements are already in place to mitigate and manage performance and control issues during 2016/2017. The 2015/2016 Annual Governance Statement confirms that the UHB has continued to mature as an organisation and no significant internal control or governance issues have been identified. We are, and will continue to address our key risks and embed good governance and appropriate controls throughout the organisation. In summary, my review confirms that in general the Board has a sound system of internal control that supports its policies, aims and objectives.

Signed by:

Adam Cairns Chief Executive 2nd June 2016

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Appendix 1 – Board Committee Membership Name and position

Area of expertise representation role

Board and committee membership 1 April ‘15 – 31 March ‘16

Number of meetings attended during tenure

Champion roles

Abigail Harris Director of Planning

Board

6

n/a

Adam Cairns Chief Executive

Board

5

n/a

Alice Casey Chief Operating Officer

Board

4

n/a

Brendan Sadka Independent Member

Capital and Estates

Board People, Performance and Delivery Committee Audit Committee

17

Older People

Christopher Elmore Independent Member

Local Authority

Board Mental Health and Capacity Legislation Committee

3

Children and Young People

Board Charitable Funds Committee

8

n/a

Christopher Lewis Acting Director of Finance (17.11.14 – 8.12.15) Eileen Brandreth Independent Member

Information Communication Technology

Board People, Performance and Delivery Committee Mental Health and Capacity Legislation Committee

8

Elizabeth Treasure Independent Member

University

Board (Chair) Quality, Safety and Experience Committee Audit Committee

14

Patient Safety (Cleaning, Hygiene and Infection Management)

Fiona Jenkins Director of Therapies and Health Sciences


8

n/a

Graham Shortland Medical Director

Board

5

n/a

Caldicott/Data Protection (Independent Member Contact)

Ivar Grey Independent Member

Finance

Board (Chair) Audit Committee Quality, Safety and Experience Committee Remuneration and Terms of Service Committee People, Performance and Delivery Committee

26

n/a

Marcus Longley Vice Chair

Primary, Community and Mental Health Services

(Vice Chair) Board (Chair) Mental Health and Capacity Legislation Committee (Chair) People Performance and Delivery Committee Remuneration and Terms of Service Committee

18

Mental Health Primary and Community

Margaret McLaughlin Independent Member

Third Sector

Board Mental Health and Capacity Legislation Committee Quality, Safety and Experience Committee Charitable funds Committee

18

Carers Welsh Language Equality and Human Rights

(Chair) Board (Chair) Remuneration and Terms of Service Committee

9

Public and Patient Involvement Concerns

Board (Chair) Health and Safety Committee (Chair) Charitable Funds Committee Mental Health and Capacity Legislation Committee Quality, Safety and Experience Committee Remuneration and Terms of Service Committee

22

Health and Safety Violence and Aggression

Maria Battle Chair

Martyn Waygood Independent Member

Legal

Name and position

Area of expertise representation role

Board and committee membership 1 April ‘15 – 31 March ‘16

Number of meetings attended during tenure

Champion roles

Paula Martyn Associate Member

Stakeholder Reference Group

Board

4

n/a


2

Board

1

n/a

Board

6

n/a

Board Quality, Safety and Experience Committee Mental Health and Capacity Legislation Committee

7

Board

5

n/a

Robert Chadwick, Director of Finance (from 9.12.15) Rosemarie Whittle Associate Independent Member (to 30 September 2015)

Healthcare Professionals Forum

Ruth Walker Director of Nursing Saleem Kidwai Independent Member

Community

Sharon Hopkins Director of Public Health Sian Walker Associate Independent Member (to 30 September 2015)

Local Authority

Board

2

n/a

Stuart Egan Independent Member

Trade Union

Board Charitable Funds Committee Health and Safety Committee Remuneration and Terms of Service Committee Audit Committee People, Performance and Delivery Committee

25

Armed Forces and Veterans

* Note – Executive directors are not Members of Committees (apart from Charitable Funds) – they are “In attendance”. Directors’ attendance is not shown as they are often invited to attend Committee on ad-hoc basis depending on agenda items. It should also be noted that some extraordinary meetings were arranged during the year which has impacted on some Members attendance.