PTHB Integrated Medium Term Plan PTHB Integrated Medium Term Plan

230 Pages·2015·4.37 MB·English

PTHB Integrated Medium Term Plan
2014-2017

PTHB Integrated Medium Term Plan
March 2015

2015-2018

“Truly integrated care centred on the needs of the individual”

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MESSAGE FROM THE CHAIR & CHIEF
EXECUTIVE

Health and wellbeing plays such an important part at every stage of our lives, and whilst we all hope
to lead healthy lives we know that there are times when we will need the services of health or social
care. This Plan sets out how over the next 3 years Powys teaching Health Board intends to work
together with the population of Powys, professionals and others to help achieve better health and
better health and care services. We start from a strong base of having a population that is generally
healthy, communities that are generally strong, health care services that generally serve the
population well and a health and care workforce that is truly committed to Powys. We know
however that there are areas where health is poorer that it could be and that inequalities exist; that
some health and care services are fragile; that some service provision is outdated and doesn’t
provide the best experience possible for people; and that some staff (whether doctors, nurses,
therapists, critical support staff, or managers) are stretched. Importantly, we also know that staff
across the county; individuals, communities and the groups that represent them; and leaders of
health, social care and other services are highly motivated to work together to continue to improve
the lives of people and communities in Powys.
Whilst the period of financial austerity for public services continues, we are determined that we use
such challenging times as a means to help us work more innovatively and creatively with the
population to improve health and provide better health and care services. Being ‘prudent’ is going
to be essential, and spending public money efficiently and effectively is critical, and is something
that we all collectively have responsibility for. Our plan focuses on 3 key elements:
Enhancing Primary and Community Care - Providing high quality and efficient care in
or close to home makes sense on all fronts, especially in our rural county. Supporting
GP teams, pharmacists, optometrists/opticians and dentists is key, as is developing a
wide range of services in health and social care settings and our community hospitals.
Integrated Working – Finding new and better ways to work jointly with people who
use our services, with other health organisations in and outside of Wales who provide
services to the people of Powys, and essentially with our key partner Powys County
Council. Powys, with its often complex arrangements and multiple borders, can
demonstrate leadership and expertise on integrated working to others.
Excellent Commissioning – There are services we will continue to need to ‘buy’ from
others for the people of Powys. We want these to be high in quality and effectiveness,
innovative in approach and sensitive to the needs of the individuals who use them.

We anticipate that over the coming 3 years there will be change. Firstly, we intend to support people
to make positive changes in their own health and wellbeing. Secondly many of the services we ‘’buy’
on behalf of the people of Powys are needing to change and we will be working together with others
to help design and implement those changes, and last but certainly not least, the services we
provide in Powys will also need to change and we look forward to engaging positively with people to
deliver better services for all.

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TABLE OF CONTENT
Message from the Chair & Chief Executive............................................................................................. 2
Table of Content ..................................................................................................................................... 3
1. Summary .................................................................................................................................... 5
2. Progress in Delivering 2014/15 Plan ........................................................................................ 14
3. Health Board Profile ................................................................................................................. 17
3.1. HEALTH ECONOMY OVERVIEW ...................................................................................................... 17
3.2. POWYS TEACHING HEALTH BOARD PROFILE ..................................................................................... 19
3.3. PARTNERSHIPS ............................................................................................................................ 20
3.4. HOSTED NATIONAL SERVICES ........................................................................................................ 29
3.5. OUR WORKFORCE ....................................................................................................................... 30
3.6. FINANCE .................................................................................................................................... 35
3.7. CURRENT PERFORMANCE ............................................................................................................. 36
4. Local Health Needs and Challenges ......................................................................................... 39
4.1. WORKING WITH PARTNERS TO UNDERSTAND HEALTH NEEDS .............................................................. 39
4.2. POWYS POPULATION DEMOGRAPHICS............................................................................................. 40
4.3. WIDER DETERMINANTS OF HEALTH ................................................................................................ 42
4.4. HEALTH SERVICE UTILISATION ....................................................................................................... 50
4.5. FOCUSING ON OUTCOMES ............................................................................................................ 52
5. Strategic Approach to Transformation .................................................................................... 55
5.1. NATIONAL POLICY DRIVERS ........................................................................................................... 55
5.2. STRATEGIC DIRECTION ................................................................................................................. 56
5.3. STRATEGIC FRAMEWORK .............................................................................................................. 57
5.4. DEMAND, CAPACITY AND FINANCIAL MODELLING ............................................................................. 58
5.5. TRANSFORMATION PROGRAMME ................................................................................................... 59
5.6. ORGANISATIONAL DEVELOPMENT .................................................................................................. 64
6. Quality and Safety Improvement ............................................................................................. 67
6.1. QUALITY DELIVERY PLAN .............................................................................................................. 67
7. Health Board Priorities ............................................................................................................. 73
7.1. PRIMARY CARE ........................................................................................................................... 74
7.2. EXCELLENT COMMISSIONING ......................................................................................................... 94
7.3. INTEGRATED WORKING .............................................................................................................. 103
8. Service Delivery Plans and Initiatives ..................................................................................... 107
8.1. PREVENTION AND HEALTH IMPROVEMENT ..................................................................................... 108
8.2. UNSCHEDULED CARE ................................................................................................................. 117
8.3. PLANNED CARE ......................................................................................................................... 122
8.4. INTEGRATED CARE FOR OLDER PEOPLE .......................................................................................... 131
8.5. MENTAL HEALTH ...................................................................................................................... 133
8.6. LEARNING DISABILITIES SERVICE ................................................................................................... 145
8.7. CANCER SERVICES ..................................................................................................................... 147
8.8. HEART DISEASE SERVICES ........................................................................................................... 149
8.9. DIABETES SERVICES ................................................................................................................... 151
8.10. SERVICES FOR END OF LIFE .......................................................................................................... 153
8.11. CRITICALLY ILL .......................................................................................................................... 156
8.12. STROKE SERVICES ...................................................................................................................... 157
8.13. RESPIRATORY SERVICES .............................................................................................................. 159
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8.14. NEUROLOGICAL CONDITIONS ....................................................................................................... 161
8.15. LIVER DELIVER PLAN .................................................................................................................. 163
8.16. ORGAN DONATION ................................................................................................................... 163
8.17. SUBSTANCE MISUSE .................................................................................................................. 164
8.18. MATERNITY SERVICES ................................................................................................................ 166
8.19. CHILDREN’S SERVICES ................................................................................................................ 167
8.20. SEXUAL HEALTH ........................................................................................................................ 169
9. Workforce & Organisational Development ........................................................................... 170
9.1. AN ENGAGED WORKFORCE ......................................................................................................... 171
9.2. A SUSTAINABLE AND SKILLED WORKFORCE .................................................................................... 175
9.3. PROFESSIONAL DEVELOPMENT............................................................................................ 181
9.4. WORKFORCE CHANGES .............................................................................................................. 183
10. Finance ................................................................................................................................... 186
10.1. FINANCIAL STRATEGY AND APPROACH TO COST REDUCTION .............................................................. 186
10.2. “SHIFT LEFT”............................................................................................................................ 188
10.3. SCOPE AND SCALE AND MANAGEMENT APPROACH TO COST REDUCTION ............................................. 190
10.4. THREE YEAR SUMMARY FINANCIAL PLAN AND FINANCIAL ASSUMPTIONS ............................................. 193
10.5. COST PRESSURES ...................................................................................................................... 196
10.6. SAVINGS PLAN .......................................................................................................................... 199
10.7. SUMMARY FINANCIAL THREE YEAR PLAN ....................................................................................... 201
10.8. RISKS AND FURTHER ACTIONS...................................................................................................... 203
10.9. FUTURE YEAR PLANNING SCENARIOS ............................................................................................ 204
10.10. CONCLUSION ............................................................................................................................ 206
11. Building Capability & Delivery ................................................................................................ 207
11.1. INFORMATION TECHNOLOGY ....................................................................................................... 207
11.2. CAPITAL & ESTATE .................................................................................................................... 210
11.3. RESEARCH & DEVELOPMENT ....................................................................................................... 214
11.4. INNOVATION ............................................................................................................................ 216
12. Stewardship and Governance ................................................................................................ 218
12.1. THE PLANNING PROCESS ............................................................................................................ 218
12.2. THE ENGAGEMENT PROCESS ....................................................................................................... 221
12.3. THE DELIVERY PROCESS .............................................................................................................. 222
12.4. FINANCIAL ASSURANCE .............................................................................................................. 226
12.5. THE ASSURANCE PROCESS AND CORPORATE GOVERNANCE ............................................................... 226

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1. SUMMARY

Powys has a unique opportunity to place healthcare services secured for the citizens in the County
on a sustainable footing. This Integrated Medium Term Plan (IMTP) sets out how the Powys
Teaching Health Board (PTHB) will set out on this path, through being a leader in Wales in the way in
which primary care and community services lead and drive healthcare services. The THB will achieve
this through strengthening the approach to planning and commissioning high quality services from
neighbouring organisations, and accelerating our joint ambitions for integration with Powys County
Council for the benefit of citizens.
The plan is grounded in the principles of prudent healthcare. Providing as much care as can
appropriately delivered in Powys is better care, is what patients are asking for, and for many services
can be provided at lower cost on a sustainable basis. This is an ambitious plan that invests in service
transformation in both the lifetime of the plan and beyond. In 2014-15 the THB is well placed to
have achieved a balanced financial outturn. In addition to reshaping its own resources, the THB has
secured additional funding from Invest to Save and set how additional funding from Welsh
Government will be applied to transformation in Powys. This Plan therefore sets out investment in:
 Primary care and community services to continue our approach to provide more services in
Powys, and to secure robust and sustainable primary care sector;
 Maintaining performance against access targets, and delivering improvement where required
through investment in primary care, greater focus on efficiency and effectiveness and delivery of
additional capacity to meet demand;
 Securing delivery of a sustainable healthcare and social care system through investment in the
organisation’s capacity to plan, deliver and performance manage change.
The THB and the residents of Powys know that the primary care and community based services
provided within Powys are highly regarded and help people to stay safe and healthy. We want to
ensure that when care is required across our borders that this is provided on a timely basis, is of high
quality, and returns people to local services as soon as possible – using it only when necessary.
Integrated working with Powys County Council across the range of services provided by both
organisations is also central to our ambition to citizens receiving a well-coordinated and local service
within Powys.
This IMTP covers the period 2015-18 and is designed around the vision set out by the Board to
deliver “truly integrated care centred on the needs of the individual”. The Plan is built on the Joint
Strategic Needs Assessment (JSNA) that has been further developed in the last year with an
additional focus on understanding poverty in the County. The THB faces unique challenges in Wales.
The County covers 25% of the land-mass of Wales with only 5% of the population, and that
population has the fastest growing proportion of older people in Wales. The level of rurality,
challenging transport links and reliance on neighbouring health boards in Wales and NHS Trusts in
England for acute services inform this Plan.
The THB has three strategic challenges of its own for the future:
 Designing and delivering a clinically and financially sustainable rural service model, providing as
much care as local to home as possible through a continued shift from hospital to community
based models of care;
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 Meeting the changing needs of Powys residents as demographic change and improvements in
healthcare continue to make their impact felt on demand for, and cost of, services;
 Working with partners and the public to support sustainable rural communities in a period of
public sector austerity.
The success of our plan will be measured by progress in the seven domains of the NHS Outcomes
Framework that was published in 2014. These outcomes are defined as:
 People in Powys are well informed and supported to manage their own health;
 People in Powys are protected from harm and protect themselves from known harm;
 People in Powys receive the right care and support as locally as possible and are enabled to
contribute to make that care successful;
 People in Powys are treated with dignity and respect and treat others the same;
 People in Powys have timely access to services based on clinical need and are actively involved in
decisions about their care;
 People in Powys are treated as individuals with their own needs and responsibilities;
 People in Powys can find information about how their NHS is resourced and make careful use of
them.
The plan is set out to broadly follow the requirements of the NHS Planning Framework for Integrated
Medium Term plans. It is framed by our strategic priorities and associated strategic objectives in
three areas:
 Primary Care and Community Services;
 Commissioning;
 Integration with Powys County Council.
The plan also sets out our focus and aspirations for improving the health of the population, our
response to the NHS Wales Service Delivery Plans and our supporting strategies for workforce and
organisation development, IT and estates, supported by the focussed work around our
transformation agenda.
Primary Care and Community Services
Powys THB has three mature GP clusters in the north, mid and south of the County. Their views,
articulated though local ‘cluster plans’, have strongly influenced the developing priorities set out in
this Plan. Delivery of this plan will build resilience in primary care and community services and by
securing and expanding strong general medical services, work alongside other high street health
providers to support citizens in the County. Supporting and building GP leadership of the local rural
healthcare system is a key feature of this Plan. Developing a new rural model of healthcare with
primary care at its heart is the main focus of the THB’s response to the Mid Wales Study
recommendations. Primary Care will be therefore central to leading the Health Board’s Plans for
transformation of service delivery in the short, medium and long term.
Commissioning
The THB is primarily a commissioning organisation with over half its financial resource devoted to
securing services on both an unscheduled and planned basis from neighbouring health boards and
NHS Trusts. Each of these organisations are moving forward with strategic change programmes to
deliver sustainable service models for the future, and the THB will work with partner NHS
organisations to both re-shape services in the medium to long term and secure effective, high
quality and efficient service delivery through the contract arrangements with these organisations. In
2014 the THB has reviewed its approach to commissioning and following this will strengthen these
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arrangements through establishing a Commissioning Programme, with a new Commissioning Board
at its heart. Strong commissioning is a key enabler to the delivery of this Plan, driving performance,
quality and efficiency.
Figure 1: PTHB Strategic Priorities and Objectives
Strategic Priorities
Primary Care and
Commissioning Community Integration
Services
•Commission sufficient •Increase the capacity of •Place the citizen at the
capacity to meet the primary care and centre of integrated
need for timely and high community services to service delivery through
quality healthcare deliver a greater joined up systems,
services across the proportion of care in processes and teams,
community and hospital Powys delivered at
system, with a shift in •Increase the resilience of neighbourhood level
emphasis to prevention primary care and •Develop integrated
and early intervention community services approaches to support
•Embed an innovative and direct service provision systems and functions
prudent approach to •Strengthen the clinical across all areas of our
service commissioning leadership role of shared business with
focused on patient primary care and Powys Council
outcomes community staff in •Put in place joint
•Provide assurance on the service planning, strategy, governance and
quality and effectiveness commissioning and scrutiny arrangements
of healthcare services delivery with Powys Council
across the healthcare
system
Integration with Powys County Council
The strategic partnership with Powys County Council through the Local Service Board and our single
integrated plan; the One Powys Plan, is central to the THB’s approach to the integration of health
and social care services at all levels within the organisations. Mental health services and services for
people with learning disabilities, older people and carers are key joint areas for attention. Powys
THB and Powys County Council are also focussed in their response to the Commission for Public
Service recommendation for greater integration of the two organisations. The two organisations
have a strong track record in integrated approaches to wider functions such as IT and the utilisation
of property and assets, and will further build on this work in strategic areas of joint interest.
Achievements
Powys already works from a strong base in respect of the degree to which its primary care and
community service led approach drives service delivery, quality and drives down cost through a
prudent approach. The THB’s business is structured around three GP Clusters, and in 2014 the THB
has for the first time given these clusters a voice on the Board through the creation of a new
appointment of a Director of Primary Care and Community Services. This Plan takes significant
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account of the work Practices have undertaken to develop their own cluster plans. These have been
developed in response to the local challenges that GPs and their local multi-disciplinary teams face.
The THB has already demonstrated the power that GP clusters can bring to delivering new
approaches to patient care. In South Powys the ‘Virtual Ward’ provides an enhanced multi-
disciplinary GP led primary care and community service model; here early evaluation demonstrates a
reduction in the level of emergency admissions to out of county Hospitals. This model provides the
evidence for how GP leadership can design and deliver new models of care; the THB, following a
successful Invest to Save bid, plans to roll out this approach across the County over the next year.
The implementation of technology will also enable a step-change in the way in which multi-
disciplinary teams communicate with, and about patients. The THB with Powys Council will aim to
implement the Community Care Information System in 2015, supported by other innovative
technology developments including the learning the THB is gaining through its European technology
partnership projects, Carewell and Mastermind.
During 2014 the THB has taken action to focus attention on the performance of both its own services
and those of its secondary care providers. The THB has achieved close to 100% delivery of the 26
week Referral to Treatment Time. The THB has also delivered an improving position for diagnostics
and therapy waits. With its partners the THB is aiming to eliminate waits in excess of 52 weeks by
the end of March 2015 and for 2016 will aim for no patients to wait longer than 36 weeks. Across all
of its commissioned and directly provided services the THB is tantalisingly close to its aspiration of
achieving the 95% threshold for 26 week waits.
Both the Glan Irfon Integrated Health and Social Care Centre and the ‘Virtual Ward’ model are
examples of how the THB is transforming its service delivery to support the unscheduled care
system. The THB has also worked with the Welsh Ambulance Service to implement new pathways of
care that enable ambulance crews to assess patients and transfer their care safely to Powys services
including our Minor Injury Units, to avoid conveyance out of county. Conveyance rates by WAST
from Powys to Emergency Departments are the lowest in Wales. The IMTP sets out further work in
respect of unscheduled care to further strengthen the flow of patients back to Powys, particularly
where this has been compromised through capacity challenges in social care services in the
community. The THB will also work with the Emergency Ambulance Service Committee to develop a
specification for services that matches the local service model. The commissioning of the Emergency
Medical Retrieval and Transfer Service (EMRTS) will also provide a significant improvement in access
to services for people from Powys with acute health needs including stroke, myocardial infarction
and major trauma as well as significant progress in ambulance response times.
The THB’s ambition is to make significant progress against the requirements set out within Welsh
Government’s ‘Together for Health’ strategy and the associated plans, and to strive to deliver the
targets set out in the NHS Outcomes Framework for Wales. Progress with these Plans are set out in
Section 7 of this Plan and the profiles for delivery of targets are set out in Section C1. Delivering this
ambition for Powys residents within the current financial envelope, without compromising on
quality is extremely challenging and will take all of the efforts of the organisation, its partners and
the community to deliver. The THB is confident that it will meet this challenge.
In 2014 the THB has further strengthened its musculo-skeletal services in-county that operate on the
principles of prudent healthcare to avoid escalation of care to specialist orthopaedic services. These
are popular and well-received local services and such models are at the heart of our planned care
programme, grounded in the capacity and demand modelling. Creating new opportunities to
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harness the skills of nurses, therapists, and professionals working in ‘High Street’ primary care
services, are identified throughout this plan.
Case for Change
The achievements in service change to date have been based on an emerging model that will
continue to inform the Health Board’s future transformation of service delivery. A core goal is to
refocus current investment to support health and wellbeing and the delivery of effective disease
prevention services and when people need services to secure them as close to home as possible
using a range of new models of delivery including use of new technology and integrated service
models to ensure safe, sustainable and economic deliver of care. The impact of the Transformation
Programme is to shift the balance of integrated care to secure a sustainable shift of activity towards
prevention, self-care and primary and community intervention, as illustrated in the diagram below:
Figure 2: Shifting the Balance of Care
In 2015 the teaching Health Board plans to launch a dialogue with the public around its own
Strategic Change Programme. In the past year the THB has commissioned and received independent
strategic modelling of capacity and demand for the Powys population that further strengthens the
evidence for change in the way in which services are provided for Powys in the future. The findings
of the Mid-Wales Study also re-enforce the evidence in respect for the need for strategic change.
The key messages include:
 Our status as having the fastest rising number of elderly population will become an
unsustainable problem for the health board both in service sustainability and financial
affordability if we do nothing
 There is clear evidence that we can create more sustainable and affordable services in Powys
that will limit the impact of our challenge, through the creation of innovative, primary care
driven models of care, facilitated through improvements in technology and integrated services.
There is a recognition however that there will always be services for which is it clinically safer for
patients to travel to settings outside of Powys
 Our future model will be capital dependent given 50% of our buildings predate the NHS and our
technology is outdated
A dialogue with the public on these matters will be challenging. The work the THB and Powys
Council has undertaken in Builth Wells, with the public, to build a new service model, providing
reassurance that the THB’s ambitions are to provide more care in Powys rather than remove services
from communities provides a blue-print for how change can be co-produced and managed. Glan
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Irfon in Builth Wells was fully opened in 2014; it is an integrated health and social care delivery
model led by primary care that avoids the escalation of care and makes prudent use of resources,
and physical assets, which has been recognised as good practice by the Wales Audit Office.
Quality and safety improvement remains the golden thread underpinning our planning processes
and is central to our work and the activities that staff and teams undertake in providing safe care for
our patients. Sustaining and embedding this work is crucial to ensuring Powys residents receive the
highest standards of care. We recognise our duty in ensuring this focus is strengthened for the
services we commission and purchase from other organisations for our population.
In setting out our achievements and challenges through our Annual Quality Statement we are
continuously assessing and informing Powys residents about how well we are doing across all our
services. In 2013/2014 we set to engage all teams in organisation wide learning focusing on the
failings in Mid Staffordshire: we reached 55% of our workforce. Following the publication of the
report ‘Trusted to Care’ all ward areas and supporting teams have been engaged in self assessment
and peer review. We will continue to strengthen our approach to organisation-wide learning so that
we can assure our public that we are giving safe levels of care especially in the fields of hydration,
night sedation, continence and medicines management.
The fragility of the rural service model continues to be a major risk for service delivery in Powys.
Recruitment to the medical workforce in Powys has been a challenge to the THB in 2014, however
our GP partners have stepped up to ensure that vital local services remain open in our community
hospitals. The fragility of primary care is in itself a risk for the continued local delivery of services.
During 2014 the THB has worked with GPs to fully understand how it can support practices to ensure
primary care in Powys can be sustainable for the future. This plan therefore sets out action in three
interlinked areas:
 Enhancing the leadership role of GP clusters in the strategic direction of the Health Board;
 Supporting practices in new approaches to collaboration at cluster level to enhance their
sustainability, supported by a proactive approach to recruitment and retention;
 Enabling practices to increase the portfolio of services they directly provide.
PTHB has highly unusual and complex arrangements for NHS adult mental health services. Around
250 NHS staff working in local teams and hospital wards in the county are employed by three other
health boards, following a transfer of services. The arrangements implemented in 2009 have failed
to deliver the required strategic changes needed to deliver modern mental health services that meet
local need. After an extensive stakeholder engagement and option appraisal exercise, the case for
returning the majority of mental health services to the direct management of the Health Board was
accepted by the Board
Powys teaching Health Board and Powys County Council are working together to implement an
ambitious programme to improve the mental health of local people, following public consultation.
The predicted rise in the number of people with dementia in the county means physical and mental
health services, and all local services, must work together even more closely.
Extensive further transformation work covering the domains of commissioning, quality, and the
model of service delivery is required to deliver a sustainable rural model for mental health care for
Powys.
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