bundle primary & community care committee 9 january 2019cwmtafmorgannwg.wales/docs/primary care...

Bundle Primary & Community Care Committee 9 January 2019

0 AGENDA1 Agenda Primary and Community Care Committee 9 January 2019.docx

1 PART 1 - PRELIMINARY MATTERS1.1 Welcome & Introductions1.2 Apologies for absence1.3 Declarations of Interest1.4 Unconfirmed Minutes of the meeting held on 10 October 2018

1.4 Unconfirmed Primary and Community Care Committee minutes 10 October 2018 PCCC 9 Jan2019.doc

1.5 Matters Arising1.6 Action Log

1.6 Action Log PCCC 9 January 2019.docx

1.7 Chairs Report2 PART 2 - ITEMS FOR DISCUSSION2.1 A Healthier Wales/Primary Care Strategic Plan

2.1 Strategic Programme for Primary Care PCCC 9 Jan 2019.pdf

2.1.1 Strategic Programme for Primary Care Nov 2018 PCCC 9 Jan 20192.1.1 Strategic Programme for Primary Care Nov 2018 PCCC 9 Jan 2019.pdf

2.2 Results of Population Segmentation2.2 Population segmentation PCCC 9 Jan 2019.docx

2.2.1 Rhondda Cluster Population Segmentation Risk Stratification PCCC 9 Jan 20192.2.1 Rhondda Cluster Population Segmentation Risk Stratification PCCC 9 Jan 2019.pdf

3 PART 3 - GOVERNANCE, PERFORMANCE & ASSURANCE3.1 Report of the Director of Primary, Community & Mental Health

3.1 Director of Primary Community and Mental Health report PCCC 9 Jan 2019.doc

3.2 IMTP Monitoring Report3.2 IMTP Monitoring Report paper PCCC 9 Jan 2019.docx

3.2.1 Appendix 1 IMTP tracker quarterly report PCCC 9 Jan 20193.2.1 Appendix 1 IMTP tracker quarterly report PCCC 9 Jan 2019.docx

3.3 Directorate Risk Register3.3 Directorate risk register Primary Care and Localities PCCC 9 Jan 2019.doc

3.3.1 Appendix 1 Directorate Risk Register PCCC 9 Jan 20193.3.1 Appendix 1 Directorate Risk Register PCCC 9 Jan 2019.xls

4 PART 4 - ITEMS FOR APPROVAL4.1 Organisational Risk Register

4.1 Org Risk Register PCCC 9 Jan 2019.doc

5 PART 5 - OTHER MATTERS5.1 To Review the Forward Look for 2019/20

5.1 Forward Look PCCC 9 January 2019.doc

5.2 Any other urgent business5.3 Date of Next Meeting

0 AGENDA

1 1 Agenda Primary and Community Care Committee 9 January 2019.docx

PRIMARY AND COMMUNITY CARE COMMITTEE

Wednesday 9 January 2019 Ynysmeurig House, Navigation Park, Abercynon

09.00 - 12.00

AGENDA

Lead / Attachment

PART 1 - PRELIMINARY MATTERS

1.1 Welcome and Introductions Chair / Oral

1.2 Apologies for Absence Chair / Oral

1.3 Declaration of Interests Chair / Oral

1.4 Unconfirmed Minutes of the meeting of the Primary

Care Committee held on 10 October 2018.

Chair

Attachment

1.5 Matters Arising Chair / Oral

1.6 Action Log Chair

Attachment

1.7 Chair’s Report Chair / oral

PART 2 - ITEMS FOR DISCUSSION

2.1 A Healthier Wales / Primary Care Strategic Plan (Sue Morgan in attendance)

Director of Primary,

Community & Mental Health

Presentation (to follow)

2.2 Results of Population Segmentation

Director of Public Health

Presentation (to follow)

PART 3 - GOVERNANCE, PERFORMANCE AND ASSURANCE

3.1 Report of the Director of Primary, Community and Mental Health



Presentation

3.2 IMTP Monitoring report Director of Primary,


Attachment

3.3 Directorate Risk Register



Presentation

PART 4 – ITEMS FOR APPROVAL

4.1 Organisational Risk Register Interim Board Secretary

Attachment

PART 5– OTHER MATTERS

5.1 To review the Forward Look for 2019/20 Chair

Attachment

5.2 Any other urgent business Chair / Oral

5.3 Date of Next Meeting

Wednesday 3 April 2019 at 9.00am

Rhondda and Cynon Rooms, Ynysmeurig House, Abercynon CF45 4SN

1.4 Unconfirmed Minutes of the meeting held on 10 October 2018

1 1.4 Unconfirmed Primary and Community Care Committee minutes 10 October 2018 PCCC 9 Jan 2019.doc

Agenda Item 1.4

Unconfirmed minutes of the Primary and

Community Care Committee

10 October 2018

Page 1 of 9

Primary and Community

Care Committee Meeting

9 January 2019

CWM TAF UNIVERSITY HEALTH BOARD

MINUTES OF THE MEETING OF THE PRIMARY AND COMMUNITY

CARE COMMITTEE HELD ON 10 OCTOBER 2018 AT YNYSMEURIG HOUSE, ABERCYNON

PRESENT:

Maria K Thomas − Vice Chair of the Health Board (Chair) Robert Smith − Independent Member

Keiron Montague Dilys Jouvenat

− Independent Member − Independent Member

IN ATTENDANCE:

Alan Lawrie − Interim Director Primary, Community & Mental Health

Ruth Treharne − Deputy Chief Executive and Director of

Planning and Performance Kelechi Nnoaham − Director of Public Health

Ana Riley − Head of Finance for Primary Care Alyson Davies − Assistant Director for Therapies and Health

Sciences Craige Wilson − Assistant Director for Primary Care, Children

and CAMHS

Brian Hopkins

− Community Pharmacy Wales

− Pharmacy Ian Jones − Optometry Wales

Sarah Bradley − Head of Primary Care Dr Kurt Burkhardt − Clinical Director (Taf Ely Locality)

Dr Kevin Thomas − Local Medical Committee Representative Gwenan Roberts − Head of Corporate Services

Kate Bowd − Secretariat

Nicola Powell − Welsh Government - Observer

PCCC/18/059 WELCOME & INTRODUCTIONS

Maria Thomas (Chair) welcomed everyone to the meeting and Members were invited to introduce themselves. The Chair welcomed

Nicola Powell, Head of Capital, Welsh Government to the meeting as an observer and shadowing Ruth Treharne.

PCCC/18/060 APOLOGIES FOR ABSENCE

Apologies for absence were received from Robert Williams, Jayne

Howard, Dr Stuart Hackwell, Suzanne Scott-Thomas, Dr Gareth Jordan and Alison Lagier.

PCCC/18/061 DECLARATIONS OF INTERESTS

There were no additional declarations of interests.

Agenda Item 1.4



10 October 2018

Page 2 of 9



9 January 2019

PCCC/18/062 MINUTES OF THE PREVIOUS MEETING

The minutes of the meeting held on 27 June 2018 were RECEIVED

and APPROVED subject to minor typographical amendments.

PCCC/18/063 ACTION LOG

Members RECEIVED and discussed the action log and the following items were discussed:

• PCC/17/057 Sexual Assault Referral Centre (SARC) – It was

agreed to receive feedback from Angela Hopkins outside of meeting and sign off the proposal for new pathways.

• PCC/18/027 – Success/Evaluation Criteria – Alan Lawrie agreed to further discuss with Executive Directors and report back at

the next meeting.

• PCC/18/053 – Wales Audit Office (WAO) Discharge Planning Report – it was agreed to receive the management response at the

January meeting.

PCCC/18/064 MATTERS ARISING

Craige Wilson provided an update on the Post Payment Verification Progress Report. Members were advised that staff from NHS Wales

Shared Services Partnership had met with optometry colleagues to discuss the issues identified and the progress made to provide

assurance.

PCCC/18/065 COMMITTEE CHAIR’S REPORT

The Chair provided an oral update.

Vice Chairs meeting – The Chair advised Members that the Vice Chairs meeting with the Cabinet Secretary for Health and Social Service

was cancelled and rescheduled for a date in November. However, the Vice Chairs met with Andrew Goodall and the agenda was primarily

focused on ‘A Healthier Wales’ Transformation Plan. Members NOTED

that the Transition Board had been established with the Welsh Government and the role of the Regional Partnership Board was to

provide assurance on the plan. Andrew Goodall advised the work would be monitored through the Joint Executive Team (JET) meetings with the

Cwm Taf Executive Team.

Out of Hours (OOH) Peer Review – The Vice Chair provided an update on the outcome of the OOH peer review. The review aimed to

assist in the development of a robust plan to ensure a coherent OOH service and delivery plan.

Agenda Item 1.4



10 October 2018

Page 3 of 9



9 January 2019

The final version of the review would be presented to the Executive

Board for approval. The first 111 Project Implementation Board was scheduled for the forthcoming week.

Members RESOLVED to NOTE the Chair’s update.

PCCC/18/066 BABY TEETH DO MATTER

Craige Wilson presented the report on Baby Teeth Do Matter. The purpose of the report was to provide the Committee with the

evaluation information from the first year of the Baby Teeth Do Matter initiative.

Members NOTED that the initiative had been launched in April 2017

and the pilot had been offered in the first instance to dental practices in the Merthyr Tydfil area. Initially, 5 practices indicated that they

were keen to participate in the pilot but only 3 practices took part.

Children under 5 were identified when attending baby clinics in GP practices and by Health Visitors who encouraged parents to take the

child to the dentist.

Members NOTED that the report provided two graphs. Graph 1 illustrated the number of children attending a General Dental Service

(GDS) practice in the last 24 months and Graph 2 illustrated an increase in trend for adults also in attending a GDS practice. The

Health Board invested additional units of dental activity (UDAs) in the Merthyr Tydfil area and as part of the launch of Baby Teeth Do Matter,

the trend increased by 1,500.

Craige Wilson advised Members that the results of the pilot had been discussed at the Clinical Business Meetings (CBMs) with a

recommendation that Baby Teeth Do Matter be rolled out across the

whole of Cwm Taf. Nine practices had expressed an interest in participating and discussions remained ongoing regarding

implementation. Members NOTED that there was no additional funding required for the initiative and there was also a maximum of a 5%

reduction in UDA target for each practice as an incentive to take part.

Members were advised that there was a 39% increase in attendance for children under 5 and significant improvement in dental contract

performance. There were also opportunities for innovation funding support for dental contracts although the scheme was not offered to

underperforming practices.

Members welcomed the improvement in attendance at dental practices and NOTED that this was a good news story for the Health Board.

Members RESOLVED to: • NOTE the report:

• ENDORSE the positive evaluation of the service.

Agenda Item 1.4



10 October 2018

Page 4 of 9



9 January 2019

PCCC/18/067 ORGANISATIONAL RISK REGISTER

Members RECEIVED and DISCUSSED the Organisational Risk Register. The purpose of the report was to provide the Committee

with the organisational risk register and to consider whether the recorded risks were appropriately assigned.

Gwenan Roberts presented the report and provided an update on the

risk register categories and the summary of the assessed risks. The Committee had 4 assigned risks and Members were asked to consider

the risk rating and any mitigating actions.

Members were asked to NOTE that since the last review the report had been presented to the Executive Board in August and the Quality

Safety and Risk Committee in September. Members discussed in detail

the risks allocated to the Committee:

Risk 029 – Failure to sustain Primary Care Services across RCT and Merthyr Tydfil but particularly in Rhondda Valleys. The Committee

agreed that the lead Director review the risk to ensure that it remained suitable for the current position.

Risk 036 – Primary care workforce - recruitment and sustainability. Members felt that this was not specific enough and following advice

from the management team AGREED this risk should be removed from the risk register.

Risk 030 – Failure to continue to provide and sustain GP Out of Hours Services as configured. Members felt that the risk rating should be

increased to 20 until the plan was approved, implementation commenced and improvements seen.

Risk 038 – Inconsistent approach and arrangements in place for the

management and monitoring of patients requiring anticoagulation management in Cwm Taf. Members AGREED to remove the risk from

the register in line with the changes to the service and receive further assurance on progress at a future meeting (added to action log/

forward look).

Members AGREED to receive the Directorate’s risk register at the next meeting to better understand the operational risks to link with the

organisational risk register (added to action log/ forward look).

Members RESOLVED to: • NOTE the report

• ENDORSE the allocated risks to the Committee subject to the amendments identified.

Agenda Item 1.4



10 October 2018

Page 5 of 9



9 January 2019

GOVERNANCE PERFORMANCE AND ASSURANCE

PCCC/18/068 REPORT OF THE DIRECTOR OF PRIMARY, COMMUNITY AND MENTAL HEALTH

Alan Lawrie presented the report and provided an update to the

Committee on key areas within the portfolio of the Director of Primary, Community & Mental Health and to provide assurance on the progress.

• Community Dental Services Transfer from Cardiff – Members NOTED the Health Board had agreed to repatriate the

services from Cardiff & Vale UHB as of 31 March 2019. Concerns regarding the workforce and funding arrangements had been

escalated to Director of Finance. The Chair requested an update at the next meeting to monitor the progress.

• The Cwm Taf Transformation Plan – Members received an

update on the Cwm Taf Transformation plan. The partnership transformation proposal has been developed and signed off by

the Regional Partnership Board. The key priorities were highlighted as: population health segmentation, proactive

technology model, central resource team, primary care out of hours and rapid response. Members NOTED that funding had

been secured for 2018/19 and 2019/20. Members discussed the enhanced community resource team and developments at the

cluster level. Keiron Montague expressed concerns regarding the pace of the resource shift into primary care and the degree of

acuity and level of investment required for years 3 and 4 to support key issues of change. Members AGREED to receive an

update report on financial sustainability at a future meeting (added to action log/ forward look).

• Eye Care Plan update by exception – Members NOTED that

the redesign of glaucoma services was continuing although were disappointed that the lead consultant for glaucoma services had

recently taken up a post with a neighbouring health board and prospects of recruiting a substantive replacement in the short

term were deemed low. Work had now commenced in earnest to look at alternative models of care, particularly with the Bridgend

boundary changes to redesign services. • Oral Health Report update by exception - Members received

an update on the reform of Dental Contracts. An update report on dental services would be provided in April (added to action

log/ forward look). • GP Sustainability - Members NOTED that two managed

practices had transferred back to independent status with effect from 1 October 2018. In relation to the potential closure of a

branch surgery meetings had been scheduled with Assembly

Members (AMs) / Members of Parliament (MPs), local councillors and the Community Health Council.

Agenda Item 1.4



10 October 2018

Page 6 of 9



9 January 2019

• Primary Care Measures - Members NOTED the All Wales

Directors of Primary Care had commissioned the primary care development and innovation hub to produce a national primary

care measures report. The report would provide comparison data across Wales.

• Wales Audit Office (WAO) Report on Primary Care Services - Members NOTED the Health Board had received the

final report on primary care services and that the Health Board was considered to have a good plan and had made good

progress in implementing key elements of the national vision.

Members RESOLVED to: • NOTE the report.

• AGREED to RECEIVE more information on specific areas for assurance.

PCCC/18/069 PRIMARY AND COMMUNITY CARE INTERNAL AUDIT REPORT (SUBSTANTIAL ASSURANCE)

Members RECEIVED a copy of the Primary and Community Care

Internal Audit Report which provided the Committee with the rating of substantial assurance.

The key actions from the report were:

• Adding training for Committee members to the terms of reference (TOR) in line with the Standing Orders

• Amend the TOR to clarify whether the chair was included in the membership for quoracy in line with other Committees

• Amend the TOR to correct duplications of responsibilities • Ensuring the Committee received timely reports.

Members discussed the report and AGREED that the Chair sign the amendments based on the recommendations in order for submission

to the next Audit Committee meeting.

Members RESOLVED to: • NOTE the report.

• AGREED to take Chair’s action to sign off recommendations in the report before submission to Audit Committee.

PCCC/18/070 INVERSE CARE LAW PROGRAMME (CARDIOVASCULAR HEALTH CHECK PROGRAMME)

Kelechi Nnoaham presented the report. The purpose of the report was

to inform Members on the progress of the two population health

programmes in Cwm Taf.

Agenda Item 1.4



10 October 2018

Page 7 of 9



9 January 2019

The Inverse Care Law (ICL) health check programme is a critical

programme to improve the health and wellbeing of adults aged 40-75 through early identification and management of pre-existing medical

conditions. Members were advised that a risk management tool had been developed and data was audited and reported monthly; referrals

were also monitored as part of the evaluation outcomes. Members NOTED that there were also evaluation strands undertaken jointly

with Aneurin Bevan University Health Board as part of the National ICL programme which continued to be rolled out across Cwm Taf. A service

review was being undertaken by new programme leads to ensure objectives were met and the service was effective and sustainable.

Kelechi Nnoaham advised Members that an evaluation report would be provided as soon as available (added to action log/ forward look).

The Population Health Management pilot was a population

segmentation and risk stratification approach across Rhondda primary

care cluster to support health management across Cwm Taf. The pilot was seeking to understand patient populations, groups, clusters by

characteristics related to their need and use of health care resources that could help GPs assess and deliver anticipatory and pre-emptive

care for patients based on holistic need rather than disease condition. A process evaluation was being undertaken to inform the potential roll

out of this approach which included assessment of the usefulness of the approach to GP practice and its potential to inform targeting of

interventions at population segments based on holistic need. Members discussed in detail the population health management and the risks

associated and sustainability for a future model.

Kelechi Nnoaham confirmed the initial iteration of the segmentation model had identified 36 different segments. The Health Board was also

working with Sollis Ltd to modify the model to make sure it was

adapted in the local population.

Phase 2 of the pilot would commence in May 2019 during which GP Practices would access the live reports for a period of 1 month. This

would allow any trends over the 6 month intervening period to be identified. Measures of the accuracy of the model in predicting risk for

the pilot population would be available at this stage for the Committee.

Members RESOLVED to: • NOTE the progress of the ICL programme in Cwm Taf, reported

outcomes and plans to revise the model going forward • Receive a more detailed report to include the SAIL analysis and

revised delivery model to be presented as soon as available • NOTE the progress of the Population Health Management Pilot

Agenda Item 1.4



10 October 2018

Page 8 of 9



9 January 2019

PCCC/18/071 CLUSTER UPDATE

Sarah Bradley presented the report. The purpose of the report was to

present Members with an update on work being undertaken by the Primary Care Clusters.

Sarah Bradley advised Members that the cluster plans were developed

and considered as a key element of the Integrated Medium Term Plans (IMTP) and funded through the Welsh Government (WG) service

delivery agreements. The Clusters were required to set out a 3 year action plan and the approach supported consistency of service

provision across the cluster and would assist in effectively managing the impact of increasing demand against financial and workforce

challenges.

Sarah Bradley confirmed the primary care clusters aim was to improve

service sustainability; improved access and more services available in the community. The clusters had developed multi-disciplinary teams

with professionals to extend skills and deliver professional care.

Members NOTED that workshops had been planned for the future delivery model and Members were advised that there were longer term

issues to be resolved with the NHS Wales Informatics Service (NWIS) on the information required for the data dashboard. Sarah Bradley

advised that the evaluation report informed by SAIL had been delayed which was a challenge to planning and developing the service and

measuring outcomes for the proposed delivery model.

Alan Lawrie proposed a critical appraisal be undertaken to ensure the evaluation report was built in to the transformation process and

approval via the Executive Board.

Members RESOLVED to:

• NOTE the report

PCCC/18/072 DELIVERY AGREEMENTS

Sarah Bradley presented the 6 month progress reports for the Primary Care Delivery Agreements, covering the period from 1 April to 30

September. Members were advised that the reporting timescale for the Welsh Government was now every 6 months and not quarterly. The

Health Board was reporting a forecast end of year underspend of £77k which was being monitored over the forthcoming months with the aim

to breakeven.

Alan Lawrie advised Members that monthly conference calls were being

scheduled with Welsh Government to discuss the delivery agreements in line with the set expectations.

Agenda Item 1.4



10 October 2018

Page 9 of 9



9 January 2019

Members NOTED that the next progress reports would be the year end

reports to be submitted to Welsh Government by 11 April 2019; the committee would receive at the meeting in April prior to the

submission date.

Members RESOLVED to NOTE the report.

FOR INFORMATION

PCCC/18/073 PRIMARY CARE NEWSLETTER

Members RECEIVED a copy of the Welsh Government Primary Care Newsletter for information.

Members RESOLVED to NOTE the Newsletter.

PCCC/18/074 NATIONAL PRIMARY CARE BOARD

The minutes of the meeting of the National Primary Care Board which was held on 16 March were received.

PCCC/18/075 INTEGRATED MEDIUM TERM PLAN (IMTP) MONITORING

REPORT

Members RECEIVED the usual overview of the IMTP for information which linked closely with the ongoing transformation work.

PCCC/18/076 TO REVIEW THE FORWARD LOOK

The forward look was received and would be amended in line with the

agreed actions.

PCCC/18/077 ANY OTHER URGENT BUSINESS

There was none.

PCCC/18/078 DATE OF NEXT MEETING

The next Primary and Community Care Committee meeting was

planned to take place 9 January 2019, 9am to 12pm, Ynysmeurig House, Abercynon.

SIGNED …………………………………………………….

MARIA THOMAS, CHAIR

DATE ……………………………………………………

1.6 Action Log

1 1.6 Action Log PCCC 9 January 2019.docx

AGENDA ITEM 1.6

Action Log Page 1 of 2

Primary and Community Care Committee Meeting 9 January 2019

PRIMARY AND COMMUNITY CARE COMMITTEE ACTION LOG

No MEETING

DATE SUBJECT KEY ACTIONS/DECISIONS RESPONSIBLE

OFFICER COMPLETED/

updated PCC/17/16 & PCC/18/042

15 March

2017

Baby Teeth DO

Matter

Receive formal evaluation after 12 months Dr Kelechi

Nnoaham

Completed

PCCC/17/057 & PCC/18/042

27 Sept

2017 & 4 April 2018

SARC The Executive Team to further discuss SARC

in Cwm Taf in relation to the new pathways and with Women’s Aid – update on progress

Angela Hopkins Completed

PCCC/17/061 27 Sept

2017

Inverse Care

Law

Obtain a copy of the data in Aneurin Bevan

UHB for comparison with Cwm Taf.

Kelechi

Nnoaham

Completed

PCCC/18/023 4 April

2018

GP

Sustainability /

Out of Hours Service

Workshop held in February,

Transformational plan developed, discussed

at Board. Presentation at the meeting – update agreed

Alan Lawrie Completed

PCCC/18/027 4 April 2018

Success /evaluation

criteria

Executive Team to discuss and develop a proposal – update at a future meeting

Executive Team To be confirmed

PCCC/18/045 27 June 2018

Changes to risk register

Risk 033 to be reallocated to the Quality Safety and Risk Committee

Risk 029 to be reviewed

Alan Lawrie and

Robert Williams

Completed

PCCC/18/046 27 June

2018

Primary and

Community Transformation

plan

Update to be provided at the next meeting Alan Lawrie Completed

PCCC/18/053 27 June 2018

WAO Discharge Planning Report

Full response to the report Alan Lawrie April 2019

AGENDA ITEM 1.6

Action Log Page 2 of 2

Primary and Community Care Committee Meeting 9 January 2019

No MEETING DATE

SUBJECT KEY ACTIONS/DECISIONS RESPONSIBLE OFFICER

COMPLETED/ updated

PCCC/18/067 10 October

2018

Anticoagulation Update to be provided on progress made

with new service model and implementation

Stuart Hackwell Added to forward look April

Remove risk 038 from the organisational risk register

Gwenan Roberts Completed

Directorate Risk Register

Receive the directorate risk register to better understand the operational risks and

link with

Alan Lawrie On agenda

PCCC/18/068 10 October 2018

Cwm Taf Transformation

plan

Update on financial sustainability and links with the Transformation plan

Ana Riley Added to forward look

April

Oral Health Update on dental contracts Craige Wilson Added to forward look April

PCCC/18/069 10 October 2018

Terms of Reference

Make changes in accordance with Internal Audit Report via Chair’s action

Maria Thomas Gwenan Robert

On agenda

PCCC/18/070 10 October

2018

Inverse Care

Law

Cardiovascular health check programme –

receive evaluation report (with SAIL analysis)

Kelechi

Nnoaham

Added to forward look April

2.1 A Healthier Wales/Primary Care Strategic Plan

1 2.1 Strategic Programme for Primary Care PCCC 9 Jan 2019.pdf

The Primary Care Model for Wales

Sue Morgan

National Director & Strategic Programme Lead for Primary & Community Care

Primary Care Plan for Wales 2015-18.

Five priority areas for action:

• Planning care locally• Improving access & quality• Equitable access• A skilled local workforce• Strong leadership

Progress Against Primary Care Plan

Planning care locally- Pacesetter programme, 24 projects 2015-18- ‘Transformational’ primary care modelImproving access & quality- 111 roll-out, choose pharmacy & common ailmentsA skilled local workforce- New roles eg community paramedics, navigatorsEquitable access- Inverse care lawStrong leadership- P&C Care Hub, development programmes

DP&CC Annual Report 2017-18

Key Messages

• Get better at measuring what really matters to people

• Greater emphasis on wellbeing

• Health and Social Care will work together…... joined up and scaled up

• Work as a single system, everyone working together

• Invest in new technologies

• Shift services out of hospitals into the community

• Implement the Primary Care Model for Wales

Pacesetter Programme 2015 – 18

24 projects evaluated on ‘Once for Wales’ basis

MDT Primary Care Clusters are the way forward

Safe & effective triage systems direct people to the right professional in the team

Integrated teams ensure a holistic approach to care -physical, mental and social well-being

Services must work well across in- and out-of-hours

Success also depends on an informed public

Integrated, whole systems approach: Well Being of Future Gen Act

Stable Primary

Care

New Cluster

Models

Reduced preventable &

avoidable

ED / hospital admissions

Range of new

community

services

Improved

access to

quality

care

Complex &

Specialised Care

in Community

IMPROVING ACCESS & QUALITY...

Releases GP &

Adv Practitioner

time and skills

Releases

hospital

specialists Enhanced

Multiprofessional

PC Teams

Sustainable Models

of Care

Stable Primary

Care

New Cluster

Models

Motivated

professionals

Reduced

preventable &

avoidable

ED/hospital

admissions

Integrated, Whole

Systems Approach

Complex &

Specialised Care

in Community

Sustainable

Community Resources

Increased

citizen

wellbeing

Promotion of

Healthy Living

Accessible

Resources

Wide Range of Community

Resources

Support for

Self Care

Increased

Community

Resilience

Informed

Public

Empowered

Citizens

Improved

access to

quality

care

ALL WALES WHOLE SYSTEM APPROACH

Components of the Primary Care Model for Wales

1. Informed Public

2. Empowered Citizens

3. Support for Well-being, Disease Prevention and Self Care

4. Community Services

5. Cluster Working

Cluster planning, Integration, Sustainability, Cluster Development, Evaluation, MDT Working

6. Call-handling, Signposting, Clinical Triage / Telephone First Systems

7. Urgent Care - 111 and Out of hours & In hours

8. Shifting Resource

9. Complex Care in the Community

10. Infrastructure to support Transformation

What next for Primary Care….

• Reinforces our direction of travel

• Looking for pace & scale

“Strategic Programme for Primary Care”

Not a ‘new’ plan…continuation of the journey

Primary Care Model for Wales

Social model of care

Three strategic areas to progress

I. Primary Care Specific Workstreams• Prevention and wellbeing• 24/7 Model• Digital Technology & Data• Workforce & Organisational Development• Communication & Engagement• Transformation & the Vision for Clusters

II. Seamless Working• Health Board• Wider Stakeholders

III. Primary Care Contractors

• GMS, Pharmacy, Optometry, Dental

Delivery Mechanism

I. Primary Care Specific Workstreams

Prevention and wellbeing – Hilary Dover & Dr Sarah Aitken• Prevention in clinical settings - alignment with priorities of DoPH & PHW• Prevention in non-clinical settings – d/w AMDs • Information for Citizens & Social Prescribing – d/w national leads• Making Every Contact Count (MECC) & health and wellbeing hubs –

establish guidance on good practice in urban and rural areas• Cardiovascular Risk Assessment & Reduction- evaluation report• Optimise Delivery of National Programmes

• Programme Management approach – March 2019• Programme Management Board as part of DPCC Meeting

reporting into the National Primary Care Board• Whole system inclusion – DPCC lead with ‘expert’ co-chair

Delivery MechanismI. Primary Care Specific Workstreams cont…

24/7 Model – Alan Lawrie & Nick Wood (Jeremy Griffith & Richard Bowen)• Urgent Care – identify urgent on-the-day demand (DU) • Community services – map in hours and out of ours services• Escalation Processes – a system in place for winter 2019• Self care – map existing work• Telephone first / sign-posting / triage – evidence & standards• Management of rising risk – scope what is currently available

Digital Technology & Data – Lisa Dunsford & NWIS Director (TBC)Review of existing Primary Care IM&T Board membership and priorities:• Maximise use of current systems available • Maximise use of new GP systems & offer to MDT working• Patient-facing – telephony, video & skype, apps (DEWIS etc)• Information – data availability & governance. Measures including RAG

escalation, time spent at home, primary care measures


Workforce & OD – Sian Millar & Lisa Gostling (HEIW & WG)• Workforce Planning & Modelling

- learn from existing pilots/initiatives - workforce planning tool April 2019

• Pay & Employment – a good place to work- locum pay rates, locum bank, salaried GP rates, ‘TWL’ campaign

Comms & Engagement – Dr Chris Stockport & Clare Jenkins• Communication

Public Facing – raise awareness and promote behaviour change in accessing new wider model at General Practice levelStakeholder Communication - user friendly articulation of the model for stakeholders (basis of training for public facing staff)

• Engagement - development of key components of the model. First point of contact a high priority. Compassionate communities.


Transformation & the Vision for Clusters – TBC

II. Seamless Working

III. Primary Care Contractors

• Health Board – ‘buddy’ leads and wider expertise

• Wider Stakeholders – on workstream and task finish groups. Awareness raising with key partners. Regional Partnership Boards.

Led by WG with DPCC Lead – Jill Patterson.

For Consideration….

• How does this fit with your IMTP & Transformation Plans?

• What emerges from this as a priority to support your plans?

• Anything local to input to frame these national discussions?

2.1.1 Strategic Programme for Primary Care Nov 2018 PCCC 9 Jan 2019

1 2.1.1 Strategic Programme for Primary Care Nov 2018 PCCC 9 Jan 2019.pdf

1

Strategic Programme for Primary Care

November 2018

2

Foreward The case for change as set out in The Parliamentary Review and the required ‘revolution from within’ is fully recognised by the National Primary Care Board. A Healthier Wales provides a clear plan for progressing this and we welcome the reinforcement of cluster working as part of the national model for local health and care. Whilst significant progress has been made through implementing the recommendations set out in the Primary Care Plan for Wales 2015 – 2018, there is still much to do to ensure our part in the National Transformation Programme and to fully implement the Primary Care Model for Wales. This document sets out the strategic programme of work for primary care which has been developed following the publication of A Healthier Wales. Some areas are a continuation of previous work, recognising that the pace and scale needs to be increased. Other areas have emerged as a priority in response to ‘A Healthier Wales’. Specifically of note, is the whole system approach to health and social care, stating that it will be a ‘wellness’ system, which aims to support and anticipate health needs, to prevent illness, and to reduce the impact of poor health and inequality. Primary care, as the first point of contact for the majority of citizens accessing health services, has a key role in maximising the opportunities for prevention and self-management. At the heart of the strategic programme for primary care is working closely with partners, shifting the focus to a social model of care, ensuring timely access to primary care services when required and working seamlessly across the whole system. This strategic programme sets out, at a high level the key workstreams required to progress this work. This is underpinned by detailed action plans. Whilst many actions fall to those that work within primary care, seamless models of care requires all partners to work together and I am would like to acknowledge the commitment of all those involved in the progress that has been made to date and the challenges ahead. The full implementation of the primary care model for Wales and the integral part that primary care plays within the national transformation programme gives primary care the permission to be bold, an opportunity that we must not miss. Judith Paget Chair, National Primary Care Board & Lead Chief Executive for Primary Care

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Executive Summary Our Plan for a Primary Care Service for Wales up to March 2018’ was published by Welsh Government in February 2015 and has provided the context and framework for the development of primary and community care over the last three years. Good progress has been made locally and the investment provided by Welsh Government to support innovation and development in primary care was provided at cluster level, health board level and at national level via a £40million primary care fund which included the Pacesetter Programme. Learning from the first cycle of Pacesetters influenced the development of a whole system, 24/7, transformational model for primary and community care. This has enabled a whole system approach to redesign, driven by national quality standards but with flexibility to respond to local community needs. Clusters are seen as pivotal to the delivery of this model. In January 2018, the Parliamentary Review of Health and Social Care in Wales was published and in June 2018 Welsh Government provided a response in ‘A Healthier Wales: our Plan for Health and Social Care’ which called for bold new models of seamless local health and social care at the local and regional level. The transformational model for primary and community care, which is a whole system approach to sustainable and accessible local health and wellbeing care, supports the vision set out in ‘A Healthier Wales’ and is now adopted as the Primary Care Model for Wales. Clusters remain at the heart of this model and, given the key principles that underpin ‘A Healthier Wales’ can be described as:

“A cluster brings together all local services involved in health and care across a geographical

area, typically serving a population between 25,000 and 100,000. Working as a cluster ensures care is better co-ordinated to promote the wellbeing of individuals and

communities.” Whilst work continues on the implementation of the Primary Care Model for Wales, ‘A Healthier Wales’ has brought a wider context to this work in terms of the links to the Regional Partnership Boards and the wider community infrastructure as the ‘wellness system’ approach is reinforced. It is therefore timely to review the strategic programme for primary care within this context and the following key strategic areas have emerged as priorities to run alongside the normal planning and delivery functions of Health Board teams:

Primary care key workstreams

Seamless working in Health Boards and with partners

Primary care contract reform A high level summary of actions are provided in this document against each of these priorities. There is also supporting documentation that provides more detailed action plans and a delivery mechanism for the strategic programme.

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1. Introduction This paper provides the key workstreams required for primary and community services to build on the work undertaken in response to ‘Our Plan for a Primary Care Service for Wales up to March 2018’ (Welsh Government, February 2015) and respond to ‘A Healthier Wales’ (Welsh Government, June 2018). The workstreams are not intended to replace work planned or underway at a local level by clusters, health boards, regional partnership boards, or to cut across wider transformational work, but rather to complement and enable pace and scale of transformation. 2. Strategic Context ‘Our Plan for a Primary Care Service for Wales up to March 2018’ was published by Welsh Government in February 2015 and has provided the context and framework for the development of primary and community care over the last three years. The plan was supported by A Planned Primary Care Workforce for Wales setting out the direction required to support a sustainable workforce shaped by local population needs and prudent health care principles. The definition of primary care used in the plan was very broad, see below, and now underpins this document.

What is primary care?

Primary care is about those services which provide the first point of care, day or night for more than 90% of people’s contact with the NHS in Wales. General practice is a core element of primary care: it is not the only element – primary care encompasses many more health services, including, pharmacy, dentistry, and optometry. It is also – importantly - about coordinating access for people to the wide range of services in the local community to help meet their health and wellbeing needs. These community services include a very wide range of staff, such as community and district nurses, midwives, health visitors, mental health teams, health promotion teams, physiotherapists, occupational therapists, podiatrists, phlebotomists, paramedics, social services, other local authority staff and all those people working and volunteering in the wealth of voluntary organisations which support people in our communities.

The scope of work has been influenced by a number of publications and areas of work during the period 2015 – 2018, which have added to the direction and breadth of the changes in primary care, as follows:

The Social Services and Well-being (Wales) Act 2014

The Well-being of Future Generations (Wales) Act 2015

Prudent Healthcare – Securing Health and Well-being for Future Generations 2016

Taking Wales Forward 2016 – 2021 Welsh Government

Prosperity for All – national strategy. The Welsh Government wellbeing objectives 2017 (September 2017)

Ministerial Taskforce on Primary Care Workforce - Train, Work, Live in Wales campaign 2017

GP Services in Wales: The Perspective of Older People (Older People’s Commissioner for Wales February 2017)

Health, Social Care and Sport Committee - Inquiry into Primary Care Clusters 2017

Services Fit for the Future – Quality and Governance in Health and Care in Wales (June 2017)

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In January 2018, the Parliamentary Review of Health and Social Care in Wales was published and in June 2018 Welsh Government provided a response in ‘A Healthier Wales: our Plan for Health and Social Care’ which called for bold new models of seamless local health and social care at the local and regional level. The primary care model for Wales, which is a whole system approach to sustainable and accessible local health and wellbeing care supports the vision set out in ‘A Healthier Wales’. ‘A Healthier Wales’ sets out the whole system approach to health and social care, stating that it will be a ‘wellness’ system, which aims to support and anticipate health needs, to prevent illness, and to reduce the impact of poor health and inequality. Primary care, as the first point of contact for the majority of citizens accessing health services, has a key role in maximising the opportunities for prevention and self-management. Working closely with partners, primary and community care must not miss opportunities to promote a social model of care and avoid over-medicalising. 3. ‘Our Plan for a Primary Care Service for Wales up to March 2018’ – Progress to Date ‘Our Plan for a Primary Care Service for Wales up to March 2018’ Welsh Government, February 2015, (hereafter referred to as the Primary Care Plan) detailed key actions to be taken forward at a national level, alongside 26 key actions to be taken forward at the local level. Welsh Government established the £43m national primary care fund to back the plan. The Integrated Care Fund also invested in local services improvements. A high level summary of progress against the actions included in the Primary Care Plan against the five themes follows.

I. Planning Care Locally

Pacesetter/Pathfinder Programme – 24 projects 2015-18, 15 projects commencing 2018

Emergence of a new ‘transformational’ model of primary care

Critical appraisal – external evaluation, workshop October 2018

Primary Care One website launched November 2017 as online resource for sharing good practice and learning

Cluster level needs assessments and plans with £10m for clusters to invest

Cluster development – Cluster Governance Framework of Good Practice

Pipeline of capital developments and integrated health and care centres

II. Improving Access and Quality

National project for directory of services

Signposting and triage – scoping exercise and recommendations complete

111 – roll out planned

Primary Care Measures Phase 1 and 2a introduced

Key Indicators for GMS developed

Capacity and demand modelling – Pathfinder project

Workshop to define what ‘good’ access looks like

Roll out of Choose Pharmacy and common ailments service

More eye care moved out of hospital and delivered in the community

Social prescribing (or community referral) models for systematic access to non clinical wellbeing services

Primary care contract reform programme

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III. Skilled Workforce

MDT working – review and recommendations complete

Physicians Associates

Community Paramedics

Compendium of new roles and models, including cluster level posts and indemnity solutions

Workforce planning in primary care training

Advanced practice training, such as non-medical prescribing

Expansion of Academic Fellows scheme beyond South Wales

Train, Work, Live campaign

IV. Equitable Access

Inverse care law schemes established in three health boards and learning shared

Transgender project

British Sign Language project

Welsh Language tool kit

V. Strong Leadership

National Primary Care Board

National Directors of Primary and Community Care peer group and sub groups

Primary and Community Care Development and Innovation Hub

National Professional Lead & National Director and Strategic Programme Lead

Confident leaders programme x 3

Cluster leads development programme ongoing

Further detail is available in the Directors of Primary & Community Care (formerly the Directors of Primary, Community & Mental Health) Annual Report 2017 – 18. Supporting documentation is available on the Primary Care One website. The investment provided by Welsh Government to support innovation and development in primary care was provided at cluster level, health board level (via Integrated Medium Term Plans) and at national level via a Pacesetter Programme. The Pacesetter Programme is a comprehensive range of initiatives, funded by Welsh Government, to stimulate innovation and promote the redesign of primary care services. The first cycle of 24 pacesetter projects began in April 2015 included a focus on at least one of the following:

improved access to services

moving care closer to home

increased sustainability of primary care services. These were led by Primary Care Teams across Wales and supported by the Primary Care Hub (Public Health Wales). Learning from the first cycle of Pacesetters influenced the development of a whole system, 24/7, transformational model for primary and community care. This has enabled a whole system approach to redesign, driven by national quality standards but with flexibility to respond to local community needs (see diagram overpage). Clusters are seen as the pivotal to the delivery of this model with 64 clusters in Wales.

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Further detail on the model and the key components can be found on the Primary Care One website. Critical Appraisal and Evaluation As part of the pacesetter evaluation process, the University of Birmingham was commissioned to undertake a critical appraisal of the Pacesetter Programme. The overall aim of the research was to strengthen the learning for future primary care transformation programmes in Wales through investigating the experiences of Pacesetter teams, exploring the views of stakeholders and comparing outcomes with current research evidence and international best practice. The final report, was published in June 2018 and can be found at: http://www.primarycareone.wales.nhs.uk/home The following sets out the implications of the findings for future Primary Care Transformation.

Development of evaluation capacity within health boards to assess the impact and mechanism of change have the connected skills, access to data and analytical support.

Workforce plans to include the development of competencies related to inter-professional working and teams, patient and community engagement, and leadership of change.

Availability of suitable infrastructure to embed engagement within transformation programmes.

Local infrastructure to support innovation in primary care that ensures those undertaking such changes are supported with project management and related tasks.

Opportunity for networking across health boards for those involved in leading innovation to provide peer support and challenge.

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4. The Primary Care Model for Wales The transformation model for primary and community care aligns well with ‘A Healthier Wales’ and as the full implementation of the recommendations arising from ‘A Healthier Wales’ moves forward it is important that primary care is pivotal to the proposed bold and seamless models of care that are aspired to. As described in section 3, the pacesetter work has informed a transformation programme for primary care with the components of the model set out. This has been reinforced by ‘A Healthier Wales’ and is now adopted as the Primary Care Model for Wales. Key components of this model are:

Informed public

Empowered citizens

Support for self care

Community services

First point of contact

Urgent care

Direct access

People with complex care needs

MDT working Clusters remain at the heart of this model and, given the key principles that underpin ‘A Healthier Wales’ can be described as:

“A cluster brings together all local services involved in health and care across a geographical

area, typically serving a population between 25,000 and 100,000. Working as a cluster ensures care is better co-ordinated to promote the wellbeing of individuals and

communities.” The Primary Care Model for Wales is predicated on a social model of care and critical to this is the need to work across organisational boundaries in order to maximise all the assets in a community. Existing primary care clusters are predominantly health focused and delivered. Having said that, there are examples of clusters who have expanded beyond the boundaries of health in their development. Moving forward, clusters need to consider the assets available within their community for their local population. This means working across social care and the wider local authority services. The role of the third sector needs greater consideration both in terms of current delivery and potential opportunities in the future. Regional Partnership Boards and Area Plans are essential links to this wider network and whilst these have not featured highly for clusters in the past they will be pivotal going forward. 5. The Primary Care Model for Wales – Areas of Focus ‘A Healthier Wales’ shifts the focus to a ‘wellness system’. Whilst the primary care model for Wales includes elements that support such a system, there has been limited focus on these to date (with the exception of social prescribing). Going forward, a social model of care needs further development. This requires a focus on wellbeing and prevention and understanding the opportunities that exist across the health, social care and third sector workforce in order to really understand what matters to people and make every contact count. Whilst considering the development of the social model of care, the existing actions from a health perspective must continue. Of particular, note is the join up of in hours and out of hours primary care services to a 24/7 model to ensure access at the right time particularly for patients presenting with urgent primary care needs.

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‘A Healthier Wales’ points towards exploring digital solutions, which is not an area previously explored in depth or systematically from a primary and community care perspective. Work to date on the primary care model for Wales has identified numerous workforce issues. There are currently a number of groups looking at the workforce issues and this needs a review and refocus within the context of ‘A Healthier Wales’. The Critical Appraisal highlights the need for health boards to develop local infrastructure to enable transformation within primary and community care. Health boards became integrated organisations in 2009 and it is timely for them all to reflect on how well developed their internal arrangements are in order to maximise the potential of integration. In turn, consideration of developing the relationships with key partners such as social services, wider Local Authority services and the Third Sector is required in order to ensure seamless working within the whole system at a local and regional level. It is noted that this may be undertaken through local transformation programmes. ‘A Healthier Wales’ makes reference to the contract reform programme of national primary care contracts. The contribution of this needs to be clear. The communication and engagement on the primary care model for Wales needs careful consideration and dedicated expertise to ensure understanding by all stakeholders and the public are clear on what this means going forward. The key strategic areas of work required to progress the implementation of the primary care model for Wales at pace are:

Primary care key workstreams

Seamless working across Health Boards and with partner organisations

Primary care contract reform

The following sections provide an overview of the tasks required under each strategic area. More detailed action plans will underpin each work stream, maximising the existing support from organisations such as the NHS Wales Shared Services Partnership and the Primary Care Hub (Public Health Wales) but also building new links with the Regional Partnership Boards, Directors of Social Services and Health Education and Improvement Wales (HEIW). 5.1 Primary Care Key Workstreams 5.1.1 Prevention and wellbeing Primary and community services have a key role in the ‘wellness’ system as described by ‘A Healthier Wales’ and every contact with a citizen or their carer/guardian should be used to promote prevention and self-management opportunities. Specifically, this includes:

Information for citizens to access – join up of Directory of Services, DEWIS & INFOENGINE and systematically embed in GP practice and cluster based websites to promote self-care.

Social prescribing (or community referrals) and local area co-ordination to increase in capacity of wellbeing services – action is required at regional level and national level.

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- At cluster and Regional Partnership Board level, a join up is required between health, social care and the third sector to map the community assets available in that footprint and the ‘navigator’ roles already in place. A plan for sustainability of these assets should be developed.

- Local Area Co-ordination linked to Directory of Services.

- At a national level key enablers such as information sharing (information governance and information technology), evaluation frameworks for these types of interventions and the development of national definitions and standards for community navigators/connectors.

Making Every Contact Count (MECC) – systematic roll out of training across primary care underpinned by an understanding of the local community infrastructure (as described above at Regional Partnership Board level).

Prevention in clinical settings – maximising population benefit on key clinical risk factors (high BMI, high BP, fasting blood glucose, cholesterol), behavioural risk factors (smoking, alcohol consumption, rate of physical activity and diet) screening and immunisation.

Prevention in non clinical settings (e.g. whole school approach to prevention and wellbeing, falls risk)

Population risk reduction programmes – linked to prevention in clinical settings, learning from programmes such as the Inverse Care Law in Aneurin Bevan, ABMU and Cwm Taf Health Boards.

Compassionate Communities or equivalent e.g.

Health and well-being hubs/centres – ensure that the wellness approach and social model of care is a prominent feature of the planning.

Scaling up the delivery of national programmes, (e.g. NERS, Help Me Quit).

5.1.2 24/7 Model “Services which are seamless, delivered as close to home as possible” is set out by ‘A Healthier Wales’ and references that primary and community care is key to this. The transforming primary care model was developed as a 24/7 model but implementation has been predominantly focussed on in hours only. Many of the elements of the model can be applied to primary care delivery out of hours whilst recognising there are some issues specific to in hours delivery and out of hours delivery. Also, increased sustainability of primary care in hours and improved access will support out of hours delivery.

Urgent Care – scope includes urgent primary care both in hours and out of hours. Workstreams include: peer review of out of hours services workforce link to Unscheduled Care Programme including winter planning focus on key pathways such as end of life care, paediatrics and mental health opportunities to address capacity at peak times

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Escalation Processes – whilst escalation processes are well developed and routinely used in secondary care, this has not been the case for primary care. More recently, work has been undertaken in OOHs but there is an inconsistency in reporting that requires attention. In addition, a ‘RAG’ rating for in hours services needs to be developed.

Self care and wider primary care contractor professions – “Choose Well” and the offer from contractor professions needs to be scoped and well articulated in order to promote population behaviour change. (Note: this links to the communication workstream and the prevention and wellbeing work steam, specifically the information to citizens).

Telephone first / sign-posting / triage – informed by the detailed review undertaken by the Primary and Community Care Development and Innovation Hub, there is a clear need to develop national definitions and standards, national training and competency framework.

Services in the community – there is a need to ensure join up across the separate services that are in place across the community (e.g. community nursing, community resource teams etc) to ensure best use of resources. This needs a further sense check against the local authority and third sector services available. Further, maximising the use of diagnostics and point of care testing in the community should be considered.

Management of rising risk – implementation of a structured approach (recognising there are a range of tools available for this) to risk identification and links to the appropriate responses to respond (from the whole system e.g. Third Sector, Local Authority).

5.1.3 Data & Digital Technology While the national primary care plan recognised the role of technology in improving access, previous strategic work on the development of primary care has not focussed on the potential of new technologies. ‘A Healthier Wales’ identifies this as a key enabler of transformation change to support new models of care. In the first instance, there will be a focus on ‘ensuring the relevant information is accurate, complete, up to date and shared between everyone responsible for the individuals care’ before moving on to new ways of accessing services and then more advanced digital solutions. Specifically, this will include:

Maximising the use of current systems available to maximise and share data and information. For example My Health Online, Welsh Community Care Information System (particularly the interface across services) and embedding the integrated DEWIS, Directory of Services and infoengine into practice/cluster websites

Maximising the use of new GP and pharmacy systems and the offer to MDT working

Specifically for pharmacy, progress the Welsh Hospital Electronic Prescribing, Pharmacy and Medicines Administration (WHEPPA) project will enable the computerisation of the process of prescribing, processing, stock control and recording the administration medicines in secondary care hospitals.

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Progress IT solutions for eye care, specifically: implement optometry primary care e-referral to enable patients to be referred to secondary care safely; implement ophthalmic two-way IT systems between primary care and secondary care to enable ‘shared care’ of patients between different health professionals and care settings.

Data to demonstrate activity and outcomes

Information sharing across cluster and organisations

Understanding the requirement around the use of mobile devices including the governance and workforce issues.

Digital systems to facilitate risk identification to drive patient safety.

Telephony – develop national telephony standards.

Video and skype – generally supported in principle yet under-utilised. There is a need to consider governance, security of data, training and integration to health record requirements.

Consideration needs to be given to the barriers to embracing technology including poverty and influencing behaviour change of the population.

5.1.4 Workforce & Organisational Development ‘A Healthier Wales’ references the multidisciplinary team approach as the common characteristic of the best new models being developed in Wales which is fundamental to the Primary Care for Wales. Work has been led by the Primary Care Workforce Group which has produced a final report highlighting the work undertaken to date and has identified key priorities for future work. In addition, the recent report on ‘Multi-Professional Roles within the Transforming Primary Care Model in Wales’ highlights areas requiring further work. Combining these recommendations the following are the key themes for focus:

Workforce planning and modelling – developing local population based modelling based upon demand analysis. This will inform the required competencies of the workforce required and inform workforce planning at community and national level.

A good place to work – addressing the issues of recruitment and retention, pay and employment terms as well as a focus on well-being.

Specific Role Development – priority areas include developing a national framework and training for the community navigator role and triage roles.

Education, training and skills – this includes developing mechanisms to increase opportunities for education and training within primary care settings, including mentoring and supervision requirements and career pathways.

Sharing best practice – building on the compendium of models and roles produced to date with the development of workforce elements of evaluation of new models.

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5.1.5 Communication & Engagement Whilst the primary care model for Wales is predicated on a social model of care, the focus has been on the health elements of the model to date. Further, it is recognised that the language has been from a health perspective and that this needs to widen to ensure the narrative is accessible to all and there are consistent communications from all stakeholders on the model. Initially, this will focus on:

User friendly articulation of the whole and different elements of the model for stakeholders (e.g. social care, third sector, secondary care). Consideration of how clusters/primary care interface with Regional Partnership Boards needs to be considered.

Forming the basis of how staff are trained to manage this message (e.g. receptionist/navigator role).

A public awareness and information/education campaign to promote and the embed the model with citizens across Wales.

‘A Healthier Wales’ talks about people having ‘a greater role and greater control in managing their own health and wellbeing, making decisions about treatment, and managing long term conditions’. This requires readily available information to citizens and an understanding of new models of care in order to influence behavioural change. As part of the Welsh Government’s ‘Transformation Programme’, there may be an over-arching workstream which primary care could align to. As a minimum this would need to include, both at national and local level: - New ways of accessing information

- Understanding of the new wider model at General Practice level e.g. enhanced MDT,

social prescribing (or community referral) and signposting to alternative practitioners (physiotherapists, counsellors, audiologists and existing contractor services e.g. community pharmacy and optometry).

- Links to existing national campaigns such as Choose Well and national plans such as Eye Health.

5.1.6 Transformation & the Vision for Clusters As the transformation programme develops (as per ‘A Healthier Wales’ recommendations), it is important that any learning is shared quickly across primary care and further informs the vision for clusters. Of specific note, will be any plans to accelerate the implementation of the full primary care model at cluster and regional level. Key links will be made with the national Transformation Programme and local transformation programmes.

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5.2 Seamless Working 5.2.1 Health Board arrangements to maximise seamless working The Critical Appraisal of the pacesetter programme referred to in section 3, set out the need for Health Boards to consider their local infrastructure and identify the capacity, skills and resources required to support the transformation of primary care. Based upon the recommendations of the Critical Appraisal, the following requires attention at health board level:

- Setting out arrangements for increasing the profile of primary care at health board level.

- Ensuring arrangements are in place to support data capture to inform demand/capacity planning for primary and community services.

- Having short, medium and long term planning in place informed by clusters that are evidenced in IMTPs.

- Demonstrating the use of the primary care measures and the key GMS indicators have informed these plans.

- Demonstrating the use of the financial framework to support rebalancing resources across the health system (WHC issued July 2018).

- Recognising the scale of change, ensuring workforce planning and organisational development plans are in place to support this.

- Ensuring evaluation frameworks supported by skilled support are in place to evidence impact on pacesetter/transformation model/transformation fund initiatives to inform business case development and investment decisions.

5.2.2 Seamless working across the whole system ‘A Healthier Wales’ sets out the need for services from different providers to be seamlessly co-ordinated and the need to develop shared values and partnership. Therefore, the following requires attention from a primary perspective:

- Consideration of the profile of primary care within the regional partnership board structures both in terms of the understanding of the primary care model by partners and representation within these structures.

- Ensure that regional partnership board plans are informed by cluster planning.

- Consideration of the priorities and actions plans of Public Service Boards and the

alignment locally with cluster plans.

- Build stronger relationships with key partners.

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5.3 How Primary Care Contractors will respond This section considers how primary care contractors will respond to ‘A Healthier Wales’ under the following headings,

- Resilience of individual/community

- Advice/access when required

- Supported and delivering workforce

5.3.1 GMS Resilience of individual/community – in conjunction with the commitments on access more generally within Prosperity for All, and the programme of reform, which has commenced (and is a tripartite approach of Welsh Government, GPC Wales and NHS Wales), the GMS contract reform will consider how best to contract and sustain GMS and deliver against a range of key priorities, recognising the value of the independent contractor model. The contract reform will explore ways to continue to improve access across primary care, particularly through clusters, to enable adoption and adaptation of the Primary Care Model. The policy for some time, and reinforced in ‘A Healthier Wales’, has been a shift to greater cluster working. During 2018-19 the Welsh Government Contract Reform Team is considering a new contracting mechanism to expedite clusters maturing and embedding a better population focussed service planning for General Practice across Wales. The proposed approach could see a potential shift of a number of additional services (such as Enhanced Services and quality measurement) to a cluster level and wider cluster workforce solutions to release capacity within GP practices and support delivery of local services to patients and enable cluster population based service planning and delivery. Advice/access when required - As part of the 2018-19 GMS contract negotiations it was agreed that GP practices should continue to optimise the availability of consultations during core hours, standardise messaging to patients out of hours and for each practice to review access and agree its position on the telephone first / sign-posting / triage component of the model. Demonstrating and developing quality improvement methodology in General Practice is another key priority with a view to deliver improved outcomes and experience for Welsh citizens, with a focus on the cluster as the vehicle for taking this forward. Supported and delivering workforce – Recruiting, retaining and diversifying the workforce is another key priority. As part of the GMS reform agenda, a number of areas will be taken forward across the General Practice workforce to ensure the longer term ambition of a sustainable workforce, reducing the barriers to becoming and remaining a GP. 5.3.2 Pharmacy Resilience of individual/community: Community pharmacies are a health asset, fulfilling a social and well-being function, often in the areas of Wales where the health and social challenges are greatest. Pharmacies contribute to social capital and build resilience in high streets in towns across Wales, but changing consumer habits means we must work with the community pharmacy sector helping it to adapt and ensure this contribution is maintained. Community pharmacies must continue to redefine their role, making them the most accessible source of an increasing range of clinical services and face to face advice from a healthcare professional - not simply a place to have a prescription dispensed.

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Key priorities include,

Community pharmacy contractual arrangements rebalanced to incentivise delivery of services which meet the needs of the communities they serve and not just the dispensing of prescriptions.

Pharmacies continue to target their services at those whose need is greatest and where there is potential for greatest health gain and narrowing of health inequality.

Community pharmacy fully integrated with primary care clusters to ensure delivery of efficient equitable services.

Advice/access when required: Community pharmacies are highly accessible, often open at weekends and evenings, they provide a convenient and less formal environment for people unable to, or who do not wish to, visit other health services. Key priorities include,

Community pharmacists continue to diagnose and treat a wider range of acute illnesses, relieving pressure on other parts of the NHS.

Community pharmacists accessing the Welsh GP record nationally and across all services to facilitate pharmacists safely and effectively meeting urgent and unscheduled care demand.

Communication with the public and action by other health services consistently promoting the role of community pharmacy as citizens’ first port of call for treatment of common ailments and advice on medicines.

Supported and delivering workforce: Community pharmacists are highly skilled primary care generalists; they manage minor illness and provide advice on medicines. Pharmacy technicians are critical to the safe and efficient operation of pharmacies, freeing up pharmacists to deliver more clinical services and increasingly delivering clinical services themselves. To increase the breadth of services available from community pharmacies, we will continue to raise the competence and confidence of the workforce in areas such as patient centred consultation, making every contact count, quality improvement, advanced clinical skills, and prescribing. Key priorities include,

All community pharmacists and pharmacy technicians to continue to be supported in developing their patient centred consultation skills and in “making every contact count”.

An improved awareness and understanding of quality improvement embedded in community pharmacy teams.

Continue to provide opportunities to access up to 200 modern apprenticeships for pharmacy technicians working in community pharmacy by 2021.

Continue to provide opportunities to train 100 community pharmacists as independent prescribers by 2020.

5.3.3 Optometry Resilience of individual/community: Community Optometry is a highly skilled workforce fulfilling a key health function, contributing to the social capital and building resilience in high streets in towns across Wales, community optometric practices continue to deliver the most accessible and appropriate professional eye health care for patients. There is a need to raise their profile and the awareness of the contribution they make. Commercial pressure to subsidise sight tests with spectacle sales leads to patients expecting a visit to the optometrist to be expensive and this can reduce the uptake of NHS eye care services. Moving the emphasis to eye health care will ensure optometric practices continue to be a health asset in the community and the first port of call for a patient with an eye problem. Regular and consistent access for optometric practice with primary care clusters is vital to develop integrated services and ensure understanding of the important role optometrists play in the eye health care of patients.

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Key priorities include,

Optometric practices targeting their services where there is potential for greatest health gain - the emphasis on eye health care

Community optometric contractual reform rebalancing the need for cross subsidy of clinical services.

Community optometry fully integrated with primary care clusters to ensure delivery of efficient, equitable services.

Advice/access when required: Continue to increase access to a range of NHS eye health care services and provide a wider range of clinical services in optometric practices. Community optometric practices are highly accessible, often open at weekends and evenings. Providing additional qualifications for community optometrists to deliver more integrated eye care services, shifting between primary and secondary care, for both scheduled and unscheduled eye health care is essential. Key priorities include,

Community optometrists to continue to be involved in diagnosis and treatment of a wider range of eye care pathways, specifically, through the development of primary care ophthalmic diagnostic and treatment centres.

Access to electronic referrals and single shared electronic patient record.

Communication with the public to promote the role of community optometric practice, consistently promoting the role of community optometry - Doctors of the eyes.

Supported and delivering workforce: community optometrists are eye care generalists. It is important to continue to enhance the skill mix required to manage and treat a wider number of eye conditions in the community setting. This will enable a greater shift of services from secondary to primary care in line with current policy and prudent healthcare. To increase the breadth of services available from community optometry there is a need to enhance the workforce through advanced training and accreditation, whilst additionally providing a career structure for the optometric profession. Key priorities include,

Independent prescribing optometrists rolled out across primary care clusters.

Placements in hospital eye departments to achieve qualifications in medical retina, glaucoma, independent prescribing and leadership.

An improved awareness and understanding of quality improvement embedded in community optometry through contractual arrangements.

5.3.4 Dental

Resilience of individual/community; to raise the profile of the contribution improving oral health can make to wider health and well-being by empowering and guiding patients and the public to value, maintain and protect their own oral health, and that of their dependents. An increase in oral health literacy is important in achieving this and we want patients to understand how their behaviour affects their likelihood of developing dental disease. We want dental teams to personalise key messages by delivering consistent and correct advice to assist patients to lower their risk of oral disease so they can maintain and improve their oral health. Key priorities include,

Preventive advice and intervention ‘expectations’ being delivered in clinical practice.

All patients in contact with primary dental care will have their oral health need and risk assessed, explained and reported, so they understand their oral health status and the behaviours they can change to reduce their risk of oral disease.

Advice/access when required: to increase access to NHS primary care dentistry and provide dental services (primary, specialist, or urgent care) that meet the needs of local communities. Care should be accessible for those with the greatest health need first – a principle of Prudent Healthcare. The commitment is to increase access to NHS dental care, particularly for patients

18

who have not seen a dentist in the previous two years (one year for children). Key priorities include,

Year-on-year increase in the proportion of people who have seen an NHS dental practitioner in the last 2 years (1 year for children) in all Health Boards.

Contracts which build in daily access flexibility and expanded opening hours.

Anyone experiencing dental pain affecting daily life will receive effective dental treatment and receive a timely offer to return and have a comprehensive oral health risk and need assessment completed.

All patients attending NHS primary dental care services will receive an oral health risk and need assessment at least once a year with follow up reviews dictated by the findings.

Supported and delivering workforce: a step-up in the effective use of skill mix within dental practice teams and specialist services through an increase in the number of hygienists, therapists and dental nurses with additional skills, trained and retained in Wales, and working to the extent of their scope of practice. This will create an efficient preventive-led dental team. Widened access to employment opportunities will offer prospects for individuals from local communities, motivate dental teams and support them to achieve their professional and personal goals by offering a career structure. Key priorities include,

Dental Care Professional Faculty established and Making Prevention Work in Practice programme rolled-out in 2018.

Innovation fund supporting expansion of Dental Care Professionals in practice

6. Conclusion This paper provides the primary care response to ‘A Healthier Wales’, describing a status position on the development of primary care and identifies key strategic areas for further focus. This forms the basis of a strategic programme for primary care. There will be a delivery and evaluation mechanism to support this strategic programme which will provide the detail of actions, milestones and outcomes at cluster, regional and national levels. It should be noted that some areas of work will continue under ‘business as usual’ led by the Health Board Directors of Primary & Community Care.

2.2 Results of Population Segmentation

1 2.2 Population segmentation PCCC 9 Jan 2019.docx

Population health management pilot Page 1 of 10 Primary and Community Care Committee Meeting

9 January 2018

AGENDA ITEM 2.2

9 January 2019

Primary and Community Care Committee Report

POPULATION HEALTH PROGRAMME UPDATE: POPULATION HEALTH MANAGEMENT PILOT

Executive Lead: Director of Public Health / Director Primary Care, Community & Mental Health

Authors: Consultant in Public Health

Contact Details for further information: Kimberley Cann

[email protected] (Cwm Taf Local Public Health Team- 01685 351440)

Purpose of the Primary and Community Care Committee Report

The purpose of this report is to inform the Primary and Community Care

Committee as to the progress of the Population Health Management pilot in Cwm Taf and seek agreement on the population segments to prioritise for

the next steps.

Governance

Link to Health

Board Strategic Objective(s)

The Board’s overarching role is to ensure its Strategy outlined within ‘Cwm Taf Cares’ 3 Year Integrated

Medium Term Plan 2017-2020 and the related organisational objectives aligned with the Institute of

Healthcare Improvement's (IHI) ‘Triple Aim’ are being progressed, these in summary are:

• To improve quality, safety and patient experience

• To protect and improve population health • To ensure that the services provided are

accessible and sustainable into the future

• To provide strong governance and assurance • To ensure good value based care and treatment

for our patients in line with the resources made available to the Health Board.

This report aims to support all of the above objectives The programme supports the principles of ‘Cwm Taf

Cares’ with particular reference to the organisational objective of protecting and improving population health.

The Population Health Management Pilot is a cornerstone of the Fifth Wave Cwm Taf Population

Health Strategy

Supporting evidence

Programme development has been based on current evidence base and best practice.


9 January 2018

Engagement – Who has been involved in this work?

Primary Care, Public Health, and a variety of community partners are key

stakeholders.

Primary and Community Care Committee Resolution to:

APPROVE ENDORSE DISCUSS √ NOTE

Recommendation

The Primary and Community Care Committee is asked to:

• DISCUSS the contents of this report and agree the population segments to prioritise for the next steps.

Summarise the Impact of the Primary and Community Care Committee Report

Equality and

diversity

The Population Health Management pilot identified

population segments which take account of these characteristics.

Legal implications None

Population Health Population segmentation will enable evidence based

interventions to be targeted to the need of sub-

populations.

Quality, Safety &

Patient Experience

Any interventions that are implemented as a result of

this pilot will take into account these factors.

Resources The pilot was conducted using underspend from the

Directors of Public Health budget for 2017/18.

The programme also forms part of the Transformation Fund bid to Welsh Government funding.

Risks and Assurance The ability to target interventions at the population segments most likely to benefit will enable better

outcomes.

Health and Care Standards

Health and Care Standards (2015) 1.1 Health promotion, protection and improvement

2.1 Managing risk and promoting health and safety 3.1 Safe and clinically effective care

3.4 Information governance and communication technology

7.1 Workforce

Workforce Population Health Management Pilot – Health Board (and PHW) funding was secured to pilot this approach.

Freedom of information status

Open


9 January 2018

POPULATION HEALTH PROGRAMME UPDATE:

POPULATION HEALTH MANAGEMENT PILOT

1. SITUATION / PURPOSE OF REPORT

Population segmentation and risk stratification has been piloted across the

Rhondda primary care cluster to assess the feasibility of this approach to support population health management across Cwm Taf UHB. This report presents the

initial findings of the pilot and seeks to encourage strategic decision-making on the focus of further work.

2. BACKGROUND / INTRODUCTION

The Population Health Management pilot seeks to understand patient populations, groups or clusters by characteristics related to their need and use

of health care resources which can help Primary Care Clusters and GPs to decide

how best to use limited time and resources to deliver anticipatory and pre-emptive care for patients. Segmenting the population based on a range of factors

can identify groups by their holistic need and ability to benefit from anticipatory care.

What is population segmentation and risk stratification?

• Population segmentation is grouping the local population by what kind of

care they need as well as how often they might need it. • Risk stratification means understanding who, within each segment, has the

greatest risk of having a significant health event or is at most risk of deterioration.

Why is it important?

• Current systems of health & care categorise populations by the kind of services they utilise at a point in time, e.g. non-elective admissions,

primary care attendances etc. • This does not respond efficiently to need - it creates waste and gaps. For

example, about 25% of admissions from accident and emergency (A&E) do not require admission. They have accessed a service they do not need

(waste). At the same time, mortality from cardiovascular disease (CVD) is higher in populations with the least access to preventative health care

(gaps). • Waste and gaps can be reduced (thus improving population health and

reducing health disparities) by adapting health and care services more closely to the needs of populations. This is what segmentation aims to

achieve.


9 January 2018

What impact will it have?

• The intelligence will enable services and interventions that are already in

place to be targeted to individuals according to, not only their current, but

future need making their prevention capacity more effective and efficient. • More timely, targeted upstream prevention intervention will increase

effectiveness and efficiency leading to improved patient outcomes. • Where gaps exist, new interventions can be identified from the published

evidence with support from Public Health.

How has this approach been piloted?

• Primary and secondary care data has been extracted and combined to create a single integrated dataset for the Rhondda Cluster population of

nearly 80,000 people. • Ten distinct, mutually exclusive segments have been identified for the pilot

population based on their age group, number of long-term conditions, presence of high-risk attributes, and healthcare utilisation.

• The Adjusted Clinical Groups model developed by Johns Hopkins University has been applied, amongst others, to predict individual patient’s risk of

different health outcomes. Using this approach, three strata of patients

have been identified within each segment: high, moderate and low risk. • Information is available by segment strata to support prioritisation for

future work.

3. ASSESSMENT / GOVERNANCE AND RISK ISSUES

The findings of the pilot will be presented verbally to the Primary and Community

Care Committee using PowerPoint to visualise the segments. Key information is also presented here:

3.1 Population profiling

• One percent of the pilot population make up 19% of healthcare costs, and

the top 5% make up 41% of costs.

• 22% of the pilot population have one long-term condition (LTC), while 31%

have two or more LTCs. • Average costs and average activity counts increase with increasing multi-

morbidity, with the biggest total spend being on patients with 2-4 LTCs - £18.6 million.

• For patients with a LTC it is more common for them to have at least one other LTC. For example, 94% of patients with chronic obstructive pulmonary

disease (COPD) in the Rhondda cluster carry at least one other LTC. • A significant proportion of patients with a chronic condition also have a

mental health diagnosis. For example, 20% of patients with COPD also have a mental health diagnosis.

• As the number of LTCs increases so does cost; number of LTCs are a greater driver of cost than age.


9 January 2018

• Intervention programmes should not be based on individual conditions but

on multi-morbidity. • Intervention programmes which aim to reduce cost should focus on multi-

morbidity and not be restricted by age.

3.2 Population segmentation and risk stratification

We found 10 segments in the Rhondda cluster population (n=79,600) which are detailed below. For each segment, the population was stratified according to risk

of future emergency hospital admission in the next 12 months creating 3 segment strata for each segment: low, moderate and high risk.

Segment 1: 0-12 years, generally well (low overall care use)

• Makes up 14% (n=11,380) of the pilot population and 6% of the cost.

• The average cost per person is £264 and their total annual spend is

£3,004,802. • Non-elective in-patient attendances make up a significant proportion of

their costs. • The segment is lower than the cluster average for all aspects of care

utilisation (elective admissions, non-elective admissions, outpatient attendances – first and follow-up, A&E attendances, GP visits, and

prescriptions). • Key chronic conditions found in the high risk strata were asthma and

seizure disorders. • Key high risk attributes found in the high risk strata were deprivation,

frequent attender, and psychosocial condition.

Segment 2: 0-12 years, multiple LTCs (high emergency and primary care use)

• Makes up <1% (n=312) of the pilot population and 1% of the cost. • The average cost per person is £1,584 and their total annual spend is

£494,188. • Non-elective in-patient attendances make up a significant proportion of

their costs. • They are much higher than the cluster average for non-elective in-patient

attendances. Also noticeably higher than average for GP visits and A&E attendances.

• Lower than the cluster average for elective in-patient admissions and prescribing.

• Key chronic conditions found in the high risk strata were seizure disorders and asthma.

• Key high risk attributes found in the high risk strata were frequent attender, deprivation and psychosocial condition.


9 January 2018

Segment 3: 13-17 years, generally (low overall care use)

• Makes up 5% (n=4,142) of the pilot population and 2% of the cost.

• The average cost per person is £234 and their total annual spend is

£971,112. • Lower than the cluster average for all aspects of care utilisation.

• The key chronic condition found in the high risk strata was asthma. • Key high risk attributes found in the high risk strata were frequent attender,

deprivation, psychosocial condition and smoker.

Segment 4: 13-17 years, multiple LTCs (high out-patient follow-up care use)

• Makes up <1% (n=215) of the pilot population and <1% of the cost. • The average cost per person is £877 and their total annual spend is

£188,503. • Non-elective in-patient attendances make up a significant proportion of

their costs. • Much higher than the cluster average for out-patient follow-up

attendances. Also noticeably higher than average for A&E attendances, GP visits, and out-patient first attendances.

• Lower than the cluster average for prescribing and elective in-patient

attendances. • Key chronic conditions found in the high risk strata were asthma, seizure

disorders, depression and diabetes. • Key high risk attributes found in the high risk strata were frequent attender,

psychosocial condition, deprivation and smoker.

Segment 5: 18-64 years, generally well (low overall care use)

• Makes up 44% (n=35,178) of the pilot population and 18% of the cost. • The average cost per person is £267 and their total annual spend is

£9,406,550. • Prescribing makes up a significant proportion of their costs.

• Lower than the cluster average for all aspects of care utilisation. • Key chronic conditions found in the high risk strata were asthma and

depression, and to a lesser extent hypertension, low back pain and

diabetes. • Key high risk attributes found in the high risk strata were psychosocial

condition, smoker, and deprivation, and to a lesser extent frequent attender.

Segment 6: 18-64 years, multiple LTCs (low overall care use, but slightly

higher elective hospital and prescribing use)


£1,247,616. • Prescribing makes up a significant proportion of their costs, and to a lesser

extent A&E attendances.


9 January 2018

• Slightly higher than the cluster average for elective in-patient admissions

and prescribing. Lower than the cluster average for all other aspects of care utilisation.

• Key chronic conditions found in the high risk strata were hypertension,

asthma and diabetes, and to a lesser extent hyperthyroidism. • No key high risk attributes were found.

Segment 7: 18-64 years, multiple LTCs (high need, but low emergency

care use)

• Makes up 14% (n=10,951) of the pilot population and 26% of the cost. • The average cost per person is £1,226 and their total annual spend is

£13,421,102. • Prescribing makes up a significant proportion of their costs, and to a lesser

extent non-elective in-patient attendances. • Higher than the cluster average for elective in-patient admissions,

prescribing, out-patient first-attendances, and A&E attendances, and to a lesser extent out-patient follow-up attendances. Slightly lower than the

cluster average for non-elective in-patient attendances. • Key chronic conditions found in the high risk strata were depression,

asthma, hypertension, diabetes and COPD, and to a lesser extent seizure

disorders, hyperthyroidism, ischemic heart disease, low back pain and schizophrenia.

• Key high risk attributes found in the high risk strata were psychosocial condition, smoker, frequent attender and deprivation.

Segment 8: 65+ years, 2-3 LTCs (low emergency care use, but slightly

higher prescribing use)


£6,572,900. • Prescribing make up a significant proportion of their costs.

• Lower than the cluster average for all care utilisation measures except prescribing.

• Key chronic conditions found in the high risk strata were hypertension, and

to a lesser extent COPD, diabetes, asthma, ischemic heart disease, chronic renal failure (CRF) and hyperthyroidism.

• Key high risk attributes found in the high risk strata were deprivation, frequent attender, psychosocial condition and smoker.

Segment 9: 65+ years, 4+ LTCs (low overall need, but very high elective

hospital and prescribing use)

• Makes up 1% (n=650) of the pilot population and 2% of the cost. • The average cost per person is £1,555 and their total annual spend is

£1,010,837. • Prescribing make up a significant proportion of their costs, and to a lesser

extent non-elective in-patient attendances.


9 January 2018

• Higher than the cluster average for elective in-patient attendances and

prescribing. Lower than average for A&E attendances, out-patient follow-up attendances, and non-elective in-patient attendances.

• Key chronic conditions found in the high risk strata were hypertension, and

to a lesser extent ischemic heart disease, diabetes, CRF, asthma, COPD, and hyperthyroidism.

• No key high risk attributes were found.

Segment 10: 65+ years, multiple LTCs (high overall need)

• Makes up 7% (n=5,392) of the pilot population and 29% of the cost. • The average cost per person is £2,727 and their total annual spend is

£14,705,032. • Non-elective in-patient attendances and prescribing make up a significant

proportion of their costs, and to a lesser extent non-elective in-patient attendances.

• Lower than the cluster average for all care utilisation measures, in particular prescribing and elective in-patient attendances.

• Key chronic conditions found in the high risk strata were hypertension, and to a lesser extent ischemic heart disease, COPD, diabetes, CRF, asthma,

chronic heart failure (CHF), depression and hyperthyroidism.

• Key high risk attributes found in the high risk strata were frequent attender, psychosocial condition, deprivation and smoker.


9 January 2018

3.3 Case-mix adjustment

The pilot also supports provision of case-mix adjusted analyses by GP practice and can provide information back to GPs adjusted for their population. For each

healthcare utilisation GP practices can see the rate for their practice, how they compare to the cluster average, whether use is higher or lower than would be

expected for their population, and the potential opportunity (the difference between actual and expected).

A&E attendances (case-mix adjusted)

0

50

100

150

200

250

300

350

400

450

500

Practice4

Practice11

Practice8

Practice3

Practice10

Practice7

Practice1

Practice6

Practice2

Practice12

Practice9

Practice5

Actual rate per 1000 Rhondda Cluster Average per 1000 Expected Rate per 1000


9 January 2018

Next steps


• Discuss and agree which two segments to prioritise and take forward in the pilot.

Work will then continue to:

• Identify the system goal based on the profile of the segment e.g. segment 8:

to reduce prescribing costs; segment 10: to reduce non-elective in-patient admissions.

• Explore the inclusion of additional layers of data to improve our understanding of need and complexity of care in our segments, to inform reducing

fragmentation of care e.g. district nursing data, social care data. • Identify the health and care priorities of people in these segments.

• Identify achievable outcomes and indicators of success, including benchmarking.

• Identify evidence-based interventions to achieve outcomes. • Implement then monitor outcomes and cost to inform value.

The Population Health Management cycle:

4. RECOMMENDATION


• DISCUSS the contents of this report and agree the population segments

to prioritise for the next steps.

Freedom of information status

Open

Profile the population

(segmentation and risk stratification)

Select segments & risk strata of interest based on

health system goals

Identify the health & care priorities of people in those

segments

Identify achievable outcomes and indicators of

success, including benchmarking

Identify evidence-based interventions to achieve

outcomes

Implement, then monitor outcomes and cost to

inform value

2.2.1 Rhondda Cluster Population Segmentation Risk Stratification PCCC 9 Jan 2019

1 2.2.1 Rhondda Cluster Population Segmentation Risk Stratification PCCC 9 Jan 2019.pdf

Population Profiling to Support New Models of Care in Cwm Taf

Prof. Kelechi Nnoaham

Director of Public Health

Results from the Rhondda Cluster Pilot of Population Segmentation and Risk Stratification

Profile the population

(segmentation and risk stratification)

Select segments & risk strata of interest based on

health system goals

Identify the health & care priorities of people in

those segments

Identify achievable outcomes and indicators

of success, including benchmarking

Identify evidence-based interventions to achieve

outcomes

Implement, then monitor outcomes and cost to

inform value

The Population Health Management cycle in Cwm Taf

This is where we are at this time

Schemes to reduce expenditure in our

health & care system tend to focus on this population but there are genuine concerns about ‘impactability’

Distribution of patients and costs in the pilot population

1. Profiling the population: Multimorbidity

The John Hopkins ACG system defines a chronic or Long Term Condition as “an alteration in the structures or functions

of the body that is likely to last longer than 12 months and is likely to

have a negative impact on health or functional

status”

Distribution of Long Term Conditions in the pilot population

Long Term

Condition Count*

% of Rhondda

pilot population

0 47%

1 22%

2-4 24%

5-7 5%

8 or more 2%

Nearly 1 in 3 people in the Rhondda Cluster

population have 2+ LTCs

Resource Utilisation Band Distribution across GP Practices in the Rhondda Cluster

• This Venn diagram helps to illustrate the degree of overlap between patient cohorts in the Rhondda Cluster.

• The key message is that it is important to use the correct predictive model to identify specific patient cohorts.

• If we were, for example, looking to reduce emergency admissions, by focusing only on patients with frailty we would exclude 488 at risk patients (254 + 234) and erroneously include 977 patients with frailty but who are not at risk (968 + 89).

Healthcare utilisation costs by number of long term conditions

Average indicative cost

and activity counts for the

Rhondda Cluster

population increase with

multimorbidity

The biggest total spend is with patients who have 2-4

long term conditions

No.

LTCs

Patient

CountTotal Cost

Average

Total

Cost

Average

Number of

Emergency

Admissions

Average

Number

of First

OP

Attenda

nces

Average

Number

of Follow

Up OP

Attendan

ces

Average

Number

of GP

Appoint-

ments

Average

Distinct

Drug

Count

0 37,255 £7,459,580 £200 0.07 0.18 0.41 0.4 2

1 17,770 £7,568,289 £426 0.1 0.31 0.77 0.6 4

2-4 19,013 £18,659,360 £981 0.17 0.52 1.42 1.1 8

5-7 4,295 £10,291,752 £2,396 0.43 0.86 2.58 2.1 14

8+ 1,274 £7,044,145 £5,529 1.34 1.29 4.15 3.6 20

For patients who carry a long term condition, it is more common for them to carry at least one other condition.

Distribution of chronic conditions in the pilot population

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Single Condition Condition +1 Condition +2 Condition +3 Condition +4

For example, 94% of patients with COPD in the Rhondda Cluster

also carry at least one other condition

A significant proportion of patients with a

chronic condition also have a mental health

diagnosis

Diseases occurring with mental health issues

For example, nearly 20% of patients with

COPD also have a mental health

diagnosis

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Mental Health Diagnosis

As the number of chronic conditions

increases, so does cost.

Average patient cost by degree of multimorbidity and Age Band

Age is less relevant when

looking at patient costs

£0

£1,000

£2,000

£3,000

£4,000

£5,000

£6,000

£7,000

0C 0D 0B 0A 0E 1C 1B 1D 1A 1E 2B 2C 2D 2A 2E 5D 5B 5C 5E 8E 8D 8C

Ave

rage

To

tal

Co

st

Multimorbidity/Age Band

Mutually exclusive segments were created based on number of chronic conditions and age. The group number corresponds to the number of

chronic conditions and the group letter corresponds to the patient’s age.

0 = No chronic conditions; 1 = 1 chronic conditions; 2 = 2-4 chronic conditions; 5 – 5-7 chronic conditions; 8 = 8+ chronic conditions.

A = 0-17 years; B = 18-44 years; C = 45-64 years; D = 65-79 years; E = 80+ years.

£0

£500

£1,000

£1,500

£2,000

£2,500

£0

£500

£1,000

£1,500

£2,000

£2,500

£3,000

£3,500

0 to 4 5 to 9 10 to 1415 to 1920 to 2425 to 2930 to 3435 to 3940 to 4445 to 4950 to 5455 to 5960 to 6465 to 6970 to 7475 to 7980 to 8485 to 8990 to 94 95+

AverageCost2+LTCs AverageCostAllPop

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

£0

£1,000

£2,000

£3,000

£4,000

£5,000

£6,000

£7,000

£8,000

£9,000

0 LTCs 1 LTCs 2 LTCs 3 LTCs 4 LTCs 5 LTCs 6 LTCs 7 LTCs 8 LTCs 9 LTCs 10+ LTCs

Average Cost Patient Count

Multimorbidity key points

• Multimorbidity is the norm in the care-seeking population of the Rhondda Cluster

• 13-23% of patients in the Rhondda Cluster population who have a long term condition also have a mental health diagnosis

• Multimorbidity, rather than age, is the key driver of cost. Age is less relevant when looking at patient cost

• Our intervention programmes (e.g. a multimorbidity service) should not be based on individual conditions but on multimorbidity

• Our intervention programmes that aim to reduce costs should focus on multimorbidity and not be restricted by age

2. Profiling the population: Population Segmentation & Risk Stratification

“Segmentation is grouping the local population by what kind of care they need as well as how often they

might need it.

The Better Care Fund. ‘How to’ guide: the BCF technical toolkit, section 1: population segmentation, risk stratification and information governance. 2014. https://www.england.nhs.uk/wp-content/uploads/2014/09/1-seg-strat.pdf.

Risk stratification means understanding who, within each segment, has the greatest risk of having a

significant health event or is at most risk of deterioration”.

Achieving improvements requires understanding of populations and their needs

Current systems of health & care categorise populations by the kind of services they utilise at a point in time, e.g. non-elective admissions, primary care attendances etc

This does not respond accurately to need - it creates waste and gaps. For example, 25% of admissions from A&E do not require admission. They have accessed a service they do not need (waste). At the same time, mortality from CVD is higher in populations with the least access to preventative health care (gaps). Waste and gaps can be reduced (thus improving population health and reducing health disparities) by adapting health and care services more closely to the needs of populations.

This is what segmentation aims to achieve.

A

B

C

Waste

Gaps

Pa

tie

nt/

po

pu

lati

on

ne

ed

Service provision

……..now

A

B

C

Pa

tie

nt/

po

pu

lati

on

ne

ed

Service provision

……..with segmentation

• Need is either measured by a combination of age and LTC (traditional segmentation) or by some index of healthcare utilisation (data-driven segmentation).

• Traditional segmentation – allows priorities to be identified for age groups and people with specific diseases but those without any LTCs are left undifferentiated.

• These non-differentiated population groups are not homogenous as far as actual use of care is concerned and indeed, as far as prevention is concerned, they’re a key group to understand.

• Utilisation-based segmentation differentiates population using 6 multi-setting utilisation variables.

• These are: (1) non-elective admissions, (2) elective admissions, (3) outpatient attendances, (4) GP Practice visits, (5) GP home visits and (6) number of prescriptions

• Involves conducting cluster analysis using both hierarchical (to identify number of natural segments in population) and non-hierarchical (to handle large dataset) methods.

• Followed by review and profiling of segments by relevant characteristics such as age and morbidities

• Limitation of both approaches is that they don’t really tell you much about people who are most likely to benefit from primary preventative healthcare – e.g. those with health-related risk factors who currently have no LTC nor are utilising healthcare services.

• They don’t capture ‘capacity to benefit’. So in reality, they are not needs-based.

• Future research could seek to identify a set of primary preventative need variables (e.g. deprivation index, number of unhealthy behaviours, presence of low threshold mental health condition etc), and basing segmentation on it

Parameters for population segmentation in the Rhondda Pilot

Age In different age bands – 0-12, 13-17, 18-64, 65+ and also in 5year bands

Long Term Condition

As defined for the purposes of the John Hopkins ACG system

High Risk Attributes

Psychosocial condition, Obese, Smoker, DNA Childhood immunisations, DNA Flu immunisation, Sick Note, Learning Disability, Physical Disability, Social Isolation, End of Life, Frequent Attender, eFI Moderate or Severe, Band 1 or 2 deprivation band (lowest bands)

High Risk

Moderate Risk

Low Risk

> 75th

percentile of median risk score

Between 25th and 75th


< 25th


Number of people

Mean age Mean Deprivation index

Prevalence of key chronic conditions

Prevalence of High Risk Attributes

Proportion in residential care

The 10 segment-strata we found in the Rhondda Cluster population

Segment 1 - 0-12 yrs., Generally well

14.30% 5.89%

Proportion of total population

Proportion of total cost Type of cost Care Utilisation

(Low overall care use)

PopulationAverage cost

per capitaTotal spend

Non-Elective In-Patient Episodes

11,380 £264 £3,004,802 2,107

-200%

-150%

-100%

-50%

0%

50%

100%

150%

200%ELIP NEIP OPFA OPFU ED attend GP Visit Prescribing

Assessment – generally well children, some of whom may have high risk attributes not reflected here

Care utilisation – lower than average across all settings Next step – (1) risk stratify this segment based on ‘probability of high total cost’, (2) profile

each segment-stratum by (a) mean age, (b) prevalence of key chronic conditions, (c) prevalence of ‘high risk attributes’, (d) population size and (e) deprivation

High

Risk

Moderate Risk

Low Risk

Number of people

Mean age (years)

Mean Deprivation index

Prevalence of key chronic conditions Prevalence of High Risk Attributes

Proportion in nursing or residential care

2,845 3 2.76 -

5,690 6 2.89 -

2,845 8 2.97 -

0%1%

2%3%

4%5%

6%7%

0%

1%

2%

3%

4%

5%

6%

7%

0%

1%

2%

3%

4%

5%

6%

7%

Segment 1 – Probability of emergency hospital admission

in the next 12 months

0%

10%

20%

30%

40%

50%

0%

10%

20%

30%

40%

50%

0%

10%

20%

30%

40%

50%

Segment 2 - 0-12 yrs., Multiple LTCs



(High emergency & primary care use)




312 £1,584 £494,188 330

0.39% 0.97%

-200%

-150%

-100%

-50%

0%

50%

100%

150%


Assessment – children with 1 or more chronic condition, some of whom may have high risk attributes not reflected here

Care utilisation – Very high use of emergency care and primary care could hint at room for strengthening disease management in primary care/community

Next step – (1) risk stratify this segment based on ‘probability emergency hospitalisation’ & ‘probability of extended hospitalisation’, (2) profile each segment-stratum by (a) mean age, (b) prevalence of key chronic conditions, (c) prevalence of ‘high risk attributes’, (d) population size and (e) deprivation

High

Risk

Moderate Risk

Low Risk

Number of people

Mean age (years)




79 3 2.79 -

157 7 2.92 -

78 8 2.63 -



0%

10%

20%

30%

40%

0%

10%

20%

30%

40%

0%

10%

20%

30%

40%

0%

10%

20%

30%

40%

50%

60%

0%

10%

20%

30%

40%

50%

60%

0%

10%

20%

30%

40%

50%

60%

Segment 3 – 13-17 yrs., Generally well







4,142 £234 £971,112 348

5.20% 1.90%

-200%

-150%

-100%

-50%

0%

50%

100%

150%


Assessment – generally well adolescents, some of whom may have high risk attributes not reflected here.

Care utilisation – lower than average use of health care across all settings Next step – (1) risk stratify this segment based on ‘probability of high total cost’, (2) profile


High

Risk

Moderate Risk

Low Risk

Number of people

Mean age (years)




1,036 15 2.91 -

2,071 15 2.97 -

1,035 13 3.04 -



0%

4%

8%

12%

16%

0%

4%

8%

12%

16%

0%

4%

8%

12%

16%

0%

10%

20%

30%

40%

0%

10%

20%

30%

40%

0%

10%

20%

30%

40%

Segment 4 – 13-17 yrs., Multiple LTCs



(High Out-Patient Follow-Up care use)




215 £877 £188,503 79

0.27% 0.37%

-200%

-150%

-100%

-50%

0%

50%

100%

150%


Assessment – adolescents with 1 or more chronic condition, some of whom may have high risk attributes not reflected here

Care utilisation – very high use of specialist care and relatively low primary care use may indicate need for strategies that involve primary care more effectively in outpatient services

Next step – (1) risk stratify this segment based on ‘probability of high total cost’, (2) profile each segment-stratum by (a) mean age, (b) prevalence of key chronic conditions, (c) prevalence of ‘high risk attributes’, (d) population size and (e) deprivation

High

Risk

Moderate Risk

Low Risk

Number of people

Mean age (years)




54 14 2.77 -

108 15 2.61 -

53 15 3.19 -



0%

10%

20%

30%

40%

0%

10%

20%

30%

40%

0%

10%

20%

30%

40%

0%

10%

20%

30%

40%

50%

60%

0%

10%

20%

30%

40%

50%

60%

0%

10%

20%

30%

40%

50%

60%

Segment 5 – 18-64 yrs., Generally well







35,178 £267 £9,406,550 1,842

44.19%

18.44%

-200%

-150%

-100%

-50%

0%

50%

100%

150%


Assessment – generally well adults, some of whom may have high risk attributes not reflected here. Quite a large age band so further profiling will need to incorporate age. They’re not different in care use profile to adolescents who are generally well

Care utilisation – generally low care use across all settings Next step – (1) risk stratify this segment based on ‘probability of high total cost’, (2) profile


High

Risk

Moderate Risk

Low Risk

Number of people

Mean age (years)




8,795 41 2.82 0.02%

17,589 38 3.05 -

8,794 36 3.12 -



0%

2%

4%

6%

8%

10%

12%

0%

2%

4%

6%

8%

10%

12%

0%

2%

4%

6%

8%

10%

12%

0%

10%

20%

30%

40%

50%

60%

0%

10%

20%

30%

40%

50%

60%

0%

10%

20%

30%

40%

50%

60%




(Low overall need but slightly higher elective hospital and prescribing use)




1,636 £762 £1,247,616 138

2.06% 2.45%

-200%

-150%

-100%

-50%

0%

50%

100%

150%


Assessment – adults with 1 or more chronic condition, who overall have low care needs Care utilisation – generally low care use across most settings but moderately high elective

admissions and medication use. May suggest ACS conditions well-managed by medications Next step – (1) risk stratify this segment based on ‘probability of high pharmacy cost’,

probability of inpatient hospitalisation’ and ‘probability of extended hospitalisation’, (2) profile each segment-stratum by (a) mean age, (b) prevalence of key chronic conditions, (c) prevalence of ‘high risk attributes’, (d) population size and (e) deprivation

High

Risk

Moderate Risk

Low Risk

Number of people

Mean age (years)




409 52 3.96 -

818 53 4.12 -

409 48 4.20 -



0%

10%

20%

30%

40%

50%

60%

0%

10%

20%

30%

40%

50%

60%

0%

10%

20%

30%

40%

50%

60%

0%

20%

40%

60%

80%

100%

0%

20%

40%

60%

80%

100%

0%

20%

40%

60%

80%

100%




(High needs but low emergency care use)




10,951 £1,226 £13,421,102 2,858

13.76% 26.30%

-200%

-150%

-100%

-50%

0%

50%

100%

150%


Assessment – adults with 1 or more chronic condition, who overall have high care needs Care utilisation – despite high overall care use in multiple settings, primary care use and

emergency admissions were quite low in this segment. This could indicate ACS less well managed

Next step – (1) ) risk stratify this segment based on ‘probability of high pharmacy cost’, probability of inpatient hospitalisation’ and ‘probability of extended hospitalisation’, (2) profile each segment-stratum by (a) mean age, (b) prevalence of key chronic conditions, (c) prevalence of ‘high risk attributes’, (d) population size and (e) deprivation

High

Risk

Moderate Risk

Low Risk

Number of people

Mean age (years)




2,738 49 2.53 0.26%

5,476 48 2.65 0.07%

2,737 44 2.77 -



0%

10%

20%

30%

40%

50%

0%

10%

20%

30%

40%

50%

0%

10%

20%

30%

40%

50%

0%

20%

40%

60%

80%

100%

0%

20%

40%

60%

80%

100%

0%

20%

40%

60%

80%

100%

Segment 8 –65+ yrs., 2-3 LTCs



(Low emergency care but slightly higher prescribing use)




9,749 £674 £6,572,900 682

12.25%

12.88%

-200%

-150%

-100%

-50%

0%

50%

100%

150%


Assessment – older adults with 2-3 chronic conditions, who overall have low care needs Care utilisation – low overall care use across multiple settings and slightly higher prescribing Next step – (1) risk stratify this segment based on ‘probability of high pharmacy cost’, (2)

profile each segment-stratum by (a) mean age, (b) prevalence of key chronic conditions, (c) prevalence of ‘high risk attributes’, (d) population size, (e) proportion in residential/nursing homes, and (f) deprivation

High

Risk

Moderate Risk

Low Risk

Number of people

Mean age (years)




2,438 78 3.07 2.42%

4,874 72 3.10 0.10%

2,437 69 3.12 -



0%

10%

20%

30%

40%

50%

0%

10%

20%

30%

40%

50%

0%

10%

20%

30%

40%

50%

0%

10%

20%

30%

40%

0%

10%

20%

30%

40%

0%

10%

20%

30%

40%

Segment 9 –65+ yrs., 4+ LTCs



(Low overall need but very high elective hospital and prescribing use)




650 £1,555 £1,010,837 149

0.82% 1.98%

-200%

-150%

-100%

-50%

0%

50%

100%

150%


Assessment – older adults with 4+ chronic conditions, who overall have low care needs Care utilisation – low overall care use across multiple settings but much higher elective

admissions and prescribing may reflect impact of rising multiple morbidity or that presence of particular LTCs tip patients over into increased elective care use

Next step – (1) risk stratify this segment based on ‘probability of high pharmacy cost’, probability of inpatient hospitalisation’ and ‘probability of extended hospitalisation’, (2) profile each segment-stratum by (a) mean age, (b) prevalence of key chronic conditions, (c) prevalence of ‘high risk attributes’, (d) population size, (e) proportion in residential/nursing homes, and (f) deprivation

High

Risk

Moderate Risk

Low Risk

Number of people

Mean age (years)




163 81 4.06 1.23%

325 76 4.08 0.62%

162 72 4.16 -



0%

20%

40%

60%

80%

100%

0%

20%

40%

60%

80%

100%

0%

20%

40%

60%

80%

100%

0%

20%

40%

60%

80%

0%

20%

40%

60%

80%

0%

20%

40%

60%

80%

Segment 10 –65+ yrs., Multiple LTCs



(High overall need)




5,392 £2,727 £14,705,032 2,683

6.77%

28.82%

-200%

-150%

-100%

-50%

0%

50%

100%

150%


Assessment – older adults with multiple chronic conditions, who have high care needs Care utilisation – high overall care use across multiple settings suggests these people have

complex care needs likely to benefit from integrated multidisciplinary care and case management

Next step – (1) risk stratify this segment based on ‘probability of high pharmacy cost’, ‘probability of emergency admission’, probability of inpatient hospitalisation’ and ‘probability of extended hospitalisation’, and ‘probability of High Total Cost’, (2) profile each segment-stratum by (a) mean age, (b) prevalence of key chronic conditions, (c) prevalence of ‘high risk attributes’, (d) population size, (e) proportion in residential/nursing homes, and (f) deprivation

High

Risk

Moderate Risk

Low Risk

Number of people

Mean age (years)




1,348 80 2.95 4.9%

2,696 77 2.77 1.0%

1,348 72 2.70 0.5%



0%

20%

40%

60%

80%

0%

20%

40%

60%

80%

0%

20%

40%

60%

80%

0%10%20%30%40%50%60%70%80%90%

100%

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

0%

10%

20%

30%

40%

50%

60%

70%

High Risk

Moderate Risk

Low Risk

High Risk

Moderate Risk

Low Risk

Segment 8 – system goal to reduce prescribing costs

Segment 10 – system goal to reduce non-elective inpatient

spells

Case Management

Prevention, Promotion of Wellbeing

Disease Management & Supported Care

Identify system goal based on profile of segment, then risk stratify based on goal

Medication review, MDT care

Patient education

Clinical decision support technology

Identify the health & care priorities of people in those segments

• Epidemiological health needs assessments

• Focussed Group Discussions with a cohort of representative patients from relevant segments as well as professional groups

• Involve carers depending on population segment of interest

• Find alignment between system goals and patient-defined priorities. Resolve conflict through iterative process

• Secure senior public health leadership of process

Identify achievable outcomes and indicators of success (benchmarking)

How Impact is calculated

NEIP ELIP ED OPFA

Benchmark Cwm Taf against relevant peers

Reduce rate to median for peer group

x-y% a-b% c-d% e-f%

Review national and international evidence base – published and grey literature

Review evidence for impact of specific interventions, apply to Cwm Taf

Conduct expert interviews – a quasi Delphi process

Include expert opinion in setting goal

Identify Evidence-based interventions to achieve outcomes

• Thorough review of the evidence – published and grey literature

• Focussed Group Discussions with a cohort of representative patients from relevant segments as well as professional groups

• Involve carers depending on population segment of interest

• Consider representativeness, applicability to Cwm Taf context

• Secure senior public health practitioner and researcher lead for process

Examples of possible initiatives

DescriptionEstimated

cost, £Cost per person, £

People Covered

NEIPs to be avoided before service is self-

paying

Care co-ordination

Rapid Response

SPOC (incl. early assessment)

Early Supported Discharge

Short term care

Import

ant

to h

ave

a des

crip

tio

n/d

efin

itio

n s

har

ed b

y

all

loca

l st

akeh

old

ers

Document and appraise initiatives for selected population segments

Pop NEIP AdmImpact on NEIP Adm

Savings in £

Initiative Cost, £Net

Impact, £

Population

Segment

Developing a value-based health frame work

Evaluation• We recognise the importance of a carefully considered approach to evaluation that involves both summative and formative components and which

accompanies the development of the initiative. We are also aware of the need to ensure that evaluation considers what outcomes or impact we propose to demonstrate with our transformation proposal and that these form the focus for the summative component of our evaluation. This is important as the question of sustainability of initiatives is inevitably high on our collective minds and we expect that a robust approach to framing and delivering the evaluation will inform how we go about embedding whole or selected aspects of this proposal.

• We have set out key deliverables and intended outcomes for specific components of our proposal. Our evaluation framework incorporates these and will involve a formative component that evolves with the implementation as well as a summative component that asks - ‘did we achieve the outcomes we set out to achieve?’

• To this end, we are developing in-house capacity for evaluation through our local public health team. Crucially too, we are developing new academic collaborations with Cardiff University and Cardiff Metropolitan University to enhance our overall capacity to evaluate this initiative comprehensively, learning from it and shaping ongoing delivery and future mainstreaming.

• Finally, we will establish a collaborative approach with ICHOM (International Consortium for Health Outcomes Measurement) to develop a Value-Based health framework for delivering the triple aim components of the ‘quadruple aim’ (improve population health, improve quality/patient experience and reduce cost per capita of care). The approach we are deploying to the transformation of our health and care services is one that is based on a data-driven profiling of our population to understand the natural clusters of persons in segments defined by care need rather than by disease condition, exclusively. These segments present a novel natural grouping within which to measure baseline and post-intervention costs and outcomes. While ICHOM’s standard sets are currently largely disease-based, there is a good opportunity here to explore development of segment-based standard sets for outcomes based on and, in turn, informing our evaluation framework. We will commit funds to developing this collaborative work with ICHOM as part of our evaluation approach and commit to accompanying the outcome standard set development with segment-based measurement of costs in order to create a novel Value-Based health framework that will no doubt be useful on a national scale

Understanding variation: Case mix-adjusted analyses of care use by Practice

Resource Utilisation Band Distribution across GP Practices in the Rhondda Cluster

0

10

20

30

40

50

60

70

80

90

100

Practice 1 Practice 2 Practice 6 Practice 4 Practice 5 Practice 3 RhonddaClusterMean

Practice 7 Practice 8 Practice 11 Practice 9 Practice 10 Practice 12

Non-users Healthy Low Moderate High Very High

A&E attendances (case-mix adjusted)

0

50

100

150

200

250

300

350

400

450

500

Practice 4 Practice 11 Practice 8 Practice 3 Practice 10 Practice 7 Practice 1 Practice 6 Practice 2 Practice 12 Practice 9 Practice 5


Elective admissions (case-mix adjusted)

0

20

40

60

80

100



Emergency admissions (case-mix adjusted)

0

20

40

60

80

100

120

140

160

180

200



Outpatient attendances (case-mix adjusted)

0

200

400

600

800

1000

1200

1400



Total Cost (case-mix adjusted)

£0

£100,000

£200,000

£300,000

£400,000

£500,000

£600,000

£700,000


Actual cost per 1000 Rhondda Cluster Average Cost per 1000 Expected cost per 1000

Activity and cost profile – top three practices per care setting

A/E attendances Elective admissions

Emergency admissions

Outpatient attendances

Total Cost

Above Average for Rhondda Cluster

Practice 5 Practice 5 Practice 12 Practice 5 Practice 9



Higher than expected




Understanding cost saving opportunities Practice 5

£0.00

£100,000.00

£200,000.00

£300,000.00

£400,000.00

£500,000.00

£600,000.00

£700,000.00

£800,000.00

A&E Attendances Elective Admissions Emergency Admissions Outpatient Appointments Prescriptions

Potential Opportunity Actual Total Cost (last 12 months) Casemix-adjusted Expected Total Cost (last 12 months)

Understanding cost saving opportunities Practice 1

0

100000

200000

300000

400000

500000

600000

700000

800000

900000

1000000


Potential opportunity Actual Total Cost (last 12 months) Casemix-adjusted Expected Total Cost (last 12 months)

(£200,000)

£0

£200,000

£400,000

£600,000

£800,000

£1,000,000

£1,200,000

£1,400,000

£1,600,000


Potential Opportunity Actual Total Cost (last 12 months) Casemix-adjusted Expected Total Cost (last 12 months)

Understanding cost saving opportunities for Practice 9

Practice 5: Case mix-adjusted count of care use activity

Activity Cube display for Practice 5

Map of Probability of emergency hospitalisation for all chronic conditions in 50+ persons in Rhondda Cluster

3.1 Report of the Director of Primary, Community & Mental Health

1 3.1 Director of Primary Community and Mental Health report PCCC 9 Jan 2019.doc

Report of the Director of Primary Community and Mental Health

Page 1 of 7 Primary and Community Care Committee Meeting

9 January 2018

AGENDA ITEM 3.1

9 January 2019


REPORT OF THE DIRECTOR OF PRIMARY, COMMUNITY AND MENTAL HEALTH

Executive Lead: Alan Lawrie, Director of Primary, Community and Mental

Health

Author: Craige Wilson, Assistant Director of Primary Care, Children and

Community Services.

Contact Details for further information: [email protected]


The purpose of the report is for the Director of Primary, Community and Mental Health to provide information for the Committee to assure progress

against key areas and to provide high level information for a range of services.

Governance

Link to Health


The Board’s overarching role is to ensure its Strategy

outlined within ‘Cwm Taf Cares’ 3 Year Integrated Medium Term Plan 2015-2018 and the related

organisational objectives aligned with the Institute of Healthcare Improvement's (IHI) ‘Triple Aim’ are being

progressed, these in summary are: • To improve quality, safety and patient

experience • To protect and improve population health

• To ensure that the services provided are accessible and sustainable into the future

• To provide strong governance and assurance

• To ensure good value based care and treatment for our patients in line with the resources made

available to the Health Board. This report aims to support all of the above objectives.

Supporting evidence

Supporting information is provided where required throughout the report


The Primary and Community Care Team, Independent Contractors and

other community based staff.



9 January 2018


APPROVE ENDORSE DISCUSS √ NOTE √

Recommendation The Primary and Community Care Committee is asked to:

• DISCUSS and NOTE the report.

Summarise the Impact of the Primary and Community Care

Committee Report

Equality and diversity

There are no specific equality and diversity implications identified

Legal implications There are no specific legal implications identified

Population Health The aim of the services identified within the

report aim to contribute to improving the population health

Quality, Safety & Patient Experience

The aim of the services referred to in the report aim to improve the quality, safety and patient

experience.

Resources There are no specific resource implications identified and the work is in line with Integrated

Medium Term Plan and is reported by the locality.

Risks and Assurance The specific risks are identified where appropriate within the document.

Health & Care

Standards

The 22 Health & Care Standards for NHS Wales

are mapped into the 7 Quality Themes: Staying Healthy

Safe Care Effective Care

Dignified Care Timely Care

Individual Care Staff & Resources

http://www.wales.nhs.uk/sitesplus/documents/1

064/24729_Health%20Standards%20Framework

_2015_E1.pdf

The work reported in this summary supports many of the health and care standards

Workforce Workforce implications are identified where appropriate within the report

Freedom of

information status

Open



9 January 2018

REPORT OF THE DIRECTOR OF PRIMARY, COMMUNITY AND MENTAL

HEALTH


The purpose of the report is for the Director of Primary, Community and Mental

Health to provide information for the Committee to assure progress against key areas and to provide high level information on a range of services of interest to

the Committee.

Following discussion at the Committee more detailed reports can be provided in

each area. There is also the opportunity to add matters to the forward work programme of the Committee as a result of discussion.


This reports aims to give an overview of the following areas: • Neighbourhood Nursing pilot

• Transformation Plan • Urgent Primary Care Out of Hours Service/111

• Eye Care Plan (update by exception) • Oral Health Report (update by exception)

• GP Sustainability • Wales Audit Office – Primary Care Services


3.1 Neighbourhood Nursing

The launch event for the Neighbourhood Nursing pilot took place on 4

December 2019 and successfully demonstrated the commitment of the District

Nursing staff to the pilot and the wider interest from stakeholders in this work.

The Malinko scheduling system, is now in the second month of its implementation. Support staff from Malinko are periodically on-site and dealing

with any issues which have been minimal. Overall the system is working very

well and staff are fully engaged and enthused with this flexible and agile technology. The initial 3 month trial period concludes in February 2019 with a

clear plan to extend this for a further 12 months.

The other elements of the pilot (Chronic obstructive pulmonary disease (COPD), Virtual Ward and Advanced Care Planning) are also now in progress. The new

Band 4 health care support workers (HCSWs) and Community Navigator posts are already delivering some exceptionally positive feedback from the two pilot

teams. In addition, explorations of the opportunity to work with academic colleagues at both the University of South Wales and the University of Bath

regarding formal research opportunities are being made.



9 January 2018

Paul Labourne, Nursing Officer, Welsh Government, spent a whole day with the

Hirwaun District Teams on 10 December 2019 and reported back to Chief Nursing Officer that ‘he was very pleased with our ambition and commitment to

the model in Cwm Taf’. Lesley Lewis, Head of Nursing and Paul Crank, Deputy

Head of Nursing, attended a meeting with Jos De Blok and Buurtzorg Britain and Ireland on 14 December in London with NHS leaders from England &

Scotland.

The three Welsh pilot sites are currently working with Buurtzorg Britain & Ireland to deliver training sessions during February & March to support the

team development. In addition, Cwm Taf UHB has developed links with other

European partners in Switzerland and Germany to consider international comparison.

Cwm Taf UHB along with the other sites in Aneurin Bevan UHB and Powys

Teaching Health Board will produce a national report at the end of 2020/21 outlining the success or otherwise of this model of operation for District Nursing

and make recommendations on the manner by which such success can be rolled out across Wales. It would be Cwm Taf UHBs intention to roll out a

successful model across the Health Board once proven.

3.2 Transformation Plan (Extended Community Cluster Team)

The Extended Community Cluster Team (ECCT) is a key element of the Cwm Taf area Transformation Plan ‘Staying well in your community’. It provides a

solid foundation for widespread anticipatory care whilst at the same time

delivering sustainable primary care across the Health Board.

The Governance framework and structure to take this work forward has now been established. In addition, in order to be able to respond rapidly to the

announcement of funds role profiles for many of the clinical and managerial / support roles within the team are ready to go. There has been significant work

with the clusters over the last few weeks at cluster lead level, practice managers and at full cluster meetings.

It is crucial to ensure that the clusters fully understand and are able to continue

to influence the model and its development; highlighting their local needs based on their practice population and public health data. Progress in terms of further

recruitment is however ‘on hold’ whilst awaiting final funding confirmation from the Welsh Government.

3.3 Urgent Primary Care Out of Hours Service

The Out of Hours (OOH) service continues to face challenges and remains our highest risk. Shift fill rate has been on average between 78-84% for the last 4

weeks. The pinch point for bases is still Prince Charles Hospital (PCH) at weekends; this is being supported by the use of GP trainees in A&E (ST2 & ST3

– specialist training years 2 and 3).



9 January 2018

However, multiple aactivities are underway to deliver the OOH redesign and the

implementation of 111. The actions being taken are mutually supportive and contribute to the winter resilience plans:

• Service redesign has been approved by Executive Board. These will see a number of new measures to improve delivery and fill rates and will be

implemented over an 18 month period • A new Clinical Shift Lead role (flight controller) has been introduced which

has had a positive impact on service delivery enabling rapid streaming of patients and timely referral to partners such as the Welsh Ambulance

Services NHS Trust (WAST). • Clinical pharmacists are now supporting service delivery at the weekend

as part testing of the 111 Clinical Support Hub model. • The service has two advanced nurse practitioners (ANPs) working on an

ad-hoc basis covering a number of pinch point shifts • Purchase of Rotamaster to allow easy booking of shifts by staff

• Development and banding of ANP job description – triage and face to face sessions

• Development of stronger pathways to mental health advise/specialists • Development of stronger pathways for respiratory

• Additional mobile cover has been arranged for weekends

• 2nd 111 Implementation Project Board has met. Implementation plan with key milestones has been drafted and roll-out is anticipated for Quarter 3

or 4 2019.

3.4 Eye Care Plan (update by exception)

Glaucoma

A task and finish group has been established with the locum consultant to agree a service model for glaucoma. Three meetings have been held to date and a

consensus reach about creating a less-medically dependent model with an expansion of an optometrist led Ophthalmic Diagnostic and Treatment Centre,

including some that are community based. This model is consistent with that being developed by other health boards in South East Wales.

There is potential that funding will be available from Welsh Government to assist in developing this model.

Cataract Pathway

A recent bid to Welsh Government to re-design the current cataract pathway

was successful and funding is now available to appoint clinical nurse specialists to see patients rather than consultant staff. Recruitment to these appointments

has commenced with a view to introducing the new service, which will reduce the number of stages in the pathways for patients, during 2019



9 January 2018

3.5 Oral Health Report (update by exception)

Dental Contract Reform

Committee members will be aware that at the last meeting it was reported that the UHB had received expression of interest from practices in Taf Ely to become

Dental Contract Reform Practices. This allowed the UHB to meet the 10% target set for health boards and attracted additional funding (£45,000) to offset any

lost in the patient charge revenue.

The UHB has recently received correspondence from the Chief Dental Officer that this target will be increased to a minimum of 20% of dental practices from

April 2019. This followed a Written Statement from the Cabinet Secretary for Health and Social Services on dental contract reform and the expansion of the

number of practices taking part in the programme. Although a specific target has yet to be set, further expansion of the programme is anticipated from

October 2019.

The UHB needs to identify practices by 4 March 2019 who are willing to participate in the Dental Contract Reform programme and therefore expression

of interest are being sought from practices in both Cwm Taf and Bridgend

areas.

GP Sustainability

The consultation process for the permanent closure of Pantglas Surgery (Aberfan), branch surgery of Brookside Surgery (Troedyrhiw) has now

finished. Public consultations and feedback was received from patients and this was fed back and considered by the Contract Variation Group which consisted

of representation from the Community Health Council, Independent Medical Advisor and Local Medical Committee. The recommendation to the Executive

Board in January will be a permanent closure of the premises working with Merthyr Tydfil County Borough Council to explore the options to build a new all-

purpose facility to accommodate the two remaining surgeries within the Aberfan/Troedyrhiw area.

The Directorate is not reporting any further sustainability issues for this quarter.

3.6 Primary Care Welsh Audit Office Report

Committee members will recall that a summary of the finding was provided at

the last Committee. The final report and management response will be discussed at the Health Board’s Audit Committee on 14 January 2019.



9 January 2018

4. RECOMMENDATION

Members of the Primary and Community Care Committee are asked to:

• DISCUSS and NOTE the report

Freedom of

information status

Open

3.2 IMTP Monitoring Report

1 3.2 IMTP Monitoring Report paper PCCC 9 Jan 2019.docx

Primary and Community Care IMTP Monitoring Report

Page 1 of 6 Primary & Community Care Committee Meeting

9 January 2019

AGENDA ITEM 3.2

9 January 2019

Primary & Community Care Committee Report

PRIMARY AND COMMUNITY CARE INTEGRATED MEDIUM TERM PLAN

(IMTP) MONITORING REPORT

Executive Lead: Director of Primary, Community, Children and Mental Health

Author: Alison Lagier, Locality Manager

Contact Details for further information: Lauren Morgan, 01443 443755 or email [email protected]

Purpose of the Primary & Community Care Committee Report

The purpose of this paper is for the Primary & Community Care Committee to

receive and NOTE the Monitoring Report for the Primary and Community Care Delivery Plan, IMTP (See attached as Appendix 1).

Governance

Link to Health


The Board’s overarching role is to ensure its Strategy outlined

within ‘Cwm Taf Cares’ 3 Year Integrated Medium Term Plan 2015-2018 and the related organisational objectives aligned

with the Institute of Healthcare Improvement's (IHI) ‘Triple Aim’ are being progressed, these in summary are:

• To improve quality, safety and patient experience.

• To protect and improve population health. • To ensure that the services provided are accessible and

sustainable into the future. • To provide strong governance and assurance.

• To ensure good value based care and treatment for our patients in line with the resources made available to the

Health Board. This report supports all of the Strategic Objectives.

Supporting

evidence

‘Setting the Direction’ Welsh Government

‘Our plan for primary care services in Wales’ Welsh Government 2014

Cwm Taf UHB 3yr Integrated Medium Term Plan.


Primary Care & Localities Management Team and wider directorate staff, All Primary Care CD's and Assistant Medical Director for Primary & Community

services. Primary & Community Care Committee of the Board, Clinical Engagement with Secondary Care, Locality Leadership Group (LA & 3rd sector partners), Local

Medical Committee (LMC), Acute Directorate Managers, GP Practice Managers, Executive Board, GP Cluster Leads, UHB Directors.



9 January 2019

Primary and Community Care Committee Resolution To:

APPROVE ENDORSE DISCUSS NOTE √

Recommendation The Primary & Community Care Committee is asked to:

• NOTE the Monitoring Report for the Primary and Community Care Delivery Plan IMTP.

Summarise the Impact of the Primary and Community Care Committee Report

Equality and

Diversity

A large part of the plan attempts to address the deprivation

and Inverse Care Law implications for our population. It also recognises the specific needs of identified client groups.

Specific components of the plan will be Equality Impact Assessed as necessary and mitigating actions will be

addressed.

Legal Implications None noted to date.

Population Health The plan is based on the health needs assessment undertaken by Public Health Wales ‘A profile of health and

lifestyle in Cwm Taf – Nov 2013’ produced to support Cluster Plan development.

Quality, Safety &

Patient Experience

The plan centres on improving the quality of our services to

patients and enhancing the patient’s experience.

Resources The resources to develop the plan currently all rest within the Primary Care & Localities management team. The key

delivery actions highlighted are already identified within the Primary Care and Localities section of the UHB 3 year

Integrated Medium Term Plan and are prioritised against the

Welsh Government primary care funding.

Risks and

Assurance

Any potential or actual risks in relation to the plan will

continue to be monitored and featured in our risk register and will be discussed at the Primary Care Committee of the

Board.

Health & Care Standards

The 22 Health & Care Standards for NHS Wales are mapped into the 7 Quality Themes:

Staying Healthy Safe Care Effective Care Dignified Care

Timely Care Individual Care Staff & Resources

http://www.wales.nhs.uk/sitesplus/documents/1064/24729_Health%20Standards%20Framework_2015_E1.pdf

The Primary & Community Care Delivery Plan reflects the related quality themes.



9 January 2019

Workforce There are key workforce issues associated with this work in relation to demand on GP’s and practice staff in general and

also the demand on acute services. The intention is that this work will support alternative roles and skill mix to deliver on

the ever growing needs of our population. The workforce issues outlined within the Plan are again reflected in detail

within our Integrated Medium Term Plan which should be read in conjunction with this document.

Freedom of

Information status

Open



9 January 2019

THE PRIMARY AND COMMUNITY CARE IMTP MONITORING REPORT

1. SITUATION/PURPOSE OF REPORT

The purpose of this paper is to receive and NOTE the Monitoring Report on the

Action Plan for the Primary and Community Care Delivery Plan IMTP. The full report is available online at:

http://cwmtaf.wales/Docs/Board_Papers/Legacy%202015-2016/15-11%20November%202015/AI%20%203%202%20Appendix%201%20Primary

%20and%20Community%20Care%20Delivery%20Plan%20UHB%204%20Nov%202015.pdf. The Monitoring Report is attached as Appendix 1

2. BACKGROUND/INTRODUCTION

In November 2014, the Welsh Government launched ‘Our Plan for a Primary Care Service for Wales up to March 2018’, which clearly set out the work NHS

Wales would do by March 2018 to further develop and improve Primary Care and Community Services.

Welsh Government required Health Boards to move more resources out of

hospital based care and support a clear shift of care into local communities. It was critical to ensure that there was sufficient capacity and investment in

Primary Care and Community Services to support the strengthening of prevention initiatives whilst better managing growing demand.

The development of the Integrated Medium Term Plan (IMTP) has provided the opportunity to align the planning and delivery of primary care services as an

integral part of the Health Board’s overall strategic direction. The Localities and Primary Care Team have developed a Primary Care and Community Plan with a

renewed emphasis on the changes required across the Health Care System detailing a vision for Primary Care. It is now a key feature of the Health Board’s

IMTP, along with emphasis on addressing health inequalities, strengthening prevention and building capacity and managing demand. We constantly aim to

secure and sustain progress made in the previous year, whilst refreshing our plan to reflect new national requirements, our local priorities and the desire to

‘fast track’ innovation/ modernisation and new models of delivery in Primary Care.

3. ASSESSMENT/GOVERNANCE AND RISK ISSUES

Governance The report as outlined in Appendix 1 is used by the directorate to track and

report on progress of all the key elements that are within the Primary and Community Care IMTP. The report is up-dated for each new financial year and

reflects the current priorities within the IMTP for 2018/19 along with the

refreshed Welsh Government Delivery Agreements.



9 January 2019

This is a live document that is up-dated quarterly by the directorate and used to report progress. Any key risks are also highlighted and are then included

within our own risk register for monitoring. Key elements of the plan would also feature via designated papers to the Integrated Quality and Safety Committee

within the directorate and any other committees within the UHB as appropriate.

Overview of Red and Amber Actions

There is one RED risk identified Out of Hours /111 Sustainability. This has been identified in our directorate Risk Register. Shift fill rate have been on

average between 78-84% over the last 4 weeks. The pinch point at base is still PCH at weekends but this is being supported by the use of GP trainees in A&E

(ST2 & ST3). The service has two ANPS working on an ad-hock basis currently which is proving helpful.

The service redesign proposals has been approved by Executive Board and this will result in a number of new initiatives designed to improve delivery and shift

fill rates. A new Clinical Shift Lead role has been introduced which has had a positive impact on service delivery enabling rapid streaming of patients and

timely referral to partners such as WAST. Clinical pharmacists are now supporting service delivery on weekends as part testing of the 111 Clinical

Support Hub model; initial feedback on this initiative has been positive.

There are four AMBER risks identified:

Mountain Ash There has been a considerable amount of work undertaken to progress this new

and much needed development for the Cynon Valley. The Health Board’s project manager has been working tirelessly with a range of stakeholders, including

RCT Local Authority and the developer, Apollo, to move the scheme forward.

However, there are 3 key issues that are outstanding:

1. The land exchange. Apollo is indicating that the land has a number of ‘abnormals’ associated with the site and therefore wish to negotiate again

the land value to offset the increase in estimated build costs. Professional Advisors in NWSSP Estates and Property are facilitating these discussions

to ensure they are reasonable. It is important to note that despite the delay in the land transfer Apollo have undertaken necessary site

(geological) investigations at their own financial risk, which is quite considerable, and at pace. This demonstrates their commitment to the

development despite the land not being officially in their ownership.

2. Agreement of rental value. Apollo and the District Valuer, who negotiates on behalf of the NHS, are still to agree the enabling Value for

Money. This is normal practice and discussions can take time to resolve.

However the District Valuer is aware of timescale linked to Welsh Government funding.



9 January 2019

Apollo are in the processes of building a similar scheme in a neighbouring

health board. Recently Apollo’s request for a higher rental value was declined by this Health Board on the grounds of value for money; this

should assist the ongoing discussions.

3. Planning Submission. The original project timeline indicated that Apollo would submit planning application in December 2018. It is now anticipated

that this will now take place in February 2019 following the resolution of the last two issues.

Despite the fact that three important milestones above are still to be reached

and this scheme is now on the risk register as ‘Amber’ as a result, the scheme is still on track to be delivered by the 31st March 2021 deadline. Every effort

will be made to commission the facility even sooner than this.

Development of MDT and Transformation Model - All actions within Q1 & Q2 were completed. We have also now set up the Governance framework and

several Job profiles have been developed and matched. There has been significant work with the clusters to better understand the model; and their local

needs however we are unable to progress any further as we are still awaiting

funding confirmation from Welsh Government

Development of @Home service and links to SW@H - All local actions have been complete to identify the resource and staffing requirements to link into the

developments of Stay Well @Home phase 2. As above, awaiting however we are unable to progress any further as we are still awaiting funding confirmation from

Welsh Government

CHC Cost Containment - All actions complete and procurement resource in place to consider any options for cost reduction. Despite this the unpredictability

of this patient group has seen an increase in numbers of cases and therefore cost this year.

4. RECOMMENDATION


• NOTE the Monitoring Report for the Primary and Community Care IMTP

Freedom of Information status

Open

3.2.1 Appendix 1 IMTP tracker quarterly report PCCC 9 Jan 2019

1 3.2.1 Appendix 1 IMTP tracker quarterly report PCCC 9 Jan 2019.docx

DIRECTORATE: PRIMARY CARE & LOCALITIES – 2018/19 PRIORITIES

1

The table below outlines the top 10 priorities for the Directorate in 2018/19 APPENDIX 1

Key Priority Quarter 1

Milestones

Quarter 2

Milestones

Quarter 3

Milestones

Quarter 4

Milestones

Risks RAG Rating

(Red, Amber, Green)

1. Out of

Hours/111

Sustainability

Maintain shift fill

rate ( 80% target)

Introduction of

shift breaks to

ensure max 6

hour shift

Set up clinical

reference group

Increase pay

rates to

harmonise with

neighbouring

HBs

Implement

regional working

overnight SE

Wales

Utilise clinical

services hub 111

pharmacist

Rebranding as

Urgent PC OOH

service

Evaluate

Clinical Service

Hub regional fill

rates

UHB lack of

agreement to

increasing pay

rates

Fill rate

decreases

RAG Red

OOH’s Shift fill rate has been 78-84% for the last 4 weeks so is better but still unpredictable. (see further information within the cover report)

2. Pacesetter

Training Hub

Establish steering

group

Establish hub and

spokes

implementation

plan

Trainees in

placements

Recruit

pharmacist

trainer

Development of

mentorship

capacity and

available

placements

Share learning

on all Wales

basis

Evaluation and

student

feedback

Students

consolidation in

primary care/

job offers on

registration

Securing

continued

funding,

placements and

job

opportunities

RAG Green

All milestones achieved,

positive interest from WG

who wish to use this as a

model to roll out across

Wales


2


Milestones

Quarter 2

Milestones

Quarter 3

Milestones

Quarter 4

Milestones

Risks RAG Rating

(Red, Amber, Green)

3. Development of

Primary &

Community Care

Estate

Identification of

key demand and

capacity issues

Mountain Ash –

establishment of

project board and

steering group;

Agreement for

land to transfer

directly from LA to

Apollo;

Development of

timeline

Tonypandy –

submission of

further

information to WG

to secure funding

Development of

P&CC Estates

Strategy

Mountain Ash –

Heads of Terms

agreed;

Revised

timeline;

Agreement on

accommodation

schedule;

Apollo liaise

with DV re

rental value;

Apollo instruct

initial design

architects

Tonypandy –

actions

dependent on

WG approval

Monitor

implementation

of Estates

Strategy

Mountain Ash –

Public

consultation

meeting

Pre-application

consultation

ADET and BREAM

pre-assessment

Business Case

submission

Tonypandy -

actions

dependent on

WG approval

Monitor

implementation

of Estates

Strategy

Mountain Ash –

Planning

permission

submitted

Detailed design,

RDS and

specification

Tonypandy -

actions

dependent on

WG approval

Planning

permission

Failure to

complete build

within

timeframe and

receive WG

Funding

RAG Green RAG AMBER

Q1 & Q2

Mountain Ash - Amber

3 outstanding issues are

being reported and include

1. Delay in exchange of

land. Heads of Terms

were not reflected in

the documentation

produced by RCTCBC

and abnormals

reported via site

survey leading to

estimated increase in

building costs.

2. Failure of DV and

Apollo to agree rental

value for premises

3. Delay in submission

of planning

application. Date

moved from

December 18 to

February 2019 as a

result of two other

issues.

Tonypandy - Green Yes on Track Funding approval now received from WG


3


Milestones

Quarter 2

Milestones

Quarter 3

Milestones

Quarter 4

Milestones

Risks RAG Rating

(Red, Amber, Green)

4. Development of

MDT and

Transformation

Model

Development of

initial draft

transformation

plan

Submission of

Transformation

Plan

Recruitment

campaign

SLAs drafted

Appointment

into new roles

WG approval RAG AMBER

All actions Q1 & Q2

complete

Governance framework set

up and several Job profiles

developed.

Still awaiting funding

confirmation from Welsh

Government


4


Milestones

Quarter 2

Milestones

Quarter 3

Milestones

Quarter 4

Milestones

Risks RAG Rating

(Red, Amber, Green)

5. Development of

Eye Care

services

Promotion of

EHEW/low vision

SPECS – await

outcome of WG

review

Continue to

monitor upward

trend and

financial impact

Identification of

funding for

SPECS

dependent on

review

To be confirmed

depending on Q1

and 2 outcomes

To be

confirmed

depending on

Q1 and 2

outcomes

Insufficient

funding to

cover

increasing low

vision EHEW

claims,

potential cost

pressure

RAG GREEN

Q1 & Q2

Actions on track

6. Improvement of

Oral Health

Outcomes

Repatriation of

Community Dental

Service

Appointment of

CDS PM;

Establish Steering

Group;

Scoping of service

Baby Teeth Do

Matter

Evaluate

effectiveness and

improvements

shown;

Epidemiology

report for 12 year

olds

Repatriation of

Community

Dental Service

Data collection

from C&VUHB;

Ascertain

intentions of

TUPEs;

Scope and cost

IT systems,

equipment,

capital and HR

implications

Baby Teeth Do

Matter

Decision re

extension and

rolling out of

scheme, based

on evaluation

outcome

Repatriation of

Community

Dental Service

TUPE contracts;

Agree shadow

implementation

plan;

Agree

management

structure

Baby Teeth Do

Matter

Dependent on

outcome Q2

Repatriation of

Community

Dental Service

Appointment of

management

structure;

Agree full

implementation

plan;

Shadow

C&VUHB

service

Baby Teeth Do

Matter

Dependent on

outcome Q2

Failure to

receive

info/data from

C&VUHB

Lack of service

continuity if

staff do not

wish to transfer

C&VUHB failure

to agree to

equipment

transfer

Baby Teeth Do

Matter scheme

evaluation

outcomes – if

not effective

the scheme will

cease

RAG GREEN

Q1 – Actions Complete

Q2 - Delay in receipt of

financial information.

Q3 – Financial Information

received and management

structure agreed.


5


Milestones

Quarter 2

Milestones

Quarter 3

Milestones

Quarter 4

Milestones

Risks RAG Rating

(Red, Amber, Green)

7. Development of

@Home service

and links to

SW@H

Contribute to

development of

business case of

SW@H 2

Review Health

@Home

requirements

with Therapies

to align with

SW@H 2

requirements

Review position

and potential

additional

resource or

redesign

requirements

Work with

partners to

develop SW@H2

implementation

plan should

funding become

available

Develop

investment

proposal for

Health @Home

if needed for

IMTP (or

Therapies)

If funding made

available,

commence

implementation

of plan

Funding RAG Amber

All local actions complete

awaiting funding agreement

from Welsh Government to

progress transformation

plans

8. Palliative Care

service

development

New Y Bwthyn

Work with

planning team to

ensure build stays

on target

Establish Project

Group to develop

operational detail

for service

Service

Modernisation

3rd time-out

session to focus

on detailed service

spec

New Y Bwthyn

Work with

planning team

to ensure build

stays on target

Finalise name

of new unit;

Service

Modernisation

Draft service

spec to be

developed and

shared with

specialist team

New Y Bwthyn

Work with

planning team to

ensure build

stays on target;

details of artwork

to Project Board

Service

Modernisation

Refine service

spec and shared

with wider

partners

New Y Bwthyn

Work with

planning team

to ensure build

stays on target

for completion;

development of

de-

commissioning

and

commissioning

plans

Service

Modernisation

Progress

service spec

through

P&EOLC

Delivery Group

Potential risks

associated with

capital

development

RAG Green

All actions complete and on

plan


6


Milestones

Quarter 2

Milestones

Quarter 3

Milestones

Quarter 4

Milestones

Risks RAG Rating

(Red, Amber, Green)

9.

Community

hospital ward

development

Development of

Steering Group

Visioning paper

Point prevalence

audit

Shared Care Model

with Mental Health

developed and I2S

proposal outlined

Shared care –

capital support for

undertaking of

scoping exercise

for environment

Fortnightly

meetings with

key partners –

acute,

community, LA

Programme

plan developed

with key

timescales

Point

prevalence to

be undertaken

across all

hospital wards

(acute and

community)

Shared Care

I2S to be

submitted (if

approved,

implementation

plan to be

developed)

Capital scoping

to be completed

Draft model to

include rehab

pathway and

proposals around

choice

Shared care – if

agreed,

implementation

plan to

commence

Shared care –

engagement with

stakeholders

Implement new

rehab pathway

and choice

protocol

Shared care -

implementation

Political and

public concern

around formal

implementation

of choice

Sustained

engagement,

agreement and

implementation

of all partners

I2S not

approved in

which case

capital spend

would be

abortive

RAG Green

All actions completed

however the Shared Care

scheme will not be

progressed this year as was

not prioritised from funding,

this is a top priority in the

IMTP for 2019/20.


7


Milestones

Quarter 2

Milestones

Quarter 3

Milestones

Quarter 4

Milestones

Risks RAG Rating

(Red, Amber, Green)

10.

Neighbourhood

Nursing Model

development

Establish Joint

Project Board

Confirm

agreement of

model

New JDs agreed

Recruitment of

staff

Engagement with

key stakeholders

Meet with

Buurtzhorg re

joint learning

and potential

workshop

Commissioning

of Malinko

software

Development of

communication

plan

Commencement

of model in 2 DN

teams

Implementation

of comms plan

Evaluation of

year 1 pilot

Potential

recruitment

IT

infrastructure

support

RAG Green

All actions complete, actions

plan in place with training

and development currently.

Clinically operational with a

designated caseload as of

April 2019

11 Wound service

and Lindsay Leg

club

a) Wound Service

- Identify

additional

requirements for

roll out to Taff and

Merthyr

b) Lindsay Leg

club – develop

business case,

identify area and

commence

recruitment

a) Wound

Service - Roll

out to Taff

within resource

b) Lindsay Leg

Clubs – develop

operational

process and

commence

Steering Group.

Identify

community

chair for

steering group

and trustees

a) Roll out to

Merthyr with

identified

resource

b) Lindsay Leg

Club –

commence

delivery

a) Evaluate

activity across

all 4 clusters

b) Lindsay Leg

Club

operational

Capacity

Evaluate

Sustaining

community and

trustee

engagement

RAG Green

All actions complete


8


Milestones

Quarter 2

Milestones

Quarter 3

Milestones

Quarter 4

Milestones

Risks RAG Rating

(Red, Amber, Green)

12. CHC cost

containment

Monitor and report

on spend and

achievement of

CRES at monthly

CBMs

Monitor and

report on spend

and

achievement of

CRES at

monthly CBMs

Work with

Finance to

develop a

tracker to

support the

work

Work with

procurement to

agree the

programme of

work for new

I2S resource

Monitor and

report on spend

and achievement

of CRES at

monthly CBMs

Review SLA with

Marie Curie for

end of life care

support

Monitor and

report on spend

and

achievement of

CRES at

monthly CBMs

Evaluate the

impact of the

I2S resource

and determine

any new actions

Unpredictability

of patient need

and costs

Lack of capacity

in community

care packages

Risk of costs

increasing in

sector

RAG AMBER

All actions complete and

procurement resource in

place to consider any

options for cost reduction.

Despite this the

unpredictability of this

patient group has seen an

increase in numbers of

cases and therefore cost

this year.

3.3 Directorate Risk Register

1 3.3 Directorate risk register Primary Care and Localities PCCC 9 Jan 2019.doc

Report of the Director of Primary

Community and Mental Health Page 1 of 3 Primary and Community Care

Committee Meeting 9 January 2018

AGENDA ITEM 3.3

9 January 2019


PRIMARY CARE & LOCALITIES RISK REGISTER

Executive Lead: Alan Lawrie, Interim Director of Primary, Community and Mental Health

Author: Lesley Lewis , Head of Nursing , Primary Care & Localities

Contact Details for further information: [email protected]


The aim of the report is to update the Primary and Community Care

Committee of key risks within the portfolio of Primary Care & Localities.

Governance

Link to Health Board Strategic

Objective(s)

The Board’s overarching role is to ensure its Strategy outlined within ‘Cwm Taf Cares’ 3 Year Integrated

Medium Term Plan 2017-2020 and the related organisational objectives aligned with the Institute of

Healthcare Improvement's (IHI) ‘Triple Aim’ are being progressed, these in summary are:

• To improve quality, safety and patient

experience • To protect and improve population health

• To ensure that the services provided are accessible and sustainable into the future

• To provide strong governance and assurance • To ensure good value based care and treatment

for our patients in line with the resources made

available to the Health Board.

This report aims to support all of the above objectives.

Supporting

evidence

Supporting information is provided where required

throughout the report


The Primary and Community Care Team, independent contractors and other community based staff.





APPROVE ENDORSE DISCUSS √ NOTE √

Recommendation The Primary and Community Care Committee is asked to:

• DISCUSS and NOTE the report.

Summarise the Impact of the Primary and Community Care

Committee Report

Equality and diversity

There are no specific equality and diversity implications identified

Legal implications There are no specific legal implications identified

Population Health The aim of the services identified within the

report aim to contribute to improving the population health

Quality, Safety & Patient Experience

The aim of the services referred to in the report aim to improve the quality, safety and patient

experience.

Resources There are no specific resource implications identified and the work is in line with Integrated

Medium Term Plan and is reported by the locality.

Risks and Assurance The specific risks are identified where appropriate within the document.

Health & Care

Standards

The 22 Health & Care Standards for NHS Wales

are mapped into the 7 Quality Themes: Staying Healthy

Safe Care Effective Care

Dignified Care Timely Care

Individual Care Staff & Resources

http://www.wales.nhs.uk/sitesplus/documents/1

064/24729_Health%20Standards%20Framework

_2015_E1.pdf

The work reported in this summary supports many of the health and care standards

Workforce Workforce implications are identified where appropriate within the report

Freedom of

information status

Open




PRIMARY CARE & LOCALITIES RISK REGISTER


The purpose of the report is for the Director of Primary, Community and Mental Health to provide information for the Primary and Community Care Committee

to assure key risks within the portfolio of Primary Care & Localities are managed.


Attached at Appendix 1 is the current risk profile for Primary Care & Localities for those risks scoring 16 and above.


The detail of the risk, score, descriptor of risk and mitigating actions to reduce and control risk is available at Appendix 1.

Anticoagulation services feature a high risk due to the complexity of the

interface across the pathway. Work has taken place to mitigate risks, led by the Assistant Medical Director for Primary Care. This has included:

• Joint training. • Encouraging practices to undertake Level 4 Anticoagulation services and

DOAC (direct oral anticoagulant). • Drafting protocol guidance.

• Establishing the Cwm Taf Thrombosis Committee to provide scrutiny and assurance.

Primary Care has undertaken all actions as above to mitigate risk. Further work

has been identified by secondary care colleagues within Pathology/

Haematology Directorate to include: • Use of the ‘DAWN’ dosing system in clinics serviced by secondary care in

Prince Charles Hospital, Keir Hardie University Health Park and Ysbyty Cwm Cynon.

• Clinical lead from Haematology. • Discharge of stable patient to Primary Care.

• Networking of practices.

4. RECOMMENDATION

Members of the Primary and Community Care Committee are asked to:

• DISCUSS and NOTE the report and appendix.

Freedom of

information status

Open

3.3.1 Appendix 1 Directorate Risk Register PCCC 9 Jan 2019

1 3.3.1 Appendix 1 Directorate Risk Register PCCC 9 Jan 2019.xls

ID Date Executive Lead Risk Domain Activity/Risk/ClinicalProcedure

Description of Hazard/Risk Current control measures in place Current RiskRating

Description (Action Plan Summary) Lead for Action £ TargetRating

Lead Committee Target Date

1489 20/05/2014 Director of Primary,Community &Mental Health

Quality /Complaints / Audit

Difficulties in the recruitmentand rention of primary careGPs and other staff groups

1. Significant problems around recruitment and retention of GPs and Practice Nursing in some areas ofCwm Taf. 2. Result of an ageing workforce,the growing number of GPs retiring, GPs choosing to become locums instead of partners and salaried,changes of pension and tax allowances3. Low number of training practices in 3 of the 4 localities. 4.Sustainability issueshave been identified particularly for a number of smaller practices which are finding it difficult to recruit.5. The average list size per GP in Cwm Taf is the highest across Wales.

1. Directly employment of salaried GPs and nurses via the Primary Care Support Unit.2. Deployment salaried staff to directly managed practices or within practices struggling with recruitment whilst recoveryplans are worked up. 3. Sustainability review process toidentify vulnerable practices4. Plans in place to ensure the primary care team are pro-active in anticipating sustainability issues.5. A robust recruitment campaign to attract new GPs to PCSU and GMS, using website to promote work life live6. Attendance at national and UK wide recruitment events & Vocational Training Schemes.7. Directly management of pratices where necessary8. Initiatives being implemented to support the development of primary care professionals e.g. the Workforce andDevelopment Training Cymru (Training Hub and Spoke model) for nursing careers (pre-reg, GP ready and ANP nursing)9. Support employement of new roles and partnership working to create wider MDT as part of emerging transformationmodel 10. Supportingpractices where there is a desire to work collaboratively or formerly merge.11. Peer support groups for nursing. planning pilot is also taking place in the Cynon Valley.12. Joint working with the LMC.

High 16 1. Regular review of sustainability2. Continue to directly manage 2 practices and to improve thequality and range of services3. Utilise LES to support formal mergers but also continue tosupport informal collaborative discussions5. Progress and deliver various training programmes in place toenhance the skills, knowledge and competencies of MDT inprimary care to ensure there is a workforce fit for purpose 6.Continue with the workforce planning pilot and lessons learnt inCynon Valley7. Implementation of the new transformation programme anddevelopment of the ECCT in each cluster

Sarah Bradley Mod 12 Quality &safety 27/07/2018then31/03/18


Impact on thesafety of patients,staff or public(physical/psychological harm)

Rostering of GPs to provideGP Out of Hours Service

1. Insufficient numbers of GPs willing to work within the the GP Out of Hours service and therefore not allthe shifts on the rota can be covered with GPs

1. Escalation process in place when there is insufficient GPs to provide the service at Primary Care Centres and triage.2. A&E departments are notified as patients will be diverted to A&E if they have an urgent cre issues which cannot waituntil their own GP practice is open. 3. Additional doctors (ST2&ST3) arerostered in A&E to support any additional flow of patients.4. Urgent Primary Care (out of Hours) service will secure additonal telephone triage to mitigate shortage of GPs in face-to-face settings. 5. Regularcommunications are distributed to GPs to try and encourage shift updtake.6. Work with the Deanery to inform GPs in training of GP Out of Hours opportunities.7. Liaison with neighbouring services to see if they are able to assist with any service shortfalls. 8. The UrgentPrimary Care (OOH) telephone messaging has been changed to emphasise he urgent nature of the service to avoid patientswho do not have an urgent healthcare issue accessing the service.9. Implementation of a redesign of the Urgent Primary Care Service (OOH) to a more robust MDT approach and routing ofpatients to appropriate advice and support 10. The ability to engage GP registrars to workin minor illness capacity in A&E. 11. Improved liaison between A&E and GP OOH.12. WRPS indemnity cover extended awaiting technical notes from Welsh Government. Despite the above,potential for gaps remain. Work is now taking place to develop amore multidisciplinary workforce which will include ANPs and nurses. In addition to this work is being undertaken with the111 National Team to take the opportunity to tap into the Clinical Support Hub and also Regionally to work collaboratielyover night week days. Other ways of securing GP sessional time through a GP onsortium is being progressed.

High 16 1.Redesign of the Out of hours service to attract more Gps to theservice to create greater sustainability2. Increase to pay rates3. implementation of rota master to make booking of shiftseasier for GPs4. revision to algorithms5. review of pathways e.g. respiratory, ACP6. Access to resources in 111 Clinical Support Hub, e.g. pharmacyand mental health7. Exploring the use and benefits of AI / digital technologies tomanage demand8. Developing a new contract to secure GP input9. Development of MDT within the Urgent Primary Care Service,particularly nursing triage and face to face

Martine Randall Mod 12 Quality & Safety then31/03/19


Impact on thesafety of patients,staff or public(physical/psychological harm)

Poor staffing levels inMerthyr & Cynon Locality

There is currently a high level of sickness, maternity leave & vacancies in Merthyr Tydfil & CynonLocalities with Mountain Ash team experiencing 47% absence rate currently. There is a risk of patientsnot being seen on time, delays in treatment & care not being delivered at a satisfactory level of quality.Staff in these areas are having an increased workload to make up for the absence in their teams. This willresult in poor morale, risk of burnout & further absence.

1. Daily review of caseload allocation and pritisation of high risk patients. 2. Coporate working of D/N team South Cynon.3.Support from other areas of D/N service mobilised.

16 1.Review of long term sickness by Deputy Head of Nursing & HR.2. Review of casleloads and risk. 3. Recruitment completed forvacencies with newly registered staff

Mair Thomas 6 Quality & Safety 15/10/2018


Service/businessinteruption

Failure for the developmentof the new Mountain AshFacility to be completedwithin the timescaleidentified by WG

1.Key milestones have been missed within the Project Plan, these include2. Failure to exchange and complete on land sale3. Failure for Apollo to agree with the District Valuer (DV) rental value within envelope agreed with WG4. Failure to submit planning permission within sufficent timescale to enable the build to be completedwithin the timescale

1. Professional support and advice being given from NWSSP Property and Estates Advisors2. Apollo and DV informed of final deadline for negotiations and threshold of value otherwise alternative options will besought

16 1. Apollo have to report final rental figure by the 10th January2. NWSSP involved in negotiations on transfer of land andoverseeing progress between RCTCBC and Apollo3. Feedback from Project Board and expectations regardingdelivery of the project provided to Apollo4. Project Risk Register and mitigations beingoverseen/monitoried by Project Board

Craige Wilson 9 Quality & Safety 31/01/2019

4.1 Organisational Risk Register

1 4.1 Org Risk Register PCCC 9 Jan 2019.doc

Organisational Risk Register Page 1 of 16 Primary and Community Care Committee Meeting

9 January 2019

AGENDA ITEM 4.1

9 January 2019


ORGANISATIONAL RISK REGISTER

Executive Lead: Interim Board Secretary

Author: Interim Board Secretary

Contact Details for further information: Gwenan Roberts 01443 744818 or email [email protected]


The purpose of this report is for the Primary and Community Care Committee Members to review and discuss the organisational risk register

and consider whether the assessed and recorded risks are appropriately

assigned. The Organisational Risk Register was last considered by the Executive Board in November 2018 and by the Quality Safety and Risk

Committee (QSR) in December 2018. Changes made since are identified in RED font.

Governance

Link to Health


The Board’s overarching role is to ensure its strategic

objectives, and the related organisational objectives outlined within the 3 Year Integrated Medium Term Plan

2018-2021, are being progressed. Aligned with the

‘Quadruple Aim’ described within ‘A Healthier Wales’ (Welsh Government, June 2018) these objectives are:

• To improve quality, safety and patient experience.

• To protect and improve population health. • To ensure that the services provided are

accessible and sustainable into the future. • To provide strong governance and assurance.

To ensure good value based care and treatment for our patients in line with the resources made available

to the Health Board.

Supporting evidence

• There are a number of assessments that help inform the content of the organisational risk

register. • The content of this report is informed by the

University Health Board’s (UHB) Risk Management Strategy.


The information contained within this report has been developed following

engagement with senior staff and Executive Directors.


9 January 2019


APPROVE ENDORSE √ DISCUSS √ NOTE √

Recommendation The Primary and Community Care Committee is asked to: • DISCUSS and NOTE the update provided within

this report and the risks assigned to the Board and its Committees and;

• ENDORSE the updated risk register and the assignment of risks. Summarise the Impact of the Primary and Community Care

Committee Report Equality and

diversity

There are no identified equality & diversity implications.

Legal implications It is essential that the Board has robust arrangements in place to assess, capture and

mitigate risks faced by the organisation, as failure to do so could have legal implications for the UHB.

Population Health No specific impact.

Quality, Safety & Patient

Experience

Ensuring the organisation has robust risk management arrangements in place that ensure

organisational risks are captured, assessed and mitigating actions are taken, is a key requisite to

ensuring the quality, safety & experience of patients receiving care and staff working in the

UHB. Resources The risks outlined within this report have resource

implications which are being addressed by the respective Executive Director leads and taken into

consideration as part of the Board’s IMTP processes.

Risks and Assurance

This report and the organisational risk register is an

integral element of the Board’s risk and assurance arrangements. It should be no ted that this work

continues to develop.

Health & Care

Standards

The 22 Health & Care Standards for NHS Wales are

mapped into the 7 Quality Themes but within a

Governance Framework. This report focuses mainly on Governance & Accountability but also spans

many of the 7 quality themes. Workforce Failure to capture, assess and mitigate risks can

impact adversely on the workforce.

Freedom of Information status

Open


9 January 2019

ORGANISATIONAL RISK REGISTER


The purpose of this report is for the Primary and Community Care

Committee Members to review and discuss the organisational risk register

and consider whether the assessed and recorded risks are appropriately assigned. The Organisational Risk Register was last considered by the

Executive Board in November 2018 and by the Quality Safety and Risk Committee (QSR) in December 2018. Changes made since are identified in

RED font.


The organisational risk register summarises the key ‘live’ extreme risks facing the Health Board and the actions being taken to mitigate them. The

Health Board manages risk through i t s Directorate structures and in

close alignment with the Board’s ‘approved’ Assurance Framework. The Assurance Framework reports into the Audit Committee for periodical

review, monitoring and scrutiny and also features (at least annually) on the agenda of the Board.

It is also important to NOTE that the Executives, as risk owners, are

appropriately sighted and involved in the development of the organisational risk register, providing updates, including reports on

mitigating actions. The organisational risk register is reviewed and where appropriate updated on a bi-monthly basis with input from the Executive

lead as required.

All organisational risks have a lead Executive Director and the risk assigned to either the Board, or as appropriate, a Committee of the Board

to ensure appropriate review, scrutiny and where relevant updating. Each Director is responsible for the ownership of the risk(s) and the reporting of

the actions in place to manage/control and/or mitigate the risks.

The organisational Risk Register is reported quarterly to the Executive

Board and routinely to the Quality, Safety & Risk Committee of the Board, for information and where appropriate, scrutiny of any assigned risks.

Whilst this cover report summarizes the detail, the supporting appendices provide more detail.

Improvement continues to be made with directorates and localities

routinely completing integrated risk reporting templates that are used for exception reporting.


9 January 2019

3. ASSESSMENT OF GOVERNANCE AND RISK ISSUES

Following discussion at the Quality Safety and Risk Committee in December

and the Executive Board in November, the following changes to the register were agreed:

• Brexit has been added to the risk register (045) • System failure in IT has been added (044)

• Finance risk has been updated • ICT strategy risks would need to recognise that investment was required

to implement the strategy • Follow up appointments not booked needed to include that additional

funding would be required to improve the position • Medical Manpower – combining the risks of 7, 8 and 37 would be

considered further by the Medical and Nurse Directors • Risk 35 be amended to include ‘midwifery staff’ and arrangements to be

compliant with the Nurse Staffing Wales Act.

Overall analysis

The organisational risk register currently includes 35 Extreme / High risks

which are categorised into the following groupings:

Categories / Risk

Rating

Extreme

(rated 15 -25)

High

(rated 8-12)

Business objectives / projects 5 4

Impact on Safety 9 1

Statutory duty / inspections 8 2

Finance (including claims) 1 1

Workforce / Organisational Development / Staff Competence

0 1

Service Business Interruptions 2 1

Total Risks 25 (+1) 10 (+1)

High / Extreme Risks (Rating 20 and above)

In considering the robustness of a developing organisational risk register,

Board Members need to consider whether the top recorded risks are those that Members of the Board can relate to and indeed evidence that they are

informing the work of the Board and its Committees in delivering its related

Strategy.

The top risks outlined within the Organisation’s risk register are:

• Failure to recruit sufficient numbers of medical & dental staff and its related impact on rotas and finance going forward (also aligned with South Wales Programme outcome)

• Reduction in medical staff training posts

• Failure to recruit sufficient numbers of registered nursing and midwifery staff


9 January 2019

• Increasing dependency on agency staff to cover registered nursing and medical staff gaps

• Fire Safety compliance and ongoing issues with Prince Charles

Hospital site (Ground & First Floor)

• Lack of control and capacity to accommodate all hospital

follow up outpatient appointments • Failure to ensure delivery of a viable balanced/break even 3

year integrated medium term plan.

• Achieving financial break even on a recurring basis.

• Under reporting of serious incidents in maternity services. • Failure to continue to provide and sustain GP Out of Hours

Services as currently configured.

Of the categorised risks, these have been broken down under one of our

existing Strategic Objectives:

• There are currently 24 extreme (reduced by 1) and 10 high (stayed the same risks, assigned to the Board and its various Committees

• The majority of assessed risks are linked with workforce shortages and

their related impact.

Organisational Risk Register Page 6 of 16 Primary and Community Care Committee meeting

9 January 2019

Risk Register Category – Business Objectives / Projects (9 risks)

Strategic

Objective

Risk

Reference

Description of risk

identified

Initial

Score

Current

Score

Trend Controls Last

Reviewed

Scrutiny

Committee

Setting the

Direction and

Performance

and

Operational

Efficiency

028

Failure to ensure delivery of a viable

balanced/break even 3 year

integrated medium term plan.

20

(was 16)

20

November

2018

Health Board

015

Reputational damage & potential legal

challenge on the decision making on

Funded Nursing Care (FNC). 16 12

November

2018

Health Board

029

Failure to invest in and develop

Primary Care Services, across RCT

and Merthyr Tydfil but particularly in

the Rhondda Valleys.

16 16 November

2018

Primary & Community

Care

036 Primary Care Workforce - Recruitment

and sustainability 16 16 November

2018

Primary & Community

Care

030

Failure to continue to provide and

sustain GP Out of Hours Services as

currently configured.

16 20

November

2018

Primary & Community

Care

002 Failure to achieve Referral to

Treatment targets. 12 12

(was 20)

November

2018 Finance, Performance

& Workforce

003

Failure to achieve the 4, 8 and 12

hour emergency (A&E) waiting times

targets. 12 16

November

2018

Finance, Performance &

Workforce

013 Implementation of South Wales

Programme outcomes.

12 12 November

2018 Health Board

023

Failure to meet the timescale relating

to issuing concerns (complaints)

responses to patients and/or carers.

16 12

November

2018

Quality, Safety & Risk

The Trend column indicates whether the risk overall (from when first assessed), is increasing (), reducing () or unchanged ().

The Controls column indicates whether assessed controls overall are improved (), reduced () or unchanged () from when first

assessed. Regardless of whether the risks rating has changed.


9 January 2019

Risk Register Category - Impact on Safety (10 risks)

Strategic

Objective

Risk

Reference

Description of risk identified Initial

Score

Current

Score

Trend Controls Last

Reviewed

Scrutiny

Committee

To improve

quality,

safety

and patient

experience.

007 Failure to recruit sufficient medical & dental

staff. 25 20 November

2018 Quality, Safety &

Risk

034

Increasing dependency on Agency Staff

cover in Medical and Nursing areas, which

has the potential to impact on continuity of

care and patient safety and is actually

impacting on the UHB financial position.

20 20 November

2018

Quality, Safety &

Risk

035 Failure to recruit sufficient registered

nursing and midwifery staff. 20 20 November

2018 Quality, Safety

& Risk

008

Reduction in medical training posts within

various specialties & capacity to meet

workload demands.

20

20

November

2018

Quality, Safety &

Risk

027

Lack of control and capacity to

accommodate all hospital follow up

outpatient appointments.

20

20

(was 16)

November

2018

Finance,

Performance &

Workforce

032 Sustainability of a safe & effective

Ophthalmology Service. 20 16

November

2018 Quality, Safety

& Risk

005

Failure to sustain services as currently

configured to meet cancer targets.

20 16

November

2018

Finance,

Performance &

Workforce

033

Failure to sustain Child & Adolescent

Mental Health Services across the Network 16 16

November

2018 Quality, Safety &

Risk

037

Ensuring the development, approval and

implementation of a Strategy for IM&T,

that is clinically led and supports staff in

care delivery

12 12

November

2018

Health Board

038

Inconsistent approach and arrangements in

place for the management and monitoring of

patients requiring anticoagulation

management within Cwm Taf UHB.

16 16

November

2018

Primary &

Community Care


9 January 2019

Strategic

Objective

Risk

Reference

Description of risk identified Initial

Score

Current

Score

Trend Controls Last

Reviewed

Scrutiny

Committee

(043)

New

Possible Under Reporting of Clinical

Incidents in Maternity Services 20 20 September

2018

Quality, Safety &

Risk

Risk Register Category – Statutory Duty / Inspections (10)

Strategic

Objective

Risk

Reference

Description of risk

identified

Initial

Score

Current

Score

Trend Controls Last

Reviewed

Scrutiny

Committee

Statutory

Compliance 017 Failure to meet Fire Safety Standards

on ground and first floor PCH. 20 20

November

2018

Quality, Safety &

Risk

021

Failure to ensure all Staff obtain

competency/ compliance with

mandatory training requirements. 16 16

November

2018

Quality, Safety &

Risk

025 Failure to meet Fire Safety

Standards across the UHB. 16 16 November

2018

Quality, Safety &

Risk

018

Failure to achieve statutory and

mandatory planned preventative

maintenance (PPM) programme. 15 15 November

2018

Quality, Safety &

Risk

031

Failure to appropriately apply

Deprivation of Liberties Safeguards

(DoLS) legislation following the West

Cheshire court judgement.

16

(was 12)

12

November

2018

Quality, Safety &

Risk

016 Failure to comply fully with the

arrangements for managing Asbestos 16 12

November

2018

Quality, Safety &

Risk

039

(New)

Failure to ensure sufficient storage

capacity (or alternative solutions) are in

place to safely store and secure patient

records.

N/A 16

November

2018

Quality, Safety &

Risk


9 January 2019

Strategic

Objective

Risk

Reference

Description of risk

identified

Initial

Score

Current

Score

Trend Controls Last

Reviewed

Scrutiny

Committee

040

(New)

Failure to fully comply with all the

requirements of the Welsh Language

Standards, as they apply to the

University Health Board.

N/A 15 November

2018

Quality, Safety &

Risk

041

(New)

Failure to fully meet all the licensing

requirements of the Human Tissue

Authority in relation to Mortuary &

Services for the Deceased.

N/A 16

November

2018

Quality, Safety &

Risk

042

(New)

Failure to ensure successful

implementation of the Welsh

Governments decision to realign the

Health Boundary, as it applies to the

resident population of the Bridgend

County Borough.

N/A 15

November

2018

Health Board

(Joint Transition

Board)

Risk Register Category – Finance / Including Claims (2)

Strategic

Objective

Risk

Reference

Description of risk

identified

Initial

Score

Current

Score

Trend Controls Last

Reviewed

Scrutiny

Committee

Financial

Viability 011

Failure to achieve financial balance

on a recurring basis and mitigate

reliance on in year non recurring

funding slippage.

15 20

November

2018

Health Board

012

Failure to Deliver Major &

Discretionary Capital programmes 12 12 November

2018

Capital

Programme

Board


9 January 2019

Risk Register Category – Human Resources / Organisational Development / Staff Competency (1)

Strategic

Objective

Risk

Reference

Description of risk

identified

Initial

Score

Current

Score

Trend Controls Last

Reviewed

Scrutiny

Committee

Workforce

Sustainability/

OD and

Innovation

019

Failure to achieve the Management of

Absence target. 15 12

November

2018

Finance,

Performance

& Workforce

Risk Register Category – Service / Business Interruption (1)

Strategic Objective Risk

Reference

Description of risk

identified

Initial

Score

Current

Score

Trend Controls Last

Reviewed

Scrutiny

Committee

Business Continuity

006

Failure to appropriately manage

Discharge Delays from Hospitals 12

12

(Was 16)

November

2018

Finance,

Performan

ce &

Workforce

Business Continuity

Information

Technology Systems 044

(NEW)

Risk of information technology

failures following national outage

during 2018 and cyber security

risk which could lead to loss of

information or information

governance issues

15 15

New Risk Executive

Board

Business Continuity

Brexit 045

(NEW)

Risk of interruption to service

sustainability, provision and

destabilising the Board's financial

position as a result of Brexit.

16 16

New Risk Executive

Board

Organisational Risk Register Page 11 of 16 Quality, Safety & Risk Committee

6 December 2018

Quality, safety and patient experience

The Health Board’s risk management arrangements are in place to ensure risks

are assessed and mitigating actions taken to improve the quality, safety and

experience of patients and where appropriate escalation arrangements are in place to inform the Board via its key sub-committees.

Use of resources

There is a significant risk to the service if robust risk based assessment

arrangements are not in place. Good governance arrangements, including effective risk management help to ensure the effective use of resources. It is

important to note that routinely as part of the Internal Audit and Assurance Annual Plan, 3 clinical and 1 corporate directorate undergo a governance review

each year, which includes a review of its risk management arrangements. This

is in addition to the organizational related audit reviews.

Compliance with Legislation There may be an adverse effect on the organization if arrangements are not in

place to manage and mitigate risks.

Performance

Assessment and monitoring of risks within the Health Board is undertaken within Directorates/Localities/Departments. The extreme / high organizational

risks will be monitored by the Executive Team / Board and be reviewed and scrutinized by the Board and/or its Committees.

As a general rule the organisational risk register will be routinely reviewed by

the Quality, Safety & Risk Committee and elements discussed at the Integrated

Governance Committee, although all Committees of the Board have a role to play in ensuring risks assigned to a Board Committee are considered as part of

its work. Risk management arrangements will also be a key element of internal audit work and key risks will help to inform the annual internal audit plan.

4. RECOMMENDATION


• DISCUSS and NOTE the update provided within this report and the risks assigned to the Board and its Committees; and

• ENDORSE the updated risk register and the assignment of risks.

Freedom of

Information

Open


9 January 2019

HEALTH BOARD ORGANISATIONAL RISK REGISTER SUMMARY OF ASSESSED RISKS (OVERALL TREND) – JANUARY 2019

Imp

act/

Co

nse

qu

ence

5 042 Bridgend Boundary change 044 ‘New’ Loss of IT due to system outages

017 Failure to meet Fire Safety Standards on Ground & First Floor Prince Charles Hospital ↔

031 Failure to appropriately apply DOLS legislation following West Cheshire court judgement 043 Possible under reporting of serious incidents in maternity services

011 Failure to achieve financial balance

007 Failure to recruit Medical & Dental Staff ↔

4

002 Failure to achieve RTT 037 Ensuring the development, approval and implementation of a Strategy for Digital Health, that is clinically led and supports staff in care delivery ↔ 016 Management of asbestos 012 Failure to deliver major and discretionary capital programmes ↔ 006 Discharge delays from acute hospitals ↔ 013 South Wales Plan outcomes ↔ 023 Deterioration in the timescale relating to issuing concerns (complaints) responses to patients and or carers ↔ 015 Reputational damage & potential legal challenge (FNC)

032 Sustainability of safe & effective Ophthalmology Services

005 Failure to sustain services as currently configured to meet cancer targets

033 Sustaining CAMH Services ↔

029 Failure to Invest in and develop Primary Care Services, particularly in Rhondda ↔

036 Primary Care workforce – recruitment & sustainability ↔

038 inconsistent approach and arrangements in place for the management and monitoring of patients requiring anticoagulation management within CTUHB ↔

025 Failure to meet Fire Safety standards across the UHB ↔ 030 Continuing to provide GP Out of Hours Services as currently configured ↔ 021 Staff competency – compliance with statutory/mandatory training 041 Human Tissue Act compliance mortuary / deceased services 045 Brexit (NEW)

028 Producing Viable balanced 3 year IMTP

034 Increasing dependency on agency staffing (medical & nursing) finance impact↔

035 Failure to recruit registered nursing staff ↔

008 Reduction in medical training posts within various specialities & capacity to meet workload ↔ 003 Failure to achieve 4 & 8 hour Emergency access targets. ↔

027 Lack of control & capacity to accommodate Follow Up Outpatients↔ 039 Ensuring Sufficient Health Records Storage

3 019 Failure to achieve the management of absence target

018 Failure to achieve statutory and mandatory planned preventative maintenance programme ↔

040 Compliance with Welsh Language Standards

2

1

C x L

1 2 3 4 5

Likelihood


9 January 2019

Objective: Setting the Direction & Performance & Operational Delivery

Director Lead: Director of Primary, Community and Mental Health

(DPCMH)

Assuring Committee: Primary and Community Care Committee

Risk: Failure to invest in and develop Primary Care services across RCT and

Merthyr Tydfil but particularly in the Rhondda Valley

Date last reviewed: November 2018

Risk Rating

0

5

10

15

20

25

Sep

-17

No

v-1

7

Jan

-18

Mar

-18

May

-18

Jul-

18

Sep

-18

No

v-1

8

Risk Score

Target Score

Rationale for current score:

(consequence x

likelihood):

Initial: 5 x 4 = 16

Current: 4 x 4 = 16

Target: 4 x 3 =12

The ongoing difficulties in recruiting staff for Primary Care reflects a

national problem

Rationale for target score:

There are ongoing and continuing problems in recruiting staff to

primary care areas but particularly within the Rhondda locality

There are a total of 16 practices within the Rhondda Valleys, (covering

65,000 approximate population) and over half are advertising for GP

sessions currently due to GP vacancies. Some have been advertising

for over a year.

Level of Control

=70%

Date added to the

risk register

December 2014

Controls (What are we currently doing about the risk?) Mitigating actions (What more should we do?)

• Where possible the Primary Care Team is working with practices to find

solutions for an exit strategy and are considering directly managing the

practices or recruiting on their behalf.

• The UHB has been successful following submission of bids against non

recurring Primary Care monies;

• The Board has developed its Strategy for Primary Care aligned with its

Integrated 3 Year Plan and National guidance. This includes milestones for

addressing some of the related reported risks. Progress in strengthening

the new IMTP. Board aware of the ongoing work and regular reports

received on progress.

• The good work developed as part of the Strategy is fully factored into

UHBs IMTP.

Action Lead Deadline

A report for additional investment in the

Primary Care Support Team has been

considered and taken forward.

Director of

PCMH

Oct 2017

Complete

Rhondda docs have developed a proactive

website to support recruitment

Director of

PCMH

Complete

Primary and Community Care Committee in

place to scrutinise IMTP delivery.

Primary Care Sustainability being discussed

with Clusters

Director of

PCMH

Director of

PCMH

Ongoing

Ongoing

Assurances

(How do we know if the things we are doing are having an impact?)

Gaps in assurance

(What additional assurances should we seek?)

Numbers of staff recruited; retention levels.

Current Risk Rating

Additional Comments

Ref No.

029

Current Risk Rating : 4 x 4 = 16

We are working closely with the Welsh Government on

the recruitment of staff – Train,Work,Live campaign


9 January 2019



(DPCMH)


Risk: Primary Care Workforce – recruitment and sustainability Date last reviewed: November 2018

Risk Rating

0

5

10

15

20

25

No

v-1

7

Jan

-18

Mar

-18

May

-18

Jul-

18

Sep

-18

No

v-1

8

Risk Score

Target Score


(consequence x

likelihood):

Initial: 5 x 4 = 20

Current: 4 x 4 = 16

Target: 4 x 3 =12

An increasing number of practices across the UHB are advertising for

GP sessions currently due to (and other staff groups) vacancies.


Recruitment to Primary Care for GPs and some other professional

groups across Cwm Taf UHB remains challenging (reflecting a National

problem).

Level of Control

=60%

Date added to the

risk register

August 2016


• Where possible the Primary Care Team is working with the practices to find

solutions, which include practice mergers; considering where possible

directly managing solutions and/or working to recruit on behalf of the

practices.

• Primary and Community Care Committee in place to scrutinise delivery of

the IMTP.

• Local and National recruitment campaigns progressed, with some reported

success.


Development of the Cluster arrangements

maturing, working with Primary Care and

localities to develop solutions;

DPCMH Ongoing

The UHB has been successful following

submission of bids against non recurring

Primary Care monies;

DPCMH Complete

The Board has developed its Strategy for

Primary Care aligned with its Integrated 3

Year Plan and National guidance. This

includes milestones for addressing some of

the related reported risks.

DPCMH

Ongoing

milestones

being

monitored

Assurances


Gaps in assurance


Recruitment and retention data.

Current Risk Rating

Additional Comments

Ref No.

036


We are working closely with the Welsh Government on

the recruitment of staff – Train, Work, Live campaign


9 January 2019



(DPCMH)


Risk: Failure to continue to provide GP out of hours services as currently

configured


Risk Rating

0

5

10

15

20

25

Sep

-17

No

v-1

7

Jan

-18

Mar

-18

May

-18

Jul-

18

Sep

-18

No

v-1

8

Risk Score

Target Score


(consequence x

likelihood):

Initial: 5 x 4 = 20

Current: 5 x 4 = 20

Target: 4 x 3 =12

The Out of Hours team is encouraging GPs to fill shifts. However,

many sessions are filled via Locum Agency Doctors, which is

expensive and flexible sessions are offered. However, the fill rate

remains variable and is challenging to maintain services. The effect

of the HMRC tax implications is now having an impact.


There are ongoing and developing Primary Care recruitment

problems (reflecting a National problem). It is becoming increasingly

difficult to secure GP sessions for the GP Out of Hours Service and

many sessions especially on the weekend remain unfilled putting

additional demand on both existing A&E departments.

Level of Control

=60%

Date added to the

risk register

November 2014


• OOHs services reconfigured and number of centres reduced from 4 to 2 in

order to sustain services. An evaluation update considered by the Board

in July 2016, agreed to continue with the current service which is

scrutinized and monitored by the Primary and community Care Committee.

• There continues to be ongoing engagement and discussions with those

practitioners currently supporting the revised model.

• There continues to be engagement with key stakeholders including the

Community Health Council, GPs and patients.

• Further options are being considered in order to address ongoing

sustainability issues with the current service configuration


The out of hours team continuing to work

with GPs and other primary care staff, in a

flexible way for the best shift fill rates.

DPCMH Ongoing

All Wales approach being progressed to

mitigate variability of approaches across

NHS Wales Health Boards

Directors

of W&OD/

Directors

of PC&MH

Ongoing

(2017/18)

Regular dialogue with OOHs service and

Primary Care Clusters to ensure OOHs

cover is strengthened and supported.

DPCMH Ongoing

Assurances


Gaps in assurance


Shift fill rates; patient experience surveys The current service model is not sustainable and alternative solutions

are required.

Current Risk Rating

Additional Comments

Ref No.

030


Lack of an All Wales Approach results in HBs competing

with each other on GP sessional pay rates.


9 January 2019

Objective: To improve quality, safety and patient experience

Director Lead: Director of Primary Community and Mental Health


Risk: Inconsistent approach and arrangements in place for the management

and monitoring of patients requiring anticoagulation management within Cwm

Taf UHB


Risk Rating

0

5

10

15

20

25

Sep

-17

No

v-1

7

Jan

-18

Mar

-18

May

-18

Jul-

18

Risk Score

Target Score


(consequence x

likelihood):

Initial: 4 x 4 = 16

Current: 4 x 4 = 16

Target: 4 x 3 =12

Progress being made with influential clinical lead for the

anticoagulation service (Dr Stuart Hackwell – Assistant Medical

Director for Primary Care); Clarity regarding service provision and

variation being quantified and addressed.

Level of Control

=50%


Section 28 Reports received from HM Coroner in relation to the

variation in services and the risks of anticoagulation for patients –

risks cannot be completed eradicated but improvements can be made

to processes across the Health Board

Date added to risk

register

June 2017


• Linked also with HM Coroner Regulation 28 Report (s), a review overseen

by Dr M Page which concluded in 2016, provided a series of

recommendations directing improvement actions. Progress continues to be

made with the related taken forward and being led by Dr Stuart Hackwell.

• Discussions regarding Local and National Enhanced Service progressed;

• Planned lead from Primary Care to explore necessary support in order to

take the known and agreed improvement actions forward. Progress to be

routinely monitored via the Primary Care & Community Committee of the

Board and as necessary Executive Board

• Executive Board approved a pilot to implement phase 1 of the plan which

included capital investment etc


Progress being discussed and scrutinised at

the Primary and Community Care

Committee

Stuart

Hackwell

Ongoing

Action plan developed and agreed –

monitoring progress

DPCMH Ongoing

Ensure capital investment for DAWN

(dosing system in place) and actioned

across the health board through Executive

Capital Management Group

DPCMH /

Med

Director

Ongoing

Assurances


Gaps in assurance


Ensure evaluation takes place in 12 months from the start of phase 1. Ensuring investment required built into IMTP process across the

health board

Current Risk Rating

Additional Comments

Ref No.

038


Recognised as a major patient safety issue in Cwm Taf

5.1 To Review the Forward Look for 2019/20

1 5.1 Forward Look PCCC 9 January 2019.doc

Agenda Item 5.1

Forward Look Primary and Community Care Committee

Page 1 of 2

Primary and Community Care Committee 9 January 2019

PRIMARY & COMMUNITY CARE COMMITTEE: FORWARD LOOK 2019/20

Wednesday 9 January 2019 at 9am Ynysmeurig House Abercynon

Standard items

• Primary and Community Care Delivery Plan – Progress on Implementation Alan Lawrie

• Progress on Delivery Agreements Alan Lawrie

• Spotlight on Cluster Hub Development Progress on cluster plan (Locality to be confirmed) – Rhondda or Taff Ely

Sarah Bradley

• Organisational Risk Register related to the Committee Robert Williams

• GP Sustainability Framework – any applications? Alan Lawrie

• Primary Care Indicators Alan Lawrie

Additional items

• Plan for update on Neighbourhood Nursing (Director’s report) Angela Hopkins / Alan Lawrie

• Review the Directorate’s risk register Craige Wilson

• Full response to WAO Discharge Planning Report Alan Lawrie

• Plan for WAO Primary Care review Alan Lawrie

• Primary Care Estate (new plan) Craige Wilson

• Palliative Care – overview report Craige Wilson

• Update on Medicines Management Alan Lawrie

• IMTP Monitoring report for information Alan Lawrie

3 April 2019 at 9am Ynysmeurig House Abercynon

Standard items

• Progress on Delivery Agreements Alan Lawrie

• Spotlight on Cluster Hub Development Progress on cluster plan (Locality to be confirmed) –

Rhondda or Taff

Sarah Bradley

• Organisational Risk Register related to the Committee ( Robert Williams

• GP Sustainability Framework – any applications? (Director’s Report) Alan Lawrie

• Primary Care Indicators (Director’s Report) Alan Lawrie

Additional items

• Primary Care Estate (new plan) Craige Wilson

• Palliative Care – overview report Craige Wilson

Agenda Item 5.1

Forward Look Primary and Community Care Committee

Page 2 of 2

Primary and Community Care Committee 9 January 2019

• Update on Medicines Management Alan Lawrie

• Update on the progress of anticoagulation services (risk removed in October) Stuart Hackwell

• Update on financial sustainability for services linked with Transformation Plan Ana Riley

• Update on dental contract / services Craige Wilson

• Evaluation Report on the Inverse Care Law Programme (Cardiovascular health check

programme) with SAIL analysis

Kelechi Nnoaham

• Full response to WAO Discharge Planning Report Alan Lawrie

Items to consider

• Links between the GMS Directly Enhanced Service (DES) for Care Homes and the National Enhanced Service

(NES) for Community Pharmacy for the same Sept 2019 • Population Health Management pilot Phase 2 (after May)

• Palliative Care

Annual requirements

• Annual Governance Statement Contribution • Terms of Reference in line with the Standing Orders to

take place in March 2019 • Committee Annual Report June 2019

Next meetings

Wednesday 10 July 2019

9.00am Rhondda & Cynon Rooms YMH

NB - Urgent items will be accommodated as required and the Forward Look is subject to change.

Wednesday 9 October 2019

9.00am Rhondda & Cynon Rooms YMH

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