hywel dda 







Date of Submission: 23 May 2019


1.    Hywel Dda University Health Board (the Health Board) welcomes the opportunity to contribute to the Health, Social Care and Sport Committee’s general scrutiny inquiry.


About the Organisation


2.    The Health Board is responsible for the health and well-being of its resident population and plans, provides and oversees delivery of NHS healthcare services for people in Carmarthenshire, Ceredigion, Pembrokeshire and its bordering counties. Our 11,000 members of staff provide primary, community, in-hospital, mental health and learning disabilities services for around 384,000 people across a quarter of the landmass of Wales. We do this in partnership with our three local authorities and public, private and third sector colleagues, including our volunteers, through:


·         Four main hospitals: Bronglais in Aberystwyth, Glangwili in Carmarthen, Prince Philip in Llanelli and Withybush in Haverfordwest;

·         Seven community hospitals: Amman Valley and Llandovery in Carmarthenshire; Tregaron, Aberaeron and Cardigan in Ceredigion; and Tenby and South Pembrokeshire Hospital Health and Social Care Resource Centre in Pembrokeshire;

·         48 general practices (4 of which are managed practices), 47 dental practices (including 3 orthodontic), 99 community pharmacies, 44 general ophthalmic practices (43 providing Eye Health Examination Wales and 34 low vision services),17 domiciliary only providers, and 11 health centres;

·         Numerous locations providing mental health and learning disabilities services; and

·         Highly specialised and tertiary services commissioned by the Welsh Health Specialised Services Committee, a joint committee representing the seven health boards across Wales.


Strategic Overview


3.    For the last three years, the Health Board has been moving from an organisation in turnaround to one of transformation.  Our Big NHS Change (a period of engagement and consultation with our population and stakeholders) provided an opportunity to improve the way that we plan and provide health services for our population.  



4.    The Health Board’s aim is to shift the focus from hospital-based care and treatment toward prevention and building the resilience of people and communities.  Following a period of engagement and consultation, in November 2018, the Health Board’s Health and Care Strategy: A Healthier Mid and West Wales – Our future generations living well was approved by Board.  This is our strategic vision for services that are safe, sustainable, accessible and kind and is based on an integrated social model of health.   Closely linked to our Health and Care Strategy is the Health Board’s first Framework for Continuous Engagement approved by Board in January 2019. 


5.    In January 2019, leading from our Health and Care Strategy, the Health Board published A Health and Well-being Framework for Hywel Dda.  This Population Health driven framework takes advantage of the opportunities provided by the Health and Care Strategy and empowers our communities to work together and create a movement for change through continuous involvement of people in our communities, our staff and our partners – a social model for health.


6.    In the next year, we will be scoping how many of our services, through quality and pathway improvements, could work towards shorter waiting times, including improved access to therapy services and diagnostic services.


7.    Our Big NHS Change programme followed the Health Board’s Transforming Mental Health Services programme that engaged with the public and stakeholders on proposals to change how care and treatment is provided to meet the mental health needs of people now, as well as future generations. A new model of care was co-designed, learning from engagement, co-design, international collaboration and public consultation that includes:


·         24-hour services – ensuring anyone who needs help can access a mental health centre for support at any time of the day or night;

·         No waiting lists – so that people receive first contact with mental health services within 24 hours and for their subsequent care to be planned for in a consistent and supportive way;

·         Community focus – to stop admitting people to hospital when it isn’t the best option and provide support in the community when people need time away from home, extra support or protection; and

·         Recovery and resilience – services that don’t purely focus on treating or managing symptoms, but instead help people to live independent, fulfilling lives with the help and support they need.   


There have already been some positive outcomes, such as a drop-in centre in Llanelli; a joint venture with third sector partners, MIND and Hafal, which is due to be operational from July 2019.  In addition, work is progressing in North Ceredigion to move to 24/7 day working with a drop-in facility, which we hope will be operational from January 2020; the team will be gradually phasing up its hours of operation until that time.





Planning and Integration


8.    Annual Plan: following Board approval on 29 March 2019, the Health Board has submitted a Draft Interim Plan to Welsh Government and is awaiting formal feedback.   Our Plan is aligned to Welsh Government’s A Healthier Wales with a focus on county and locality planning and co-produced with all local stakeholders.


9.    Regional Planning: the relationship between the Health Board and Swansea Bay UHB has been strengthened through the opportunities provided by A Regional Collaboration for Health (ARCH) and a Joint Regional Planning and Delivery Committee (JRPDC). The focus for the JRPDC is on shorter-term priorities and delivery, whilst ARCH, which also includes Swansea University, focuses on the medium to longer term.  The Health Boards are working together on a number of short and long term regional priorities. 


10. Regional Working: the Health Board is a key member of the West Wales Care Partnership (West Wales Regional Partnership Board) (the RPB), which is led by a Regional Leadership Group comprising the Chief Executives of all four statutory partners (the Health Board and the three Local Authorities); the Health Board’s Chair; and Cabinet Members from the LAs, facilitating joint decision making on a regional basis.  In addition, there is an Integrated Executive Group, comprising the three Directors of Social Services, key Health Board Directors and a Third Sector Chief Officer, supporting integration at an operational level.


11. The Health Board is a statutory member of Public Services Boards (PSBs) in Carmarthenshire, Ceredigion and Pembrokeshire.  A number of meetings have taken place over recent months to strengthen PSB and RPB links, and identify synergy between population well-being actions and client-specific actions, which are being led by the RPB. This includes opportunities to align work streams and reduce duplication; for example, in relation to green health and social prescribing, the Director of Public Health has secured PSB and RPB support to establish a single overarching regional group to draw this work, and all the partners involved, together.


12. Transformation Fund: in December 2018, the RPB submitted a bid for Transformation funding: A Healthier West Wales; an ambitious programme of change closely aligned to the Health Board’s Health and Care Strategy.  The bids aim to remodel the whole system of health and care in West Wales over the medium to long term. Work is underway across partner agencies to develop detailed implementation plans for the three Healthier West Wales programmes that been approved to date, with allocated resources from the Transformation Fund totalling £11.8 million. The successful bids include:


(i)            Proactive, technology-enabled care: based on a successful Spanish model of care that targets selected vulnerable individuals to identify changes in their condition or a heightened risk, allowing early intervention;

(ii)          Fast tracked, consistent integration: trialling integrated delivery structures at a county and locality level to avoid admissions to hospital; and

(iii)         Creating connections for all: embedding a community connectors approach with a regional volunteering programme aimed at promoting interaction between generations, where skills are shared.

Escalation Levels


13.Following the decision made by the now Minister for Health and Social Services in September 2016 to move the Health Board from enhanced monitoring to Targeted Intervention status (NHS Wales Escalation Framework), members of the Executive Team meet with the Chief Executive NHS Wales and members of his senior team in Welsh Government on a regular basis.  The last meeting was held on 13 May 2019. 


14.Welsh Government continues to be concerned about the sustainability of the Health Board’s financial position and this will be the main focus for the Targeted Intervention meetings in 2019/20.


15.Following each Targeted Intervention meeting, the Health Board reports the outcome of the discussions to its Audit and Risk Assurance Committee that meets bi-monthly, allowing for scrutiny by Independent Members. In addition, the same information is included in the Chief Executive’s Public Board Report.




16.Planned Care: in March 2019, the Health Board achieved zero breaches for patients waiting over 36-weeks from referral to treatment (RTT), patients waiting more than 8-weeks for a diagnostics, and patients waiting over 14-weeks for a specified therapy. These were achieved through rigorous monitoring, outsourcing, waiting list initiatives, overtime and the sheer hard work and dedication from staff:




17.Cancer Services: during 2018/19, compliance ranged from 95.5% to 100.0% for non-urgent suspected cancers (target 98%) and 78.8% to 93.5% for urgent suspected cancers (target 93%).  Key challenges included treatment delays in the tertiary cancer centers and local capacity pressures within key diagnostic services. To improve performance, a variety of actions are being progressed, including recruitment to key vacancies (both in Hywel Dda and in the tertiary centres), commissioning of additional activity to supplement existing capacity (e.g. Dermatology), and continued escalation of delays with tertiary centre providers. 


18.Infection Control: in 2018/19, there was a 6% reduction in Clostridium difficile cases and a 22% reduction in Escherichia coli cases. However, there was a 4% increase in Staphylococcus aureus (5 cases). An improvement plan is in place for 2019/20.


19.Unscheduled Care: there were unscheduled care challenges across all hospital sites in 2018/19, but some improvements were seen, including patients seen within 4-hours in our Accident and Emergency (A&E) departments/Minor Injury Units (MIU), where performance improved from 80.3% in March 2018 to 81.7% in March 2019. The number of patients waiting over 12-hours in A&E/MIU is a particular challenge and is a key focus area for improvement in 2019/20, with the following actions planned or already underway:


·         Rolling out of  a single patient plan which will follow the patient, a staged approach developing on stay well – anticipatory – advance care plans;

·         Embedding a culture of Think AEC First and Home First, developing a standard for Ambulatory Emergency Care (AEC) and developing current AEC services on all four sites; 

·         Developing front door pit stop model, collaborative approach with therapies;

·         Refocusing on embedding SAFER patient bundle, board rounds, 4 questions and Red2Green across all wards on all sites, commencing with medical wards;

·         Developing 24/7 rapid access community services in Ceredigion and Pembrokeshire to provide consistent access to services across the Health Board;

·         Working with the Delivery Unit on pilot project Right Sizing Community Services, mapping our regional model based to fully understand community demands on discharge;

·         Developing the Intermediate Care offer for the region; and

·         Developing the standard for End of Life Care, defining what good looks like and subsequent improvement actions, working in partnership with Community, Social Care and Third Party organisations.


20.Stroke: in 2018/19 the national stroke targets for CT scan within 1 hour, admission to a stroke unit within 4 hours, and assessed by a stroke consultant within 12 hours, were all met.  Special funding enabled multi-disciplinary support to be provided to patients in their own home, facilitating earlier discharge. Withybush General Hospital achieved the first ‘A’ grade ever awarded to a stroke unit in Wales. Whilst the thrombolysis performance compares well with other Welsh Health Boards, the target was not met and improvements need to be made to the door to needle times, particularly out of hours. Work is underway to re-design stroke services across the Health Board in line with the new quality improvement measures.  This will focus on the provision of an early supported discharge service, better therapy provision, and consideration of psychology services.


21.Mental Health: performance has been achieved throughout 2018/19 in respect of Parts 2 and 3 of the Mental Health (Wales) Measure 2010 targets.


22.Primary Care: the GP Out of Hours service successfully integrated all areas of the Health Board into the new 111 system, which provides access to urgent and unscheduled care out of hours. The Health Board invested in additional dental services during 2018/19, which increased access for an additional 8,000 patients to be seen over a 2-year period. Following work undertaken by the Health Board in liaison with GP practices to improve access for our patients, improvements were seen in the availability of GP appointments and opening hours.


23. Childhood Vaccination Rates: overall, uptake of childhood immunisations remained stable in 2018 and the performance trend improved. Uptake of six in one vaccine by age 1 increased in Carmarthenshire to greater than 95% target for the first time in the past year, and uptake of two doses of MMR increased in all three Local Authority areas to between 90-95.  The aim for 2019/20 is to see continued improvements in uptake of childhood immunisations, to meet the Welsh Government target, and to improve public health and well-being.  The uptake in vaccination measures will protect and prevent infection and support children to have a healthy start to life.




24. Financial management was also an area identified for improvement under the Health Board’s Targeted Intervention status, with a particular emphasis on the need to reduce its deficit in a safe and sustainable way.  Significant progress has been made. 


25. Welsh Government commissioned Deloitte to undertake a zero based review of acute healthcare services provided by the Health Board. Its purpose was to allow Welsh Government to understand the potential impact of the Health Board’s current configuration and resources that limited its ability to produce an approved Integrated Medium Term Plan. The Review suggested that there were some costs that may be unavoidable; this resulted in additional funding of £27m being provided on a recurrent basis.


26. The Health Board’s financial deficit was £69.4m in 2017/18. During 2018/19, following the allocation of £27m of additional funding by Welsh Government and a reduction of £7m made by the Health Board through savings initiatives, the reported position for 2018/19 represents a deficit of £35.4m.



27. The Health Board recognises that the challenge remains to deliver financial breakeven and is working closely with Welsh Government on an improvement trajectory. The Health Board has been provided with a control total of £25m by Welsh Government for the 2019/20 financial year, which recognises that delivering a breakeven position would not be possible in the short term. However, this does represent a £10.4m further improvement in the deficit from 2018/19. This also recognises that the Health Board will maintain its position on Referral to Treatment times.


28. Delivering the improvement in the deficit position requires a focus on transforming our services to deliver greater value to our population. Maintaining and building on the rigour which has been in place since 2017 in addressing known areas of inefficiency, alongside beginning to implement our Health and Care Strategy, will be a critical part of our plan over the coming financial year. This will be supported through the Welsh Government’s Transformation Fund, which enables investment in community health services and enable a shift from more expensive care settings.


29. The Health Board is also adopting a Value Based Health Care approach, which links clinical and patient outcomes with the cost of achieving those outcomes. This approach is critical in not only ensuring that we operate as efficiently as possible, but that our clinical interventions are effective in improving outcomes for patients and our population. This is crucial if ambitions to transfer resources into primary, community and preventative healthcare are to be realised. Whilst this approach is in its infancy globally, the Health Board is well placed to capitalise on this, especially in areas such as respiratory medicine and lung cancer, for which the Health Board is recognised as a leading organisation.


Workforce and Integrated Working


Organisational Culture

30. To achieve our organisational vision, the Health Board has been developing a culture of engagement, openness and honesty in which all elements of the workforce are encouraged to be innovative.  Central to this, is the need for clear and supportive leadership, including robust and empowering clinical leadership and staff engagement.   The Health Board recognises that there needs to be a culture shift where psychological safety is assured; this will enable employees to feel comfortable to challenge and speak out when the values are not demonstrated at any level.


31. Evidence demonstrates that organisational performance is directly linked to levels of employee engagement; the latest results from the staff survey indicate that the Health Board’s Staff Engagement Index is above the NHS Wales average at 3.85 and improvements were noted in many domains.  The Health Board has been awarded the Corporate Health Standard Platinum Level, has sickness rates which are amongst the lowest of the large NHS organisations in Wales, and provides Occupational Health and Psychological Well-Being Services.



32. The Health Board’s Values and Behaviours have now been in place for over two years. The values were developed to support the organisational mission and vision and incorporate personal values that our staff identified and believed they should live and breathe: dignity, respect, fairness, integrity, honesty, openness and caring, kindness and compassion. There are also three separate value statements that the organisation would adhere to and demonstrate through all that it does:


  Putting people at the heart of everything we do



Working together to be the best we can be


Striving to deliver and develop excellent services


33. The values form the basis of driving change of the organisational culture and support a consistent level of leadership to Hywel Dda.  The behaviour of leaders is integral to embedding the values. To further support strong leadership in the organisation, the Health Board has completed a thorough review of leadership programmes, which are now aligned with NHS leadership competencies.


34. To support the focus on cultural change and embedding values, during 2018, the OD team delivered bespoke values sessions across the organisation in both acute and community sites.  The session also conveys the need for psychological safety and that staff experience is vital for the organisation to progress and develop into an Employer of Choice.  Our Values and Behaviours underpin our Corporate Induction and are fundamental to ensure all new starters are aware of the expectations from day one, and can reflect on their personal behaviours in relation to the organisational expectations.


Recruitment Challenges

35. Our greatest asset is the people we employ to provide our services and care for our patients. This remains however an area of high vulnerability and is the focus of significant effort and innovation to maximise recruitment and retention.  Recognising that recruitment and retention across the contractor professions is a challenge in the more rural areas, the need for a stable primary care footprint is paramount to the modernisation and development of service provision that is aligned to national strategic direction and also that of the Health Board.


36. The Health Board uses the all Wales Split Creative in posters featuring Hywel Dda staff, in line with national #trainworklive guidelines, in all of our campaigns and also continues to use all advertising media to attract candidates who are interested in employment within our region. The Health Board has also worked collaboratively with Powys tUHB and Betsi Cadwaladr UHB to launch its most recent rural recruitment campaign.

37. In addition to recruitment to replace existing roles, the Health Board is establishing apprenticeship routes where possible to attract and train individuals to become the professionals needed for the future.  A Healthcare Apprenticeship has recently been launched to support individuals throughout a programme, which will ultimately lead to professional nurse registration.



38. In some professional groups, the Health Board currently experiences turnover at a level which is higher than the NHS Wales average. In nursing, current turnover is 9.6%, although the Health Board has met with some success in recruiting registered nurses and retention rates are improving. In relation to medical and dental, turnover is 12.1% compared to a NHS Wales turnover rate of 9.2%.  Actions linked to the Health Board’s Values and Behaviours are being taken to seek to address high turnover and create an environment where individuals wish to remain.  This also links with innovative staff development programmes where individuals are able to pursue their careers. 


39. The Health Board is also working closely with its Social Services partners and is introducing the integrated induction programme.  Given the task of now delivering on the Health Board’s Service Strategy,focus has been placed on developing our leadership body; this includes the introduction of System Level Senior Leadership Programmes and an Aspiring Medical Leader programme.


The Nurse Staffing Levels (Wales) Act 2016

40. The Health Board has taken a robust approach to implementing the Nurse Staffing Levels (Wales) Act 2016 ensuring that the duties within the Act are met and evidenced. The Director of Nursing, Quality and Patient Experience has been identified as the responsible person on behalf of the Board, charged with leading and monitoring the calculations of staffing levels in all relevant wards. There are currently 31 wards covered under the Act; however, this remains subject to the required six monthly review in line with service developments. The Quality, Safety, Experience Assurance Committee and Board have received detailed reports based upon the triangulated method of calculation and costing associated with implementation of the Act. The Board has agreed an implementation plan, which recognises the national and local recruitment challenges, together with acknowledgement of the potential wider impact on the regional domiciliary and care workforce.


Primary Care

41. The Health Board currently supports four Managed Practices to deliver general medical services in two out of the three counties.  In the last six months, the Health Board has recruited salaried GPs, which has led to a decrease in reliance on locum GPs and has enabled each Managed Practice to have a designated clinical lead.  Where GP locums are required, a locally agreed cap has been placed on their sessional rate, which has reduced the expenditure and fortunately has not seen a decrease in the number of GP locums looking to work with us.




42. In accordance with the Primary Care Model for Wales, the Health Board is reviewing its workforce model to deliver safe and effective services through Managed Practices. There are plans in place to see if three of the four Managed Practices can be returned to independent contractor status within the next year.  It is important to ensure that where independent contractor Practices are keen to seek out innovative solutions to service delivery challenges and workforce pressures, that we harness and support their desire to learn more about different ways of working.  Coupled with an ageing GP workforce, the need to consider new and sustainable ways of working at practice, cluster and locality level, is key.


43. The Health Board is also reviewing existing Pacesetter funding schemes to identify those that need to be mainstreamed and those that need to be reviewed, refined or terminated. Similarly, potential new schemes will be considered where innovation in service models to support the national aims of the Pacesetter programme are demonstrated.  Success to date has included the development of Walk-In Community Pharmacies, which has been supported locally with Primary Care colleagues across the contractor professions, as well as Community Pharmacy Wales.


44. Clusters are supported through baseline assessments of the existing workforce, understanding the current workforce demographic, and looking at how at cluster level services can be delivered through new models.  This includes taking the learning from local cluster innovation and national Pacesetter/Pathfinder programmes to identify the most appropriate skill mix.  The South Ceredigion cluster funded a golden hello as a mechanism to attract GPs; unfortunately, this has been unsuccessful and the cluster is considering what other options, if any, could make working in this area a more attractive proposal.


45. The Health Board is currently engaged in developing the Primary Care Academy at Swansea University, placing a Year 3 Medical Students in a GP practice for 11 weeks to provide them with an enhanced experience of working in general practice.  This programme will expand in 2019/20 to 4/6 students being placed in practices across West Wales.  The Health Board is also working with Swansea University to test the feasibility of securing the ongoing Academic Fellow Programme, as well as considering a programme for ST4 (newly qualified) GPs to have a placement within General Practice, whilst receiving ongoing training, development and mentorship.


Preparations for EU Withdrawal – Brexit


46. Brexit preparedness has been a significant priority for the past year and as an organisation we have been planning for a potential no-deal scenario, risk assessing potential impact to service delivery and business continuity across the Health Board.


47. The Health Board’s nominated Executive Director-level Senior Responsible Officer (SRO) (the Director of Public Health supported by the Civil Contingencies Manager) oversees the preparations locally, and contributing to a national group of SROs.




48. The Health Board recognises that it still has much to do to continue with its plan to transform services by implementing and delivering A Healthier Mid and West Wales, which will help to improve and create a more sustainable financial position.


49. Health Board executives are looking forward to the opportunity to discuss the above, and any other areas of interest to the Health, Social Care and Sport Committee, at the forthcoming scrutiny session.