Health, Social Care and Sports Committee

Request for Information from Health Boards

Cwm Taf UHB – 28 September 2018

Mental Health

1. A detailed breakdown of spend on mental health services for the last 3 years (including how total spend compares to the ring-fenced allocation).

	16/17	15/16	14/15
	£m	£m	£m
General Medical Services ( including Quality Outcomes Framework and Enhanced Services)	2.2	3.0	2.9
Prescribing	3.2	3.8	4.2
Total Primary Care	5.4	6.8	7.1
Cwm Taf – Mental Health	43.8	40.9	40.6
Cwm Taf - CAMHS	3	2.4	2
Other Welsh providers	1.4	1.0	1.0
Other secondary care	0	2.7	1.2
WHSSC	4.1	4.0	5.7
Total Secondary Care	52.3	51.0	50.5
Continuing Healthcare	19.9	17.4	17.3
Grand Total	77.6	75.3	75.0

The following additional funding for Mental Health services have been received by the Health Board:

· 2015/16 – CTUHB received additional funding of £0.7m from the Welsh Government (WG) for investment in a psychological liaison service, psychological therapies, perinatal services and dementia support workers. The UHB also received £1.0m of additional WG funding for child and adolescent mental health services (CAMHS) and £0.5m Delivery Agreement funding for older persons community redesign.

· 2016/17 – The UHB received additional funding of £0.5m from the WG for inpatient psychological therapies, hospital based flexible resource and Local Primary Mental Health Support Services(LPMHSS) as well as £96k development plan funding for community outreach.

· 2017/18- The UHB received additional investment of £1.1m to support a number of developments. This funding is being used to:

- redesign our older persons mental health services by creating Dementia Care Hubs in Treorchy and in Merthyr Tydfil.

- Extend the Psychiatric Liaison Service and provide additional health care support worker staff on inpatient wards.

· 2018/19- The UHB received additional investment of £1.44m to support inflationary pressures upon Mental Health Services together with a commitment of a further £0.78m available to bid against to support investment and development of Mental Health Services.  In addition, the Integrated Care fund had identified a sum of £0.48m being made available to bid against for the dementia action plan

The chart below illustrates the ring fenced allocation and the actual programme budget expenditure for the last 3 years of published data. Whilst we support the principle of the ring fence for this important area, it has not influenced spending decisions in CTUHB as we have consistently spent more than the ring fenced allocation.

	2016/17	2015/16	2014/15
	£m	£m	£m
Ring fenced Allocation	66.9	65.0	65.0
Total Programme Budget Return	77.6	75.3	75.0

2. What mechanisms are used to track spend on mental health to patient outcomes

Alongside monitoring and reporting of expenditure on mental health services, the Health Board’s performance management arrangements and the performance dashboard track actual delivery of services to mental health patients, through a wide variety of Tier 1 and other performance measures.

3. Health board priorities for mental health services /spend for the next 3 years. How outcomes will be measured.

The Health Board has worked hard on the together for mental health plan in the region and has used this as the plan to deliver improved mental health services over the past few years and mapped into the next three years. The Health Board has utilised the Mental Health transformation fund to develop community services and capacity, crisis services and the transformation of old age mental health services, through our Valleys Life programme.  The outcomes for service users will be key for us and the development of national outcomes indicators is essential.

ENHANCING FORENSIC CARE

· Reduction in ALOS in low secure units

· Reduction in number of out of area low secure placements

· Reduction in CHC costs for low secure placements

· Reduction in re-offending / readmission

BUILDING ON VALLEY LIFE – CARE FOR PEOPLE LIVING WITH DEMENTIA AND THOSE THAT CARE FOR THEM WHEREVER THEY RESIDE

· Reduced emergency admissions

· Reduced ALOS

· 7 day access to support in the community

· Increased patient, carer satisfaction

· Dietetic activity and case studies with outcome measures

· Reduction in therapist visits when evidencing occupational performance such as routines and structures in cases where there are discrepancies between the service users, family and professionals opinions of the home situation and performance.

ADVANCING PRACTICE IN ADULT MENTAL HEALTH INPATIENT CARE

· Number of clinical sessions by advanced practitioner

· Measurement of patient satisfaction of advanced practitioner interventions

· 2 case study / outcome reflections of involvement of advancer practitioner

· 2 case study / outcome reflections of therapeutic care

· 2 case study / outcome refections form recovery unit community interventions

· Retrospective review of all discharges from recovery unit for 1 year post increased recourse to establish level & range of community connections continued 3 months post discharge

ENHANCING CHILD AND ADOLESCENT MENTAL HEALTH LOCAL PRIMARY MENTAL HEALTH SUPPORT SERVICE

· Improved compliance with both Part 1 Mental Health Measure Targets

4. The extent to which allocated mental health funding is being used to support other services, for example where patients have a primary diagnosis of a mental health condition but require treatment for other health conditions. Do funding arrangements, including the mental health ring-fence strike the right balance between taking a holistic approach to meeting an individual’s needs, and ensuring resources for mental health are protected.

The Health board does not reallocate Mental Health funding to support other services, including services accessed by patients with existing Mental Health needs.  The ring fenced allocation is assessed based upon expenditure incurred for Mental Health conditions only.

However, the service does provide signposting and support for mental health patients in other settings, such as A&E and inpatients, particular through the Psychiatric Liaison Service.

5. How demand/capacity and spend on mental health services not directly provided by the health board is captured (e.g. in primary care, voluntary sector).

Expenditure for Mental Health Services not provided by the LHB is analysed and categorised according to guidance provided in the Programme Budgeting process.  This will include:

· Specific enhanced services provided by Primary Care Contractors

· Prescribing and dispensing costs of items classified as primarily Mental Health Treatments.

· Continue Healthcare placements for patients with a Mental Health need.

· Other NHS Wales Health Boards Mental Health Services for residents of Cwm Taf (see below).

· Specialist Commissioning of Mental Health Services via WHSSC (see below).

· Voluntary Sector agreements to support Mental Health Services (see below).

Secondary care Services from Other Health Boards and WHSSC

An annual review of services is undertaken which forms part of the Health Boards IMTP, linking with local service leads, the future requirements for demand and new models of working are developed  to form a commission plan. 

Voluntary Sector

Cwm Taf UHB commissions services from the voluntary sector for adult mental health services, via Service Level Agreements. SLAs are currently in place with a range of voluntary organisations to provide a range of counselling, advocacy, service user involvement and recovery college support. These include:

· MIND

· Hafal,

· Gofal,

· Cruse,

· Citizens Advice,

· Eye to Eye,

· New Horizons,

· New Pathways

· Interlink

An extensive review of all the above SLAs was undertaken in 2017 in order to determine whether:  

· the services commissioned continue to meet local needs and are ‘fit for purpose’

· the services are aligned to the Health Board’s and Directorate’s strategic priorities outlined in the IMTP

· the service specifications match current service activities and are flexible to adapt to any future requirements within the SLA term

· the existing arrangements have robust and appropriate performance measures and monitoring arrangements

· value for money is demonstrated

The review resulted in changes to some SLAs to improve alignment with the above criteria, the issuing of some new 3 year SLAs along with 1 year SLAs for those services where further review and evaluation was deemed necessary during 2018/19. We intend to tender for psychological therapy services from 2019 and for all commissioned services from 2021 to ensure clearer alignment with the strategic vision we are developing for mental health services in the Cwm Taf/Bridgend area.

6. A breakdown of spend on emotional and mental health services for children and young people (last 3 years). This should include information on all services, not only specialist CAMHS, and should be broken down by area (e.g. primary, secondary, crisis, therapeutic, voluntary sector etc).

Expenditure for CAMHS is included within the Mental Health programme budget expenditure. A detailed analysis is shown below:

	16/17	15/16	14/15
	£'m	£'m	£'m
Primary Care	0.1	0.1	0.1
CT Provider	2.8	2.4	2.1
WHSSC	1.5	1.0	0.9
Other Secondary care	0	1.3	0.7
Grand Total	4.4	4.9	4.0

Primary care/secondary care split

1. Health board spend on primary care for the last 3 years, including as a proportion of total health board spending. To what extent is this achieving the policy aim of shifting care from hospitals to primary care/community settings.

	17-18	16-17	15-16	14-15
	£'m	£'m	£'m	£'m
General Medical Services	48.3	46.3	45.3	45.1
Pharmaceutical Services	14.5	14.6	17.7	17.7
General Dental Services	16.2	15.4	16.2	15.8
General Ophthalmic Services	4.9	4.8	3.8	3.7
Other Primary Health Care expenditure	5.1	3.2	1.7	0.3
Prescribed drugs and appliances	55.8	55.5	56.0	55.2
Total	144.8	139.7	140.8	137.8

	17-18	16-17	15-16	14-15
	£'m	£'m	£'m	£'m
Primary Healthcare	144.9	139.8	140.8	137.8
Healthcare from Other Providers	155.8	152.2	140.1	136.5
Hospital & Community	427.5	419.8	392.7	377.1
Total Expenditure	728.1	711.8	673.5	651.5
Primary Care %	20%	20%	21%	21%

2. Whilst the value of spending on Primary Healthcare has increased from 2014/15, proportionate to total expenditure it has remained broadly static. This is because there are a number of pressures on secondary and tertiary healthcare spend, including workforce pressures, new drugs guidance, demand pressures and the improvement of specialist services. 

3. The Committee’s report on the 2018/19 draft budget recommended that ‘ the Welsh Government should support and hold health boards to account to prioritise capital funding for primary care and ensure it improves the physical capacity for multi disciplinary working and promotes new models of care’. What progress can the health board report in relation to this recommendation.

We have a well-developed primary care pipeline of projects supported by the Welsh Government.  This is enabling us to fund the Dewi Health Park development (which includes the provision of primary care practice from new premises) and Tonypandy Health Centre developments for example, as part of our wider primary care strategic development and improvement plans. We are also looking innovatively at the opportunities that the Transformation Fund and ICF capital funding can bring to supportive this objective, with our partners, across Cwm Taf.

Preventative spend/integration

1. Can the health board demonstrate a greater focus on prevention and early intervention in its allocation of resources.

Prioritising our health and social care core funding differently, alongside non-recurrent funding sources such as: the Primary Care Pacesetter Fund, Integrated Care Fund, Delivery Plan monies, Mental Health monies and others, have supported the piloting and evaluation of innovative service models such as our integrated Stay Well@Home service, developed with partners,  Inverse Care (Cardio-Vascular Disease) Health Check, Community Coordinators, Befriending, Cluster led Virtual Ward, Mental Health Valley Life Model, Community Hubs, Early Stage Cancer Diagnosis and the developing the earlier role in pathways of diagnostics.

This evidence base for population segmentation, proactive risk management and anticipatory care and support together with a rapid, flexible community response is part of the next phase of our transformation journey, which is the scale up and further integration of our community based health and social care.

2. What evidence can the health board provide about progress made towards more integrated health and social care services.

As part of the Cwm Taf Regional Partnership Board, Cwm Taf is making good progress towards more integrated health and social care services with its partners.

Within the context of an approved Integrated Medium Term Plan (IMTP) for Cwm Taf University Health Board (UHB), Merthyr Tydfil (MT) County Borough Council and Rhondda Cynon Taf (RCT) County Borough Council being approved as local authority ‘Full Flexibility’ pathfinders, and the approval of our Cwm Taf Regional Area Plan, a clear, partnership supported, transformation programme has developed. 

This programme is predicated on developing seamless services which are provided closer to home and transform outcomes for individuals and communities.

Our track record of delivery in partnership has enabled us to be bold in developing an ambitious long term model which, aligned to ‘A Healthier Wales: Our Plan for Health and Social Care’, targets the necessary urgent change required to deliver a whole system approach to the provision of health and social care across Cwm Taf.

This builds on recent successful and award-winning integrated service delivery such as our Stay Well @Home Project, which prevents unnecessary hospital admissions and facilitates earlier hospital discharge for patients where appropriate.

Cwm Taf also has several pooled budget agreements with our partners, including an integrated equipment store and older adult care home services.

3. How will outcomes be measured, given that the benefits of preventative activity may only be seen in the longer term.

With the support of our Research and Development team, as well University Partners, together with partners, we are putting a structured evaluation framework in place around the Cwm Taf Population Health and Social Care Service Model set out in our next phase of transformation. 

The development of an academically, robust framework provides the opportunity to significantly contribute to the evidence base for seamless health and social care.

Building on the knowledge of our transformation work to date, the following are examples of some of the measurable benefits we would expect to be able to demonstrate:

· Change in the profile of people in residential care placements

· Change in the profile of people needing long term social care interventions

· The shift of interventions from clinical environments to an individual’s home environment where ever that may be

· Improved access to primary care services,  i.e. reduced waiting times and patient satisfaction

· Increase in the number of people with an anticipatory care plan

· Improved patient outcomes, experience and safety (based on defined clinical need)

· A reduction in acute outpatient appointments

· A reduction in medicines management costs

· A reduction in the demand for urgent primary care out of hours services

· An increase in the support available in the community provided by the third sector

· An increase in the range of community based services accessible out of hours

· A reduction in hospital conveyances by ambulance and admissions with a reduced length of stay when someone needs acute care

· Reduction on the reliance on acute care beds – reduction in Length of Stay / Increase in time spent at home

All of the above are based on current population demographics, identified through our population assessment e.g., the growth in the elderly population living with long term multiple conditions.

Our draft outcomes are based around the quadruple aim as can be seen in the diagram below:

Admitted Patient Care

1. Spend on both elective and non elective admitted patient care in each of the last 3 years. Projected demand and spend for both elective and non elective admitted patient care for the next 3 years.

	2016/17	2015/16	2014/15
	£’m	£’m	£’m
Day Case	21.1	16.8	15.9
Elective IP	25.3	23.1	24.4
Non Elective IP	176.3	172.3	162.5
Admitted Patient Care	222.7	212.2	202.8

The Health Foundation ‘Path to Sustainability’ report suggests a 3.2% annual growth with potential cost avoidance of 2% so net 1.2%. However, this is before the new pay A4C and medical pay increases.

The forecasts in the table below assume an estimated increase in spend of 3% pa: 

	2017/18	2018/19	2019/20	2020/21
	£’m	£’m	£’m	£’m
Day Case	21.7	22.4	23.0	23.7
Elective IP	26.0	26.8	27.4	28.2
Non Elective IP	181.6	187.0	192.6	198.4
Admitted Patient Care	229.3	236.2	243.0	250.3

Workforce

1. Progress in addressing workforce pressures identified by the health board ahead of last year’s budget.

Recruitment and retention difficulties pose a significant risk to the Health Board in delivering safe and effective services, as well as being a primary driver for skill-mix change and workforce modernisation.   Building on the digital nurse recruitment campaign, the Health Board commissioned a PR company to develop the ‘Cwm Taf offer’. The focus of this campaign was Medical & Dental and Allied Health Professionals and this recruitment strategy was designed to dovetail with Welsh Government’s “TrainWorkLive” campaign.

Our International recruitment continues and there is an ongoing supply of nurses that are under offer, as we wait for them to achieve the relevant qualification and language requirements, to be able to enter the UK and achieve NMC registration. The Health Board has also further participated in MTI initiatives in a variety of medical specialties along with skill-mix change through the use of advance practice roles and introducing new roles e.g. Physician’s Associate.

We continue to work closely with our Universities building links to encourage students to select Cwm Taf as an employer of choice. 

Increased workload and, to some extent, declining income has made General Practice a less attractive career for newcomers compared with locum and hospital medicine and less attractive for the continuance of older General Practitioners, with many choosing to retire early or reduce their time commitment. In addition to the recruitment and retention issues ‘in hours’ there is also a growing problem of recruitment for GPs sessions ‘Out of Hours’. The Health Board is working on further redesign of the ‘Out of Hours’ workforce, encouraging a multi-disciplinary approach.

The Health Board has, for a number of years, worked with the University to support and encourage the placements of pre and post registration nurses within Primary Care. Many practices within Cwm Taf are willing to take and support students. The Health Board and GP Practices are now working together to devise a programme of work around a structured pre-registration placement within 2018. The Health Board has also facilitated a series of GP sustainability workshops with the 42 GP Practices within the Cwm Taf population, exploring ways in which demand and capacity planning, development of new roles/skills development, and cluster networking can inform an agreed collaborative workforce strategy.

The South Wales programme of work in respect of the Healthcare Alliance work to reshape the provision of health services across South East Wales, is now moving to implementation stage, which includes development of new workforce models. A significant Organisational Change Process is underway to facilitate these changes.

While recruitment is a key factor in our agency and locum spend, the Health Board recognises that levels of sickness absence are also a significant cost driver. While our sickness trajectory had been improving for over 12 months, over the winter period we have seen an increasing trend that positions us within the upper quartile across Wales.  This will be a key priority wit our locally set targets over the life of the plan reducing from 5% to 4.7%. A complimentary programme of wellbeing activity, aligned to our staff engagement framework, continues with the re-assessment of the Corporate Health Standard Platinum award in February 2018.

2. Actions taken to ensure sustainable workforce following the UK’s withdrawal from the EU. What assessment has been made of future funding needs post Brexit.

The Health Board is reviewing legislation and accompanying guidance notices for any right to work amendments or employer obligations required within the Brexit process, with a view to ensuring we are able to continue to recruit from EEA/EU and comply with legislation.   We will continue to support the Welsh Government’s “TrainWorkLive” campaign which is a global recruitment campaign to promote working within Wales. In addition, we will periodically refresh local recruitment campaigns to take into consideration any decisions made during the Brexit process.

The Health Board will also ensure that within the workforce planning process of the IMTP, it considers the impact of Brexit in the short, medium and longer term, understanding and planning for workforce sustainability.

3. Evidence about progress made in reducing and controlling spend on agency staff

Medical Agency Locums

The Health Board has played a lead role in the design and delivery of the Welsh Government circular - Medical and Dental Agency and Locum Deployment in Wales (October 2017) which sets out the arrangements for reducing the reliance on agency locums. 

Following implementation of this circular, the Health Board’s average monthly spend started to reduce (from January 2018) by approximately £200k per month. The agency spend in the first quarter of 2018/19 was 11.87% of total medical spend compared to 14.54% in 2017/18. 

Strategies taken by the Health Board to control agency locum spend includes a monthly scrutiny committee to review areas where there is high agency usage, requiring the Medical Director’s authorisation where the hourly rate exceeds the all Wales cap. In addition, a Medical Workforce Efficiency group meets on a monthly basis to review the processes affecting supply and demand of the medical workforce, with a particular focus on e-rostering, job planning, recruitment and alternative skill sets.

Nursing

Likewise, scrutiny of agency nurse usage takes place on a monthly basis at the Executive led Nursing Workforce Group, ensuring recruitment and retention strategies are progressing to plan. The Health Board has adhered to the All Wales Nurse Framework Agreement and does not use off-framework agencies.