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QUALITY, SERVICE, WORKFORCE & FINANCIAL FRAMEWORK 2010 - 2015

Changing for the Better

OUR FIVE YEAR PLAN Summary – August 2010

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FOREWORD Local citizens and local communities deserve good health and have a right to expect

responsive, high quality care from the NHS. This Framework sets out how

Abertawe Bro Morgannwg (ABM) University Health Board, working with its partners,

will rise to this challenge and consistently meet the needs and expectations of the

public. It specifies ambitious objectives and goals and defines a wide range of

priority action areas.

The next few years will undoubtedly be characterised by large scale, complex

change. The NHS will need to respond to unprecedented financial pressure, new

medical technologies, a changing workforce and rising demand. Our plans

acknowledge these drivers for change and anticipate the need to introduce new

integrated models of care, to focus on prevention and health improvement and to

utilise our considerable resources effectively and efficiently.

The Framework has been produced following an extensive process of engagement –

with our partners, the public and our staff. As we implement our plans, this

engagement will continue. At all times we want to ensure understanding of and

support for our work.

We look to the future with confidence. We are building on strong foundations –

there is excellence in many of our existing services, our partnerships and, above all,

our staff. There is moreover a shared sense of ambition and an appetite for

change. Our Framework Changing for the Better will harness this excellence,

enthusiasm and ambition. It will enable a high quality, responsive and sustainable

NHS across ABMU Health Board.

David Sissling Chief Executive,

Abertawe Bro Morgannwg University Health Board

Win Griffiths, Chairman

Abertawe Bro Morgannwg University Health Board

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An Ambitious Plan for the Future Underpinning all that we do is the One Wales ambition to ‘transform Wales into a self-confident, prosperous, healthy nation and society, which is fair to all’. The Welsh Assembly Government is committed to improving not only how long people live, but the quality of their lives. As part of this commitment, patient safety will be Abertawe Bro Morgannwg University Health Board’s number one priority. In order to develop the clinical strategy and priorities for the next 5 years, we invited views from partners and stakeholders. These have helped to shape our plan, Changing for the Better. ABM will work with Local Authorities, the Voluntary Sector, Swansea University, people who use our services, and their carers, staff, colleagues in primary care and the Community Health Council to ensure full commitment to develop and implement our integrated plans. We particularly look forward to pursuing opportunities for joint working. An example of this is the recent joint appointment of the Locality Director for Bridgend by the Health Board and Bridgend County Borough Council, one of the first such joint appointments in Wales.

Patient Expectations Current performance in the health care system is mixed. While we do a lot of things well, health outcomes and service quality do not always meet the high aspirations of patients or the citizens of Wales. Patient expectations are ever increasing. They want better and faster access to services, and they want more of them. Patients are also expecting to play a much more active role in the planning and delivery of their own care. Many want care to be available at home or closer to where they live. We welcome these requirements, and will do our best to meet them, as long as it is safe and practicable to do so. At the heart of our commitment to provide a safe, high quality experience, is our relationship with patients and those who support them. We will become an organisation that meets not only the physical needs of patients, but personal and emotional ones too. This means:

� Getting good quality treatment and care in a comfortable,

caring and safe environment. � Clinicians ensuring patients understand their condition and

make informed choices so they feel confident and in control. � Being listened to and spoken to as an equal.

� Being treated with honesty, respect and dignity. � Ensuring we can communicate with patients, their carers

and families in the language of their choice.

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Quality

Our quest to improve quality will drive change, and getting it right first time is the most efficient way of delivering healthcare. We need to move to a position where:

� Patients and service users

receive the same high

standard of care wherever

they are treated.

� Patients and service users are safe from harm arising from the

healthcare system.

� We meet the most common needs, but are also flexible enough

to respond to individual patient choices.

� Patients and service users are given the necessary information

and opportunities to make choices about health care decisions

affecting them.

� Patients and service users have access to their own medical

information and to clinical knowledge.

� Patients and service users receive care based on the best

available scientific knowledge.

� Patients and service users are directly involved in the

development and delivery of healthcare services.

We also need to ensure our healthcare system anticipates patient needs, rather than

simply reacting to events, and that we don’t waste resources or patient time.

Our clinicians and managers must work together to ensure effective communication

and coordination of care.

Patients must receive care when they need it and in many forms, not just face-to-

face. Patients must also have equity of access to services and are treated with

equality irrespective of their race, gender, sexual orientation or age.

We also aim to have robust processes of evaluation, monitoring and audit.

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Our Staff

Our staff will continue to be the most important part of the local NHS. Their commitment, professionalism and enthusiasm will underpin and enable all our plans. In common with many others across Wales, the Health Board does, however, face some key workforce challenges. A major issue is the ongoing UK-wide shortage of hospital

middle grade and junior doctor vacancies across many specialties, which is resulting in difficulties filling vacancies. The general economic situation means there is a reduction in the turnover of staff; while at the same time increasing integration with partner organisations, like Social Services. We also have to meet the requirements of the European Working Time Directive, which limits the time doctors and other members of staff are in work. The above means we will need to redesign services and accept the requirement for new roles, new professional relationships and a more flexible, mobile, workforce.

Finances Quality services, delivered appropriately, in the correct setting, are right at the heart of planning and delivering services. This is not only the correct approach from a health service and patient point of view, but it also makes financial sense. Financial pressures, whilst challenging, also create opportunities to find more efficient ways of working by reducing waste, harm and variation. Financial pressures are not, and can never be, an excuse for reducing quality or access. Example:

Some Day Surgery patients at Singleton Hospital now have their outpatient

appointment and surgery on the same day. The new Carpal Tunnel ‘Consult and

Treat Clinic’ means the vast majority of patients with this condition only have

to travel to hospital once to see the consultant, and if diagnosis is confirmed,

they receive surgery that day.

This new way of working aims to minimise the amount of time patients are

waiting for a clinic appointment and surgery, as well as the number of hospital

trips. All the operations are carried out using a local anaesthetic, administered

by the consultant, reducing the costs related to having an anaesthetist present.

It also frees up the anaesthetist to be available elsewhere. Consultants also

have more clinic time available as out-patient work is reduced.

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Whilst the Health Board is cost efficient, there is always room for improvement. The state of public finances means that funding will reduce in real terms over the coming years while cost pressures are likely to continue to increase. In addition, the total growth (cash) funding provided to NHS Wales over the last six years has been considerable but the service has experienced ever increasing demand and new development. NHS organisations in Wales therefore enter an even more challenging economic period with a clear need for major redesign and service change.

OUR 5 YEAR PLAN – Changing for the Better

Prevention and Health Improvement In line with Welsh Assembly strategy the ten key priorities for the Health Board are:

1. Reducing smoking prevalence;

2. Increasing participation rates in

physical activity;

3. Reducing unhealthy eating;

4. Stopping the growth in harm

from alcohol and drugs;

5. Reducing teenage pregnancy

rates;

6. Reducing accident and injury

rates;

7. Improving mental wellbeing;

8. Improving health at work;

9. Increasing vaccination and

immunisation rates to target

levels;

10. Reducing health inequities.

Unscheduled Care

Unscheduled care is when patients become suddenly ill or injured and need emergency or unplanned health care where they don’t have a pre-arranged appointment. Our goal is to develop a 24/7 healthcare system to increase the

amount of unscheduled care taking place in the community and primary care settings (e.g. GPs). However, we will ensure all four acute hospitals within the ABM area continue to accept emergency medical patients, with protocols to define the range of patients which will be admitted.

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We will listen to the views of front-line staff and patients on how unscheduled care services need to change, and act on these. We will also offer good quality, timely, care to patients in the A&E departments at the Princess of Wales and Morriston Hospitals, and improve handover times from the ambulance service. Another aim is to maintain high quality care standards checked through audit, evaluation and patient feedback.

Mental Health We aim to develop and maintain community-focused care helping people to stay in their own homes for as long as possible. Services will be provided in the least restrictive of environments while still ensuring safety of patients and others. Our services will be evidence-based, effective and supportive, and we will engage with patients and careers. Services will be integrated with Local Authority, Housing and Voluntary Sector and primary care partners.

Long Term Conditions Our goals are to improve the services for people with, or at risk of developing long-term conditions; promote wellness, rather than treating illness and support self care, independence and social inclusion. We will integrate the development of community networks, specialist community resource teams and signposting of services to improve the care for individuals with long-term conditions. This will help reduce the demand placed on hospital services. These changes are already beginning to take place. Example:

Mrs Constance Bale was referred to the Intermediate Care team in Swansea

after a complicated hip replacement. She had not been able to walk properly

for over a year and needed physiotherapy and other support to regain her

mobility.

She received professional care from the nurses and therapists in the

Intermediate Care team in her own home, and was also given equipment to

help her, including a ‘perching stool’ which let her half-sit, half-stand in

comfort. This played a big part in helping her regain her independence. She

said: “I can now cook a Sunday dinner, which is a big achievement.”

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Primary Care We intend to improve the way primary care providers (GPs, dentists, etc) and secondary care services (hospitals) work more closely together. Our aims also include ensuring primary care services are accessible and efficient, and that they are expanded to meet local needs. We will develop governance arrangements to

underpin new models of service delivery, and work with independent contractors to make changes to the range of services available. We will also ensure that primary care services are supported with modern infrastructure and premises.

Continuing Care We want to ensure patients and their carers receive high quality care and support which recognises their rights and is provided in an environment which best suits their needs. The views of patients and their carers about how services are provided and how these should change will be listened to and acted upon. It is important that there is a collaborative approach to continuing care between Local Authorities, the Health Board, the Independent Care sector, the Voluntary Sector and patients and carers. Continuing care should also be delivered as close to the individual’s home as possible, or in the majority of cases, in the patient’s own home, supported by robust care planning and coordination. We will ensure effective implementation of the Carer’s Measure, for the people who care for of continuing care patients, and repatriate individuals whose care is currently provided out of area.

Medicines Management The role of our pharmacists will be extended to allow them to make an active contribution in prevention, and chronic condition management, programmes. We will ensure effective, evidence-based medicine management

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practices, and enhance patient involvement in the planning and management of their medicines. In order to make the most efficient and effective use of medicine, we will monitor and evaluate how they are managed, and where appropriate, reduce spend – e.g. by using generic, rather than named brands, when they work the same way.

Informatics Informatics is the use of technology to support the delivery of safe, high quality care. We will support more seamless care by improving clinicians’ access to clinical information across the wider health community. We will work to ensure information systems are compatible across organisations, (supported by appropriate information sharing protocols). This information will need to be up-to-date, accurate and available wherever

care is being delivered. Electronic information held on multiple, disparate systems will be brought together, supported by a robust technical infrastructure to ensure the right information is accessible to the right people at the right time. We will also:

� Automate and streamline clinical and business processes to

reduce duplication, improve productivity and deliver

operational efficiency.

� Use technology to support new ways of working and deliver

modern services.

� Use clinical performance data to help improve care and

reduce risk.

� Secure Information and Communication Technology to

protect data, including person identifiable and organisation

sensitive information.

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THE SHAPE OF NHS SERVICES Primary & Community Services We will build on all the strengths of existing primary and community care services. We will also introduce:

• Community Networks covering relatively small populations, based around natural communities, within Local Authority boundaries.

• Specialist Community Resource Teams to support the more specialist needs in larger populations, at Local Authority level.

• A Communications Hub to coordinate and navigate services for patients and staff.

We will need to improve the way primary care and hospitals work together, and rebalance care so more can be delivered closer to people’s home - with less reliance on hospitals, unless patients really need to be there.

Community Networks Community Networks will cover populations of around 30,000-50,000 people and ensure NHS services truly meet the needs of local people. They will reflect natural communities and are aligned within Local Authority boundaries. Over time Community Networks could develop as more autonomous teams. The purpose of a community network approach is to:

� Ensure services are responsive to the local needs of patients and service users.

� Identify gaps in local provision to inform local plans. � Provide a framework for taking decision-making as close as

possible to front line service delivery. � Encourage multi agency/multi professional team-working to

develop more integrated responses for patients and service users.

� Provide care coordination and case management for people

with complex needs. � Provide a range of services from single interventions to

continuing health care. � Provide a clear links with hospitals, including regular

rotation of staff to maintain skills and understanding. � Establish effective relationships with care homes in the

geographical area.

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� Provide a clear interface with specialist community services

and resources to “top up” care provided by community network teams if needed.

It is important that Community Networks build on a pattern of effective and efficient individual GP practices as these will continue to be the first port of call for the vast majority of people. They are the cornerstone of fast, accessible healthcare. We will ensure we have the right services available locally at all times. This will require some

extension and revision to existing service delivery arrangements. It is expected that 11 Community Networks may be needed to cover the ABM area. These need to be the subject of formal agreement between the Health Board, Primary Care Contractors and Local Authorities, but the emerging thinking is outlined below. Swansea Because of its size, Swansea will have three sub-localities: West, Central and the North. Health and Social Services are already shaping some of their community teams to be coterminous with these boundaries. They include the older people’s assessment and care management function, District Nursing, and Chronic Condition Management Teams. Within the three sub-localities, a further five networks will sit. Two will feed into the North (Lower Swansea Valley and Llwchwr), and two into the West (Swansea Bay and Penderi). The Central sub locality will not be subdivided because of its smaller area and the overlaps of GP Practice populations. Neath Port Talbot Talks have taken place in Neath Port Talbot highlighting a requirement for three community networks covering the Upper Swansea Valley, Neath, and Port Talbot.

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Bridgend In Bridgend extensive work has been carried out to identify how health and social services should most effectively be grouped in the future. This has also indicated a need for three community networks – one for the northern valleys area, and 2 for the south of the area.

Specialist Community Resource Teams These teams will provide intensive intervention to help avoid admission to hospital and help patients leave hospital on time. They will be organised on Local Authority boundaries as these are services that cannot be provided safely or efficiently for the smaller populations covered by Community Networks, and need a larger catchment area. The teams have scarce specialist staff who cannot be replicated in small teams, and will need to ensure cover arrangements that span 24/7. Specialist Community Resource Teams (SCRT) will complement and top up services delivered by the Community Networks, rather than duplicate general care and support. The Teams will play an important part in intervening in a crisis, including urgent comprehensive assessment, development of individual care plans and the delivery of targeted short-term enhanced support in the home. This may be for complex health conditions or chronic diseases, and will ideally be for a defined period of intensive support. The SCRT will also focus on delivery of general and disease specific rehabilitation programmes, including those in hospital inpatient facilities. SCRTs will transfer patients to Community Network Teams at the earliest opportunity to be ready for the next urgent referral. The type of services and resources that would be available to the SCRT include:

• Enhanced primary care services

• GP support team

• Inpatient beds: sub-acute care, shared care, transitional care, rehabilitation, respite

• Hot clinics

• Day Hospital services

• Early response services

• Reablement / Intermediate care services

• Some therapies

• Specialist nurses linked to secondary care services

• Discharge liaison nurses

• Specialist voluntary sector services

• Community based medical resources linking with secondary care

• Out of Hours GP services

• Housing services

• Community equipment & adaptation services

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Communications Hub Effective communication and sharing of information is essential to underpin this system. A communication hub will provide a single point of access to services for both staff and service users. It will inform and coordinate care, and focus on individual service user level. The hub will cover the ABM area and will encompass

health; Local Authority services; independent and voluntary sector services; the Welsh Ambulance Services Trust, South Wales Police and NHS Direct. In the ABM area the Communications Hub has three aspects:

• A library of services – providing signposts to services and information

• Care Coordination for individuals – providing seamless transfer between service providers.

• Directing the Care Pathway, particularly in urgent and acute situations The first stage in developing this hub is to ensure that a comprehensive Directory of Services is available.

Interface with Hospital Services Hospitals and community services need to work closely together as they change and modernise services, to ensure the most effective and integrated models of scheduled and planned care are developed. The number of hospital beds will need to be reviewed to reflect the fact that patients with lower levels of need, who have traditionally required hospital care, will increasingly be supported in their own homes, as is already happening. Example:

Mr John Harris, following a stroke, was adamant he did not want to go into

hospital and preferred to be cared for at home. His GP was able to ensure he

was seen by a Consultant and also had a package of physiotherapy and

occupational therapy in his own home. Mr Harris said: “As far as I’m concerned

I can’t fault the system.”

Integrated care pathways are very important as different parts of the system work together. This will ensure an evidence-based approach to delivering good quality care that meets the needs of patients on every occasion.

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Hospital Services Building on the development of primary and community services, the future roles of each of the four major acute hospitals in the ABM area will need to change. All four have a long-term future and key roles to play. To provide the best quality care across ABM, their roles will complement both each other, and also the developing community services.

Unnecessary duplication of services - which is inefficient and ineffective - will be avoided. While a wide range of core services will be available across sites, hospitals will generally develop more individual roles to improve the overall package of services available to the population served by ABM. This means some services may switch sites, or be centralised, or dedicated services developed in some wards or hospitals. Service change has been gaining pace and during 2010/11 a number of changes will take place to support this strategy. The model described for each hospital takes these changes into account. Morriston Hospital Morriston is the centre for specialist emergency and complex care across the ABM area. It provides some specialist services for the whole of South West Wales, in some cases South Wales, and for the Burns and Plastic Surgery service for the South West Region of England as well. Specifically Morriston is seen as the site for the following services:

• Critical Care – All levels

• Tertiary (Specialist) Services: e.g. Renal, Cardiac, Vascular, Burns & Plastic Surgery

• Complex and Emergency Surgery

• Inpatient Paediatrics

• Major Trauma

• Emergency Medicine

• Acute Stroke care

• Accident & Emergency

• Head and Neck services

• Short-term acute care (5 days)

• Level 3 complex diagnostics

• Specialist Outpatients

• Specialist Inpatient care

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The Health Board has three other acute hospitals within its boundaries, each located in one of the three localities – Neath Port Talbot, the Princess of Wales and Singleton hospitals. There will be differences in the exact configuration of services within each of these hospitals, due to their location and traditional pattern of services. The hospitals will continue to accept emergency medical patients. The following are seen as key components which should be in place in each:

• Emergency medical admissions

• Pathology/Phlebotomy

• Radiology – rapid access, point of care

• Rapid access and step-down services

• Therapies as part of intensive rehabilitative service

• Outpatients

• Maternity care

• Critical Care – Level 2 and below

• Hot clinics for rapid assessment

• Planned surgery

• Stroke rehabilitation

In addition to these services there will be some unique aspects to each of the three acute hospitals based on their specific roles within each health community. Neath Port Talbot Hospital

This is the acute hospital for Neath Port Talbot. It will focus particularly on ambulatory care (walk-in) for this population and some areas of Swansea. It will also provide direct access services/beds for Community Networks within the Neath Port Talbot locality. Midwife-led maternity care will continue to be delivered at the hospital.

Princess of Wales Hospital This is the acute hospital for Bridgend. It will particularly focus on ambulatory care for this population and the provision of Accident and Emergency; direct access services and beds for Community Networks in Bridgend. It will also provide some more specialist services which can be sustained in two locations across the ABM area – e.g. secondary care cancer services, Ophthalmology,

Paediatrics, Obstetric and Midwife led maternity care.

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Singleton Hospital This is the acute hospital for Swansea, particularly focusing on ambulatory care for this population and providing direct access services and beds for Community Networks within the Swansea locality. It will also provide specialist cancer services, oncology and radiotherapy for ABM area and the rest of South West Wales.

Also, general Ophthalmology care for Swansea and specialist Obstetric led maternity care for South West Wales, with a Level 3 Neonatal Unit. It is, significantly, co-located with Swansea University’s Institute of Life Sciences 1 and 2. Community Hospitals The Health Board recognises the significant contribution of Community Hospitals. They will be an integral part of all the localities and provide a range of key community services. Detailed work is now proceeding to establish the future bed configuration across all hospital sites. This work will take account of how more care is increasingly being delivered in primary and community care settings. In order for the pattern of acute services to change between hospitals in the ABM area a number of issues must be addressed, these include:

• Transport and accessibility must be considered when planning new or changing services.

• The discharge process must be improved through closer joint working between hospital and community services.

• Clear admission criteria are required to help the Ambulance Service take patients to the appropriate hospital.

• Acute assessment units will need multidisciplinary teams.

• Good mechanisms are needed to ensure patients admitted for specialist care (e.g. Stroke) at Morriston and Princess of Wales Hospitals transfer quickly back to their local acute hospital for rehabilitation or back into the community, as soon as they are well enough.

• Protocols to move patients to community hospitals, direct from their own homes when appropriate, are also required.

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Implementation We are developing detailed implementation plans to allow us to pursue our objectives with pace and purpose. We will share these, as they are finalised, to enable continuous knowledge of our work and our action to improve the quality of care. If you would like to find out more about our strategy, details of our Five Year Plan, Changing for the Better is available in the full document, which is on our website: www.abm.wales.nhs.uk. We also want to know what you think, and our website has a feedback link for you to contact us and give us your views. Or write to us at: ABM University Health Board, 1, Talbot Gateway, Baglan Energy Park, Baglan, Port Talbot, SA12 7BR. Please let us have your views by 15th October 2010